1
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Seguí IG, Mingot Castellano ME, Izquierdo CP, de la Rubia J. Should we consider caplacizumab as routine treatment for acute thrombotic thrombocytopenic purpura? An expert perspective on the pros and cons. Expert Rev Hematol 2024; 17:9-25. [PMID: 38353182 DOI: 10.1080/17474086.2024.2318347] [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: 11/15/2023] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening disorder. Caplacizumab has been the latest drug incorporated into the initial treatment of acute episodes, allowing for faster platelet recovery and a decrease in refractoriness, exacerbation, thromboembolic events, and mortality. However, caplacizumab is also associated with a bleeding risk and higher treatment costs, which prevent many centers from using it universally. AREAS COVERED Studies that included iTTP and/or caplacizumab to date were selected for this review using PubMed and MEDLINE platforms. We describe outcomes in the pre-caplacizumab era and after it, highlighting the benefits and risks of its use early in frontline, and also pointing out special situations that require careful management. EXPERT OPINION It is clear that the availability of caplacizumab has significantly and favorably impacted the management of iTTP patients. Whether this improvement is cost-effective still remains uncertain, and data on long-term sequelae and different healthcare systems will help to clarify this point. In addition, evidence of the bleeding/thrombotic risk of iTTP patients under this drug needs to be better addressed in future studies.
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Affiliation(s)
- Inés Gómez Seguí
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
| | | | | | - Javier de la Rubia
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
- Internal Medicine, Universidad Católica "San Vicente Mártir", Valencia, Spain
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2
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Rock G. Biomarkers of response and prognosis in TTP. Transfus Apher Sci 2023; 62:103676. [PMID: 36890096 DOI: 10.1016/j.transci.2023.103676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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3
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Chen M, Shortt J. Plasma-cell directed therapy for immune thrombotic thrombocytopenic purpura (iTTP). Transfus Med Rev 2022; 36:204-214. [DOI: 10.1016/j.tmrv.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
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4
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Bae SH, Kim SH, Bang SM. Recent advances in the management of immune-mediated thrombotic thrombocytopenic purpura. Blood Res 2022; 57:37-43. [PMID: 35483924 PMCID: PMC9057674 DOI: 10.5045/br.2022.2022005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially life-threatening thrombotic microangiopathy caused by autoantibody-mediated severe ADAMTS13 deficiency. TTP should be suspected in patients with microangiopathic hemolytic anemia and thrombocytopenia without a definite cause. Early detection of iTTP and prompt treatment with plasma exchange and corticosteroids are essential. Rituximab administration should be considered for refractory or relapsed iTTP, and can be used as a first-line adjuvant or preemptive therapy. Treatment with caplacizumab, a novel anti-von Willebrand factor nanobody, resulted in a faster time to platelet count response, significant reduction in iTTP-related deaths, and reduced incidence of refractory iTTP. TTP survivors showed a higher rate of chronic morbidities, including cardiovascular disease and neurocognitive impairment, which can lead to a poor quality of life and higher mortality rate. Meticulous long-term follow-up of TTP survivors is crucial.
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Affiliation(s)
- Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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5
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Karsenty CL, Kirk SE, Helber HL, Esquilin JM, Despotovic JM, Grimes AB. Molecular Diagnosis Is Vital to the Accurate Classification and Management of Thrombotic Thrombocytopenic Purpura in Children. Front Immunol 2022; 13:836960. [PMID: 35479064 PMCID: PMC9038040 DOI: 10.3389/fimmu.2022.836960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening hematologic disease, presenting a myriad of diagnostic and management challenges in children. Here, we provide a review of this disorder and discuss 2 exemplary cases of TTP occurring in adolescents, emphasizing the need for consideration of late-onset congenital TTP (cTTP). We demonstrate the importance of early confirmation of ADAMTS13 enzyme deficiency and the presence or absence of ADAMTS13 inhibitor in order to rapidly initiate the appropriate life-saving therapies. Ultimately, molecular testing is paramount to distinguishing between congenital and acquired immune-mediated TTP.
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Affiliation(s)
- Cecile L. Karsenty
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
- *Correspondence: Cecile L. Karsenty,
| | - Susan E. Kirk
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Hannah L. Helber
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Jose M. Esquilin
- Methodist Children’s Hospital, San Antonio, TX, United States
- Methodist Physicians Pediatric Specialists of Texas, San Antonio, TX, United States
| | - Jenny M. Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Amanda B. Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
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6
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Pavenski K, Huang SHS, Patriquin CJ. Predictors of relapse and preventative strategies in immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:1027-1040. [PMID: 34747320 DOI: 10.1080/17474086.2021.2003703] [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] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare autoimmune blood disorder, which presents with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis and is caused by severe deficiency of ADAMTS13. iTTP may result in both acute and chronic complications and is rapidly fatal without expedient treatment. Life-time risk of relapse is approximately 40%. AREAS COVERED A number of predictors of relapse has been described in the literature. The most well-studied predictor of relapse is persistent ADAMTS13 deficiency; however, it is not a perfect marker. Relapse can be prevented by treatment with immunosuppressive medications, with rituximab being the most studied. EXPERT OPINION Patients who recover from iTTP should be regularly assessed, including with ADAMTS13 activity testing. The optimal frequency of assessments has not been established, but every 3 months is recommended. Considering the potential for significant organ damage and mortality associated with iTTP relapse, patients in remission and with persistent ADAMTS13 activity of 10-20% should be prophylactically treated with immunosuppression. Additional markers to precisely identify patients at higher risk of relapse are needed.
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Affiliation(s)
- Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Shih-Han Susan Huang
- Department of Medicine, Division of Nephrology, Western University, London, Canada
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
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Gómez-Seguí I, Pascual Izquierdo C, de la Rubia Comos J. Best practices and recommendations for drug regimens and plasma exchange for immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:707-719. [PMID: 34275393 DOI: 10.1080/17474086.2021.1956898] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. TTP pathophysiology is based on a severe ADAMTS13 deficiency, and is a medical emergency with fatal outcome if appropriate treatment is not initiated promptly. AREAS COVERED Authors will review the best options currently available to minimize mortality, prevent relapses, and obtain the best clinical response in patients with immune TTP (iTTP). Available bibliography about iTTP treatment has been searched in Library's MEDLINE/PubMed database from January 1990 until April 2021. EXPERT OPINION The generalized use of plasma exchange marked a paradigm in the management of iTTP. In recent years, strenuous efforts have been done for a better understanding of the pathophysiology of this disease, improve diagnosis, optimize treatment, reduce mortality, and prevent recurrences. The administration of front-line rituximab and, more recently, the availability of caplacizumab, the first targeted therapy for iTTP, have been steps toward a further reduction in early mortality and for the prevention of relapses.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio De Hematología Y Hemoterapia, Hospital General , Universitario Gregorio Marañón. Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier de la Rubia Comos
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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8
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Gómez-Seguí I, Fernández-Zarzoso M, de la Rubia J. A critical evaluation of caplacizumab for the treatment of acquired thrombotic thrombocytopenic purpura. Expert Rev Hematol 2020; 13:1153-1164. [PMID: 32876503 DOI: 10.1080/17474086.2020.1819230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Acquired thrombotic thrombocytopenic purpura (aTTP) is a thrombotic microangiopathy caused by inhibitory autoantibodies against ADAMTS13 protein. Until recently, the combination of plasma exchange (PEX) and immunosuppression has been the standard front-line treatment in this disorder. However, aTTP-related mortality, refractoriness, and relapse are still a matter of concern. Areas covered: The better understanding of the pathophysiological mechanisms of aTTP has allowed substantial improvements in the diagnosis and treatment of this disease. Recently, the novel anti-VWF nanobody caplacizumab has been approved for acute episodes of aTTP. Caplacizumab is capable to block the adhesion of platelets to VWF, therefore inhibiting microthrombi formation in the ADAMTS13-deficient circulation. In this review, the characteristics of caplacizumab together with the available data of its efficacy and safety in the clinical setting will be analyzed. Besides, the current scenario of aTTP treatment will be provided, including the role of other innovative drugs. Expert opinion: With no doubt, caplacizumab is going to change the way we treat aTTP. In combination with standard treatment, caplacizumab can help to significantly reduce aTTP-related mortality and morbidity and could spare potential long-term consequences by minimizing the risk of exacerbation.
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Affiliation(s)
| | | | - Javier de la Rubia
- Hematology Service, University Hospital Doctor Peset , Valencia, Spain.,Internal Medicine, School of Medicine and Dentistry, Catholic University of Valencia , Valencia, Spain
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Chao SH, Chang YL, Yen JC, Liao HT, Wu TH, Yu CL, Tsai CY, Chou YC. Efficacy and safety of rituximab in autoimmune and microangiopathic hemolytic anemia: a systematic review and meta-analysis. Exp Hematol Oncol 2020; 9:6. [PMID: 32322437 PMCID: PMC7161265 DOI: 10.1186/s40164-020-00163-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background The efficacy and safety of rituximab (RTX) on hemolytic anemia (HA) is unknown. Therefore we retrospectively analyze the efficacy and safety of RTX in autoimmune hemolytic anemia (AIHA) and microangiopathic hemolytic anemia (MAHA) from the previous literature. Methods Data in clinical trials and observational studies were collected from PubMed, Cochrane, Embase, and Google Scholar until Oct 15, 2018. The efficacy and safety of RTX in patients with AIHA or MAHA were assessed and overall response rates (ORRs), complete response rates (CRRs), adverse events (AEs) and relapse rates (RRs) were extracted if available. A meta-analysis was performed with a random-effects model, estimating mean proportions in all studies, and relative rates in comparative studies. Results After quality assessment, a total of 37 investigations encompassing 1057 patients eligible for meta-analysis were included. Pooled mean proportion of ORR was 0.84 (95% confidence interval [CI] 0.80–0.88), and that of CRR was 0.61 (95% CI 0.49–0.73). Mean AE rate was 0.14 (95% CI 0.10–0.17), and mean RR was 0.21 (95% CI 0.15–0.26). Relative ORR was 1.18 (95% CI 1.02–1.36), and relative CRR was 1.17 (95% CI 0.98–1.39) fold more than the respective non-RTX counter parts. Relative AE rate was 0.77 (95% CI 0.36–1.63), and relative RR was 0.93 (95% CI 0.56–1.55) fold less than the respective non-RTX counter parts. Conclusion RTX is more effective than the treatments without RTX for AIHA and MAHA and is well-tolerated.
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Affiliation(s)
- Shih-Hsuan Chao
- 1Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Yuh-Lih Chang
- 2Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiin-Cherng Yen
- 1Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Hsien-Tzung Liao
- 3Division of Allergy Immunology & Rheumatology, Taipei Veterans General Hospital, 201 Shih-Pai Rd Sec 2, Taipei, 112 Taiwan
| | - Tsai-Hung Wu
- 4Division of Nephrology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Li Yu
- 5Division of Rheumatology Immunology & Allergy, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Youh Tsai
- 3Division of Allergy Immunology & Rheumatology, Taipei Veterans General Hospital, 201 Shih-Pai Rd Sec 2, Taipei, 112 Taiwan
| | - Yueh-Ching Chou
- 2Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
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10
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How targeted therapy disrupts the treatment paradigm for acquired TTP: the risks, benefits, and unknowns. Blood 2019; 134:415-420. [DOI: 10.1182/blood.2019000954] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/13/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
Insights into immune-mediated thrombotic thrombocytopenic purpura (iTTP) pathophysiology have led to novel targeted therapies. Immunomodulatory strategies target anti-ADAMTS13 antibodies: rituximab is effective in inducing responses in refractory/relapsed TTP and increasing relapse-free survival; caplacizumab targets the von Willebrand factor–platelet interaction to hasten platelet count recovery and reduce mortality and TTP-related ischemic events. Bortezomib and recombinant ADAMTS13 are under investigation. This review examines how targeted therapies are disrupting current treatment paradigms to improve outcomes of iTTP.
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11
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Dane K, Chaturvedi S. Beyond plasma exchange: novel therapies for thrombotic thrombocytopenic purpura. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:539-547. [PMID: 30504355 PMCID: PMC6246029 DOI: 10.1182/asheducation-2018.1.539] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The advent of plasma exchange has dramatically changed the prognosis of acute thrombotic thrombocytopenic purpura (TTP). Recent insights into TTP pathogenesis have led to the development of novel therapies targeting pathogenic anti-ADAMTS13 antibody production, von Willebrand factor (VWF)-platelet interactions, and ADAMTS13 replacement. Retrospective and prospective studies have established the efficacy of rituximab as an adjunct to plasma exchange for patients with acute TTP, either upfront or for refractory disease. Relapse prevention is a major concern for survivors of acute TTP, and emerging data support the prophylactic use of rituximab in patients with persistent or recurrent ADAMTS13 deficiency in clinical remission. Capalcizumab, a nanobody directed against domain A1 of VWF that prevents the formation of VWF-platelet aggregates, recently completed phase 2 (TITAN) and 3 (HERCULES) trials with encouraging results. Compared with placebo, caplacizumab shortened the time to platelet recovery and may protect against microthrombotic tissue injury in the acute phase of TTP, though it does not modify the underlying immune response. Other promising therapies including plasma cell inhibitors (bortezomib), recombinant ADAMTS13, N-acetyl cysteine, and inhibitors of the VWF-glycoprotein Ib/IX interaction (anfibatide) are in development, and several of these agents are in prospective clinical studies to evaluate their efficacy and role in TTP. In the coming years, we are optimistic that novel therapies and international collaborative efforts will usher in even more effective, evidence-based approaches to address refractory acute TTP and relapse prevention.
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Affiliation(s)
- Kathryn Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD; and
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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12
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Falter T, Herold S, Weyer-Elberich V, Scheiner C, Schmitt V, von Auer C, Messmer X, Wild P, Lackner KJ, Lämmle B, Scharrer I. Relapse Rate in Survivors of Acute Autoimmune Thrombotic Thrombocytopenic Purpura Treated with or without Rituximab. Thromb Haemost 2018; 118:1743-1751. [PMID: 30235478 PMCID: PMC6202932 DOI: 10.1055/s-0038-1668545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Autoimmune thrombotic thrombocytopenic purpura (iTTP) is caused by autoantibody-mediated severe a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13 (ADAMTS13) deficiency leading to micro-angiopathic haemolytic anaemia (MAHA) and thrombocytopenia with organ damage. Patients survive with plasma exchange (PEX), fresh frozen plasma replacement and corticosteroid treatment. Anti-CD20 monoclonal antibody rituximab is increasingly used in patients resistant to conventional PEX or relapsing after an acute bout. OBJECTIVE This retrospective observational study focused on the relapse rate and possible influencing factors including treatment with rituximab first introduced in 2003. PATIENTS AND METHODS Seventy patients treated between January 2003 and November 2014 were evaluated. Number, duration, clinical manifestations, laboratory data and treatment of acute episodes were documented. Diagnostic criteria of acute iTTP were thrombocytopenia, MAHA, increased lactate dehydrogenase and severe ADAMTS13 deficiency. RESULTS Fifty-four female and 16 male patients had a total of 224 acute episodes over a median observation period of 8.3 years. The relapse rate was 2.6% per month, for women 2.4% and for men 3.5% per month. Since 2003, 17 patients with a first iTTP episode were treated with rituximab, whereas 28 were not. There was a trend towards lower relapse rates after rituximab treatment over the ensuing years. However, this was statistically not significant. CONCLUSION This analysis does not show a significant reduction of acute iTTP relapses by rituximab given during an acute bout. Initial episodes are characterized by more severe clinical signs compared with the less severe relapses. Furthermore, men suffer significantly more frequent and considerably more serious acute relapses.
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Affiliation(s)
- Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Stephanie Herold
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Veronika Weyer-Elberich
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Carina Scheiner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Veronique Schmitt
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Charis von Auer
- Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Xavier Messmer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany.,Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Philipp Wild
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany.,University Clinic of Hematology & Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Inge Scharrer
- Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Rheinland-Pfalz, Germany
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13
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Treatment of Concurrent Thrombotic Thrombocytopenic Purpura and Graves' Disease: A Report on Two Cases. Case Rep Endocrinol 2018; 2018:5747969. [PMID: 30159177 PMCID: PMC6106962 DOI: 10.1155/2018/5747969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
Abstract
Graves' disease (GD) and thrombotic thrombocytopenic purpura (TTP) are autoimmune diseases caused by autoantibodies against the TSH receptor (TRAb) and the enzyme ADAMTS13. We here report on two patients with concurrent GD and TTP, who achieved sustained remission of both conditions with the TTP treatment regimen and thiamazole. Both patients suffered from relapsing TTP and were diagnosed with GD concomitantly at the time of relapse. They were treated with steroids, plasma exchange, rituximab, and thiamazole. This therapy induced complete remission of TTP. TRAb levels also decreased rapidly and both patients developed subclinical hypothyroidism three and five weeks later. Our observations suggest that TTP and GD may be concomitant and that GD possibly triggers a relapse of TTP. The combination of thyrostatic treatment and immunosuppression with PE, rituximab, and steroids is able to induce rapid and prolonged remission of GD.
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14
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Ling J, Ma Z, Liu L, Yin J, Su J, Shen F, Xie L, Hu S. Identification of a crucial tryptophan residue in ADAMTS13 required for its secretion and enzymatic activity. Clin Exp Pharmacol Physiol 2018; 45:1181-1186. [PMID: 29920743 DOI: 10.1111/1440-1681.12996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Jing Ling
- Department of Hematology and Oncology; Children's Hospital of Soochow University; Suzhou China
| | - Zhenni Ma
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health; Jiangsu Institute of Hematology; The First Affiliated Hospital of Soochow University; Suzhou China
- Collaborative Innovation Center of Hematology; Soochow University; Suzhou China
| | - Ling Liu
- Department of Orthopedics; Clinical Medical Research Center of Jiangsu Province; The First Affiliated Hospital of Soochow University; Suzhou China
| | - Jie Yin
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health; Jiangsu Institute of Hematology; The First Affiliated Hospital of Soochow University; Suzhou China
- Collaborative Innovation Center of Hematology; Soochow University; Suzhou China
| | - Jian Su
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health; Jiangsu Institute of Hematology; The First Affiliated Hospital of Soochow University; Suzhou China
- Collaborative Innovation Center of Hematology; Soochow University; Suzhou China
| | - Fei Shen
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health; Jiangsu Institute of Hematology; The First Affiliated Hospital of Soochow University; Suzhou China
- Collaborative Innovation Center of Hematology; Soochow University; Suzhou China
| | - Liqian Xie
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health; Jiangsu Institute of Hematology; The First Affiliated Hospital of Soochow University; Suzhou China
- Collaborative Innovation Center of Hematology; Soochow University; Suzhou China
| | - Shaoyan Hu
- Department of Hematology and Oncology; Children's Hospital of Soochow University; Suzhou China
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15
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Harmon P, Cojocari E, Mader CL, Galloway C, Buchholz M, Lewis B, Sinclair S. Nurses best practices for the management of thrombotic thrombocytopenic purpura. Transfus Apher Sci 2018; 57:437-444. [DOI: 10.1016/j.transci.2018.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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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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18
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Uhl L, Kiss JE, Malynn E, Terrell DR, Vesely SK, George JN. Rituximab for thrombotic thrombocytopenic purpura: lessons from the STAR trial. Transfusion 2017; 57:2532-2538. [DOI: 10.1111/trf.14193] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Lynne Uhl
- Beth Israel Deaconess Medical Center
- Harvard Medical SchoolBoston Massachusetts
| | | | | | | | - Sara K. Vesely
- University of Oklahoma Health Sciences CenterOklahoma City Oklahoma
| | - James N. George
- University of Oklahoma Health Sciences CenterOklahoma City Oklahoma
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19
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Gavriilaki E, Sakellari I, Anagnostopoulos A, Brodsky RA. Transplant-associated thrombotic microangiopathy: opening Pandora's box. Bone Marrow Transplant 2017; 52:1355-1360. [PMID: 28287636 DOI: 10.1038/bmt.2017.39] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/01/2017] [Accepted: 02/05/2017] [Indexed: 12/20/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an early complication of hematopoietic cell transplantation (HCT). A high mortality rate is documented in patients who are refractory to calcineurin inhibitor cessation. Estimates of TA-TMA prevalence vary significantly and are higher in allogeneic compared with autologous HCT. Furthermore, our understanding of the pathophysiology that is strongly related to diagnosis and treatment options is limited. Recent evidence has linked TA-TMA with atypical hemolytic uremic syndrome, a disease of excessive activation of the alternative pathway of complement, opening the Pandora's box in treatment options. As conventional treatment management is highly inefficient, detection of complement activation may allow for early recognition of patients who will benefit from complement inhibition. Preliminary clinical results showing successful eculizumab administration in children and adults with TA-TMA need to be carefully evaluated. Therefore, realizing the unmet needs of better understanding TA-TMA in this complex setting, we aimed to summarize current knowledge focusing on (1) critical evaluation of diagnostic criteria, (2) epidemiology and prognosis, (3) recent evidence of complement activation and endothelial damage and (4) treatment options.
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Affiliation(s)
- E Gavriilaki
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece.,Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - I Sakellari
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - A Anagnostopoulos
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - R A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Clark WF, Patriquin C, Licht C, Huang SH, Rock G. Simple diagnosis and treatment algorithm for adult thrombotic microangiopathy. Transfus Apher Sci 2017; 56:50-51. [PMID: 28139433 DOI: 10.1016/j.transci.2016.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- W F Clark
- University of Western Ontario, London Health Sciences Centre, London, Canada.
| | | | - C Licht
- Sick Kids Hospital, University of Toronto, Toronto, Canada
| | - S H Huang
- University of Western Ontario, London Health Sciences Centre, London, Canada
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21
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Rock G, Clark W, Foley R, Huang S, Laroche V, Klassen J, Patriquin C, Pavenski K. TTP: One of the TMA’s—How to sort it out. Transfus Apher Sci 2017; 56:57-58. [DOI: 10.1016/j.transci.2016.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Clark WF, Huang SHS, Walsh MW, Farah M, Hildebrand AM, Sontrop JM. Plasmapheresis for the treatment of kidney diseases. Kidney Int 2016; 90:974-984. [DOI: 10.1016/j.kint.2016.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 01/24/2023]
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23
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Sakellari I, Gavriilaki E, Boussiou Z, Batsis I, Mallouri D, Constantinou V, Kaloyannidis K, Yannaki E, Bamihas G, Anagnostopoulos A. Transplant-associated thrombotic microangiopathy: an unresolved complication of unrelated allogeneic transplant for hematologic diseases. Hematol Oncol 2016; 35:932-934. [DOI: 10.1002/hon.2346] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/02/2016] [Indexed: 12/28/2022]
Affiliation(s)
- Ioanna Sakellari
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Eleni Gavriilaki
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Zoi Boussiou
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Ioannis Batsis
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Despoina Mallouri
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - V. Constantinou
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | | | - Evangelia Yannaki
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Gerasimos Bamihas
- Hematology Department and BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
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24
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Acedillo RR, Govind M, Kashgary A, Clark WF. Treatment of severe, refractory and rapidly evolving thrombotic thrombocytopenic purpura. BMJ Case Rep 2016; 2016:bcr-2016-215491. [PMID: 27284100 DOI: 10.1136/bcr-2016-215491] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 36-year-old man presented to hospital with gross haematuria and evidence of severe, refractory thrombotic thrombocytopenic purpura. Initial treatment with high-volume plasma exchange therapy and early administration of rituximab failed to achieve a sustained clinical response. His clinical course was complicated by left hemianopsia and despite an urgent splenectomy he developed a large right-sided stroke with malignant cerebral oedema that required an emergent decompressive craniotomy. He also had numerous infectious complications as a consequence of an aggressive immunosuppressive strategy. While the patient did not respond to cyclophosphamide, cyclosporine, N-acetylcysteine, and one course of bortezomib, he eventually responded to a second course of bortezomib. One year later, the patient remains in remission and maintains excellent cognitive function. However, he has not completely recovered from his stroke and continues to participate in rehabilitation for his residual physical deficits.
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Affiliation(s)
- Rey R Acedillo
- Department of Medicine, Division of Nephrology, London Health Sciences Centre, London, Canada
| | - Mayur Govind
- Department of Medicine, Division of Nephrology, London Health Sciences Centre, London, Canada
| | - Abdullah Kashgary
- Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - William F Clark
- Department of Medicine, Division of Nephrology, London Health Sciences Centre, London, Canada
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25
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An Idiopathic Thrombocytopenic Purpura Patient Treated With Homeopathy: A Case Report. HOSPITAL PRACTICES AND RESEARCH 2016. [DOI: 10.20286/hpr-010271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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26
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Efficacy and safety of rituximab in Japanese patients with acquired thrombotic thrombocytopenic purpura refractory to conventional therapy. Int J Hematol 2016; 104:228-35. [DOI: 10.1007/s12185-016-2019-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/07/2016] [Accepted: 05/08/2016] [Indexed: 10/21/2022]
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27
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Soucemarianadin M, Benhamou Y, Delmas Y, Pichereau C, Maury E, Pène F, Halimi JM, Presne C, Thouret JM, Veyradier A, Coppo P. Twice-daily therapeutical plasma exchange-based salvage therapy in severe autoimmune thrombotic thrombocytopenic purpura: the French TMA Reference Center experience. Eur J Haematol 2016; 97:183-91. [DOI: 10.1111/ejh.12706] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Myriam Soucemarianadin
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Réanimation; Centre Hospitalier Métropole Savoie; Chambéry France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Inserm U1096; Rouen France
- Service de Médecine Interne; CHU Charles Nicolle; Rouen France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Néphrologie Transplantation Dialyse; Centre Hospitalier Universitaire; Bordeaux France
| | - Claire Pichereau
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Service de Réanimation Médicale; CHU Saint-Antoine; Paris France
| | - Eric Maury
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Service de Réanimation Médicale; CHU Saint-Antoine; Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Réanimation Polyvalente; Hôpital Cochin; Paris France
- Université Paris 5; Paris France
| | - Jean-Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de néphrologie-immunologie clinique; hôpital Bretonneau; Tours France
- EA 4245; université François-Rabelais 2; boulevard Tonnellé; Tours France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Néphrologie - Médecine Interne; Hôpital Sud; Amiens France
| | - Jean-Marc Thouret
- Service de Réanimation; Centre Hospitalier Métropole Savoie; Chambéry France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service d'Hématologie Biologique; Hôpital Lariboisière; Paris France
- Univ. Paris Diderot; Sorbonne Paris Cité; Paris France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Inserm U1009; Institut Gustave Roussy; Villejuif France
- Service d'Hématologie; Hôpital Saint-Antoine; Paris France
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