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Papakonstantinou A, Kalmoukos P, Mpalaska A, Koravou EE, Gavriilaki E. ADAMTS13 in the New Era of TTP. Int J Mol Sci 2024; 25:8137. [PMID: 39125707 PMCID: PMC11312255 DOI: 10.3390/ijms25158137] [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: 06/15/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening, often immune-mediated disease that affects 2-13 persons per million per year. Hemolytic anemia, thrombocytopenia, and end-organ damage due to the formation of microthrombi are characteristic of TTP. ADAMTS13 is a disintegrin, metalloproteinase, cleaving protein of von Willebrand factor (VWF) that processes the VWF multimers to prevent them from interacting with platelets and, in turn, to microvascular thrombosis. Prompt diagnosis of TTP is critical yet challenging. Thrombotic microangiopathies have similar clinical presentation. Measurement of ADAMTS13 activity helps in the differential diagnosis. Less than 10% ADAMTS13 activity is indicative of TTP. Laboratory ADAMTS13 activity assays include incubating the test plasma with the substrate (full-length VWM multimers) and detection with direct or indirect measurement of the cleavage product. The purpose of this study is to examine the diagnostic potential, advantages, and weaknesses of the ADAMTS13 potency in TTP.
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Affiliation(s)
- Anna Papakonstantinou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Panagiotis Kalmoukos
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
| | - Aikaterini Mpalaska
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
| | - Evaggelia-Evdoxia Koravou
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.K.); (A.M.); (E.-E.K.)
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2
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Patır P, Önkibar N, Subari S, Eşkazan AE. Plasma cell-directed therapy strategies in immune-mediated thrombotic thrombocytopenic purpura (iTTP). Transfusion 2024; 64:536-545. [PMID: 38235916 DOI: 10.1111/trf.17716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Püsem Patır
- Department of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Nurtaç Önkibar
- Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Sedef Subari
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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3
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Lee NCJ, Yates S, Rambally S, Sarode R, Ibrahim IF, Shen YM, Hofmann SL, Bavli NR. Bortezomib in relapsed/refractory immune thrombotic thrombocytopenic purpura: A single-centre retrospective cohort and systematic literature review. Br J Haematol 2024; 204:638-643. [PMID: 37571963 DOI: 10.1111/bjh.19035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening haematological condition. Initial treatment involves plasma exchange (PLEX), corticosteroids, caplacizumab and rituximab. In relapsed and refractory cases despite initial treatments, further immune-modulating therapy includes the proteasome inhibitor, bortezomib. Evidence for bortezomib in this setting is limited to case reports and case series. We report our experience and perform a systematic review of the literature. We identified 21 publications with 28 unique patients in addition to our cohort of eight patients treated with bortezomib. The median age of patients was 44 years (IQR: 27-53) and 69% female. They were usually in an initial, refractory presentation of iTTP where they had received PLEX, corticosteroids, rituximab and another line of therapy. After bortezomib administration, 72% of patients had a complete response, with 85% maintaining a durable response without relapse at the last follow-up.
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Affiliation(s)
- Nicholas C J Lee
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Sean Yates
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern, Dallas, Texas, USA
| | - Siayareh Rambally
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Ravi Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern, Dallas, Texas, USA
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Ibrahim F Ibrahim
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Yu-Min Shen
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Sandra L Hofmann
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Natalie R Bavli
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
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4
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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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5
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Yin J, Tian H, Kong DQ, Li Y, Gu CY, Wu DP, Yu ZQ. [A combined regimen based on bortezomib and glucocorticoids for 6 patients with recurrent/refractory immune thrombotic thrombocytopenic purpura]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:413-417. [PMID: 37550192 PMCID: PMC10440622 DOI: 10.3760/cma.j.issn.0253-2727.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Indexed: 08/09/2023]
Abstract
Objective: To observe the efficacy and adverse reactions of a combination therapy regimen based on bortezomib and glucocorticoids in recurrent/refractory immune thrombocytopenic purpura (iTTP) . Methods: Six patients with recurrent/refractory TTP were included and treated with a glucocorticoid and two courses of bortezomib-based regimen. The clinical remission status of patients, changes in ADAMTS13 activity/ADAMTS13 inhibitor, and the occurrence of treatment-related adverse reactions were observed. Results: Of the 6 patients, 2 were males and 4 were females, with a median age of 21.5 (18-68) years. Refractory TTP was found in 1 case and recurrent TTP in 5 cases. Glucocorticoids were administered with reference to prednisone at 1 mg·kg(-1)·d(-1), and gradually reduced in dosage after achieving clinical remission. Bortezomib is subcutaneously administered at 1.3 mg/m(2) on days 1, 4, 8, and 11 with a 28-day treatment course consisting of 2 courses. Six patients achieved clinical remission after receiving bortezomib as the main treatment. ADMATS13 activity returned to normal in all patients with TTP after treatment, and the ADAMTS13 inhibitor turned negative. Thrombocytopenia is the most common adverse reaction after treatment, with other adverse reactions, including peripheral neuritis and abdominal pain, but ultimately all patients returned to normal. In a median follow-up of 26 (9-41) months, 5 patients maintained sustained remission, and 1 patient relapsed after 16 months of bortezomib treatment. Conclusion: Combination therapy of bortezomib and glucocorticoids has a satisfactory therapeutic effect and controllable adverse reactions for recurrent/refractory iTTP.
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Affiliation(s)
- J Yin
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - H Tian
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - D Q Kong
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - Y Li
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - C Y Gu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - D P Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - Z Q Yu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
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6
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Joseph A, Joly BS, Picod A, Veyradier A, Coppo P. The Specificities of Thrombotic Thrombocytopenic Purpura at Extreme Ages: A Narrative Review. J Clin Med 2023; 12:jcm12093068. [PMID: 37176509 PMCID: PMC10179719 DOI: 10.3390/jcm12093068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy (TMA) related to a severe ADAMTS13 deficiency, the specific von Willebrand factor (VWF)-cleaving protease. This deficiency is often immune-mediated (iTTP) and related to the presence of anti-ADAMTS13 autoantibodies that enhance its clearance or inhibit its VWF processing activity. iTTP management may be challenging at extreme ages of life. International cohorts of people with TTP report delayed diagnoses and misdiagnoses in children and elderly people. Child-onset iTTP shares many features with adult-onset iTTP: a female predominance, an idiopathic presentation, and the presence of neurological disorders and therapeutic strategies. Long-term follow-ups and a transition from childhood to adulthood are crucial to preventing iTTP relapses, in order to identify the occurrence of other autoimmune disorders and psychosocial sequelae. In contrast, older iTTP patients have an atypical clinical presentation, with delirium, an atypical neurological presentation, and severe renal and cardiac damages. They also have a poorer response to treatment and prognosis. Long-term sequelae are highly prevalent in older patients. Prediction scores for iTTP diagnoses are not used for children and have a lower sensitivity and specificity in patients over 60 years old. ADAMTS13 remains the unique biological marker that is able to definitely confirm or rule out the diagnosis of iTTP and predict relapses during follow-ups.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Bérangère S Joly
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Adrien Picod
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Department, Saint-Antoine hospital, Public Assistance Hospitals of Paris, 75571 Paris, France
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Yin J, Tian H, Kong D, Li Y, Gu C, Wang Z, Wu D, Yu Z. Bortezomib, a promising alternative for patients with refractory or relapsed thrombotic thrombocytopenic purpura after rituximab treatment. Br J Haematol 2022; 199:619-622. [PMID: 36076349 DOI: 10.1111/bjh.18430] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jie Yin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Hong Tian
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Danqing Kong
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yun Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Chengyuan Gu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Zhaoyue Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Ziqiang Yu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.,NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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8
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Chen M, Shortt J. Plasma-cell directed therapy for immune thrombotic thrombocytopenic purpura (iTTP). Transfus Med Rev 2022; 36:204-214. [DOI: 10.1016/j.tmrv.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
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9
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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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10
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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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