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Wiegley N, Arora S, Norouzi S, Rovin B. A Comprehensive and Practical Approach to the Management of Lupus Nephritis in the Current Era. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:234-245. [PMID: 39004463 DOI: 10.1053/j.akdh.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/27/2023] [Accepted: 11/29/2023] [Indexed: 07/16/2024]
Abstract
Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE) and is one of the leading causes of morbidity and mortality in patients with SLE. It is estimated that up to 60% of individuals with SLE will develop LN, which can manifest at any stage of a patient's life; however, it commonly emerges early in the course of SLE and tends to exhibit a more aggressive phenotype in men compared to women. Black and Hispanic patients are more likely to progress to kidney failure than white patients. LN is characterized by kidney inflammation and chronic parenchymal damage, leading to impaired kidney function and potential progression to kidney failure. This article provides a comprehensive overview of the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of LN, highlighting the importance of early recognition and treatment of LN to prevent progressive, irreversible kidney damage and improve patient outcomes. Additionally, the article discusses current and emerging therapies for LN, including traditional immunosuppressive agents, biological agents, and novel therapies targeting specific pathways involved in LN pathogenesis, to provide a practical guide for clinicians in properly diagnosing LN and determining a patient-centered treatment plan.
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Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA.
| | - Swati Arora
- Division of Nephrology, Allegheny Health Network, Pittsburgh, PA
| | - Sayna Norouzi
- Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA
| | - Brad Rovin
- Division of Nephrology, Ohio State University, Columbus, OH
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2
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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Mostkowska A, Rousseau G, Raynal NJM. Repurposing of rituximab biosimilars to treat B cell mediated autoimmune diseases. FASEB J 2024; 38:e23536. [PMID: 38470360 DOI: 10.1096/fj.202302259rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
Rituximab, the first monoclonal antibody approved for the treatment of lymphoma, eventually became one of the most popular and versatile drugs ever in terms of clinical application and revenue. Since its patent expiration, and consequently, the loss of exclusivity of the original biologic, its repurposing as an off-label drug has increased dramatically, propelled by the development and commercialization of its many biosimilars. Currently, rituximab is prescribed worldwide to treat a vast range of autoimmune diseases mediated by B cells. Here, we present a comprehensive overview of rituximab repurposing in 115 autoimmune diseases across 17 medical specialties, sourced from over 1530 publications. Our work highlights the extent of its off-label use and clinical benefits, underlining the success of rituximab repurposing for both common and orphan immune-related diseases. We discuss the scientific mechanism associated with its clinical efficacy and provide additional indications for which rituximab could be investigated. Our study presents rituximab as a flagship example of drug repurposing owing to its central role in targeting cluster of differentiate 20 positive (CD20) B cells in 115 autoimmune diseases.
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Affiliation(s)
- Agata Mostkowska
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Guy Rousseau
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Noël J-M Raynal
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Centre de recherche du CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
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Angelucci E, Artoni A, Fianchi L, Dovizio M, Iacolare B, Saragoni S, Esposti LD. Real-World Data Analysis of Patients Affected by Immune-Mediated Thrombotic Thrombocytopenic Purpura in Italy. J Clin Med 2024; 13:1342. [PMID: 38592185 PMCID: PMC10931660 DOI: 10.3390/jcm13051342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The therapeutic management of immune-mediated thrombotic thrombocytopenic purpura (iTTP) has recently benefited from the introduction of caplacizumab, an agent directed at the inhibition of platelet aggregation. This real-world analysis investigated the epidemiology and the demographic and clinical characteristics of iTTP patients in Italy before and after caplacizumab introduction in 2020. Methods: Hospitalized adults with iTTP were included using the administrative databases of healthcare entities covering 17 million residents. Epidemiological estimates of iTTP considered the 3-year period before and after caplacizumab introduction. After stratification by treatment with or without caplacizumab, iTTP patients were characterized for their baseline features. Results: The annual incidence before and after 2020 was estimated in the range of 4.3-5.8 cases/million and 3.6-4.6 cases/million, respectively. From 2018 to 2022, 393 patients with iTTP were included, and 42 of them were treated with caplacizumab. Caplacizumab-treated patients showed better clinical outcomes, with tendentially shorter hospital stays and lower mortality rates (no treated patients died at either 1 month or 3 months after caplacizumab treatment initiation, compared to 10.5% and 11.1% mortality rates at 1 and 3 months, respectively, of the untreated ones). Conclusions: These findings may suggest that caplacizumab advent provided clinical and survival benefits for patients with iTTP.
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Affiliation(s)
- Emanuele Angelucci
- U.O. Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Andrea Artoni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milano, Italy;
| | - Luana Fianchi
- Dipartimento Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
| | - Melania Dovizio
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
| | - Biagio Iacolare
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
| | - Stefania Saragoni
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
| | - Luca Degli Esposti
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
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Leisring J, Brodsky SV, Parikh SV. Clinical Evaluation and Management of Thrombotic Microangiopathy. Arthritis Rheumatol 2024; 76:153-165. [PMID: 37610060 DOI: 10.1002/art.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
Thrombotic microangiopathy (TMA) refers to a diverse group of diseases that share clinical and histopathologic features. TMA is clinically characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and organ injury that stems from endothelial damage and vascular occlusion. There are several disease states with distinct pathophysiological mechanisms that manifest as TMA. These conditions are associated with significant morbidity and mortality and require urgent recognition and treatment. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are traditionally considered to be primary forms of TMA, but TMA more commonly occurs in association with a coexisting condition such as infection, pregnancy, autoimmune disease, or malignant hypertension, among others. Determining the cause of TMA is a diagnostic challenge because of limited availability of disease-specific testing. However, identifying the underlying etiology is imperative as treatment strategies differ. Our understanding of the conditions that cause TMA is evolving. Recent advances have led to improved comprehension of the varying pathogenic mechanisms that drive TMA. Development of targeted therapeutics has resulted in significant improvements in patient outcomes. In this article, we review the pathogenesis and clinical features of the different TMA-causing conditions. We outline a practical approach to diagnosis and management and discuss empiric and disease-specific treatment strategies.
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Affiliation(s)
- Joshua Leisring
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Samir V Parikh
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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Terra POC, De Santis GC, Prado Júnior BDPA, Oliveira LC. Outcomes of thrombotic thrombocytopenic purpura patients submitted to therapeutic plasma exchange in a single center in Brazil. Hematol Transfus Cell Ther 2023:S2531-1379(23)02606-8. [PMID: 38614932 DOI: 10.1016/j.htct.2023.11.006] [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: 07/25/2023] [Revised: 11/18/2023] [Accepted: 11/29/2023] [Indexed: 04/15/2024] Open
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (iTTP) is characterized by acute systemic microvascular thrombosis and is associated with a high morbidity and mortality, especially in delayed diagnosis (later than 6-7 days from symptoms). iTTP data in Brazil is scarce, so we aimed to characterize the clinical presentation and identify predictors of death risk in patients with this disease in Brazil. METHODS In this single-center retrospective study the patients who underwent therapeutic plasma exchange (TPE) for presumptive or confirmed iTTP were evaluated regarding the epidemiological, clinical, laboratorial characteristics and management. RESULTS A total of 50 patients (90 % female), with median age (IQR) of 34.1 (27-47) years, were enrolled, of which 12 (24 %) died. The most frequent symptoms were neurological (96 %), bleeding (76 %), gastrointestinal (52 %), fever (38 %), and cardiovascular (22 %). Neurological focal deficit and cardiovascular symptoms were more frequently observed in the non-survivor group (P = 0.0019 and P = 0.007, respectively). The mean ± SD number of days from beginning of symptoms to first TPE was 12.22 ± 7.91. We identified an association regarding mortality rate with a score MITS ≥ 2 points (P = 0.04), a higher indirect bilirubin (P = 0.0006), a higher number of transfused red blood cell units (P = 0.025), and platelet transfusion (P = 0.027). CONCLUSION Delayed diagnosis appears to be associated with a higher frequency of neurological symptoms and mortality. Intensity of hemolysis and signs of organ ischemia, such as cardiovascular symptoms and focal neurological deficit, are indicators of death risk.
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Affiliation(s)
- Patrícia Oliveira Cunha Terra
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.
| | - Gil Cunha De Santis
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Benedito de Pina Almeida Prado Júnior
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Luciana Correa Oliveira
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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8
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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Völker LA, Brinkkoetter PT, Cataland SR, Masias C. Five years of caplacizumab - lessons learned and remaining controversies in immune-mediated thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:2718-2725. [PMID: 37562668 DOI: 10.1016/j.jtha.2023.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare hematologic disease caused by autoantibodies against ADAMTS-13 that trigger microangiopathic hemolytic anemia. Therapeutic plasma exchange and glucocorticoids have been the mainstay of treatment for the past 30 years. In 2019, caplacizumab was approved as an addition to this regimen for the acute treatment of iTTP. Randomized controlled trials and real-world evidence have shown that caplacizumab reduces the time to platelet count normalization, refractoriness, and exacerbations of the disease, with an acceptable safety profile. In the past 5 years, there have been arguments against the upfront use of caplacizumab in all patients with iTTP, particularly related to the perceived lack of clinical benefit, safety concerns related to bleeding risk, and high costs. This perspective aimed to address these concerns in the context of the experience of expert centers that have used the drug for >5 years.
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Affiliation(s)
- Linus Alexander Völker
- Department II of Internal Medicine, Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany.
| | - Paul Thomas Brinkkoetter
- Department II of Internal Medicine, Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany
| | - Spero R Cataland
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
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Kelen K, Horváth O, Kis É, Mikes B, Sallay P, Prohászka Z, Szabó AJ, Reusz GS. Immunosuppressive Therapy of Antibody-Mediated aHUS and TTP. Int J Mol Sci 2023; 24:14389. [PMID: 37762692 PMCID: PMC10531618 DOI: 10.3390/ijms241814389] [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: 08/17/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The recent classification of pediatric thrombotic microangiopathies (TMA) takes into consideration mechanisms of disease for guidance to targeted therapies. We present our experience with seven patients with antibody mediated atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP). Five children had aHUS with antibodies against complement factor H (CFH-ab) and two with TTP with antibodies against metalloproteinase ADAMTS13. In the aHUS cases diagnosed and treated before the eculizumab era, CFH-ab was detected using the ELISA assay. Mutational analysis of selected complement genes was performed. TTP was diagnosed if, in addition to microangiopathic hemolytic anemia and thrombocytopenia, ischemic organ involvement and severe deficiency in ADAMTS13 activity were present. Treatment protocol consisted of plasma exchanges (PE) and steroid pulses, followed by the combination of cyclophosphamide and rituximab to achieve long-term immunosuppression. Four patients with CFH-ab and the TTP patients with ADAMTS13 antibodies came into sustained remission. After a median follow-up of 11.7 (range 7.7-12.9) years without maintenance therapy, no disease recurrence was observed; nevertheless, six patients, two had hypertension and two had proteinuria as a late consequence. One patient, with late diagnosis of CFH-ab and additional genetic risk factors who was treated only with PE and plasma substitution, reached end-stage renal disease and was later successfully transplanted using eculizumab prophylaxis. In the cases of antibody-mediated TMAs, PE and early immunosuppressive treatment may result in sustained remission with preserved kidney function. Further data are needed to establish optimal treatment of anti-FH antibody-associated HUS.
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Affiliation(s)
- Kata Kelen
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Orsolya Horváth
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Éva Kis
- Department of Pediatric Cardiology, Gottsegen György Hungarian Institute of Cardiology, 1096 Budapest, Hungary;
| | - Bálint Mikes
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Péter Sallay
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Zoltán Prohászka
- Research Laboratory, Department of Medicine and Hematology, Semmelweis University, 1083 Budapest, Hungary;
| | - Attila József Szabó
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
- Pediatric Center, MTA Center of Excellence, Semmelweis University, 1083 Budapest, Hungary
- ELKH-SE Pediatrics and Nephrology Research Group, 1052 Budapest, Hungary
| | - György S. Reusz
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
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Falter T, Rossmann H, de Waele L, Dekimpe C, von Auer C, Müller-Calleja N, Häuser F, Degreif A, Marandiuc D, Messmer X, Sprinzl M, Lackner KJ, Jurk K, Vanhoorelbeke K, Lämmle B. A novel von Willebrand factor multimer ratio as marker of disease activity in thrombotic thrombocytopenic purpura. Blood Adv 2023; 7:5091-5102. [PMID: 37399489 PMCID: PMC10471935 DOI: 10.1182/bloodadvances.2023010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/05/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP), an autoantibody-mediated severe ADAMTS13 deficiency, is caused by insufficient proteolytic processing of von Willebrand factor (VWF) multimers (MMs) and microvascular thrombi. Recurrence of acute iTTP is associated with persistence or reappearance of ADAMTS13 deficiency. Some patients remain in remission despite recurring or persisting severe ADAMTS13 deficiency. In a prospective 2-year observational study, we investigated VWF MM patterns and ADAMTS13 in patients with iTTP in remission and at acute episodes. Of the 83 patients with iTTP, 16 suffered 22 acute episodes whereas 67 remained in clinical remission during follow-up, including 13 with ADAMTS13 <10% and 54 with ADAMTS13 ≥10%. High -molecular weight to low-molecular weight VWF MM ratio based on sodium dodecyl sulfate-agarose gel electrophoresis was compared with ADAMTS13 activity. VWF MM ratio was significantly higher in patients in remission with <10% compared with ≥10% ADAMTS13 activity. Fourteen samples obtained from 13 to 50 days (interquartile range; median, 39) before acute iTTP onset (ADAMTS13 <10% in 9 patients and 10%-26% in 5) showed VWF MM ratios significantly higher than those from 13 patients remaining in remission with ADAMTS13 <10%. At acute iTTP onset, VWF MM ratio decreased significantly and was low in all patients despite <10% ADAMTS13. The VWF MM ratio does not depend exclusively on ADAMTS13 activity. The disappearance of high molecular weight VWF MMs resulting in low VWF MM ratio at iTTP onset may be explained by consumption of larger VWF MMs in the microcirculation. The very high VWF MM ratio preceding acute iTTP recurrence suggests that VWF processing is hampered more than in patients remaining in remission.
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Affiliation(s)
- Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Laure de Waele
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charlotte Dekimpe
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charis von Auer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Nadine Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Friederike Häuser
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Adriana Degreif
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Dana Marandiuc
- Transfusion Center, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Xavier Messmer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Martin Sprinzl
- Medical Department I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karl J. Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- University Clinic of Hematology & Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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Español I, Leal JD, Blanquer M, García-Candel F, Heredia A, Gómez-Espuch J, González C, Montserrat J, Díaz-Carrasco MS, Martínez A, Moraleda JM. N-Acetylcistein for thrombotic thrombocytopenic purpura: an observational case series study. Ann Hematol 2023:10.1007/s00277-023-05248-9. [PMID: 37171598 PMCID: PMC10176284 DOI: 10.1007/s00277-023-05248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder. N-Acetylcysteine (NAC) rapidly degrades ultra-large von Willebrand factor multimers by disrupting the disulfide bonds. We report a series of twelve consecutive patients diagnosed with acquired TTP successfully treated with high-dose NAC (150 mg/kg/day) in combination with plasma exchange and steroids. Eight patients also received rituximab. Two patients presented refractory TTP. All patients achieved a quick clinical response in a median time of 5.5 days after starting NAC and are alive after a median follow-up of 29 months. The treatment was feasible and well tolerated. These data provide further evidence of the potential benefit and safety of adding NAC to the standard of care.
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Affiliation(s)
- Ignacio Español
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain.
| | - Juan Diego Leal
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Miguel Blanquer
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Faustino García-Candel
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Angela Heredia
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Joaquín Gómez-Espuch
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - Celia González
- Pharmacy Department, IMIB-Pascual Parrilla, University of Murcia, Murcia, Spain
| | - Jorge Montserrat
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | | | - Antonio Martínez
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
| | - José M Moraleda
- Hematology Department, University Hospital Virgen de la Arrixaca, IMIB-Pascual Parilla, Carretera Madrid-Cartagena s/n, 30120 El Palmar, Murcia, Spain
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13
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Mingot-Castellano ME, Izquierdo CP, Del Rio Garma J. Spanish registry of thrombotic thrombocytopenic purpura (REPTT): Data evidence and new developments. Transfus Apher Sci 2023:103725. [PMID: 37202322 DOI: 10.1016/j.transci.2023.103725] [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: 05/20/2023]
Abstract
Immuno Thrombotic thrombocytopenic purpura (iTTP) is a rare and potentially fatal disorder characterized by systemic microvascular thrombosis because of a severe deficiency of ADAMTS13. It is difficult to generate knowledge about TTP because of its low incidence and the lack of clinical trials. Most of the evidence on diagnosis, treatment, and prognosis has been generated from real-world data registries. In 2004, the Spanish Apheresis Group (GEA) implemented the Spanish registry of TTP (REPTT) with 438 patients suffering 684 acute episodes in 53 hospitals up to January 2022. REPTT has studied several aspects of TTP in Spain. The iTTP incidence in Spain our country is 2.67 (95 % CI 1.90-3.45) and the prevalence is 21.44 (95 % CI % 19.10-23.73) patients per million inhabitants. The refractoriness incidence is 4.8 % and exacerbation incidence was 8.4 %, with a median of follow-up of 131.5 months (IQR: 14-178 months). In a 2018 review, the mortality in the first episode due to TTP was 7.8 %. We have also found that de novo episodes require fewer PEX procedures than relapses. Since June 2023, REPTT will involve Spain and Portugal, with a recommended sampling protocol and new variables to improve the neurological, vascular and quality of life evaluation of these patients. The main strength of this project will be the involvement of a combined population of more than 57 million inhabitants, which implies an annual incidence of close to 180 acute episodes per year. This will allow us to provide better answers to questions like treatment efficacy, associated morbidity and mortality, and the possible neurocognitive and cardiac sequelae.
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Affiliation(s)
- María Eva Mingot-Castellano
- Servicio de Hematología, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla. Sevilla, Spain.
| | - Cristina Pascual Izquierdo
- Servicio de Hematología, Hospital Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón, Madrid, Spain
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14
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Lancellotti S, Sacco M, Tardugno M, Ferretti A, De Cristofaro R. Immune and Hereditary Thrombotic Thrombocytopenic Purpura: Can ADAMTS13 Deficiency Alone Explain the Different Clinical Phenotypes? J Clin Med 2023; 12:3111. [PMID: 37176552 PMCID: PMC10179526 DOI: 10.3390/jcm12093111] [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: 03/13/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy caused by a hereditary or immune-mediated deficiency of the enzyme ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13). TTPs are caused by the following pathophysiological mechanisms: (1) the presence of inhibitory autoantibodies against ADAMTS13; and (2) hereditary mutations of the ADAMTS13 gene, which is present on chromosome 9. In both syndromes, TTP results from a severe deficiency of ADAMTS13, which is responsible for the impaired proteolytic processing of high-molecular-weight von Willebrand factor (HMW-VWF) multimers, which avidly interact with platelets and subendothelial collagen and promote tissue and multiorgan ischemia. Although the acute presentation of the occurring symptoms in acquired and hereditary TTPs is similar (microangiopathic hemolytic anemia, thrombocytopenia, and variable ischemic end-organ injury), their intensity, incidence, and precipitating factors are different, although, in both forms, a severe ADAMTS13 deficiency characterizes their physiopathology. This review is aimed at exploring the possible factors responsible for the different clinical and pathological features occurring in hereditary and immune-mediated TTPs.
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Affiliation(s)
- Stefano Lancellotti
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy;
| | - Monica Sacco
- Dipartimento di Medicina e Chirurgia Traslazionale, Facoltà di Medicina e Chirurgia “Agostino Gemelli”, Università Cattolica S. Cuore, 00168 Roma, Italy; (M.S.); (M.T.)
| | - Maira Tardugno
- Dipartimento di Medicina e Chirurgia Traslazionale, Facoltà di Medicina e Chirurgia “Agostino Gemelli”, Università Cattolica S. Cuore, 00168 Roma, Italy; (M.S.); (M.T.)
| | - Antonietta Ferretti
- Dipartimento di Medicina e Chirurgia Traslazionale, Facoltà di Medicina e Chirurgia “Agostino Gemelli”, Università Cattolica S. Cuore, 00168 Roma, Italy; (M.S.); (M.T.)
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy;
- Dipartimento di Medicina e Chirurgia Traslazionale, Facoltà di Medicina e Chirurgia “Agostino Gemelli”, Università Cattolica S. Cuore, 00168 Roma, Italy; (M.S.); (M.T.)
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15
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He J, Qi J, Han H, Xu X, Li X, Song X, Han Y. Efficacy and safety of caplacizumab in the treatment of thrombotic thrombocytopenic purpura: a systematic review and meta-analysis. Expert Rev Hematol 2023; 16:377-385. [PMID: 37045600 DOI: 10.1080/17474086.2023.2202850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy. Several studies have demonstrated the efficy of caplacizumab in iTTP. However, the effect on different populations remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the effectiveness and safety of caplacizumab for treating iTTP. MATERIALS AND METHODS We searched PubMed, Embase, and the Cochrane Library for studies until March 24, 2023. Participants were hospitalized patients with iTTP. Interventions included caplacizumab versus placebo or standard of care (SOC). Outcomes assessed included all-cause mortality, exacerbation, relapse, refractory, time-to-platelet-count-recovery, length of TPE and hospital stay, bleeding, and thrombosis. RESULTS A total of 1119 patients from eight studies were subjected to meta-analysis. The results of the meta-analysis showed that iTTP patients treated with caplacizumab achieved a reduction in mortality (RR 0.38, 95% CI: 0.19-0.75), exacerbation (RR 0.29, 95% CI: 0.14-0.61) and refractory (RR 0.50, 95% CI: 0.31-0.81). Besides, adding caplacizumab to SOC was associated with a shorten time-to-platelet-count-recovery (MD -2.31, 95% CI: -3.86 to -0.77) and the length of TPE (MD -4.61, 95% CI: -6.20 to -3.02). In terms of safety, the bleeding rate was higher in the caplacizumab group (RR 1.57, 95% CI: 1.21-2.02), while there was no significant difference in hospital stay and thrombosis between the two groups. CONCLUSIONS Caplacizumab is an effective treatment for patients with iTTP, especially in reducing all-cause mortality, exacerbations, refractoriness, and the time-to-platelet-count-recovery. Although the risk of bleeding may be increased, it is generally modest and manageable.
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Affiliation(s)
- Jingyi He
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
| | - Jiaqian Qi
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Haohao Han
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Xiaoyan Xu
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Xueqian Li
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Xiaofei Song
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
| | - Yue Han
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, Jiangsu province, China
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16
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Therapeutic plasma exchange-free treatment for first-episode TTP: A systematic review. Transfus Apher Sci 2023:103661. [PMID: 36878741 DOI: 10.1016/j.transci.2023.103661] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA), and therapeutic plasma exchange (TPE) is currently the standard treatment. However, TPE sometimes cannot be implemented. The aim of this study was to systematically review patients with a first TTP episode who were treated without TPE. METHOD The PubMed, Embase, Web of Science and Cochrane Library databases were searched by two investigators independently to collect case reports and clinical studies on TTP patients treated without TPE. After removing duplicate records and records that did not meet the inclusion criteria, the patients' data of eligible studies, including the basic characteristics, treatment regimens, and outcomes were extracted for further analysis. RESULTS A total of 5338 potentially relevant original studies were identified, from which 21 studies, including 14 cases, 3 case series and 4 retrospective studies, met eligibility requirements and were included. Treatment regimens in the absence of TPE were found to vary based on individual information. Most patients recovered, with normal platelet counts and ADAMT13 activity at discharge. In the meta-analysis of retrospective studies, the TPE-free group had no higher mortality than the TPE-treated group. CONCLUSION Our study shows that TPE-free treatment may not increase the mortality of TTP patients, which provides a new treatment concept for patients with first episodes of TTP. However, the current evidence is not high due to the lack of randomized controlled trials, so more well-designed prospective clinical trials are warranted to investigate the safety and efficacy of TPE-free treatment regimens in TTP patients.
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17
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Frontiers in pathophysiology and management of thrombotic thrombocytopenic purpura. Int J Hematol 2023; 117:331-340. [PMID: 36757521 DOI: 10.1007/s12185-023-03552-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a fatal disease in which platelet-rich microthrombi cause end-organ ischemia and damage. TTP is caused by markedly reduced ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity. Hereditary or congenital TTP (cTTP) is caused by ADAMTS13 gene mutations. In acquired or immune TTP (iTTP), ADAMTS13 activity is reduced by anti-ADAMTS13 autoantibodies. TTP is characterized by thrombocytopenia, hemolytic anemia, fever, renal dysfunction, and neuropsychiatric symptoms. Therapeutic plasma exchange (TPE) and immunosuppressive therapy are the mainstays of treatment. As untreated TTP has a high mortality rate, immediate initiation of TPE is recommended when TTP is suspected. Conventionally, corticosteroids have been used for immunosuppressive therapy. Current drug therapies include rituximab, an anti-CD20 antibody that is effective in newly diagnosed cases and refractory cases, as well as for relapse prevention, and caplacizumab, an anti- von Willebrand factor (VWF) nanobody that inhibits the binding of platelets to VWF and prevents microthrombi formation. Recombinant human ADAMTS13 is a promising treatment for cTTP. Although these therapeutic advances have improved the outcomes of TTP, early diagnosis and prompt initiation of appropriate therapy are necessary to achieve these outcomes.
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18
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Ręka G, Stefaniak M, Lejman M. Novel Molecular Therapies and Genetic Landscape in Selected Rare Diseases with Hematologic Manifestations: A Review of the Literature. Cells 2023; 12:cells12030449. [PMID: 36766791 PMCID: PMC9913931 DOI: 10.3390/cells12030449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
Rare diseases affect less than 1 in 2000 people and are characterized by a serious, chronic, and progressive course. Among the described diseases, a mutation in a single gene caused mastocytosis, thrombotic thrombocytopenic purpura, Gaucher disease, and paroxysmal nocturnal hemoglobinuria (KIT, ADAMTS13, GBA1, and PIG-A genes, respectively). In Castleman disease, improper ETS1, PTPN6, TGFBR2, DNMT3A, and PDGFRB genes cause the appearance of symptoms. In histiocytosis, several mutation variants are described: BRAF, MAP2K1, MAP3K1, ARAF, ERBB3, NRAS, KRAS, PICK1, PIK3R2, and PIK3CA. Genes like HPLH1, PRF1, UNC13D, STX11, STXBP2, SH2D1A, BIRC4, ITK, CD27, MAGT1, LYST, AP3B1, and RAB27A are possible reasons for hemophagocytic lymphohistiocytosis. Among novel molecular medicines, tyrosine kinase inhibitors, mTOR inhibitors, BRAF inhibitors, interleukin 1 or 6 receptor antagonists, monoclonal antibodies, and JAK inhibitors are examples of drugs expanding therapeutic possibilities. An explanation of the molecular basis of rare diseases might lead to a better understanding of the pathogenesis and prognosis of the disease and may allow for the development of new molecularly targeted therapies.
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Affiliation(s)
- Gabriela Ręka
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
- Correspondence:
| | - Martyna Stefaniak
- Student Scientific Society of Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
| | - Monika Lejman
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
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19
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[Thrombotic thrombocytopenic purpura-a differential diagnostic challenge in an emergency]. Med Klin Intensivmed Notfmed 2023; 118:301-308. [PMID: 36598518 PMCID: PMC10160152 DOI: 10.1007/s00063-022-00982-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/07/2022] [Accepted: 12/01/2022] [Indexed: 01/05/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP), which comprises thrombocytopenia, elevated lactate dehydrogenase levels, and anemia in the combination of organ involvement, is a rare but life-threatening condition associated with an extremely high lethality in the acute phase if left untreated. Using the example of a 49-year-old woman admitted to the hospital with unexplained abdominal symptoms and subfebrile temperatures, recommendations for the emergency situation are presented. Increased awareness of the disease and targeted further diagnostics with determination of the PLASMIC score or ADAMTS13 activity may lead directly to diagnosis of TTP; delayed diagnosis is usually associated with secondary complications.
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20
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Chaurasiya PS, Khatri A, Gurung S, Karki S, Shahi S, Aryal L. Rituximab for acute plasma-refractory thrombotic thrombocytopenic purpura: A case report. Ann Med Surg (Lond) 2022; 82:104789. [PMID: 36268380 PMCID: PMC9577965 DOI: 10.1016/j.amsu.2022.104789] [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: 08/01/2022] [Revised: 09/20/2022] [Accepted: 09/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction and importance Thrombotic thrombocytopenic purpura (TTP) is a rare disease due to deficiency of ADAMTS13 which can present with anemia and thrombocytopenia. The study highlights the role of PLASMIC score in diagnosis and rituximab in the treatment of this condition. Case presentation Herein, we report a case of 38 years old female who had presented with fever, irritability, and altered sensorium. On investigations, she had hemolytic anemia, and thrombocytopenia with peripheral blood smear showing occasional schistocytes and managed with steroids and plasma exchange. As her platelet, LDH, and a few other lab parameters failed to normalize and met the criteria of refractory TTP, hence she was started on 5 cycles of rituximab and her condition improved. Clinical discussion Thrombotic thrombocytopenic purpura can be presumed based upon PLASMIC score where if the score is 5 or more while ADAMTS13 assay is required for confirmation. It is a life-threatening condition where treatment options include therapeutic plasma exchange (PEX), glucocorticoids, Rituximab, and caplacizumab. Rituximab is considered particularly in refractory cases. Conclusion Thrombotic thrombocytopenic purpura can lead to complications due to low platelet counts. Hence, early diagnosis and intervention are crucial to prevent such complications. Thrombotic thrombocytopenic purpura is a rare disease due to deficiency of ADAMTS13 where patients can present with anemia and thrombocytopenia. PLASMIC score can be used for presumptive diagnosis of this condition while ADAMTS13 assay is required for confirmation. Steroids and plasma exchange are the preferred treatment. In case of refractory cases, Rituximab can play a role to treat as well as prevent recurrence.
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21
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Chaturvedi S, Antun AG, Farland AM, Woods R, Metjian A, Park YA, de Ridder G, Gibson B, Kasthuri RS, Liles DK, Akwaa F, Clover T, Baumann Kreuziger L, Sadler JE, Sridharan M, Go RS, McCrae KR, Upreti HV, Liu A, Lim MY, Gangaraju R, Zheng XL, Raval JS, Masias C, Cataland SR, Johnson A, Davis E, Evans MD, Mazepa MA. Race, rituximab, and relapse in TTP. Blood 2022; 140:1335-1344. [PMID: 35797471 PMCID: PMC9710186 DOI: 10.1182/blood.2022016640] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/24/2022] [Indexed: 01/02/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is characterized by recurring episodes of thrombotic microangiopathy, causing ischemic organ impairment. Black patients are overrepresented in iTTP cohorts in the United States, but racial disparities in iTTP outcome and response to therapy have not been studied. Using the United States Thrombotic Microangiopathies Consortium iTTP Registry, we evaluated the impact of race on mortality and relapse-free survival (RFS) in confirmed iTTP in the United States from 1995 to 2020. We separately examined the impact of rituximab therapy and presentation with newly diagnosed (de novo) or relapsed iTTP on RFS by race. A total of 645 participants with 1308 iTTP episodes were available for analysis. Acute iTTP mortality did not differ by race. When all episodes of iTTP were included, Black race was associated with shorter RFS (hazard ratio [HR], 1.60; 95% CI, 1.16-2.21); the addition of rituximab to corticosteroids improved RFS in White (HR, 0.37; 95% CI, 0.18-0.73) but not Black patients (HR, 0.96; 95% CI, 0.71-1.31). In de novo iTTP, rituximab delayed relapse, but Black patients had shorter RFS than White patients, regardless of treatment. In relapsed iTTP, rituximab significantly improved RFS in White but not Black patients. Race affects overall relapse risk and response to rituximab in iTTP. Black patients may require closer monitoring, earlier retreatment, and alternative immunosuppression after rituximab treatment. How race, racism, and social determinants of health contribute to the disparity in relapse risk in iTTP deserves further study.
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Affiliation(s)
| | - Ana G. Antun
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Ryan Woods
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Ara Metjian
- Department of Medicine, University of Colorado, Denver, CO
| | - Yara A. Park
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Geisinger Medical Laboratories, Danville, PA
| | - Briana Gibson
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Raj S. Kasthuri
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Darla K. Liles
- Department of Medicine, East Carolina University, Greenville, NC
| | - Frank Akwaa
- Department of Medicine, University of Rochester, Rochester, NY
| | | | - Lisa Baumann Kreuziger
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - J. Evan Sadler
- Department of Medicine, Washington University, St Louis, MO
| | | | - Ronald S. Go
- Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Harsh Vardhan Upreti
- Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Angela Liu
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ming Y. Lim
- Department of Medicine, University of Utah, Salt Lake City, UT
| | | | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Jay S. Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM
| | | | | | | | - Elizabeth Davis
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Michael D. Evans
- Clinical & Translational Science Institute, University of Minnesota, Minneapolis, MN
| | | | - for the United States Thrombotic Microangiopathies Consortium
- Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Medicine, Emory University, Atlanta, GA
- Department of Medicine, Wake Forest University, Winston-Salem, NC
- Department of Medicine, University of Colorado, Denver, CO
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Geisinger Medical Laboratories, Danville, PA
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, East Carolina University, Greenville, NC
- Department of Medicine, University of Rochester, Rochester, NY
- St Charles Healthcare, Bend, OR
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Washington University, St Louis, MO
- Department of Medicine, Mayo Clinic, Rochester, MN
- Department of Medicine, Cleveland Clinic, Cleveland, OH
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Department of Medicine, University of Utah, Salt Lake City, UT
- Department of Medicine, University of Alabama at Birmingham
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
- Department of Pathology, University of New Mexico, Albuquerque, NM
- Baptist Health South Florida, Miami, FL
- Department of Medicine, The Ohio State University, Columbus, OH
- Department of Laboratory Medicine and Pathology
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Clinical & Translational Science Institute, University of Minnesota, Minneapolis, MN
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How I treat immune-mediated thrombotic thrombocytopenic purpura after hospital discharge. Blood 2022; 140:438-444. [PMID: 35667044 DOI: 10.1182/blood.2021014514] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/14/2022] [Indexed: 11/20/2022] Open
Abstract
Immune-mediated thrombocytopenic purpura (iTTP) is a thrombotic microangiopathy characterized by an acquired ADAMTS13 deficiency as a result of the presence of an antibody inhibitor of ADAMTS13 leading to the formation of ultralarge von Willebrand multimers. Treatment of iTTP includes plasma exchange, high-dose glucocorticoids, rituximab, and, more recently, caplacizumab, to prevent the development of exacerbations. There is the risk of both relapse and long-term complications that include neurocognitive deficits and cardiovascular events that occur in patients in remission after recovery from an acute iTTP episode. Data on the risk factors for the development of these complications, the appropriate screening, and treatment are limited due to the paucity of research. This article is a review of the current understanding on the risk factors for exacerbation, relapse, and long-term complications of iTTP and discusses an approach to observing patients with iTTP after hospital discharge and during the long-term follow-up in the outpatient setting.
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23
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COVID-19-Associated Thrombotic Thrombocytopenic Purpura: A Case Report and Systematic Review. Hematol Rep 2022; 14:253-260. [PMID: 35997402 PMCID: PMC9397065 DOI: 10.3390/hematolrep14030035] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction: The proliferation of literature regarding the COVID-19 pandemic has served to highlight a wide spectrum of disease manifestations and complications, such as thrombotic microangiopathies. Our review with a brief case presentation highlights the increasing recognition of TTP in COVID-19 and describes its salient characteristics. Methods: We screened the available literature in PubMed, EMBASE, and Cochrane databases from inception until April 2022 of articles mentioning COVID-19-associated TTP in English language. Results: From 404 records, we included 8 articles mentioning data of 11 patients in our review. TTP was predominantly reported in females (72%) with a mean age of 48.2 years (SD 15.1). Dyspnea was the most common symptom in one third of patients (36.6%). Neurological symptoms were reported in 27.3% of cases. The time to diagnosis of TTP was 10 days (SD 5.8) from onset of COVID-19. All 11 cases underwent plasma exchange (PLEX), with a mean of 12 sessions per patient, whereas 6 cases received Rituximab (54.5%), and 3 received Caplacizumab (27.3%). One patient died from the illness. Conclusion: This review of available literature highlights the atypical and refractory nature of COVID-19-associated TTP. It required longer sessions of PLEX, with half of the patients receiving at least one immunosuppressant.
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24
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Mingot Castellano ME, Pascual Izquierdo C, González A, Viejo Llorente A, Valcarcel Ferreiras D, Sebastián E, García Candel F, Sarmiento Palao H, Gómez Seguí I, de la Rubia J, Cid J, Martínez Nieto J, Hernández Mateo L, Goterris Viciedo R, Fidalgo T, Salinas R, Del Rio-Garma J. Recommendations for the diagnosis and treatment of patients with thrombotic thrombocytopenic purpura. Med Clin (Barc) 2022; 158:630.e1-630.e14. [PMID: 34266669 DOI: 10.1016/j.medcli.2021.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/09/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by the development of microangiopathic haemolytic anaemia, thrombocytopenia, and ischaemic organ dysfunction associated with ADAMTS13 levels lower than 10% in most cases. Recently there have been numerous advances in the field of PTT, new, rapid and accessible techniques capable of quantifying ADAMTS13 activity and inhibitors. The massive sequencing systems facilitate the identification of polymorphisms in the ADAMTS13 gene. In addition, new drugs such as caplacizumab have appeared and relapse prevention strategies are being proposed with the use of rituximab. The existence of TTP patient registries allow a deeper understanding of this disease but the great variability in the diagnosis and treatment makes it necessary to elaborate guidelines that homogenize terminology and clinical practice. The recommendations set out in this document were prepared following the AGREE methodology. The research questions were formulated according to the PICO format. A search of the literature published during the last 10 years was carried out. The recommendations were established by consensus among the entire group, specifying the existing strengths and limitations according to the level of evidence obtained. In conclusion, this document contains recommendations on the management, diagnosis, and treatment of TTP with the ultimate objective of developing guidelines based on the evidence published to date that allow healthcare professionals to optimize TTP treatment.
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Affiliation(s)
| | | | - Ataulfo González
- Servicio de Hematología y Hemoterapia, Hospital Universitario de San Carlos, Madrid, España
| | - Aurora Viejo Llorente
- Servicio de Hematología, Área de Hemoterapia, Hospital Universitario La Paz, Madrid, España
| | - David Valcarcel Ferreiras
- Unidad de Hematología Intensiva y Terapia Celular, Departamento de Hematología, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Faustino García Candel
- Sección de Hemostasia y Trombosis, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Inés Gómez Seguí
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Joan Cid
- Unidad de Aféresis y Terapia Celular, Servicio de Hemoterapia y Hemostasia, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Martínez Nieto
- Servicio de Hematología y Hemostasia, Hospital Universitario Clínico San Carlos. Instituto de Investigación Sanitaria San Carlos (IdissC), Madrid, España
| | - Luis Hernández Mateo
- Servicio de Hematología y Hemoterapia, Hospital General de Alicante, Valencia, España
| | - Rosa Goterris Viciedo
- Servicio de Hematología y Hemoterapia, Hospital Clínico Valencia. INCLIVA, Valencia, España
| | - Teresa Fidalgo
- Departamento de Hematología Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ramon Salinas
- Banc de Sang i Teixits de Catalunya, Barcelona, España
| | - Julio Del Rio-Garma
- Servicio de Transfusión. Servicio de Hematología. Complexo Hospitalario Universitario de Ourense, Galicia, España.
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25
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Alterations in B- and circulating T-follicular helper cell subsets in immune thrombotic thrombocytopenic purpura. Blood Adv 2022; 6:3792-3802. [PMID: 35507753 PMCID: PMC9631570 DOI: 10.1182/bloodadvances.2022007025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/19/2022] [Indexed: 11/20/2022] Open
Abstract
Abnormal B-cell phenotype in acute iTTP with decreased transitional and post–germinal center memory cells and increased plasmablasts. Decreased total and PD1+ circulating T-follicular helper cells and changes in B-cell CD80 expression suggest altered B- and T-cell interactions.
T follicular helper (Tfh) cells regulate development of antigen-specific B-cell immunity. We prospectively investigated B-cell and circulating Tfh (cTfh) cell subsets in 45 patients with immune thrombotic thrombocytopenic purpura (iTTP) at presentation and longitudinally after rituximab (RTX). B-cell phenotype was altered at acute iTTP presentation with decreased transitional cells and post–germinal center (post-GC) memory B cells and increased plasmablasts compared with healthy controls. A higher percentage of plasmablasts was associated with higher anti-ADAMTS13 IgG and lower ADAMTS13 antigen levels. In asymptomatic patients with ADAMTS13 relapse, there were increased naïve B cells and a global decrease in memory subsets, with a trend to increased plasmablasts. Total circulating Tfh (CD4+CXCR5+) and PD1+ Tfh cells were decreased at iTTP presentation. CD80 expression was decreased on IgD+ memory cells and double-negative memory cells in acute iTTP. At repopulation after B-cell depletion in de novo iTTP, post-GC and double-negative memory B cells were reduced compared with pre-RTX. RTX did not cause alteration in cTfh cell frequency. The subsequent kinetics of naïve, transitional, memory B cells and plasmablasts did not differ significantly between patients who went on to relapse vs those who remained in remission. In summary, acute iTTP is characterized by dysregulation of B- and cTfh cell homeostasis with depletion of post-GC memory cells and cTfh cells and increased plasmablasts. Changes in CD80 expression on B cells further suggest altered interactions with T cells.
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26
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Bae SH, Kim SH, Bang SM. Recent advances in the management of immune-mediated thrombotic thrombocytopenic purpura. Blood Res 2022; 57:37-43. [PMID: 35483924 PMCID: PMC9057674 DOI: 10.5045/br.2022.2022005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially life-threatening thrombotic microangiopathy caused by autoantibody-mediated severe ADAMTS13 deficiency. TTP should be suspected in patients with microangiopathic hemolytic anemia and thrombocytopenia without a definite cause. Early detection of iTTP and prompt treatment with plasma exchange and corticosteroids are essential. Rituximab administration should be considered for refractory or relapsed iTTP, and can be used as a first-line adjuvant or preemptive therapy. Treatment with caplacizumab, a novel anti-von Willebrand factor nanobody, resulted in a faster time to platelet count response, significant reduction in iTTP-related deaths, and reduced incidence of refractory iTTP. TTP survivors showed a higher rate of chronic morbidities, including cardiovascular disease and neurocognitive impairment, which can lead to a poor quality of life and higher mortality rate. Meticulous long-term follow-up of TTP survivors is crucial.
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Affiliation(s)
- Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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27
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Graça NAG, Joly BS, Voorberg J, Vanhoorelbeke K, Béranger N, Veyradier A, Coppo P. TTP: From empiricism for an enigmatic disease to targeted molecular therapies. Br J Haematol 2022; 197:156-170. [PMID: 35146746 PMCID: PMC9304236 DOI: 10.1111/bjh.18040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022]
Abstract
The 100th anniversary of the first description of Thrombotic Thrombocytopenic Purpura (TTP) as a disease by Dr. Eli Moschcowitz approaches. For many decades, TTP remained mostly a mysterious fatal condition, where diagnosis was often post-mortem. Initially a pentad of symptoms was identified, a pattern that later revealed to be fallible. Sporadic observations led to empiric interventions that allowed for the first impactful breakthrough in TTP treatment, almost 70 years after its first description: the introduction of plasma exchange and infusions as treatments. The main body of knowledge within the field was gathered in the latest three decades: patient registries were set and proved crucial for advancements; the general mechanisms of disease have been described; the diagnosis was refined; new treatments and biomarkers with improvements on prognosis and management were introduced. Further changes and improvements are expected in the upcoming decades. In this review, we provide a brief historic overview of TTP, as an illustrative example of the success of translational medicine enabling to rapidly shift from a management largely based on empiricism to targeted therapies and personalized medicine, for the benefit of patients. Current management options and present and future perspectives in this still evolving field are summarized.
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Affiliation(s)
- Nuno A. G. Graça
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
| | - Bérangère S. Joly
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Nicolas Béranger
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Agnès Veyradier
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
- Service d'HématologieHôpital Saint‐Antoine, AP‐HPParisFrance
- Sorbonne UniversitéUPMC Univ ParisParisFrance
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28
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Zhou M, Yin J. Complete recovery of deep venous thrombosis from Coombs (+) thrombotic thrombocytopenic purpura: case report. J Cardiothorac Surg 2022; 17:43. [PMID: 35313908 PMCID: PMC8935836 DOI: 10.1186/s13019-022-01789-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 03/13/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute thrombotic thrombocytopenic purpura (TTP) is an aggressive thrombotic microangiopathy that if not treated, can have a 90% mortality rate. Timely, extensive plasma exchange (PEX) has been indicated to reduce the mortality rate to < 10%, but its side effects are not well-known. We present here a case of a patient presented with Comb (+) TTP and developed catheter-associated deep vein thrombosis (DVT). Case presentation A 27-year-young man presented with persistent thrombocytopenia and Coombs positive anemia was firstly diagnosed with Evans syndrome. However, he was refractory to a methylprednisolone pulse therapy with a combination of platelet transfusion and eventually developed microangiopathy of central nerve system. Several pathological manifestations of the disease were prevented by PEX. The immediate start of PEX (1500 mL/d) induced a complete remission of acquired TTP and disappearance of neurological signs and symptoms. However, external iliac and femoro-popliteal venous thrombosis was diagnosed subsequently, inferior vena cava filter (IVC) filter was immediately implanted accompanied with anticoagulation therapy. Meanwhile, PEX session was sustained as well as oral anticoagulant (rivaroxaban). 14 days later, the patient got full recovery. Conclusions Catheter-related DVT under the setting of TTP should be cautious. It is necessary to start anticoagulation and antiplatelet therapy for thrombosis early, especially in such cases when PLT count > 50 × 109/L.
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Affiliation(s)
- Mi Zhou
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Yin
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated With Shandong First Medical University, Jinan, Shandong, China. .,Department of Cardiology, Shandong Province Qianfushan Hospital, Shandong University, Jinan, 250014, China.
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29
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Successful preventive treatment with cyclosporine in a patient with relapsed/refractory immune-mediated thrombotic thrombocytopenic purpura: a case report and review of the literature. Int J Hematol 2022; 116:295-301. [PMID: 35274194 DOI: 10.1007/s12185-022-03319-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
Although salvage therapy with rituximab is effective in some cases of immune-mediated thrombotic thrombocytopenic purpura (iTTP) refractory to standard plasma exchange (PEX) and glucocorticoid treatment or relapsed after treatment, protocols to address the subsequent high recurrence rate have not been established. We describe the use of cyclosporine (CSA) to prevent recurrence in a patient with iTTP relapse after rituximab therapy, and present a literature review. A 24-year-old woman was diagnosed with iTTP and initially received PEX and high-dose methylprednisolone therapy. However, weekly rituximab therapy was also needed for inhibitor boosting to achieve additional immunosuppression during the initial treatment. Although the patient achieved clinical remission after weekly rituximab therapy, iTTP relapsed twice when glucocorticoids were tapered, and was treated with a triplet regimen consisting of PEX, high-dose methylprednisolone, and weekly rituximab. CSA was administered along with glucocorticoids as prophylaxis against iTTP relapse. The additional CSA therapy successfully maintained iTTP remission and allowed reduction of the corticosteroid dose. Our findings demonstrate that prophylactic CSA can potentially prevent iTTP recurrence in patients with a history of multiple relapses. Data from more cases must be accumulated to establish a useful prophylactic therapy for iTTP that is refractory even to rituximab.
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Severe Thrombotic Thrombocytopenic Purpura (TTP) with Organ Failure in Critically Ill Patients. J Clin Med 2022; 11:jcm11041103. [PMID: 35207375 PMCID: PMC8874413 DOI: 10.3390/jcm11041103] [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: 01/07/2022] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 01/27/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multiorgan disorder. Organ dysfunction occurs as a consequence of widespread microvascular thrombosis, especially in the heart, brain and kidney, causing transient or partial occlusion of vessels, resulting in organ ischemia. Intensive care unit (ICU) admission varies between 40% and 100% of patients with TTP, either because of severe organ failure or in order to initiate emergency plasma exchange (PEx). Severe neurologic manifestations and cardiac involvement have been associated with higher mortality. Acute kidney injury, although usually less severe than that in hemolytic and uremic syndrome, is common during TTP. Initial management in the ICU should always be considered in TTP patients. The current treatment of TTP in the acute phase is based on urgent PEx, combined with corticosteroid therapy, B-cell-targeted immunotherapy, rituximab and inhibition of the interaction between ultra-large Von Willebrand factor multimers and platelets, using caplacizumab, a monoclonal antibody. ICU management permits close monitoring and the rapid introduction of life-sustaining therapies. This review details the epidemiology of TTP in the ICU, organ failures of critically ill patients with TTP, and the initial management of TTP patients in the ICU.
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31
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Jung JY, Kim JW, Suh CH, Kim HA. Successful treatment of thrombotic thrombocytopenic purpura with plasmapheresis and anti-CD20 antibodies in a patient with immune thrombocytopenia and systemic lupus erythematosus: Case report. Medicine (Baltimore) 2022; 101:e28908. [PMID: 35363211 PMCID: PMC9282078 DOI: 10.1097/md.0000000000028908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology with diverse clinical and laboratory manifestations, including thrombocytopenia. About 25% of patients with SLE may be affected by thrombocytopenia, many of whom are asymptomatic. Some patients, however, experience platelet counts that drop quite low and predispose them to bleeding. Thrombotic thrombocytopenic purpura (TTP) is defined with a classic pentad of clinical features, such as thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms and signs, renal symptoms and signs, and fever. The association of TTP and SLE has been sporadically reported in the literature. PATIENT CONCERNS AND DIAGNOSIS We describe a 16-year-old girl with SLE and immune thrombocytopenia, in whom TTP was diagnosed. INTERVENTIONS AND OUTCOMES She was treated with pulse methylprednisolone, whose platelet counts normalized after therapy with plasmapheresis and an anti-CD20 monoclonal antibody (rituximab). CONCLUSION A pediatric patient with SLE and immune thrombocytopenia in whom TTP developed was treated with plasmapheresis and rituximab therapy successfully, though the patient experienced a disease relapsed after 18 months, which was controlled by the same management.
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MESH Headings
- Adolescent
- Anemia, Hemolytic/complications
- Child
- Female
- Humans
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/therapy
- Plasmapheresis
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombotic Thrombocytopenic/complications
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/therapy
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Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Ji-Won Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
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Nguyen T, Radhakrishnan SM, Radhakrishnan SJ, Johnson DH. Near-complete vision recovery from bilateral serous retinal detachment associated with thrombotic thrombocytopenic purpura. BMJ Case Rep 2022; 15:15/2/e244030. [PMID: 35131768 PMCID: PMC8823028 DOI: 10.1136/bcr-2021-244030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Ocular manifestations of thrombotic thrombocytopenic purpura (TTP) are uncommon, and bilateral retinal detachment is a rare presentation of TTP. We report a rare case of bilateral retinal detachment from underlying TTP in a patient presenting with vision loss. A 56-year-old man presented with a 4-day history of bilateral vision loss. Bilateral serous retinal detachment was confirmed using dilated ophthalmoscope examination. Laboratory results were significant for severe thrombocytopenia, peripheral smear revealed numerous schistocytes and ADAMTS13 activity of less than 1%. The patient was treated with plasma exchange (PLEX), prednisone, rituximab and caplacizumab. This case report highlights that prompt treatment of TTP with PLEX, prednisone, rituximab and caplacizumab could result in significant vision recovery.
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Affiliation(s)
- Tran Nguyen
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | | | | | - David H Johnson
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
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33
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Subhan M, Scully M. Advances in the management of TTP. Blood Rev 2022; 55:100945. [DOI: 10.1016/j.blre.2022.100945] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
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Urine Protein/Creatinine Ratio in Thrombotic Microangiopathies: A Simple Test to Facilitate Thrombotic Thrombocytopenic Purpura and Hemolytic and Uremic Syndrome Diagnosis. J Clin Med 2022; 11:jcm11030648. [PMID: 35160098 PMCID: PMC8836555 DOI: 10.3390/jcm11030648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Early diagnosis of thrombotic thrombocytopenic purpura (TTP) versus hemolytic and uremic syndrome (HUS) is critical for the prompt initiation of specific therapies. Objective: To evaluate the diagnostic performance of the proteinuria/creatininuria ratio (PU/CU) for TTP versus HUS. Patients/Methods: In a retrospective study, in association with the “French Score” (FS) (platelets < 30 G/L and serum creatinine level < 200 µmol/L), we assessed PU/CU for the diagnosis of TTP in patients above the age of 15 with thrombotic microangiopathy (TMA). Patients with a history of kidney disease or with on-going cancer, allograft or pregnancy were excluded from the analysis. Results: Between February 2011 and April 2019, we identified 124 TMA. Fifty-six TMA patients for whom PU/CU were available, including 35 TTP and 21 HUS cases, were considered. Using receiver–operating characteristic curves (ROC), those with a threshold of 1.5 g/g for the PU/CU had a 77% sensitivity (95% CI (63, 94)) and a 90% specificity (95% CI (71, 100)) for TTP diagnosis compared with those having an 80% sensitivity (95% CI (66, 92)) and a 90% specificity (95% CI (76, 100) with a FS of 2. In comparison, a composite score, defined as a FS of 2 or a PU/CU ≤ 1.5 g/g, improved sensitivity to 99.6% (95% CI (93, 100)) for TTP diagnosis and enabled us to reclassify seven false-negative TTP patients. Conclusions: The addition of urinary PU/CU upon admission of patients with TMA is a fast and readily available test that can aid in the differential diagnosis of TTP versus HUS alongside traditional scoring.
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35
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Hematologic Disorders and Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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36
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Westwood JP, Scully M. Management of acquired, immune thrombocytopenic purpura (iTTP): beyond the acute phase. Ther Adv Hematol 2022; 13:20406207221112217. [PMID: 35923772 PMCID: PMC9340390 DOI: 10.1177/20406207221112217] [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: 03/26/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Modern therapy for acute TTP has resulted in a dramatic improvement in
outcomes, with the combination of plasma exchange, immunosuppression,
and caplacizumab being associated with >90% survival rates
following an acute episode. TTP is no longer associated with just the
acute episode, but requires long-term follow-up. There remains
significant morbidity associated with acute TTP, and many patients
suffer marked neuropsychological sequelae, including impairment in
cognitive functioning, affective disorders, and reduction in
health-related quality of life measures. The focus of management
beyond the acute phase centres on relapse prevention,
via careful monitoring of patients and the use
of either ad hoc or regular immunosuppressive therapies. The main
therapy used is rituximab, but despite more limited evidence, other
immunosuppressive therapies may be required to aim for normalisation
of ADAMTS 13 activity. Follow-up with a reduction in ADAMTS 13
activity levels (ADAMTS 13 relapse), rituximab is central to
normalisation of activity levels and prevention of a clinical relapse.
Fundamental to elective therapy is the role of ADAMTS 13 activity
monitoring, and impact of reduced ADAMTS13 activity on end organ
damage. This review discusses monitoring and treatment strategy for
long-term management of TTP, including the variety of therapies
available to maintain remission, prevent relapse and a summary of a
long-term treatment pathway.
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Affiliation(s)
| | - Marie Scully
- Department of Haematology, UCLH, London, UK
- National Institute for Health Research Cardiometabolic Programme, UCLH/UCL Cardiovascular BRC, 250 Euston Road, NW1 2PG London, UK
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Updates on thrombotic thrombocytopenic purpura: Recent developments in pathogenesis, treatment and survivorship. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fage N, Orvain C, Henry N, Mellaza C, Beloncle F, Tuffigo M, Geneviève F, Coppo P, Augusto JF, Brilland B. Proteinuria Increases the PLASMIC and French Scores Performance to Predict Thrombotic Thrombocytopenic Purpura in Patients With Thrombotic Microangiopathy Syndrome. Kidney Int Rep 2021; 7:221-231. [PMID: 35155861 PMCID: PMC8820983 DOI: 10.1016/j.ekir.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/31/2021] [Accepted: 11/08/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction PLASMIC and French scores have been developed to help clinicians in the early identification of patients with thrombotic thrombocytopenic purpura (TTP). Nevertheless, the validity of these scores in thrombotic microangiopathy (TMA) cohorts with low TTP prevalence remains uncertain. We aimed to evaluate their diagnostic value in routine clinical practice using an unselected cohort of patients with TMA. We also analyzed the value of adding proteinuria level to the scores. Methods We retrospectively included all patients presenting with a biological TMA syndrome between January 1, 2008, and December 31, 2019, in a tertiary hospital. TMA etiology was ascertained, and scores were evaluated. Modified scores, built by adding 1 point for low proteinuria (<1.2 g/g), were compared with original scores for TTP prediction. Results Among 273 patients presenting with a full biological TMA syndrome, 238 were classified with a TMA diagnosis. Complete scores and proteinuria level were available in 134 patients with a TTP prevalence of 7.5%. Area under the receiver operating characteristic curve (AUC) of PLASMIC and French scores for TTP diagnosis was 0.65 (0.46–0.84) and 0.72 (0.51–0.93), respectively. AUC of modified PLASMIC and French scores was 0.76 (0.59–0.92) (P = 0.003 vs. standard score) and 0.81 (0.67–0.95) (P = 0.069 vs. standard score), respectively. Specificity, positive predictive value (PPV), and positive likelihood ratio of high-risk scores were significantly improved by adding proteinuria level. Conclusion PLASMIC and French scores have low predictive values when applied to an unselected TMA cohort. Including proteinuria level in the original scores improves their performance for TTP prediction.
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 733] [Impact Index Per Article: 244.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Long B, Bridwell RE, Manchanda S, Gottlieb M. Evaluation and Management of Thrombotic Thrombocytopenic Purpura in the Emergency Department. J Emerg Med 2021; 61:674-682. [PMID: 34518045 DOI: 10.1016/j.jemermed.2021.07.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a dangerous condition that can be misdiagnosed in the emergency department. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of TTP, with a focus on emergency clinicians. DISCUSSION TTP is a disorder with microangiopathic hemolytic anemia, severe thrombocytopenia, and multiorgan ischemic injury. It may be acquired or hereditary, and is caused by a reduced amount or function of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), which is an enzyme involved in cleaving von Willebrand factor. The classic presentation of TTP includes fever, neurologic abnormalities, thrombocytopenia with purpura, microangiopathic hemolytic anemia, and acute renal injury. However, < 7% of cases have all of these findings present. Testing should include a complete blood count, complete metabolic panel, blood smear, coagulation panel, fibrinogen, D-dimer, lactate dehydrogenase, ADAMTS13 level, troponin, human immunodeficiency virus assessment, urinalysis, pregnancy test as appropriate, and electrocardiogram. Management includes hematology consultation if available, plasma exchange and corticosteroids, and treatment of end-organ complications. All patients require admission for treatment and close monitoring. CONCLUSION TTP is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Rachel E Bridwell
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Shivon Manchanda
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Van de Louw A, Mariotte E, Darmon M, Cohrs A, Leslie D, Azoulay E. Outcomes in 1096 patients with severe thrombotic thrombocytopenic purpura before the Caplacizumab era. PLoS One 2021; 16:e0256024. [PMID: 34383822 PMCID: PMC8360509 DOI: 10.1371/journal.pone.0256024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/28/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a diagnostic and therapeutic emergency. Therapeutic plasma exchange (TPE) combined with immunosuppression has been the cornerstone of the initial management. To produce optimal benefits, emerging treatments must be used against a background of best standard of care. Clarifying current uncertainties is therefore crucial. METHODS The objective of this study was to analyze a large high-quality database (Marketscan) of TTP patients managed between 2005 and 2014, in the pre-caplacizumab era, in order to assess the impact of time to first TPE and use of first-line rituximab on mortality, and whether mortality declines over time. RESULTS Among the 1096 included patients (median age 46 [IQR 35-55], 70% female), 28.8% received TPE before day 2 in the ICU. Hospital mortality was 7.6% (83 deaths). Mortality was independently associated with older age (hazard ratio [HR], 1.024/year; 95% confidence interval [95%CI], [1.009-1.040]), diagnosis of sepsis (HR, 2.360; 95%CI [1.552-3.588]), and the need for mechanical ventilation (HR, 4.103; 95%CI, [2.749-6.126]). Factors independently associated with lower mortality were TPE at ICU admission (HR, 0.284; 95%CI, [0.112-0.717]), TPE within one day after ICU admission (HR, 0.449; 95%CI, [0.275-0.907]), and early rituximab therapy (HR, 0.229; 95% CI, [0.111-0.471]). Delayed TPE was associated with significantly higher costs. CONCLUSIONS Immediate TPE and early rituximab are associated with improved survival in TTP patients. Improved treatments have led to a decline in mortality over time, and alternate outcome variables such as the use of hospital resources or longer term outcomes therefore need to be considered.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, United States of America
| | - Eric Mariotte
- Intensive Care Department, University of Paris, Saint-Louis Hospital, Paris, France
| | - Michael Darmon
- Intensive Care Department, University of Paris, Saint-Louis Hospital, Paris, France
| | - Austin Cohrs
- Department of Public Health Sciences, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, United States of America
| | - Douglas Leslie
- Department of Public Health Sciences, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, United States of America
| | - Elie Azoulay
- Intensive Care Department, University of Paris, Saint-Louis Hospital, Paris, France
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Markmann C, Bhoj VG. On the road to eliminating long-lived plasma cells-"are we there yet?". Immunol Rev 2021; 303:154-167. [PMID: 34351644 DOI: 10.1111/imr.13015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 01/19/2023]
Abstract
Central to protective humoral immunity is the activation of B cells and their terminal differentiation into antibody-secreting plasma cells. Long-lived plasma cells (LLPC) may survive for years to decades. Such long-lived plasma cells are also responsible for producing pathogenic antibodies that cause a variety of challenges such as autoimmunity, allograft rejection, and drug neutralization. Up to now, various therapeutic strategies aimed at durably eliminating pathogenic antibodies have failed, in large part due to their inability to efficiently target LLPCs. Several antibody-based therapies have recently gained regulatory approval or are in clinical phases of development for the treatment of multiple myeloma, a malignancy of plasma cells. We discuss the exciting potential of using these emerging cancer immunotherapies to solve the antibody problem.
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Affiliation(s)
- Caroline Markmann
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Vijay G Bhoj
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Gómez-Seguí I, Pascual Izquierdo C, de la Rubia Comos J. Best practices and recommendations for drug regimens and plasma exchange for immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:707-719. [PMID: 34275393 DOI: 10.1080/17474086.2021.1956898] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. TTP pathophysiology is based on a severe ADAMTS13 deficiency, and is a medical emergency with fatal outcome if appropriate treatment is not initiated promptly. AREAS COVERED Authors will review the best options currently available to minimize mortality, prevent relapses, and obtain the best clinical response in patients with immune TTP (iTTP). Available bibliography about iTTP treatment has been searched in Library's MEDLINE/PubMed database from January 1990 until April 2021. EXPERT OPINION The generalized use of plasma exchange marked a paradigm in the management of iTTP. In recent years, strenuous efforts have been done for a better understanding of the pathophysiology of this disease, improve diagnosis, optimize treatment, reduce mortality, and prevent recurrences. The administration of front-line rituximab and, more recently, the availability of caplacizumab, the first targeted therapy for iTTP, have been steps toward a further reduction in early mortality and for the prevention of relapses.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio De Hematología Y Hemoterapia, Hospital General , Universitario Gregorio Marañón. Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier de la Rubia Comos
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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Logothetis CN, Patel A, Eatrides J, Jaglal M, Haider M, Visweshwar N, Laber DA. Post Approval Experience with Caplacizumab for Acquired Thrombotic Thrombocytopenic Purpura at a Single Institution. J Clin Med 2021; 10:jcm10153418. [PMID: 34362201 PMCID: PMC8347784 DOI: 10.3390/jcm10153418] [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: 05/15/2021] [Revised: 07/23/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022] Open
Abstract
Caplacizumab prevents platelet adhesion and has been approved for acquired thrombotic thrombocytopenic purpura (aTTP). This study was retrospective, including all patients diagnosed with aTTP and treated with caplacizumab since commercial availability in 2019 until 28 February 2021 at a single academic hospital with no exclusion criteria. Results used definitions for outcomes in aTTP from the International Working Group Consensus. Ten patients with aTTP received caplacizumab. The median age was 52 years. Six (60%) patients had refractory aTTP while 4 (40%) had newly diagnosed aTTP. The median laboratory values prior to therapy demonstrated: platelet count (PC) 29/uL, LDH 518 U/L (182-1850), ADAMTS13 activity 3% and ADAMTS13 inhibitor 1.4 BU. Everyone received glucocorticoids, rituximab, therapeutic plasma exchange (TPE) and caplacizumab. The median number of TPE was 12 days. Caplacizumab was started at a median of 5 days after the first TPE and the median treatment duration was 31 days. Normalization of PC, LDH and ADAMTS13 activity in days were 5, 3.5, and 32.5, respectively. Six (60%) patients achieved complete response, 3 (30%) had refractory disease and 1 (10%) had relapsed aTTP. No subject suffered abnormal bleeding, or thrombotic event. There were no deaths. Caplacizumab with TPE, glucocorticoids and rituximab was a safe and effective therapy for aTTP.
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Affiliation(s)
- Constantine N. Logothetis
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
- Correspondence: ; Tel.: +1-813-259-0670
| | - Ankita Patel
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
- Section of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Jennifer Eatrides
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
- Section of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Michael Jaglal
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
- Section of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Mintallah Haider
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
- Section of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Nathan Visweshwar
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
| | - Damian A. Laber
- Division of Hematology/Oncology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; (A.P.); (J.E.); (M.J.); (M.H.); (N.V.); (D.A.L.)
- Section of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
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Strong association between insufficient plasma exchange and fatal outcomes in Japanese patients with immune-mediated thrombotic thrombocytopenic purpura. Int J Hematol 2021; 114:415-423. [PMID: 34292506 DOI: 10.1007/s12185-021-03197-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Plasma exchange (PEX) using fresh frozen plasma has considerably reduced the mortality rate in patients with immune-mediated thrombotic thrombocytopenic purpura (iTTP). However, some patients still do not survive even with treatment, but little information is available regarding which treatment these patients received. This study was conducted to obtain this information in 240 patients who met the current iTTP diagnostic criteria and completed at least 30 days of follow-up except for deceased cases. These patients were divided into three groups: survivors (n = 195), TTP-related deaths (n = 32), and other cause of death (n = 13). In the TTP-related death group, 26 of 32 patients experienced sudden death, mostly following radical hypotension and bradycardia. The median follow-up time after admission was 5.0 days, and the median number of PEX sessions was 2.5. Nine patients underwent autopsy and had cardiac microvascular thrombi in arterioles. Levels of lactate dehydrogenase, total bilirubin, serum creatinine, and D-dimer were significantly higher in the TTP-related death group than in the survivors group. Frequent PEX (> 20 sessions) was not associated with TTP-related death. In the acute phase of iTTP, patients with substantial organ damage caused by microthrombi have a greater mortality risk, even after just a few PEX sessions.
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A regimen with caplacizumab, immunosuppression, and plasma exchange prevents unfavorable outcomes in immune-mediated TTP. Blood 2021; 137:733-742. [PMID: 33150928 DOI: 10.1182/blood.2020008021] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022] Open
Abstract
The anti-von Willebrand factor nanobody caplacizumab was licensed for adults with immune-mediated thrombotic thrombocytopenic purpura (iTTP) based on prospective controlled trials. However, few data are available on postmarketing surveillance. We treated 90 iTTP patients with a compassionate frontline triplet regimen associating therapeutic plasma exchange (TPE), immunosuppression with corticosteroids and rituximab, and caplacizumab. Outcomes were compared with 180 historical patients treated with the standard frontline treatment (TPE and corticosteroids, with rituximab as salvage therapy). The primary outcome was a composite of refractoriness and death within 30 days since diagnosis. Key secondary outcomes were exacerbations, time to platelet count recovery, the number of TPE, and the volume of plasma required to achieve durable remission. The percentage of patients in the triplet regimen with the composite primary outcome was 2.2% vs 12.2% in historical patients (P = .01). One elderly patient in the triplet regimen died of pulmonary embolism. Patients from this cohort experienced less exacerbations (3.4% vs 44%, P < .01); they recovered durable platelet count 1.8 times faster than historical patients (95% confidence interval, 1.41-2.36; P < .01), with fewer TPE sessions and lower plasma volumes (P < .01 both). The number of days in hospital was 41% lower in the triplet regimen than in the historical cohort (13 vs 22 days; P < .01). Caplacizumab-related adverse events occurred in 46 patients (51%), including 13 major or clinically relevant nonmajor hemorrhagic events. Associating caplacizumab to TPE and immunosuppression, by addressing the 3 processes of iTTP pathophysiology, prevents unfavorable outcomes and alleviates the burden of care.
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Alshamam MS, Sumbly V, Khan S, Nso N, Rizzo V. Acquired Thrombotic Thrombocytopenic Purpura in a Newly Diagnosed HIV Patient: A Case Report and Literature Review. Cureus 2021; 13:e15967. [PMID: 34336459 PMCID: PMC8315786 DOI: 10.7759/cureus.15967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2021] [Indexed: 11/10/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but a potentially fatal condition. Although the majority of TTP cases are of unknown etiology, certain viral infections, malignancies, and medications have been linked to the acquired form of the illness. Regardless of the underlying etiology, TTP remains a great challenge diagnostically and therapeutically. TTP remains a very uncommon complication of HIV. We reviewed the current literature to better understand the relationship between HIV and TTP and address some of the major obstacles that may impede or delay the correct diagnosis. Here, we present a case of a 28-year-old male with complaints of light-headedness, fatigue, and gingival bleeding. He was found to have severe anemia and thrombocytopenia. He tested positive for the HIV and was then diagnosed with TTP. Despite needing endotracheal intubation for airway protection, he clinically improved with packed red blood cells, plasmapheresis, and highly active antiretroviral therapy.
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Affiliation(s)
- Mohsen S Alshamam
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, NYC, USA
| | - Vikram Sumbly
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, NYC, USA
| | - Saifullah Khan
- General Medicine, Saint James School of Medicine, St. Vincent, VCT
| | - Nso Nso
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, NYC, USA
| | - Vincent Rizzo
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, NYC, USA
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Lemiale V, Valade S, Mariotte E. Unresponsive Thrombotic Thrombocytopenic Purpura (TTP): Challenges and Solutions. Ther Clin Risk Manag 2021; 17:577-587. [PMID: 34113115 PMCID: PMC8185636 DOI: 10.2147/tcrm.s205632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/14/2021] [Indexed: 01/20/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy secondary to a severely decreased A Disintegrin And Metalloprotease with ThromboSpondin type 1 repeats 13 (ADAMTS13) activity, resulting in the formation of widespread von Willebrand factor - and platelet-rich microthrombi. ADAMTS13 deficiency is mainly acquired through anti-ADAMTS13 autoantibodies in adults. With modern standards of care, unresponsive TTP has become rarer with a frequency of refractory/relapsing forms dropping from >40% to <10%. As patients with unresponsive TTP are at increased risk of mortality, prompt recognition and early therapeutic intensification are mandatory. Therapeutic options at the disposal of clinicians caring for patients with refractory TTP consist of increased ADAMTS13 supplementation, increased immunosuppression, and inhibition of von Willebrand factor adhesion to platelets. In this work, we focus on possible therapies for the management of patients with unresponsive TTP, and propose an algorithm for the management of these difficult cases.
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Affiliation(s)
- Virginie Lemiale
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Sandrine Valade
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
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ADAMTS13 and VWF activities guide individualized caplacizumab treatment in patients with aTTP. Blood Adv 2021; 4:3093-3101. [PMID: 32634237 DOI: 10.1182/bloodadvances.2020001987] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction of the nanobody caplacizumab was shown to be effective in the treatment of acquired thrombotic thrombocytopenic purpura (aTTP) in the acute setting. The official recommendations include plasma exchange (PEX), immunosuppression, and the use of caplacizumab for a minimum of 30 days after stopping daily PEX. This study was a retrospective, observational analysis of the use of caplacizumab in 60 patients from 29 medical centers in Germany. Immunosuppressive treatment led to a rapid normalization of ADAMTS13 activities (calculated median, 21 days). In 35 of 60 patients, ADAMTS13 activities started to normalize before day 30 after PEX; in 11 of 60 patients, the treatment was extended beyond day 30; and in 5 patients, it was extended even beyond day 58 due to persistent autoimmune activity. In 34 of 60 instances, caplacizumab was stopped before day 30 with a favorable outcome whenever ADAMTS13 activities were >10%. In contrast, 11 of 34 patients with ADAMTS13 activities <10% at the time of stopping caplacizumab treatment developed a nonfavorable outcome (disease exacerbation or relapse). In some cases, prolongation of the treatment interval to every other day was feasible and resulted in a sustained reduction of von Willebrand factor activity. ADAMTS13 activity measurements are central for a rapid diagnosis in the acute setting but also to tailor disease management. An ADAMTS13 activity-guided approach seems safe for identifying the individual time point when to stop caplacizumab to prevent overtreatment and undertreatment; this approach will result in significant cost savings without jeopardizing the well-being of patients. In addition, von Willebrand factor activity may serve as a biomarker for drug monitoring.
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