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Kafa K, Hoell JI. Transplant-associated thrombotic microangiopathy in pediatrics: incidence, risk factors, therapeutic options, and outcome based on data from a single center. Front Oncol 2024; 14:1399696. [PMID: 39050576 PMCID: PMC11266128 DOI: 10.3389/fonc.2024.1399696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a critical complication of hematopoietic stem cell transplantation. Awareness about TA-TMA has increased in recent years, resulting in the implementation of TA-TMA screening in most centers. Methods Retrospective analysis of children who underwent autologous or allogeneic hematopoietic stem cell transplantation at our center between January 2018 and December 2022 was conducted to evaluate the incidence, clinical features, and outcomes of TA-TMA following the administration of different therapeutic options. Results A total of 45 patients comprised the study cohort, of whom 10 developed TA-TMA with a cumulative incidence of 22% by 100 days after transplantation. Patients with and without TA-TMA in our cohort displayed an overall survival of 80% and 88%, respectively (p = 0.48), and a non-relapse mortality of 0% and 5.7%, respectively (p = 0.12), at 1 year after transplantation. Risk factors for TA-TMA development included allogeneic transplantation and total body irradiation-based conditioning regime. Among the 10 patients with TA-TMA, 7 did not meet the high-risk criteria described by Jodele and colleagues. Of these seven patients, two responded to calcineurin-inhibitor withdrawal without further therapy and five developed multiorgan dysfunction syndrome and were treated with anti-inflammatory steroids (prednisone), and all responded to therapy. The three patients with high-risk TA-TMA were treated with complement blockade or prednisone, and all responded to therapy. Conclusion TA-TMA is a multifactorial complication with high morbidity rates. Patients with high-risk TA-TMA may benefit from complement blockade using eculizumab. No consensus has been reached regarding therapy for patients who do not meet high-risk criteria. Our analysis showed that these patients may respond to anti-inflammatory treatment with prednisone.
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Affiliation(s)
- Kinan Kafa
- Department of Pediatric Hematology and Oncology, University Hospital Halle (Saale), Halle, Germany
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Peyre M, Sicre de Fontbrune F, Berceanu A, Benjemia L, Castelle M, D'Aveni M, Marçais A, Kaphan E, Bulabois CE, Sirvent A, Rohrlich PS, Coiteux V, Chantepie S, Nguyen-Quoc S, Peffault de Latour R, Coppo P. Efficacy of eculizumab in transplantation-associated thrombotic microangiopathy: results of the French nationwide study on behalf of the SFGM-TC and the CNR-MAT. Bone Marrow Transplant 2024; 59:1034-1036. [PMID: 38605146 DOI: 10.1038/s41409-024-02279-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/14/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Marion Peyre
- Hematology Department, Saint-Antoine Hospital, APHP, Paris, France
| | - Flore Sicre de Fontbrune
- Hematology Transplant Unit - French Reference Center for Aplastic Anemia, Saint Louis Hospital, APHP, Paris, France.
| | - Ana Berceanu
- Hematology Department, Besançon University Hospital, Besançon, France
| | - Lise Benjemia
- Hematology Department, Besançon University Hospital, Besançon, France
| | - Martin Castelle
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital, APHP, Paris, France
| | - Maud D'Aveni
- Hematology Department, Nancy University Hospital, Vandoeuvre-lès-Nancy, France
| | | | - Eleonore Kaphan
- Hematology Department, Grenoble University Hospital, Grenoble, France
| | | | - Anne Sirvent
- Hematology Department, Montpellier University Hospital, Montpellier, France
| | | | - Valerie Coiteux
- Hematology Department, Lille University Hospital, Lille, France
| | | | | | - Régis Peffault de Latour
- Hematology Transplant Unit - French Reference Center for Aplastic Anemia, Saint Louis Hospital, APHP, Paris, France
| | - Paul Coppo
- Hematology Department, Saint-Antoine Hospital, APHP, Paris, France.
- French Reference Center for Thrombotic Microangiopathies, Paris, France.
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France.
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3
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Benítez Carabante MI, Bueno D, Alonso García L, López Torija I, Marsal J, Fernandez Navarro JM, Uria Oficialdegui ML, Panesso M, Molina B, Beléndez Bieler C, Palomo P, Pérez Martínez A, Diaz-de-Heredia C. Use of Eculizumab in Pediatric Patients with High-Risk Transplantation-Associated Thrombotic Microangiopathy: Outcomes and Risk Factors Associated with Response and Survival. A Retrospective Study on Behalf of the Spanish Group for Hematopoietic Transplantation and Cellular Therapy (GETH-TC). Transplant Cell Ther 2024; 30:601.e1-601.e13. [PMID: 38521410 DOI: 10.1016/j.jtct.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 03/25/2024]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is associated with high morbidity and mortality. Although survival has improved significantly with the introduction of eculizumab, the need for improvement remains, especially in high-risk patients. This study aimed to describe the results obtained with eculizumab in a pediatric cohort with the attempt to define which risk factors could determine the response to treatment. We designed a national multicenter retrospective study of children treated with eculizumab for high-risk TA-TMA. The study cohort comprised 29 patients who had undergone a first (n = 28) or second (n = 1) allogeneic hematopoietic stem cell transplantation (HSCT) for malignant (n = 17) or nonmalignant (n = 12) disease. The median time from HSCT to TA-TMA diagnosis was 154 days (interquartile range [IQR], 103 to 263 days). Eleven patients (38%) who were initially diagnosed with low- to intermediate-risk TA-TMA progressed to high-risk TA-TMA (hrTA-TMA), within a median time of 4 days (IQR, 1 to 33 days). SC5b-9 was increased in 90% of 20 patients in whom it was measured. Renal (n = 12), pulmonary (n = 1), and intestinal (n = 1) biopsy confirmed the diagnosis in 12 of 14 patients (85%). Seventeen patients (58%) had extrarenal involvement with serositis (n = 13; 44,8%), pulmonary (n = 12; 41,4%), gastrointestinal (n = 8; 27.6%), cardiovascular (n = 7; 24.1%), or central nervous system (CNS) (n = 2; 6.9%) involvement. The median time from hrTA-TMA diagnosis to the initiation of eculizumab was 7 days (IQR, 1 to 8 days). Overall, 19 patients (65.5%) responded to eculizumab, of whom 17 (58.6%) achieved a complete response and 2 (6.9%) achieved a partial response. The remaining 10 patients (34.5%) did not show any of response. The overall response rate to eculizumab for TA-TMA was 27.59% (95% confidence interval [CI], 14.87% to 47.66%) at 1 month, 55.17% (95% CI, 38.43% to 73.48%) at 3 months, and 62.07% (95% CI, 45.10% to 79.13%) at 6 months after eculizumab initiation. In multivariate analysis, the pulmonary involvement decreased the probability of response (hazard ratio [HR], .18; P = .0298). The 1-year overall survival (OS) was 55.2% (95% CI, 35.6% to 71.0%) for the whole cohort and 83.3% (95% CI, 56.7% to 94.3%) for patients who responded to eculizumab. Pulmonary involvement (HR, 14.93; P = .0043) and CNS involvement (HR, 8.63; P = .0497) were associated with a statistically significant decrease in survival. We found that patients diagnosed with hrTA-TMA with pulmonary involvement had a poor response to eculizumab, and that patients with pulmonary and CNS involvement had significantly decreased survival. Given these results, we hypothesize that providing eculizumab therapy at an early stage of the disease before organ damage is established might significantly improve the response and, consequently, survival.
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Affiliation(s)
- María Isabel Benítez Carabante
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - David Bueno
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario La Paz, idiPAZ Research Institute, Madrid, Spain
| | - Laura Alonso García
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Iván López Torija
- Department of Pediatric Hematology and Oncology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Julia Marsal
- Department of Pediatric Hematology and Oncology, Hospital Sant Joan de Deu, Barcelona, Spain
| | | | - María Luz Uria Oficialdegui
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Melissa Panesso
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Blanca Molina
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Cristina Beléndez Bieler
- Department of Pediatric Hematology and Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Palomo
- Department of Pediatric Hematology and Oncology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Antonio Pérez Martínez
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario La Paz, idiPAZ Research Institute, Madrid, Spain
| | - Cristina Diaz-de-Heredia
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
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Notarantonio AB, D'aveni-Piney M, Pagliuca S, Ashraf Y, Galimard JE, Xhaard A, Marçais A, Suarez F, Brissot E, Feugier P, Urien S, Bouazza N, Jacquelin S, Meatchi T, Bruneval P, Frémeaux-Bacchi V, Peffault De Latour R, Hermine O, Durey-Dragon MA, Rubio MT. Systemic complement activation influences outcomes after allogeneic hematopoietic cell transplantation: A prospective French multicenter trial. Am J Hematol 2023; 98:1559-1570. [PMID: 37483161 DOI: 10.1002/ajh.27030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023]
Abstract
Complement activation has shown a role in murine models of graft-versus-host disease (GVHD) and in endothelial complications after allogeneic hematopoietic cell transplantation (allo-HSCT). However, its impact on post-transplant outcomes has not been so far fully elucidated. Here, we conducted a prospective multicentric trial (NCT01520623) performing serial measurements of complement proteins, regulators, and CH50 activity for 12 weeks after allo-HSCT in 85 patients receiving a myeloablative conditioning (MAC) regimen for various hematological malignancies. Twenty-six out of 85 patients showed an "activated" complement profile through the classical/lectin pathway, defined as a post-transplant decline of C3/C4 and CH50 activity. Time-dependent Cox regression models demonstrated that complement activation within the first weeks after allo-HSCT was associated with increased non-relapse mortality (hazard ratio [HR]: 3.69, 95% confident interval [CI]: 1.55-8.78, p = .003) and poorer overall survival (HR: 2.72, 95% CI: 1.37-5.39, p = .004) due to increased incidence of grade II-IV acute GVHD and in particular gastrointestinal (GI) GVHD (HR: 36.8, 95% CI: 12.4-109.1, p < .001), higher incidences of thrombotic microangiopathy (HR: 8.58, 95% CI: 2.16-34.08, p = .0022), capillary leak syndrome (HR: 7.36, 95% CI: 2.51-21.66, p = .00028), post-engraftment bacterial infections (HR: 2.37, 95% CI: 1.22-4.63, p = .0108), and EBV reactivation (HR: 3.33, 95% CI: 1.31-8.45, p = .0112). Through specific immune staining, we showed the correlation of deposition of C1q, C3d, C4d, and of C5b9 components on endothelial cells in GI GVHD lesions with the histological grade of GVHD. Altogether these findings define the epidemiology and the clinical impact of complement classical/lectin pathway activation after MAC regimens and provide a rational for the use of complement inhibitory therapeutics in a post-allo-HSCT setting.
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Affiliation(s)
- Anne Béatrice Notarantonio
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Maud D'aveni-Piney
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
| | - Simona Pagliuca
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Yayha Ashraf
- Laboratoire d'Immunologie, Hôpital Européen Georges-Pompidou, Université Paris Cité and UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | | | - Aliénor Xhaard
- BMT Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris VII, Paris, France
| | - Ambroise Marçais
- Service d'Hématologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Felipe Suarez
- Service d'Hématologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Eolia Brissot
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - Pierre Feugier
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Saik Urien
- Unité de Recherche Clinique, Paris Centre Necker Cochin, Hôpital Tarnier, Paris, France
| | - Naim Bouazza
- Unité de Recherche Clinique, Paris Centre Necker Cochin, Hôpital Tarnier, Paris, France
| | - Sébastien Jacquelin
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
| | - Tchao Meatchi
- Service d'Anatomopathologie, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrick Bruneval
- Service d'Anatomopathologie, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Frémeaux-Bacchi
- Laboratoire d'Immunologie, Hôpital Européen Georges-Pompidou, Université Paris Cité and UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Régis Peffault De Latour
- BMT Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris VII, Paris, France
| | - Olivier Hermine
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
- Service d'Hématologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Marie Agnès Durey-Dragon
- Laboratoire d'Immunologie, Hôpital Européen Georges-Pompidou, Université Paris Cité and UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Marie-Thérèse Rubio
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
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5
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Use of eculizumab in children with allogeneic haematopoietic stem cell transplantation associated thrombotic microangiopathy - a multicentre retrospective PDWP and IEWP EBMT study. Bone Marrow Transplant 2023; 58:129-141. [PMID: 36333550 DOI: 10.1038/s41409-022-01852-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 09/24/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Terminal complement blockade by humanised monoclonal antibody eculizumab has been used to treat transplantation-associated thrombotic microangiopathy (TA-TMA) in recent years. This retrospective international study conducted by the Paediatric Diseases (PDWP) and Inborn Error Working Party (IEWP) of the European Society for Blood and Marrow Transplantation (EBMT) describes outcome and response of 82 paediatric patients from 29 centres who developed TA-TMA and were treated with eculizumab between January 2014 and May 2019. The median time from hematopoietic stem cell transplantation (HSCT) to TA-TMA manifestation was 92 days (range: 7-606) and from TA-TMA diagnosis to the start of eculizumab treatment 6 days (range: 0-135). Most patients received eculizumab weekly (72%, n = 55) with a standard weight (kg)-based dose (78%, n = 64). Six months from beginning of eculizumab therapy, the cumulative incidence of TA-TMA resolution was 36.6% (95% CI: 26.2-47) and the overall survival (OS) was 47.1% (95% CI: 35.9-57.5). All 43 patients with unresolved TA-TMA died. The cause of death was HSCT-related in 41 patients. This study also documents poor outcome of patients without aGvHD and their frequent concomitant viral infections. Considering recent publications, intensified eculizumab dosing and complement monitoring could potentially improve upon outcomes observed in this study.
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Pharmacological Management of Atypical Hemolytic Uremic Syndrome in Pediatric Patients: Current and Future. Paediatr Drugs 2023; 25:193-202. [PMID: 36637720 PMCID: PMC9839393 DOI: 10.1007/s40272-022-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
Atypical hemolytic uremic syndrome is a thrombotic microangiopathy characterized by hemolysis, thrombocytopenia, and acute kidney injury, usually caused by alternative complement system overactivation due to pathogenic genetic variants or antibodies to components or regulatory factors in this pathway. Previously, a lack of effective treatment for this condition was associated with mortality, end-stage kidney disease, and the risk of disease recurrence after kidney transplantation. Plasma therapy has been used for atypical hemolytic uremic syndrome treatment with inconsistent results. Complement-blocking treatment changed the outcome and prognosis of patients with atypical hemolytic uremic syndrome. Early administration of eculizumab, a monoclonal C5 antibody, leads to improvements in hematologic, kidney, and systemic manifestations in patients with atypical hemolytic uremic syndrome, even with apparent dialysis dependency. Pre- and post-transplant use of eculizumab is effective in the prevention of atypical hemolytic uremic syndrome recurrence. Evidence on eculizumab use in secondary hemolytic uremic syndrome cases is controversial. Recent data favor the restrictive use of eculizumab in carefully selected atypical hemolytic uremic syndrome cases, but close monitoring for relapse after drug discontinuation is emphasized. Prophylaxis for meningococcal infection is important. The long-acting C5 monoclonal antibody ravulizumab is now approved for atypical hemolytic uremic syndrome treatment, enabling a reduction in the dosing frequency and improving the quality of life in patients with atypical hemolytic uremic syndrome. New strategies for additional and novel complement blockage medications in atypical hemolytic uremic syndrome are under investigation.
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Qi J, Pan T, You T, Tang Y, Chu T, Chen J, Fan Y, Hu S, Yang F, Ruan C, Wu D, Han Y. Upregulation of HIF-1α contributes to complement activation in transplantation-associated thrombotic microangiopathy. Br J Haematol 2022; 199:603-615. [PMID: 35864790 DOI: 10.1111/bjh.18377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a severe complication of haematopoietic stem cell transplantation (HSCT). Complement activation is involved in the development of TA-TMA. However, the underlying mechanism is unclear. Therefore, 21 samples of TA-TMA and 1:1 matched controls were measured for hypoxia-inducible factor-1α (HIF-1α) and complement protein. The mechanism was investigated both in vitro and in vivo. In this study, we found that levels of HIF-1α were significantly higher in TA-TMA patients than that in non-TA-TMA controls. Upregulation of HIF-1α induced an increase in membrane-bound complement C3 and dysfunction of human umbilical vein endothelial cells (HUVECs) in vitro. Increasing HIF-1α in vivo led to C3 and C5b-9 deposition in the glomerular endothelial capillary complex, thrombocytopenia, anaemia, and increased serum lactate dehydrogenase (LDH) levels in wild-type (WT) but not in C3-/- mice subjected to HSCT. High platelet aggregation in peripheral blood and CD41-positive microthrombi in the kidney were also found in dimethyloxallyl glycine (DMOG)-treated mice, recapitulating the TA-TMA phenotype seen in patients. Comprehensive analysis, including DNA array, luciferase reporter assay, chromatin immunoprecipitation (ChIP)-seq, and quantitative polymerase chain reaction (PCR), revealed that HIF-1α interacted with the promoter of complement factor H (CFH) to inhibit its transcription. Decreased CFH led to complement activation in endothelial cells.
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Affiliation(s)
- Jiaqian Qi
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Tingting Pan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Tao You
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Yaqiong Tang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Tiantian Chu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jia Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Yi Fan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Shuhong Hu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Fei Yang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Changgeng Ruan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Yue Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
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8
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Complement System as a New Target for Hematopoietic Stem Cell Transplantation-Related Thrombotic Microangiopathy. Pharmaceuticals (Basel) 2022; 15:ph15070845. [PMID: 35890144 PMCID: PMC9325021 DOI: 10.3390/ph15070845] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a complication that may occur after autologous or allogeneic hematopoietic stem cell transplantation (HSCT) and is conventionally called transplant-associated thrombotic microangiopathy (TA-TMA). Despite the many efforts made to understand the mechanisms of TA-TMA, its pathogenesis is largely unknown, its diagnosis is challenging and the case-fatality rate remains high. The hallmarks of TA-TMA, as for any TMA, are platelet consumption, hemolysis, and organ dysfunction, particularly the kidney, leading also to hypertension. However, coexisting complications, such as infections and/or immune-mediated injury and/or drug toxicity, together with the heterogeneity of diagnostic criteria, render the diagnosis difficult. During the last 10 years, evidence has been provided on the involvement of the complement system in the pathophysiology of TA-TMA, supported by functional, genetic, and therapeutic data. Complement dysregulation is believed to collaborate with other proinflammatory and procoagulant factors to cause endothelial injury and consequent microvascular thrombosis and tissue damage. However, data on complement activation in TA-TMA are not sufficient to support a systematic use of complement inhibition therapy in all patients. Thus, it seems reasonable to propose complement inhibition therapy only to those patients exhibiting a clear complement activation according to the available biomarkers. Several agents are now available to inhibit complement activity: two drugs have been successfully used in TA-TMA, particularly in pediatric cases (eculizumab and narsoplimab) and others are at different stages of development (ravulizumab, coversin, pegcetacoplan, crovalimab, avacopan, iptacopan, danicopan, BCX9930, and AMY-101).
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9
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Treatment outcome and efficacy of therapeutic plasma exchange for transplant-associated thrombotic microangiopathy in a large real-world cohort study. Bone Marrow Transplant 2022; 57:554-561. [DOI: 10.1038/s41409-022-01581-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/09/2022]
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10
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Yang LP, Liu X, Zhang XH. [Advances in the diagnosis and management of transplant-associated thrombotic microangiopathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:693-699. [PMID: 34547882 PMCID: PMC8501284 DOI: 10.3760/cma.j.issn.0253-2727.2021.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 12/02/2022]
Affiliation(s)
- L P Yang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
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11
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Risk factors and appropriate therapeutic strategies for thrombotic microangiopathy after allogeneic HSCT. Blood Adv 2021; 4:3169-3179. [PMID: 32658984 DOI: 10.1182/bloodadvances.2020002007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, so far, no large cohort study determined the risk factors and the most effective therapeutic strategies for TA-TMA. Thus, the present study aimed to clarify these clinical aspects based on a large multicenter cohort. This retrospective cohort study was performed by the Kyoto Stem Cell Transplantation Group (KSCTG). A total of 2425 patients were enrolled from 14 institutions. All patients were aged ≥16 years, presented with hematological diseases, and received allo-HSCT after the year 2000. TA-TMA was observed in 121 patients (5.0%) on day 35 (median) and was clearly correlated with inferior overall survival (OS) (hazard ratio [HR], 4.93). Pre- and post-HSCT statistically significant risk factors identified by multivariate analyses included poorer performance status (HR, 1.69), HLA mismatch (HR, 2.17), acute graft-versus-host disease (aGVHD; grades 3-4) (HR, 4.02), Aspergillus infection (HR, 2.29), and veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS; HR, 4.47). The response rate and OS significantly better with the continuation or careful reduction of calcineurin inhibitors (CNI) than the conventional treatment strategy of switching from CNI to corticosteroids (response rate, 64.7% vs 20.0%). In summary, we identified the risk factors and the most appropriate therapeutic strategies for TA-TMA. The described treatment strategy could improve the outcomes of patients with TA-TMA in the future.
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12
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Valério P, Barreto JP, Ferreira H, Chuva T, Paiva A, Costa JM. Thrombotic microangiopathy in oncology - a review. Transl Oncol 2021; 14:101081. [PMID: 33862523 PMCID: PMC8065296 DOI: 10.1016/j.tranon.2021.101081] [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: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Thrombotic microangiopathy is a syndrome triggered by a wide spectrum of situations, some of which are specific to the Oncology setting. It is characterized by a Coombs-negative microangiopathic haemolytic anemia, thrombocytopenia and organ injury, with characteristic pathological features, resulting from platelet microvascular occlusion. TMA is rare and its cancer-related subset even more so. TMA triggered by drugs is the most common within this group, including classic chemotherapy and the latest targeted therapies. The neoplastic disease itself and hematopoietic stem-cell transplantation could also be potential triggers. Evidence-based medical guidance in the management of cancer-related TMA is scarce and the previous knowledge about primary TMA is valuable to understand the disease mechanisms and the potential treatments. Given the wide spectrum of potential causes for TMA in cancer patients, the aim of this review is to gather the vast information available. For each entity, pathophysiology, clinical features, therapeutic approaches and prognosis will be covered.
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Affiliation(s)
- Patrícia Valério
- Nephrology Department, Setúbal Hospital Center, Portugal Rua Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal.
| | - João Pedro Barreto
- Laboratory Diagnosis Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Hugo Ferreira
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Teresa Chuva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Ana Paiva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - José Maximino Costa
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
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13
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Awidi M, Jain M, Baur R. Transplant-associated Thrombotic Microangiopathy Treated with Eculizumab and Romiplostim. Eur J Case Rep Intern Med 2021; 8:002294. [PMID: 33768076 DOI: 10.12890/2021_002294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 11/05/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) can occur after solid organ transplantation. It results in thrombocytopenia, haemolytic anaemia and microvascular occlusion. TA-TMA is not fully understood and treatment has not been clearly established. However, there is increasing evidence to suggest an immune-complement mediated component to its development. Eculizumab is a monoclonal antibody that inhibits the cleavage of C5 into pro-inflammatory, prothrombotic terminal complement elements and has been utilized in the treatment of atypical haemolytic uremic syndrome. We report a case of TA-TMA successfully treated with eculizumab and romiplostim. This case adds to the evidence that TA-TMA is triggered by complement dysregulation and suggests possible interventions for refractory cases. LEARNING POINTS Transplant-associated thrombotic microangiopathy (TA-TMA) may occur in solid organ transplant patients.Eculizumab may be used for the treatment of TA-TMA.
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Affiliation(s)
- Muhammad Awidi
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Meenu Jain
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Russell Baur
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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14
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Zhang R, Zhou M, Qi J, Miao W, Zhang Z, Wu D, Han Y. Efficacy and Safety of Eculizumab in the Treatment of Transplant-Associated Thrombotic Microangiopathy: A Systematic Review and Meta-Analysis. Front Immunol 2021; 11:564647. [PMID: 33552043 PMCID: PMC7856300 DOI: 10.3389/fimmu.2020.564647] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a dangerous and life-threatening complication in patients undergoing hematopoietic stem cell transplantation (HSCT). Eculizumab has been used in the treatment of TA-TMA, and several studies have confirmed the benefit of Eculizumab in patients with TA-TMA. However, the results remain controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of Eculizumab for TA-TMA. Materials and Methods We searched PubMed and Embase for studies on the efficacy and safety of Eculizumab in TA-TMA patients. Efficacy outcomes consisted of overall response rate (ORR), complete response rate (CRR), and survival rate at the last follow-up (SR). Safety outcomes were adverse events (AEs), including infection, sepsis, impaired liver function, infusion reactions, and death. Results A total of 116 patients from six studies were subjected to meta-analysis. The pooled estimates of ORR, CRR, and SR for TA-TMA patients were 71% (95% CI: 58-82%), 32% (95% CI: 11-56%), and 52% (95% CI: 40-65%), respectively. Only one patient presented with a severe rash, and infection was the most common AEs. The main causes of death were infection and GvHD. Conclusion Current evidence suggests that Eculizumab improves SR and ORR in patients with TA-TMA and that Eculizumab is well tolerated. However, the number of studies is limited, and the findings are based mainly on data from observational studies. Higher quality randomized controlled trials and more extensive prospective cohort studies are needed.
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Affiliation(s)
- Rui Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Meng Zhou
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Jiaqian Qi
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Wenjing Miao
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Ziyan Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yue Han
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
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15
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Imus PH, Tsai HL, DeZern AE, Jerde K, Swinnen LJ, Bolaños-Meade J, Luznik L, Fuchs EJ, Wagner-Johnston N, Huff CA, Gladstone DE, Ambinder RF, Gocke CB, Ali SA, Borrello IM, Varadhan R, Brodsky R, Jones RJ. Thrombotic Microangiopathy after Post-Transplantation Cyclophosphamide-Based Graft-versus-Host Disease Prophylaxis. Biol Blood Marrow Transplant 2020; 26:2306-2310. [PMID: 32961372 DOI: 10.1016/j.bbmt.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/31/2022]
Abstract
Transplant-associated thrombotic microangiopathy (taTMA) is a systemic vascular illness associated with significant morbidity and mortality, resulting from a convergence of risk factors after allogeneic blood or marrow transplantation (alloBMT). The diagnosis of taTMA has been a challenge, but most criteria include an elevated lactate dehydrogenase (LDH), low haptoglobin, and schistocytes on peripheral blood smear. We performed a retrospective review of the 678 consecutive adults who received high-dose post-transplantation cyclophosphamide (PTCy)-based graft-versus-host disease (GVHD) prophylaxis between January 1, 2015, and August 31, 2018. In April 2016, we initiated a monitoring program of weekly LDH and haptoglobin measurements and blood smears when those 2 parameters were both abnormal on all of our adult patients undergoing alloBMT for hematologic malignancies. During the entire period, the 1-year cumulative incidence of taTMA was 1.4% (95% confidence interval, 0.5% to 2.3%). Eight patients were taking tacrolimus at the time of diagnosis, and 1 was not on any immunosuppression. Eight of 9 patients (89%) were hypertensive. Four patients had invasive infections at the time of diagnosis, 4 patients required renal replacement therapy, and 5 of 9 patients were neurologically impaired. Eculizumab was given to 6 patients (0.9%), of whom 2 died and 4 recovered with resolution of end-organ dysfunction. The paucity of events made the determination of risk factors difficult; however, the low incidence of taTMA in this cohort may be related to the limited use of myeloablative conditioning regimens, low incidence of severe GVHD, and use of PTCy. PTCy-based GVHD prophylaxis appears to be associated with a low incidence of severe taTMA.
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Affiliation(s)
- Philip H Imus
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland.
| | - Hua-Ling Tsai
- Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Kevin Jerde
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Lode J Swinnen
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | | | - Leo Luznik
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ephraim J Fuchs
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | | | - Carol Ann Huff
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | | | - Richard F Ambinder
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Christian B Gocke
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Syed Abbas Ali
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ivan M Borrello
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ravi Varadhan
- Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Robert Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
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16
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Jarmoliński T, Rosa M, Puziewicz-Zmonarska A, Kałwak K. Short Course of Eculizumab May Be Effective in Dialysis-Dependent Transplantation-Associated Thrombotic Microangiopathy After Hematopoietic Stem Cell Transplantation: A Case Report. Transplant Proc 2020; 52:2544-2547. [PMID: 32917392 DOI: 10.1016/j.transproceed.2020.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (alloHSCT) could induce several complications. The most frequent viral infections and graft-vs-host disease (GvHD) sometimes lead to thrombotic microangiopathy (TMA). It is associated with significant morbidity and mortality with the risk of death reaching 90%. Effective prevention and treatment are not available to date. Recent attempts at using antibody against C5 have been made. CASE REPORT A 19-year-old girl with acute myeloid leukemia twice underwent alloHSCTs from her 10/10 HLA-matched sister. After the second HSCT severe acute steroid-resistant grade 4 GvHD occurred. Despite treatment with high doses of steroids, mycophenolate mofetil, biological therapy, and extracorporeal photopheresis, the patient developed TMA with acute kidney injury and the need for renal replacement therapy. The concentration of complement component 3 and activity of ADAMTS 13 were normal, and infection with Escherichia coli (E. coli) 0157H7 was excluded. Due to failure of all ordered therapies and severity of the condition, an attempt was taken to use eculizumab. Two 900-mg doses of eculizumab (Soliris) were administered at an interval of 2 weeks, which resulted in the improvement of renal function and amelioration of hemolysis and thrombocytopenia. Dialysis therapy was finished after 5 weeks, and then a third dose of the drug was administered. Eighteen months later, the patient is alive and well, with limited chronic GvHD. eGFR remains stable at 40 to 46 mL/min/1.73 m2, and mild hypertension requires treatment with angiotensin converting enzyme inhibitors and furosemide. CONCLUSION Even a short course of eculizumab can be sufficient in controlling the TMA after HSCT, provided that the TMA-triggering factors are well controlled.
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Affiliation(s)
- Tomasz Jarmoliński
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland; Department of Pediatrics and Pediatric Neurology, District Hospital, Gorzów Wielkopolski, Poland
| | - Monika Rosa
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Krzysztof Kałwak
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland.
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17
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Allogeneic reactivity-mediated endothelial cell complications after HSCT: a plea for consensual definitions. Blood Adv 2020; 3:2424-2435. [PMID: 31409584 DOI: 10.1182/bloodadvances.2019000143] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
Abstract
Endothelial cell (EC) activation has been suspected of triggering a group of rare and dismal complications that can occur after allogeneic hematopoietic stem cell transplantation (HSCT). Capillary leak syndrome, engraftment syndrome, transplant-associated microangiopathy, diffuse alveolar hemorrhage, and idiopathic pneumonia syndrome are the main nosological entities. Post-HSCT endotheliitis can be triggered by chemotherapy, infections, and calcineurin inhibitors, but allogeneic reactivity is claimed to be the common denominator. Endothelial damages are thought to activate several deleterious pathways (proapoptotic, procoagulant, proinflammatory) and can lead to multiorgan failure; however, clinical manifestations of each syndrome overlap, and their relationship with graft-versus-host disease could be minimal. The lack of well-defined diagnostic criteria does not allow for a clear-cut comparison in the current literature. Therapeutic efforts have been made to intercept the pathogenic mechanisms leading to EC dysfunction, but remission rates and survival remain mostly unsatisfactory. In this article, we have reviewed the incidence, clinical features, and treatment approaches of EC activation syndromes, and we plead for the development of internationally accepted standard definitions.
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18
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Han Y. [How I treat transplant-associated thrombotic microangiopathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:272-275. [PMID: 32447928 PMCID: PMC7364922 DOI: 10.3760/cma.j.issn.0253-2727.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Y Han
- Department of Hematology, the First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou 215006, China
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19
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A review of thrombotic microangiopathies in multiple myeloma. Leuk Res 2019; 85:106195. [DOI: 10.1016/j.leukres.2019.106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
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20
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Schoettler M, Duncan C, Lehmann L. Severe, persistent neurotoxicity after transplant-associated thrombotic microangiopathy in a pediatric patient despite treatment with eculizumab. Pediatr Transplant 2019; 23:e13381. [PMID: 30828947 PMCID: PMC6650335 DOI: 10.1111/petr.13381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/11/2018] [Accepted: 01/04/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND TA-TMA is a described complication of aHCT in children with neuroblastoma. Outcomes are poor with mortality rates approaching 60%. Described late effects in survivors include chronic kidney disease and persistent pulmonary hypertension. CASE We report a case of a 2-year-old with neuroblastoma who developed severe TA-TMA 35 days after high dose chemotherapy and autologous stem cell rescue. He presented with respiratory failure, pericardial and pleural effusions, hemolysis, hypertension, and mild altered mental status. He was mechanically ventilated for 3 weeks and after sedation was lifted, he was minimally responsive. He was treated with eculizumab with resolution of hemolysis, kidney injury and polyserositis. Initially he was more responsive; however, after almost a year of intensive therapy he remained nonverbal and had persistent irritability and behavioral changes. He had an extensive negative evaluation. On day +345, he presented with severe, refractory epilepsy. Three years after TA-TMA, he continues to have severe neurologic disabilities. CONCLUSIONS To our knowledge, persistent neurologic toxicity has not been reported in TA-TMA. However, deficits and seizures are reported in other TMAs, particularly in children with atypical HUS who present with significant neurologic changes at diagnosis. Our patient's persistent neurologic disability despite eculizumab response in all other involved organs may reflect irreversible damage. This case describes a new long-term sequela of TA-TMA and highlights the need for further studies to understand both acute and long-term neurologic complications of this disease.
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Affiliation(s)
- Michelle Schoettler
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
| | - Christine Duncan
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
| | - Leslie Lehmann
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
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21
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Thrombotic Microangiopathy Following Pediatric Autologous Hematopoietic Cell Transplantation: A Report of Significant End-Organ Dysfunction in Eculizumab-Treated Survivors. Biol Blood Marrow Transplant 2019; 25:e163-e168. [PMID: 30639820 DOI: 10.1016/j.bbmt.2018.12.840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/29/2018] [Indexed: 11/21/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a known complication of autologous hematopoietic cell transplantation (aHCT), particularly in children with neuroblastoma. We describe a pediatric single-institution experience of TA-TMA after aHCT. Data were abstracted from the medical record of patients who underwent aHCT between January 1, 2008, and July 1, 2018, at Boston Children's Hospital. TA-TMA was diagnosed using either the International Working Group criteria or the "probable TA-TMA criteria" of Cho et al. Overall, 318 aHCTs were performed in 243 patients. Nine patients (3.7%) were diagnosed with TA-TMA. TA-TMA occurred most frequently in children with neuroblastoma (n = 7; 78%), all of whom were conditioned with carboplatin, etoposide, and melphalan. The median age at aHCT in children who developed TA-TMA was 3 years, 5 months (range, 18 months to 25 years). TMA was diagnosed at a median of 35 days (range, 8 to 106 days) after stem cell infusion. On a retrospective chart review using the same criteria used by the provider, patients met criteria a median of 5 days before the clinical diagnosis (range, 0 to 58 days). Eight patients had renal involvement at presentation, including nephrotic range proteinuria and severe hypertension, requiring from 2 to 6 antihypertensive medications. Two patients presented with multiorgan failure. Six patients were treated with eculizumab a median of 0 days after TA-TMA diagnosis (range, 0 to 11 days). On retrospective review, patients were treated a median of 18 days (range, 0 to 58 days) after meeting criteria for TA-TMA. Before initiation of therapy, 4 of 6 patients checked for serum complement levels had normal values, 1 had elevated CH50 and 1 had elevated sC59-b and CH50. All patients had CH50 levels within the target range (≤3 CAE) after induction therapy. Two patients (33%) had no response to eculizumab and died of multiorgan failure. The other 4 had both a hematologic response with transfusion independence (median, 6.5 weeks; range, 4 to 9 weeks) and renal response, defined as resolution of nephrotic range proteinuria (median, 21 weeks; range, 13 to 25 weeks). Among the eculizumab-treated survivors, 2 patients remained on prolonged eculizumab therapy, and one had recurrence of TA-TMA after discontinuation of eculizumab. All 4 eculizumab treated survivors have persistent organ dysfunction. Three children were treated with supportive care only; 2 died of relapsed cancer, and the third is alive with stage 2 chronic kidney disease. The median duration of follow-up after TA-TMA diagnosis was 2.5 years (range, 9 months to 4 years). The 1-year overall survival was 78% (SE = 14%). However, regardless of treatment, no survivors had complete normalization of function in all organs. Three children with normal serum CH50 and sc5b-9 levels responded to eculizumab. This report highlights the importance of maintaining a high suspicion for TA-TMA after aHCT. Further study is warranted to identify individual risk factors for TMA after aHCT, predict the response to eculizumab, and capture long-term sequelae in survivors.
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22
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A Heterozygous CFHR3-CFHR1 Gene Deletion in a Pediatric Patient With Transplant-associated Thrombotic Microangiopathy Who was Treated With Eculizumab. J Pediatr Hematol Oncol 2018; 40:e544-e546. [PMID: 28991129 DOI: 10.1097/mph.0000000000000986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Complement system dysregulation, such as complement Factor H (CFH) autoantibodies and deletions in CFH-related (CFHR) genes 3 and 1, might cause transplant-associated thrombotic microangiopathy (TA-TMA). The use of eculizumab, a terminal complement inhibitor, could be a targeted therapy for TA-TMA. We report a 1-year-old girl who developed TA-TMA, just after autologous peripheral blood stem cell transplantation in neuroblastoma therapy. Eculizumab improved TA-TMA. Investigation for the complement alternative pathway showed a heterozygous CFHR3-CFHR1 gene deletion, which is involved in complement activation. The patient might develop TA-TMA as a result of complement regulatory gene mutation.
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23
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Wanchoo R, Bayer RL, Bassil C, Jhaveri KD. Emerging Concepts in Hematopoietic Stem Cell Transplantation-Associated Renal Thrombotic Microangiopathy and Prospects for New Treatments. Am J Kidney Dis 2018; 72:857-865. [PMID: 30146419 DOI: 10.1053/j.ajkd.2018.06.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 06/06/2018] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy associated with hematopoietic stem cell transplantation (HSCT-TMA) is a well-recognized complication of HSCT that has a high risk for death. Even in patients who survive, HSCT-TMA is associated with long-term morbidity and chronic organ injury. HSCT-TMA is a multisystem disease that often affects the kidneys. Renal manifestations of HSCT-TMA include reduced glomerular filtration rate, proteinuria, and hypertension. Understanding of the pathophysiology of HSCT-TMA has expanded in the last decade. Endothelial injury plays a major role. Recent studies also suggest involvement of complement activation. HSCT-TMA has also been considered by some to be an endothelial variant of graft-versus-host disease. Understanding the pathophysiology of HSCT-TMA and its association with activation of the complement system may aid in developing novel therapeutic options. In this review, we summarize current knowledge focusing on epidemiology and prognosis, evidence of complement activation, and endothelial injury; the possible link to graft-versus-host disease; and treatment options for HSCT-TMA.
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Affiliation(s)
- Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Ruthee L Bayer
- Division of Hematology and Oncology and the Northwell Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Claude Bassil
- Division of Nephrology and Hypertension, University of South Florida, Tampa, FL; Renal Service, H. Lee Moffitt Center, Tampa, FL
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Rudoni J, Jan A, Hosing C, Aung F, Yeh J. Eculizumab for transplant-associated thrombotic microangiopathy in adult allogeneic stem cell transplant recipients. Eur J Haematol 2018; 101:389-398. [PMID: 29920784 DOI: 10.1111/ejh.13127] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate response rates and survival in adults with transplant-associated thrombotic microangiopathy (TA-TMA) after allogeneic hematopoietic stem cell transplantation (HSCT) who were treated with eculizumab (ECU). METHODS Patients were identified retrospectively and data collected through HSCT and pharmacy databases. RESULTS Ten patients with TA-TMA after allogeneic HSCT were treated with ECU between 2013 and 2016. TA-TMA was diagnosed at a median of 93 days post-HSCT. Organ-specific injury was documented in all ten patients at time of TA-TMA diagnosis, the most common being renal dysfunction (90%). Acute GVHD (70%) and active infection (80%) were common at time of diagnosis. The median time to ECU initiation from TA-TMA diagnosis was 4 days. Seven patients received ECU as first-line therapy in combination with other treatment modalities, while three patients were treated with ECU as second-line therapy. ECU was well tolerated with the exception of one case of severe skin rash leading to discontinuation. ECU achieved an overall hematologic response rate of 70% and an overall survival rate of 60%. One patient achieved a complete response with corresponding organ recovery. CONCLUSION Early initiation of ECU may not alter the disease process enough to restore organ function, but it may prolong survival.
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Affiliation(s)
- Joslyn Rudoni
- Department of Pharmacy, Cleveland Clinic Health System, Cleveland, Ohio
| | - Anna Jan
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Division of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fleur Aung
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Yeh
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Jodele S. Complement in Pathophysiology and Treatment of Transplant-Associated Thrombotic Microangiopathies. Semin Hematol 2018; 55:159-166. [PMID: 30032753 DOI: 10.1053/j.seminhematol.2018.04.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 02/27/2018] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a form of microangiopathy specifically occurring in the context of hematopoietic stem cell transplantation. Similarly, to other microangiopathies, TA-TMA is characterized by hemolytic anemia, thrombocytopenia, and organ failure due to endothelial injury. Although its clinical association with medications (eg, calcineurin inhibitors), immune reactions (eg, graft vs host disease) or infectious complications is well established, the pathophysiology remains largely unknown. Recent data have highlighted the role of complement in the pathophysiology of TA-TMA, which are frequently associated with a functional impairment (either inherited or acquired) of the endogenous regulation of the complement classic and alternative pathway. This manuscript will review the data supporting the involvement of complement in the pathophysiology of TA-TMA, as well as the clinical data supporting the use of anticomplement agents in this rare condition.
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Affiliation(s)
- Sonata Jodele
- Department of Hematology, Oncology and Blood & Marrow Transplantation, USC Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
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26
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Horváth O, Kállay K, Csuka D, Mező B, Sinkovits G, Kassa C, Stréhn A, Csordás K, Sinkó J, Prohászka Z, Kriván G. Early Increase in Complement Terminal Pathway Activation Marker sC5b-9 Is Predictive for the Development of Thrombotic Microangiopathy after Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:989-996. [PMID: 29339271 DOI: 10.1016/j.bbmt.2018.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/08/2018] [Indexed: 12/17/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is a multifactorial complication, and its prediction is largely unresolved. Our aim was to analyze changes of complement profile after HSCT to identify potential markers of TA-TMA development. Thirty-three consecutive pediatric patients (9.6 ± 4.4 years old) who underwent allogeneic HSCT due to malignant (n = 17) or nonmalignant (n = 16) indications were included in this study. Graft-versus-host disease (GVHD) was diagnosed using Glucksberg criteria, viral reactivation was monitored, 5 different TA-TMA diagnostic criteria were applied, and all important clinical and laboratory parameters of TA-TMA activity were registered. Complement pathway activities, components and terminal pathway activation marker (sC5b-9) levels were systematically measured before transplantation and on days 28, 56, and 100 after HSCT. During the first 100 days after HSCT, 1 of 33 patients died (day 50, multiple organ failure), whereas 10 subjects met the criteria for TA-TMA, typically on day 61 (range, 16 to 98 days). TA-TMA was preceded by acute GVHD in 3 of 10 patients, by viral reactivation in 2 of 10, or by both in 4 of 10 cases. Baseline sC5b-9 levels did not differ in patients without (200 [interquartile range, 144 to 266] ng/mL), or with (208 [interquartile range, 166 to 271] ng/mL) subsequent TA-TMA; however, on day 28 significant differences were observed (201 [interquartile range, 185 to 290] ng/mL versus 411 [interquartile range, 337 to 471] ng/mL; P = .004). Importantly, all 10 patients with TMA showed increase in sC5b-9 level from baseline level to day 28, whereas in patients without TMA the same tendency was observed for only 9 of 23 patients (P = .031). No additional complement parameters were closely associated with the development of TA-TMA. Development of TA-TMA occurred in 30% of our patients, typically after GVHD and/or viral reactivation. However, early raise of sC5b-9 activation marker was predictive for later development of TA-TMA, and should therefore be considered as an alarming sign necessitating a careful monitoring of all TA-TMA activity markers. Further studies enrolling a higher number of patients are necessary to determine if terminal pathway activation is an independent predictor of TA-TMA.
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Affiliation(s)
- Orsolya Horváth
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary; Doctoral School of Medicine, Semmelweis University, Budapest, Hungary.
| | - Krisztián Kállay
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - Dorottya Csuka
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Blanka Mező
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - György Sinkovits
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Csaba Kassa
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - Anita Stréhn
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - Katalin Csordás
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - János Sinkó
- Department of Hematology and Stem Cell Transplantation, United St. István and St. László Hospital, Budapest, Hungary
| | - Zoltán Prohászka
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Gergely Kriván
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
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Neumann T, Plis A, Weigel M, Stracke S, Friesecke S, Stecher SS, Schneidewind L, Busemann C, Schmidt CA, Krüger WH. No Relapse of Calcineurin Inhibitor-Associated Thrombotic Microangiopathy after Discontinuation of Eculizumab. Acta Haematol 2017; 138:194-197. [PMID: 29136616 DOI: 10.1159/000481724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 01/18/2023]
Affiliation(s)
- Thomas Neumann
- Department of Internal Medicine C (Haematology and Oncology, Stem Cell Transplantation, Palliative Care), University Hospital Greifswald, Ernst-Moritz-Arndt University, Greifswald, Germany
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Qi J, Wang J, Chen J, Su J, Tang Y, Wu X, Ma X, Chen F, Ruan C, Zheng XL, Wu D, Han Y. Plasma levels of complement activation fragments C3b and sC5b-9 significantly increased in patients with thrombotic microangiopathy after allogeneic stem cell transplantation. Ann Hematol 2017; 96:1849-1855. [PMID: 28801815 PMCID: PMC6225065 DOI: 10.1007/s00277-017-3092-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 08/04/2017] [Indexed: 12/30/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an uncommon but severe complication in patients undergoing allogeneic stem cell transplantation (allo-SCT). However, the mechanism is unclear. From 2011 to 2014, 20 patients with TA-TMA, 20 patients without, and 54 patients with various other complications, including veno occlusive disease (VOD), graft-versus-host disease (GVHD), and infection, were recruited in the study. Plasma vWF antigen (vWFAg), vWF activity (vWFAc), and ADAMTS13 activity were determined in these patients by ELISAs and FRETS-vWF73 assay, respectively. Plasma C3b, sC5b-9, and CH50 were also determined by ELISAs. Plasma levels of C3b were significantly increased in patients with either TA-TMA (p < 0.0001) or GVHD (p < 0.01). Plasma sC5b-9 and CH50 levels in patients with TA-TMA were also significantly increased (p < 0.001). Plasma ADAMTS13 activity was lower in patients with VOD, but normal with other complications. Both plasma vWFAg and vWFAc levels were not elevated in patients with TA-TMA or VOD compared with those of other groups. Complement activation likely via an alternative pathway (increased C3b, sC5b-9, and CH50) may play a role in the pathogenesis of TA-TMA. ADAMTS13 activity is reduced in VOD, but the ADAMTS13/vWF axis appears to be unaffected in patients with TA-TMA.
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Affiliation(s)
- Jiaqian Qi
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jie Wang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jia Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jian Su
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Yaqiong Tang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Xiaojin Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Xiao Ma
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Feng Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Changgeng Ruan
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - X Long Zheng
- Divsion of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, 35243, USA
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China.
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China.
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.
| | - Yue Han
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China.
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China.
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.
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Khosla J, Yeh AC, Spitzer TR, Dey BR. Hematopoietic stem cell transplant-associated thrombotic microangiopathy: current paradigm and novel therapies. Bone Marrow Transplant 2017; 53:129-137. [DOI: 10.1038/bmt.2017.207] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/20/2017] [Accepted: 07/28/2017] [Indexed: 02/08/2023]
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30
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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31
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Chugh S, Kichloo A, Jafri F, Yusvirazi L, Lerner R. Multiple Myeloma as the Underlying Cause of Thrombotic Microangiopathy Leading to Acute Kidney Injury: Revisiting a Very Rare Entity. J Investig Med High Impact Case Rep 2017; 5:2324709617732797. [PMID: 28975130 PMCID: PMC5613796 DOI: 10.1177/2324709617732797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/28/2017] [Indexed: 11/17/2022] Open
Abstract
Thrombotic microangiopathy (TMA) describes a pathological process of microvascular thrombosis, consumptive thrombocytopenia, and microangiopathic hemolytic anemia, leading to end-organ ischemia and infarction, affecting particularly the kidney and brain. TMA is a pathological feature of a number of clinical disorders including thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and atypical hemolytic uremic syndrome. Rare but important, TMA may also occur in malignancy, connective tissue disease, malignant hypertension, and renal transplantation (rejection or drug toxicity). We present a very rare case where the patient developed acute kidney injury from TMA but found to have multiple myeloma as the possible underlying etiology.
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Affiliation(s)
| | - Asim Kichloo
- Central Michigan University, St Mary's Hospital, Saginaw, MI, USA
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32
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Coppo P. [Secondary thrombotic microangiopathies]. Rev Med Interne 2017; 38:731-736. [PMID: 28890263 DOI: 10.1016/j.revmed.2017.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMA) are termed secondary when associated to a specific context favouring their occurrence. They encompass mainly TMA associated with pregnancy, allogeneic hematopoietic stem cell transplantation, cancer, drugs, or HIV infection. Secondary TMA represent a heterogeneous group of diseases which clinical presentation largely depends on the associated context. It is therefore mandatory to recognize these conditions since they have a significant impact in TMA management and prognosis. A successful management still represents a challenge in secondary TMA. Significant progresses have been made in the understanding of pregnancy-associated TMA, allowing an improvement of prognosis; on the opposite, other forms of secondary TMA such as hematopoietic stem cell transplantation-associated TMA or TMA associated with chemotherapy remain of dismal prognosis. A better understanding of pathophysiology in these forms of TMA, in association with a more empirical approach through the use of new therapeutic agents that can also help in the understanding on new mechanisms a posteriori, should improve their prognosis. The preliminary encouraging results reported with complement blockers in this field could represent a convincing example.
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Affiliation(s)
- P Coppo
- Service d'hématologie, centre de référence des microangiopathies thrombotiques, hôpital Saint-Antoine, UPMC université Paris 6, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
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- Service d'hématologie, centre de référence des microangiopathies thrombotiques, hôpital Saint-Antoine, UPMC université Paris 6, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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Facchini L, Lucchesi M, Stival A, Roperto RM, Melosi F, Materassi M, Farina S, Tintori V, de Martino M, Sardi I. Role of eculizumab in a pediatric refractory gemcitabine-induced thrombotic microangiopathy: a case report. J Med Case Rep 2017; 11:209. [PMID: 28747219 PMCID: PMC5530476 DOI: 10.1186/s13256-017-1373-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 07/02/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The incidence of gemcitabine-induced hemolytic uremic syndrome has already been described in adults. Several approaches have been employed in the treatment of gemcitabine-induced hemolytic uremic syndrome with different outcomes. One of the most promising agents is eculizumab, which is a monoclonal antibody directed against C5 complement protein. CASE PRESENTATION We reported the case of a 3-year-old white boy with medulloblastoma who underwent high-dose chemotherapy and craniospinal irradiation. Afterwards he started maintenance chemotherapy with gemcitabine and oxaliplatin. After five courses he presented a progressive clinical worsening, which resulted in a systemic thrombotic microangiopathy. Initially he was treated with rituximab without clinical improvement. Therefore he started therapy with repeated cycles of eculizumab. After seven infusions he showed a gradual improvement and finally a complete remission of gemcitabine-induced hemolytic uremic syndrome. CONCLUSIONS Eculizumab prevents serious complement-mediated vascular damage for chemotherapy-induced thrombotic microangiopathy in pediatric cases.
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Affiliation(s)
- Ludovica Facchini
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, 50139, Florence, Italy
| | - Maurizio Lucchesi
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, 50139, Florence, Italy
| | - Alessia Stival
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, 50139, Florence, Italy
| | - Rosa Maria Roperto
- Nephrology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
| | | | - Marco Materassi
- Nephrology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Silvia Farina
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, 50139, Florence, Italy
| | - Veronica Tintori
- Transplantation Unit, Department of Pediatric Oncology, Meyer Children's Hospital, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, University of Florence, Meyer Children's Hospital, Florence, Italy
| | - Iacopo Sardi
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children's Hospital, Viale G. Pieraccini 24, 50139, Florence, Italy.
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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35
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Coppo P, Corre E, Rondeau E, Benhamou Y, Bachet A, Stépanian A, Veyradier A. L’activité de télémédecine dans les microangiopathies thrombotiques : un progrès dans les maladies rares nécessitant une prise en charge en urgence. Rev Med Interne 2016; 37:514-20. [DOI: 10.1016/j.revmed.2015.10.354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/21/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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36
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Dhakal P, Giri S, Pathak R, Bhatt VR. Eculizumab in Transplant-Associated Thrombotic Microangiopathy. Clin Appl Thromb Hemost 2016; 23:175-180. [DOI: 10.1177/1076029615599439] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Introduction: Transplant-associated thrombotic microangiopathy (TA-TMA) is a rare entity with no standard of care and high mortality, despite the use of plasma exchange. Methods: Using specific search terms, all cases having TA-TMA treated with eculizumab and indexed in MEDLINE (English language only) by November 2014 were reviewed. Results: A total of 26 cases, 53% men, had a median age of 33 years (range 2-61). Transplant-associated thrombotic microangiopathy occurred after stem-cell transplant (35%) or solid-organ transplant (65%), frequently associated with the use of cyclosporine or tacrolimus (96%). A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS 13) level was always >10%. After TA-TMA diagnosis, the following drug adjustments were made: discontinuation of cyclosporine or tacrolimus in 45%, dose reduction in another 27%, continuation of the drugs in 23%, and switch from cyclosporine to tacrolimus in remaining 5%. Plasma exchange was performed in ∼43%. The median interval between transplant and initiation of eculizumab was 63 days (range 11-512). A median of 5.5 doses (range 2-21) of eculizumab was utilized with 92% response occurring after a median of 2 doses (range 1-18). At a median follow-up of 52 weeks (range 3-113), the survivors (92%) were doing well. Conclusion: Within the limits of this retrospective analysis, our study demonstrates that eculizumab use may result in high response rate and 1-year survival in patients with TA-TMA refractory to discontinuation of calcineurin inhibitor and plasma exchange.
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Affiliation(s)
- Prajwal Dhakal
- Department of Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Smith Giri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ranjan Pathak
- Department of Medicine, Reading Health System, West Reading, PA, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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Risitano AM, Marotta S. Therapeutic complement inhibition in complement-mediated hemolytic anemias: Past, present and future. Semin Immunol 2016; 28:223-40. [PMID: 27346521 DOI: 10.1016/j.smim.2016.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/24/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
The introduction in the clinic of anti-complement agents represented a major achievement which gave to physicians a novel etiologic treatment for different human diseases. Indeed, the first anti-complement agent eculizumab has changed the treatment paradigm of paroxysmal nocturnal hemoglobinuria (PNH), dramatically impacting its severe clinical course. In addition, eculizumab is the first agent approved for atypical Hemolytic Uremic Syndrome (aHUS), a life-threatening inherited thrombotic microangiopathy. Nevertheless, such remarkable milestone in medicine has brought to the fore additional challenges for the scientific community. Indeed, the list of complement-mediated anemias is not limited to PNH and aHUS, and other human diseases can be considered for anti-complement treatment. They include other thrombotic microangiopathies, as well as some antibody-mediated hemolytic anemias. Furthermore, more than ten years of experience with eculizumab led to a better understanding of the individual steps of the complement cascade involved in the pathophysiology of different human diseases. Based on this, new unmet clinical needs are emerging; a number of different strategies are currently under development to improve current anti-complement treatment, trying to address these specific clinical needs. They include: (i) alternative anti-C5 agents, which may improve the heaviness of eculizumab treatment; (ii) broad-spectrum anti-C3 agents, which may improve the efficacy of anti-C5 treatment by intercepting the complement cascade upstream (i.e., preventing C3-mediated extravascular hemolysis in PNH); (iii) targeted inhibitors of selective complement activating pathways, which may prevent early pathogenic events of specific human diseases (e.g., anti-classical pathway for antibody-mediated anemias, or anti-alternative pathway for PNH and aHUS). Here we briefly summarize the status of art of current and future complement inhibition for different complement-mediated anemias, trying to identify the most promising approaches for each individual disease.
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Affiliation(s)
- Antonio M Risitano
- Hematology, Department of Clinical Medicine and Surgery; Federico II University, Naples, Italy.
| | - Serena Marotta
- Hematology, Department of Clinical Medicine and Surgery; Federico II University, Naples, Italy
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tatekawa S, Kohno A, Ozeki K, Watamoto K, Ueda N, Yamaguchi Y, Kobayashi T, Yokota I, Teramukai S, Taniwaki M, Kuroda J, Morishita Y. A Novel Diagnostic and Prognostic Biomarker Panel for Endothelial Cell Damage-Related Complications in Allogeneic Transplantation. Biol Blood Marrow Transplant 2016; 22:1573-1581. [PMID: 27246373 DOI: 10.1016/j.bbmt.2016.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/20/2016] [Indexed: 12/28/2022]
Abstract
Noninfectious transplantation-related complications (TRCs), such as graft-versus-host disease or TRC with endothelial cell damage (TRC-EC), remain as the major obstacle for successful allogeneic hematopoietic cell transplantation (allo-HCT). However, the diagnosis and prognosis for the emergence of these complications are difficult to define during the early post allo-HCT period. Here, we tried to generate a novel diagnostic system for TRC-EC by analyzing 188 adult patients who received allo-HCT. Our study found that the peripheral blood levels of angiopoietin 2 (ANG2), C-reactive protein (CRP), D-dimer, and thrombomodulin (TM) at the onset of TRCs were significantly associated with the development of TRC-EC. We next developed a composite biomarker panel incorporating the risk values of ANG2, CRP, D-dimer, and TM at the onset of TRCs, which classified these patients into 3 risk groups: low, intermediate, and high risk. As a result, the panel was useful not only for the diagnosis of TRC-EC with high specificity and sensitivity, but also for the prediction of the patients' long-term outcome. The 5-year overall survival (OS) rates of patients in the low-, intermediate-, and high-risk groups since the occurrence from TRCs were 76.2%, 54.9%, and 26.9%, respectively, and the high-risk score was significantly associated with both poor OS (hazard ratio [HR], 5.60; 95% confidence interval [CI], 2.81 to 11.20; P < .01) and frequent nonrelapse mortality (HR, 19.75; 95% CI, 5.59 to 69.77; P < .01). Thus, the composite panel proposed in this study provides a powerful tool for the diagnosis of TRC-EC and for the prediction of survival for patients with TRC-EC after allo-HCT.
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Affiliation(s)
- Shotaro Tatekawa
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Akio Kohno
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Kazutaka Ozeki
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan
| | - Koichi Watamoto
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology, Komaki City Hospital, Aichi, Japan
| | - Norihiro Ueda
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yohei Yamaguchi
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masafumi Taniwaki
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Yoshihisa Morishita
- Division of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Aichi, Japan; Department of Internal Medicine, Seirei Hospital, Nagoya, Aichi, Japan
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Teoh CW, Riedl M, Licht C. The alternative pathway of complement and the thrombotic microangiopathies. Transfus Apher Sci 2016; 54:220-31. [PMID: 27160864 DOI: 10.1016/j.transci.2016.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thrombotic microangiopathies (TMA) are disorders defined by microangiopathic hemolytic anemia, non-immune thrombocytopenia and have multi-organ involvement including the kidneys, brain, gastrointestinal, respiratory tract and skin. Emerging evidence points to the central role of complement dysregulation in leading to microvascular endothelial injury which is crucial for the development of TMAs. This key insight has led to the development of complement-targeted therapy. Eculizumab is an anti-C5 monoclonal antibody, which has revolutionized the treatment of atypical hemolytic uremic syndrome. Several other anti-complement therapeutic agents are currently in development, offering a potential armamentarium of therapies available to treat complement-mediated TMAs. The development of sensitive, reliable and easy to perform assays to monitor complement activity and therapeutic efficacy will be key to devising an individualized treatment regime with the potential of safely weaning or discontinuing treatment in the appropriate clinical setting.
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Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Magdalena Riedl
- Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
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Off-label use of the expensive orphan drug eculizumab in France 2009-2013 and the impact of literature: focus on the transplantation field. Eur J Clin Pharmacol 2016; 72:737-46. [PMID: 26915814 DOI: 10.1007/s00228-016-2027-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/11/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE The orphan drug eculizumab (Soliris ®) is one of the most expensive in the world and based on expenditures is classed among the highest in France, a scenario suggestive of off-label use. Given its pharmacological properties, it is likely to be used in organ transplantation. Our purposes were to describe the consumption trends of eculizumab for off-label indications overall and in the organ transplantation field and to assess the impact of publications on the latter use. METHODS We carried out a temporal ecological study within the French national hospitalization database (PMSI). First, the trend of eculizumab consumption (2009-2013) was compared to our estimate of the maximum on-label consumption (overall and for transplantation). Second, we evaluated the impact of the publications supporting the effectiveness of eculizumab in the transplantation field on temporal trends of eculizumab consumption. RESULTS Eculizumab total consumption exceeded our estimate of the maximum on-label consumption since the end of 2011 and increased until the end of the study. The off-label consumption represented at least 50 % of the total consumption. The off-label consumption in organ transplantation also increased since 2011. The amount of publications grew through the study period, but overall, the evidence level remained low. Statistically, publications were neither associated with the drug consumption for transplantation in the long term nor in the short term. CONCLUSION Eculizumab started being notably used for off-label indications in France since the end of 2011, and this use increased until the end of the study. We found only low-level evidence concerning the off-label use of eculizumab in the transplantation field through the studied period.
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An international consensus approach to the management of atypical hemolytic uremic syndrome in children. Pediatr Nephrol 2016; 31:15-39. [PMID: 25859752 DOI: 10.1007/s00467-015-3076-8] [Citation(s) in RCA: 346] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 01/26/2015] [Accepted: 02/16/2015] [Indexed: 12/19/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) emerged during the last decade as a disease largely of complement dysregulation. This advance facilitated the development of novel, rational treatment options targeting terminal complement activation, e.g., using an anti-C5 antibody (eculizumab). We review treatment and patient management issues related to this therapeutic approach. We present consensus clinical practice recommendations generated by HUS International, an international expert group of clinicians and basic scientists with a focused interest in HUS. We aim to address the following questions of high relevance to daily clinical practice: Which complement investigations should be done and when? What is the importance of anti-factor H antibody detection? Who should be treated with eculizumab? Is plasma exchange therapy still needed? When should eculizumab therapy be initiated? How and when should complement blockade be monitored? Can the approved treatment schedule be modified? What approach should be taken to kidney and/or combined liver-kidney transplantation? How should we limit the risk of meningococcal infection under complement blockade therapy? A pressing question today regards the treatment duration. We discuss the need for prospective studies to establish evidence-based criteria for the continuation or cessation of anticomplement therapy in patients with and without identified complement mutations.
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Fernández C, Lario A, Forés R, Cabrera R. Eculizumab Treatment in a Patient with Hematopoietic Stem Cell Transplantation-Associated Thrombotic Microangiopathy and Steroid-Refractory Acute Graft Versus Host Disease. Hematol Rep 2015; 7:6107. [PMID: 26734129 PMCID: PMC4691680 DOI: 10.4081/hr.2015.6107] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/16/2015] [Accepted: 10/20/2015] [Indexed: 11/23/2022] Open
Abstract
A 30-year-old man with acquired aplastic anemia underwent an HLA-identical bone marrow transplant. He developed a grade III acute graft versus host disease (GVHD) refractory to various lines of treatment. On post-transplant day 196, he was diagnosed with stem cell transplantation-associated thrombotic micro-angiopathy (HSCT-TMA) and he received treatment with eculizumab 900 mg iv weekly for 4 doses followed by a single dose of 1200 mg 2 weeks later. After the first dose of eculizumab, the patient ceased to require transfusions and a progressive improvement in analytical parameters for microangiopathy was observed until their complete normalization. Coinciding with the improved of HSCT-TMA, the patient presented a clear response to his acute GVHD with disappearance of the diarrhea and bilirubin normalization. He was discharged eight weeks after the start of treatment. Unfortunately, one month later, the patient was readmitted for a GVHD relapse and he died two weeks later by an acute respiratory distress syndrome. In our case, the rapid clinical and analytical response to early treatment with eculizumab supports the implication of the complement in HSCT-TMA and suggests that the drug has a beneficial effect when used as coadjuvant therapy in acute GVHD.
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Affiliation(s)
- Cristina Fernández
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda , Madrid, Spain
| | - Ana Lario
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda , Madrid, Spain
| | - Rafael Forés
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda , Madrid, Spain
| | - Rafael Cabrera
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda , Madrid, Spain
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Campistol JM, Arias M, Ariceta G, Blasco M, Espinosa L, Espinosa M, Grinyó JM, Macía M, Mendizábal S, Praga M, Román E, Torra R, Valdés F, Vilalta R, Rodríguez de Córdoba S. An update for atypical haemolytic uraemic syndrome: diagnosis and treatment. A consensus document. Nefrologia 2015; 35:421-47. [PMID: 26456110 DOI: 10.1016/j.nefro.2015.07.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a clinical entity defined as the triad of nonimmune haemolytic anaemia, thrombocytopenia, and acute renal failure, in which the underlying lesions are mediated by systemic thrombotic microangiopathy (TMA). Different causes can induce the TMA process that characterizes HUS. In this document we consider atypical HUS (aHUS) a sub-type of HUS in which the TMA phenomena are the consequence of the endotelial damage in the microvasculature of the kidneys and other organs due to a disregulation of the activity of the complement system. In recent years, a variety of aHUs-related mutations have been identified in genes of the the complement system, which can explain approximately 60% of the aHUS cases, and a number of mutations and polymorphisms have been functionally characterized. These findings have stablished that aHUS is a consequence of the insufficient regulation of the activiation of the complement on cell surfaces, leading to endotelial damage mediated by C5 and the complement terminal pathway. Eculizumab is a monoclonal antibody that inhibits the activation of C5 and blocks the generation of the pro-inflammatory molecule C5a and the formation of the cell membrane attack complex. In prospective studies in patients with aHUS, the use of Eculizumab has shown a fast and sustained interruption of the TMA process and it has been associated with significative long-term improvements in renal function, the interruption of plasma therapy and important reductions in the need of dialysis. According to the existing literature and the accumulated clinical experience, the Spanish aHUS Group published a consensus document with recommendations for the treatment of aHUs (Nefrologia 2013;33[1]:27-45). In the current online version of this document, we update the aetiological classification of TMAs, the pathophysiology of aHUS, its differential diagnosis and its therapeutic management.
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Affiliation(s)
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
| | - Miguel Blasco
- Servicio de Nefrología, Hospital Clínic, Barcelona, España
| | - Laura Espinosa
- Servicio de Nefrología Pediátrica, Hospital La Paz, Madrid, España
| | - Mario Espinosa
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, España
| | - Josep M Grinyó
- Servicio de Nefrología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Manuel Macía
- Servicio de Nefrología, Hospital Virgen de la Candelaria, Santa Cruz de Tenerife, España
| | | | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Elena Román
- Servicio de Nefrología Pediátrica, Hospital La Fe, Valencia, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Fundació Puigvert, Barcelona, España
| | - Francisco Valdés
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, España
| | - Ramón Vilalta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
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Use of Eculizumab in Patients With Allogeneic Stem Cell Transplant-Associated Thrombotic Microangiopathy. Transplantation 2015; 99:1953-9. [DOI: 10.1097/tp.0000000000000601] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Elsallabi O, Bhatt VR, Dhakal P, Foster KW, Tendulkar KK. Hematopoietic Stem Cell Transplant-Associated Thrombotic Microangiopathy. Clin Appl Thromb Hemost 2015; 22:12-20. [PMID: 26239316 DOI: 10.1177/1076029615598221] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA) is a fatal, multifactorial disorder, which may present with thrombocytopenia, hemolysis, acute renal failure, mental status changes and involvement of other organs. The pathogenesis of TA-TMA is complex and includes multiple risk factors such as certain conditioning regimens, calcineurin inhibitors (CNIs), graft-versus-host disease (GVHD), human leukocyte antigen mismatch, and opportunistic infections. The end result of these insults is endothelial injury in the kidney and other organs. Recent studies also indicate a role of complement activation in tissue damage. The lack of sensitive and specific diagnostic tests for TA-TMA often results in delayed diagnosis. Biopsy is not always possible for diagnosis because of the risk of complications such as bleeding. Recently, an emerging role of renal-centered screening approach has been demonstrated, which utilize the monitoring of blood pressure, urine protein, serum lactate dehydrogenase and hemogram for early detection. Therapeutic options are limited, and plasma exchange plays a minor role. Withdrawal of offending agent such as CNIs and the use of rituximab can be effective in some patients. However, the current treatment strategy is suboptimal and associated with high mortality rate. Recently, eculizumab has been utilized in a few patients with good outcomes. Patients, who develop TA-TMA, are also at an increased risk of GVHD, infection, renal, cardiovascular, and other complications, which can contribute to high mortality. Better understanding of molecular pathogenesis, improvement in posttransplant management, leading to early diagnosis, and management of TA-TMA are required to improve outcomes of this fatal entity.
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Affiliation(s)
- Osama Elsallabi
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Prajwal Dhakal
- Department of Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Kirk W Foster
- Department of Pathology and Microbiology, Division of Renal Pathology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ketki K Tendulkar
- Department of Internal Medicine, Division of Nephrology, University of Nebraska Medical Center, Omaha, NE, USA
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Thrombotic thrombocytopenic purpura in a patient with lenalidomide-responsive multiple myeloma. Ann Hematol 2015; 94:1605-7. [DOI: 10.1007/s00277-015-2421-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
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48
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Reig Mezquida JP, Jover AS, Ansótegui Barrera E, Escrivá Peiró J, Pastor Colom MD, Pastor Guillem J. Microangiopatía trombótica asociada a tacrolimus en trasplante pulmonar. Arch Bronconeumol 2015; 51:e23-4. [DOI: 10.1016/j.arbres.2014.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/24/2014] [Accepted: 07/07/2014] [Indexed: 11/27/2022]
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Renal and neurological response with eculizumab in a patient with transplant associated thrombotic microangiopathy after allogeneic hematopoietic progenitor cell transplantation. Case Rep Hematol 2015; 2015:425410. [PMID: 25705530 PMCID: PMC4326272 DOI: 10.1155/2015/425410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/30/2014] [Accepted: 12/30/2014] [Indexed: 01/13/2023] Open
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a challenge after allogeneic hematopoietic progenitor cell transplantation, considering the diagnostic uncertainties and lack of established treatment. We report a 43-year-old male patient who was diagnosed as TA-TMA after allogeneic progenitor cell transplantation for a progressive ALK negative anaplastic large cell lymphoma and responded to eculizumab with dramatically improving neurological status and renal function. Rapid neurological and renal recovery achieved after eculizumab could support a possible relationship between complement activation and TA-TMA. Eculizumab should be a reasonable treatment approach in patients with TA-TMA after allogeneic hematopoietic progenitor cell transplantation.
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Ojeda-Uribe M, Merieau S, Guillon M, Aujoulat O, Hinschberger O, Eisenmann JC, Kenizou D, Debliquis A, Veyradier A, Chantrel F. Secondary thrombotic microangiopathy in two patients with Philadelphia-positive hematological malignancies treated with imatinib mesylate. J Oncol Pharm Pract 2015; 22:361-70. [PMID: 25591869 DOI: 10.1177/1078155214568580] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Drug-mediated thrombotic microangiopathy may cause life-threatening medical emergencies. Novel targeted therapies have dramatically changed the prognosis of a number of oncological diseases. Tyrosine kinase inhibitors of the Breakpoint Cluster Region-Abelson (BCR-ABL) oncoprotein are used in patients with chronic myeloid leukemia or Philadelphia chromosome-positive acute lymphoblastic leukemia. Imatinib mesylate, which was the first anti-BCR-ABL tyrosine kinase inhibitor, has demonstrated a high tolerance profile and efficacy in these patients for many years. Good results have also been observed in patients with gastrointestinal stromal tumors. In this study, we describe two patients with Philadelphia chromosome-positive hematological malignancies who presented with secondary thrombotic microangiopathy that was most likely linked to the use of imatinib. Other potential causes of thrombotic microangiopathy were discarded, and the predisposing role of some comorbidities and potential short or long-term drug-drug interactions was assessed. The clinical and biological data were more indicative of atypical secondary hemolytic uremic syndrome in one of the cases and of secondary thrombotic microangiopathy with renal and cardiac impairment in the other, which is also categorized as secondary hemolytic uremic syndrome. The outcome was favorable after imatinib discontinuation and the treatment of severe cardiac and renal failures.
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Affiliation(s)
- Mario Ojeda-Uribe
- Department of Hematology and Cellular Therapy Unit, Hôpital Emile Muller, Mulhouse, France Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France
| | - Sylvain Merieau
- Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | - Marie Guillon
- Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | | | - Olivier Hinschberger
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Department of Internal Medicine, Hôpital Emile Muller, Mulhouse, France
| | - Jean-Claude Eisenmann
- Department of Hematology and Cellular Therapy Unit, Hôpital Emile Muller, Mulhouse, France
| | - David Kenizou
- Department of Cardiology, Hôpital Emile Muller, Mulhouse, France
| | - Agathe Debliquis
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | - Agnès Veyradier
- Department of Biological Hematology, Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Université Paris, Clamart, France
| | - François Chantrel
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Department of Nephrology, Hôpital Emile Muller, Mulhouse, France
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