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Willyanto SE, Alimsjah YA, Tanjaya K, Tuekprakhon A, Pawestri AR. Comprehensive analysis of the efficacy and safety of CAR T-cell therapy in patients with relapsed or refractory B-cell acute lymphoblastic leukaemia: a systematic review and meta-analysis. Ann Med 2024; 56:2349796. [PMID: 38738799 PMCID: PMC11095278 DOI: 10.1080/07853890.2024.2349796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/05/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Relapse/refractory B-cell acute lymphoblastic leukaemia (r/r B-ALL) represents paediatric cancer with a challenging prognosis. CAR T-cell treatment, considered an advanced treatment, remains controversial due to high relapse rates and adverse events. This study assessed the efficacy and safety of CAR T-cell therapy for r/r B-ALL. METHODS The literature search was performed on four databases. Efficacy parameters included minimal residual disease negative complete remission (MRD-CR) and relapse rate (RR). Safety parameters constituted cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). RESULTS Anti-CD22 showed superior efficacy with the highest MRD-CR event rate and lowest RR, compared to anti-CD19. Combining CAR T-cell therapy with haploidentical stem cell transplantation improved RR. Safety-wise, bispecific anti-CD19/22 had the lowest CRS rate, and anti-CD22 showed the fewest ICANS. Analysis of the costimulatory receptors showed that adding CD28ζ to anti-CD19 CAR T-cell demonstrated superior efficacy in reducing relapses with favorable safety profiles. CONCLUSION Choosing a more efficacious and safer CAR T-cell treatment is crucial for improving overall survival in acute leukaemia. Beyond the promising anti-CD22 CAR T-cell, exploring costimulatory domains and new CD targets could enhance treatment effectiveness for r/r B-ALL.
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Affiliation(s)
| | - Yohanes Audric Alimsjah
- Bachelor Study Program of Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Krisanto Tanjaya
- Bachelor Study Program of Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Aekkachai Tuekprakhon
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Aulia Rahmi Pawestri
- Department of Parasitology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
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2
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Wang J, Luo Y, Jia C, Yang J, Wang B, Zheng J, Jing Y, Chen W, Yang W, Zhu G, Qin M, Li S. Successful use of defibrotide to treat allogeneic hematopoietic stem cell transplantation associated thrombotic microangiopathy in pediatric patients: report from Chinese single center. Bone Marrow Transplant 2024; 59:1483-1485. [PMID: 39043925 DOI: 10.1038/s41409-024-02368-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/08/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Jiayu Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yanhui Luo
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chenguang Jia
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jun Yang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Bin Wang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jie Zheng
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yuanfang Jing
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wei Chen
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wei Yang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Guanghua Zhu
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
| | - Maoquan Qin
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
| | - Sidan Li
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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3
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Braidotti S, Curci D, Maestro A, Zanon D, Maximova N, Di Paolo A. Effect of early post-hematopoietic stem cell transplant tacrolimus concentration on transplant outcomes in pediatric recipients: One facility's ten-year experience of immunosuppression with tacrolimus. Int Immunopharmacol 2024; 138:112636. [PMID: 38991629 DOI: 10.1016/j.intimp.2024.112636] [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: 05/17/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/13/2024]
Abstract
Acute graft-versus-host disease (GVHD) is a common life-threatening complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), ranking as the second leading cause of death among recipients, surpassed only by disease relapse. Tacrolimus is commonly used for GVHD prophylaxis, but achieving therapeutic blood levels is challenging, particularly in pediatrics, due to the narrow therapeutic window and the high interindividual variability. The retrospective study conducted at IRCCS "Burlo Garofolo" in Italy aimed to assess the impact of early post-HSCT tacrolimus levels on transplant-related outcomes in pediatric recipients. The population pharmacokinetic model (POP/PK) was set up to describe tacrolimus pharmacokinetics. Elevated tacrolimus (>12-15 ng/ml) levels within the initial weeks post-HSCT are associated with reduced post-transplant infections (p < 0.0001) and decreased incidence of early transplant-related events (p < 0.01), including a lower incidence of acute GVHD (p < 0.05 on day 0). High tacrolimus exposure can lead to an increased risk of chronic GVHD (p < 0.0001) and reduced overall survival (p < 0.01). Personalized dosing and therapeutic monitoring of tacrolimus are crucial to ensure optimal outcomes. POP/PK could help achieve this goal, giving us a model by which we can balance immunosuppression while looking at the patient's general well-being and providing the necessary treatment.
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Affiliation(s)
- Stefania Braidotti
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy.
| | - Debora Curci
- Advanced Translational Diagnostic Laboratory, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy.
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy.
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy.
| | - Natalia Maximova
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy.
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Pisa, Pisa, Italy.
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4
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Yang M, Wang L, Sun XF, Yin DQ. Renal thrombotic microangiopathy is associated with poor renal survival in children with immunoglobulin A nephropathy. Nephrology (Carlton) 2024; 29:579-587. [PMID: 38716715 DOI: 10.1111/nep.14313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/16/2024] [Accepted: 04/24/2024] [Indexed: 08/17/2024]
Abstract
AIM The aim of this study was to examine the clinical and pathological characteristics as well as the prognosis of immunoglobulin A nephropathy (IgAN) accompanied by renal thrombotic microangiopathy (rTMA) in paediatric patients. METHODS After balancing epidemiological characteristics and pathological types between groups, 427 patients (rTMA group: 23, non-rTMA group: 46) were included. The clinical and pathological features, prognosis and clinical risk factors of the two groups were analysed. RESULTS IgAN-rTMA children showed more severe clinical and pathological manifestations. The findings from the logistic regression analysis indicated that hypercellularity 1 (E1) (HR: 0.805, 95% CI: 0.763 ~ 1.452, P = .016), endocapillary proliferation (HR: 1.214, 95% CI: 0.093 ~ 4.815, P = .025) and C3 staining (HR: 7.554, 95% CI: 2.563 ~ 15.729, P = .037) were the risk factors for rTMA in children with IgAN. The renal survival in rTMA group was lower than non-rTMA group (χ2 = 18.467, P = .000). Cox regression analysis showed that E1 (HR: 7.441, 95% CI: 1.095 ~ 10.768, P = .037), C3 disposition (HR: 3.414, 95% CI: 0.834 ~ 11.578, P = .027) and rTMA (HR: 8.918, 95% CI: 1.032 ~ 16.754, P = .041) were identified as independent risk factors for the development of end-stage renal disease (ESRD). CONCLUSION The presence of rTMA had a significant impact on the severity and prognosis of IgAN. And rTMA has been identified as an independent risk factor for the development of renal failure in children diagnosed with IgAN.
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Affiliation(s)
- Meng Yang
- Institute of Literature in Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Le Wang
- Department of Acupuncture and Moxibustion, Beijing GuLou hospital of Traditional Chinese Medicine, Beijing, China
| | - Xiong-Fei Sun
- Department of Pediatrics, Wuxi Deshu Clinic of Traditional Chinese Medicine, Wuxi, China
| | - Dong-Qi Yin
- Department of Pediatrics, First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
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5
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Zhou X, Ye Y, Jin A, Pan Z, Xu Z, Ding S, Yan J, Cheng Y, Huang Y, Cao K, Xie W, Zhang J, Xu L, Zhou W, Huang L. Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study. BMC Nurs 2024; 23:535. [PMID: 39113009 PMCID: PMC11304727 DOI: 10.1186/s12912-024-02093-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/13/2024] [Indexed: 08/11/2024] Open
Abstract
OBJECTIVE The early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project. METHODS This study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement. RESULTS A total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001). CONCLUSION The evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.
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Affiliation(s)
- Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhengwen Pan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhe Xu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Shuyi Ding
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jiali Yan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yin Cheng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yixuan Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Kai Cao
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Wei Xie
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jianli Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Liwei Xu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Weiwei Zhou
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Lihua Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China.
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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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Schoettler ML, Westbrook A, Watkins B, Stenger E, Qayed M, Chonat S, Williams KM. Age, GVHD prophylaxis, and timing matter in thrombotic microangiopathy after haematopoietic cell transplantation-A secondary CIBMTR analysis. Br J Haematol 2024; 205:243-255. [PMID: 38817006 DOI: 10.1111/bjh.19506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/23/2024] [Indexed: 06/01/2024]
Abstract
Most reports of risk factors (RF) for developing transplant-associated thrombotic microangiopathy (TA-TMA) and death are derived from paediatric and young adult cohorts, with minimal data on differences in RF and outcomes by age. In this secondary CIBMTR analysis, we used a previously prepared dataset that included all first allogenic haematopoietic cell transplantation (HCT) recipients with malignant or non-malignant diseases between 2008 and 2016. The incidence of TA-TMA 6 months post HCT was similar in children and adults 2.1% and 2.0% respectively. Grade 2-4 acute graft-versus-host disease (aGVHD) was a significant adjusted RF for developing TA-TMA in both children and adults. In adults, additional adjusted RFs for TA-TMA included female sex and black race, and in children an unrelated donor. Compared to a calcineurin inhibitor and sirolimus, other forms of GVHD prophylaxis had an adjusted decreased risk of developing TA-TMA in adults. Adjusted RF for death in those with TA-TMA (n = 652) included age ≥18 years old, early onset of TA-TMA diagnosis (<100 days post HCT), grade 3-4 aGVHD and a performance score of <90 prior to HCT. In this cohort, the incidence of TA-TMA was similar in children and adults, and TA-TMA timing was a newly identified RF for death.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Children's Hospital, New Orleans, Tulane Pediatric Hematology/Oncology, New Orleans, Louisiana, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
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8
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Alhomoud M, Scordo M, Perales MA. Successful use of narsoplimab to treat allogeneic transplant-associated thrombotic microangiopathy while maintaining sirolimus. Bone Marrow Transplant 2024; 59:904-906. [PMID: 38467748 DOI: 10.1038/s41409-024-02263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Mohammad Alhomoud
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Scordo
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Medical College, New York, NY, USA.
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Hill W, Sotlar K, Hautmann A, Kolb HJ, Ullmann J, Hausmann A, Schmidt M, Tischer J, Pham TT, Rank A, Hoechstetter MA. Late transplant-associated thrombotic microangiopathy verified in bone marrow biopsy specimens is associated with chronic GVHD and viral infections. Eur J Haematol 2024; 112:819-831. [PMID: 38243840 DOI: 10.1111/ejh.14174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/04/2024] [Accepted: 01/07/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES To describe late transplant-associated thrombotic microangiopathy (TA-TMA) as chronic endothelial complication in bone marrow (BM) after allogeneic hematopoietic stem cell transplantation (HSCT). METHODS BM specimens along with conventional diagnostic parameters were assessed in 14 single-institutional patients with late TA-TMA (more than 100 days after HCST), including 11 late with history of early TA-TMA, 10 with early TA-TMA (within 100 days), and 12 non TA-TMA patients. Three non-HSCT patients served as control. The time points of BM biopsy were +1086, +798, +396, and +363 days after HSCT, respectively. RESULTS Late TA-TMA patients showed an increase of CD34+ and von Willebrand Factor (VWF)+ microvascular endothelial cells with atypical VWF+ conglomerates forming thickened VWF+ plaque sinus in the BM compared to patients without late TA-TMA and non-HSCT. Severe chronic (p = .002), steroid-refractory GVHD (p = .007) and reactivation of HHV6 (p = .002), EBV (p = .003), and adenovirus (p = .005) were pronounced in late TA-TMA. Overall and relapse-free survival were shorter in late TA-TMA than in patients without late TA-TMA (5-year OS and RFS: 78.6% vs. 90.2%, 71.4% vs. 86.4%, respectively). CONCLUSION Chronic allo-immune microangiopathy in BM associated with chronic, steroid-refractory GVHD and/or viral infections are key findings of late, high-risk TA-TMA, which deserves clinical attention.
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Affiliation(s)
- Wolfgang Hill
- Department of Internal Medicine III, University Hospital Munich, University of Munich, Munich, Germany
| | - Karl Sotlar
- University Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Anke Hautmann
- Private Practice and Day Clinic for Hematology and Oncology, Regensburg, Germany
| | - Hans-Jochem Kolb
- Department of Internal Medicine III, University Hospital Munich, University of Munich, Munich, Germany
| | - Johanna Ullmann
- Department of Internal Medicine III, University Hospital Munich, University of Munich, Munich, Germany
| | - Andreas Hausmann
- Department of Internal Medicine I, Academic Teaching Hospital, München Klinik Schwabing, Munich, Germany
| | - Michael Schmidt
- Munich Cancer Registry, Institute for Medical Information Processing, Biometry, and Epidemiology, University of Munich, Munich, Germany
| | - Johanna Tischer
- Department of Internal Medicine III, University Hospital Munich, University of Munich, Munich, Germany
| | - Thu-Trang Pham
- Department of Internal Medicine I, Academic Teaching Hospital, München Klinik Schwabing, Munich, Germany
| | - Andreas Rank
- Department of Hematology and Oncology, University Hospital Augsburg, University of Augsburg, Augsburg, Germany
| | - Manuela A Hoechstetter
- Department of Internal Medicine I, Academic Teaching Hospital, München Klinik Schwabing, Munich, Germany
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10
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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [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] [Indexed: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Akahoshi Y, Spyrou N, Hoepting M, Aguayo-Hiraldo P, Ayuk F, Chanswangphuwana C, Choe HK, Eder M, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Kraus S, Al Malki MM, Merli P, Qayed M, Reshef R, Schechter T, Ullrich E, Vasova I, Wölfl M, Zeiser R, Baez J, Beheshti R, Eng G, Gleich S, Kasikis S, Katsivelos N, Kowalyk S, Morales G, Young R, DeFilipp Z, Ferrara JLM, Levine JE, Nakamura R. Flares of acute graft-versus-host disease: a Mount Sinai Acute GVHD International Consortium analysis. Blood Adv 2024; 8:2047-2057. [PMID: 38324721 PMCID: PMC11103178 DOI: 10.1182/bloodadvances.2023012091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
ABSTRACT The absence of a standardized definition for graft-versus-host disease (GVHD) flares and data on its clinical course are significant concerns. We retrospectively evaluated 968 patients across 23 Mount Sinai Acute GVHD International Consortium (MAGIC) transplant centers who achieved complete response (CR) or very good partial response (VGPR) within 4 weeks of treatment. The cumulative incidence of flares within 6 months was 22%, and flares were associated with a higher risk of nonrelapse mortality (NRM; adjusted hazard ratio [aHR], 4.84; 95% confidence interval [CI], 3.19-7.36; P < .001). Flares were more severe (grades 3/4, 41% vs 16%; P < .001) and had more frequent lower gastrointestinal (LGI) involvement (55% vs 32%; P < .001) than the initial GVHD. At CR/VGPR, elevated MAGIC biomarkers predicted the future occurrence of a flare, along with its severity and LGI involvement. In multivariate analyses, higher Ann Arbor (AA) biomarker scores at CR/VGPR were significant risk factors for flares (AA2 vs AA1: aHR, 1.81 [95% CI, 1.32-2.48; P = .001]; AA3 vs AA1: aHR, 3.14 [95% CI, 1.98-4.98; P < .001]), as were early response to initial treatment (aHR, 1.84; 95% CI, 1.21-2.80; P = .004) and HLA-mismatched unrelated donor (aHR, 1.74; 95% CI, 1.00-3.02; P = .049). MAGIC biomarkers also stratified the risk of NRM both at CR/VGPR and at the time of flare. We conclude that GVHD flares are common and carry a significant mortality risk. The occurrence of future flares can be predicted by serum biomarkers that may serve to guide adjustment and discontinuation of immunosuppression.
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Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chantiya Chanswangphuwana
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hannah K. Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Aaron M. Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan A. Grupp
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O. Hexner
- Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Monzr M. Al Malki
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Pietro Merli
- Department of Pediatric Hematology/Oncology and of Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Muna Qayed
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Department of Pediatrics, Experimental Immunology and Cell Therapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingrid Vasova
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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12
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Sawyer J, Elliott T, Orton L, Sowell H, Gatwood K, Shultes K. Prevention and management of acute toxicities from conditioning regimens during hematopoietic stem cell transplantation. Clin Hematol Int 2024; 6:1-10. [PMID: 38817311 PMCID: PMC11087001 DOI: 10.46989/001c.94952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/13/2023] [Indexed: 06/01/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) remains the only curative option for several hematological malignancies. Its use has continued to grow, with an estimated 23,500 transplants performed annually in the United States alone. The acute toxicities that occur from conditioning chemotherapy can impact the peri-transplant period and have substantial implications on patients' tolerability and outcomes, irrespective of the treatment of their disease. Chemotherapy-induced nausea vomiting (CINV), mucositis, transplant-associated thrombotic microangiopathy (TA-TMA), and sinusoidal obstruction syndrome, also known as a veno-occlusive disease (SOS/VOD) can all have significant implications for patients. These acute complications begin with the start of conditioning chemotherapy and add to potential toxicity for patients throughout the early post-transplant period, from Day +30 for CINV, mucositis, and SOS, and which can continue through at least Day +100 with the onset of TA-TMA. These toxicities must be prevented and managed appropriately. This review will summarize the literature surrounding them and guide their management.
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Affiliation(s)
- Jana Sawyer
- PharmacyVA Tennessee Valley Healthcare System
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13
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Schoettler ML, Lehmann L, Kao PC, Chen N, Jodele S, Chonat S, Williams KM, London WB, Duncan C, Dandoy C. Pediatric transplant-associated thrombotic microangiopathy health care utilization and implications of eculizumab therapy. Blood Adv 2024; 8:1220-1233. [PMID: 38154068 PMCID: PMC10912836 DOI: 10.1182/bloodadvances.2023011078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/01/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023] Open
Abstract
ABSTRACT The health care use (HCU) burden of transplant-associated thrombotic microangiopathy (TA-TMA) and its treatments are unknown. The objective of this study was to investigate inpatient costs associated with meeting criteria for TA-TMA in the first year after hematopoietic cell transplant (HCT). This institutional review board-approved retrospective multicenter study included serial children who underwent HCT from 1 January 2015 to 1 July 2019. A standardized unit cost (adjusted for geographic location, differences in cost of living, and inflation) for inpatient hospitalization was extracted from the Pediatric Health Information System data and linked to clinical data. Both total cost and cost per day from 15 days before stem cell infusion to 1-year after HCT were calculated. Among allogeneic (allo) transplant recipients, after adjusting for severe grade 3/4 acute graft-versus-host disease (GVHD), infections, and HLA mismatch, costs were not different in TA-TMA (n = 137) vs no TA-TMA (n = 238). Severe GVHD was significantly associated with increased costs. Among allo high-risk (HR) TMA-TMA, unadjusted costs were significantly higher in the eculizumab-treated cohort (n = 19) than in the supportive care group (n = 36). However, after adjusting for gastrointestinal bleeding that occurred disproportionately in the eculizumab (n = 6) vs supportive care (n = 0) cohort, eculizumab treatment was not associated with increased total costs. More studies are needed to determine the etiology of increased HCU costs in those with HR-TA-TMA and predict those more likely to benefit from eculizumab, reducing HCU and improving outcomes.
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Affiliation(s)
- Michelle L. Schoettler
- Division Blood and Marrow Transplantation, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Leslie Lehmann
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Pei-Chi Kao
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Nan Chen
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Medical Center, Cincinnati, OH
| | - Satheesh Chonat
- Division Blood and Marrow Transplantation, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Kirsten M. Williams
- Division Blood and Marrow Transplantation, Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Wendy B. London
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Christine Duncan
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Christopher Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Medical Center, Cincinnati, OH
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14
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Wei X, Chang Y, Zhu X, Hu X, Guo R, Zhang Y, Ma X, Han Y, Wang Y, Qiu H, Wu X, Wu D. The impact of pre-transplant anti-HLA antibodies in transplants from HLA-identical sibling donors: A multicenter study. HLA 2024; 103:e15286. [PMID: 38018476 DOI: 10.1111/tan.15286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 11/30/2023]
Abstract
Few studies have performed comparative analysis of the outcome of hematopoietic stem cell transplantation from HLA-identical sibling donors (ISD-HSCT) in patients with or without anti-HLA Abs. In this study we retrospectively collected data from a multicenter study to analyze the distribution and impact of the pre-existing anti-HLA Abs in ISD-HSCT. Among 402 recipients, 111 were positive for anti-HLA Abs. Gender, time from diagnosis to transplantation and distribution of primary disease might be risk factors for the occurrence of anti-HLA Abs. We found that patients with anti-HLA Abs had delayed neutrophil engraftment and were more vulnerable to experience Cytomegalovirus (CMV) reactivation. The presence of anti-HLA Abs was proved to be an independent risk factor for neutrophil engraftment (HR 1.42 95% CI 1.13-1.80, p = 0.003) and CMV reactivation (HR 2.03 95% CI 1.19-3.46, p = 0.009). We found that anti-HLA Abs have a negative impact on the prognosis in the early period after transplantation from sibling donors and anti-HLA Abs was also an independent risk factor for the overall survival (OS) at 180 days (HR 2.32, 95% CI 1.03-5.27, p = 0.042) among female recipients. In conclusion, anti-HLA Abs have a negative impact on the prognosis early after ISD-HSCT.
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Affiliation(s)
- Xiya Wei
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yingjun Chang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Beijing, China
| | - Xiaoyu Zhu
- Department Hematology, University Scientific & Technology China, Affiliated Hospital USTC 1, Hefei, China
| | - Xiaoxia Hu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, China
| | - Rong Guo
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanming Zhang
- Department of Hematology, Huai'an Second Peoples Hospital, Huai'an, China
| | - Xiao Ma
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yue Han
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Ying Wang
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Huiying Qiu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaojin Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Depei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
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15
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Ma S, Bhar S, Guffey D, Kim RB, Jamil M, Amos CI, Lee SJ, Hingorani SR, Sartain SE, Li A. Prospective Clinical and Biomarker Validation of the American Society for Transplantation and Cellular Therapy Consensus Definition for Transplantation-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2023; 29:685.e1-685.e7. [PMID: 37597686 PMCID: PMC11037887 DOI: 10.1016/j.jtct.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
Transplantation-associated thrombotic microangiography (TA-TMA) is a disorder that causes severe complications after allogeneic hematopoietic cell transplantation (allo-HCT). Diagnosing TA-TMA is challenging because of the lack of standardized criteria. In this study, we aimed to evaluate the new TA-TMA consensus definition from the American Society for Transplantation and Cellular Therapy (ASTCT) panel as part of an ongoing prospective pediatric cohort study, and also to compare the impact and outcomes of using the current definition of clinical TMA (cTMA) versus the new consensus definition. We included patients age 0 to 18 years who underwent their first allo-HCT between May 2021 and January 2023 at Texas Children's Hospital. We compared the incidence, biomarkers, and outcomes of TA-TMA applying the previous and recently proposed screening algorithms and definitions. Whereas use of the classic microangiopathic hemolytic anemia (MAHA)-based cTMA definition led to an incidence of 12.7% by day 100 post-transplantation, the ASTCT-HR definition doubled the incidence to 28.5% by day 100. In contrast to patients with a concordant diagnosis (+/+), who had significantly worse post-transplantation survival, those reclassified as TA-TMA only by the new definition (-/+) had a significantly different prognosis (100% survival at day 100) despite the lack of TMA-directed therapy. Furthermore, biomarkers of the terminal and alternative complement pathways (sC5b9 and Ba, respectively) were significantly elevated compared with non-TMA patients around day 15 in the concordant group (+/+) but not in the discordant group (-/+). The recently proposed ASTCT consensus TA-TMA diagnosis is more sensitive and allows earlier recognition of manifestation that requires closer clinical monitoring but risks overdiagnosis and overtreatment. We recommend additional prospective validation.
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Affiliation(s)
- Shengling Ma
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Saleh Bhar
- Divisions of Hematology/Oncology and Critical Care Medicine and Bone Marrow Transplantation, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Rock Bum Kim
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Mahrukh Jamil
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas
| | - Christopher I Amos
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas; Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Sangeeta R Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Sarah E Sartain
- Section of Hematology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas.
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16
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Elhadad S, Redmond D, Huang J, Tan A, Laurence J. MASP2 inhibition by narsoplimab suppresses endotheliopathies characteristic of transplant-associated thrombotic microangiopathy: in vitro and ex vivo evidence. Clin Exp Immunol 2023; 213:252-264. [PMID: 37191586 PMCID: PMC10361744 DOI: 10.1093/cei/uxad055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 05/17/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endotheliopathy complicating up to 30% of allogeneic hematopoietic stem cell transplants (alloHSCT). Positive feedback loops among complement, pro-inflammatory, pro-apoptotic, and coagulation cascade likely assume dominant roles at different disease stages. We hypothesized that mannose-binding lectin-associated serine protease 2 (MASP2), principal activator of the lectin complement system, is involved in the microvascular endothelial cell (MVEC) injury characteristic of TA-TMA through pathways that are susceptible to suppression by anti-MASP2 monoclonal antibody narsoplimab. Pre-treatment plasmas from 8 of 9 TA-TMA patients achieving a complete TMA response in a narsoplimab clinical trial activated caspase 8, the initial step in apoptotic injury, in human MVEC. This was reduced to control levels following narsoplimab treatment in 7 of the 8 subjects. Plasmas from 8 individuals in an observational TA-TMA study, but not 8 alloHSCT subjects without TMA, similarly activated caspase 8, which was blocked in vitro by narsoplimab. mRNA sequencing of MVEC exposed to TA-TMA or control plasmas with and without narsoplimab suggested potential mechanisms of action. The top 40 narsoplimab-affected transcripts included upregulation of SerpinB2, which blocks apoptosis by inactivating procaspase 3; CHAC1, which inhibits apoptosis in association with mitigation of oxidative stress responses; and pro-angiogenesis proteins TM4SF18, ASPM, and ESM1. Narsoplimab also suppressed transcripts encoding pro-apoptotic and pro-inflammatory proteins ZNF521, IL1R1, Fibulin-5, aggrecan, SLC14A1, and LOX1, and TMEM204, which disrupts vascular integrity. Our data suggest benefits to narsoplimab use in high-risk TA-TMA and provide a potential mechanistic basis for the clinical efficacy of narsoplimab in this disorder.
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Affiliation(s)
- Sonia Elhadad
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - David Redmond
- Division of Regenerative Medicine, Hartman Institute for Therapeutic Organ Regeneration, Ansary Stem Cell Institute, New York, NY, USA
| | - Jenny Huang
- Division of Regenerative Medicine, Hartman Institute for Therapeutic Organ Regeneration, Ansary Stem Cell Institute, New York, NY, USA
| | - Adrian Tan
- Genomics Resources Core Facility, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey Laurence
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
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17
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Cao XY, Zhang JP, Zhao YL, Xiong M, Zhou JR, Lu Y, Sun RJ, Wei ZJ, Liu DY, Zhang X, Yang JF, Lu P. Analysis benefits of a second Allo-HSCT after CAR-T cell therapy in patients with relapsed/refractory B-cell acute lymphoblastic leukemia who relapsed after transplant. Front Immunol 2023; 14:1191382. [PMID: 37469510 PMCID: PMC10352576 DOI: 10.3389/fimmu.2023.1191382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023] Open
Abstract
Background Chimeric antigen receptor (CAR) T-cell therapy has demonstrated high initial complete remission (CR) rates in B-cell acute lymphoblastic leukemia (B-ALL) patients, including those who relapsed after transplant. However, the duration of remission requires improvements. Whether bridging to a second allogeneic hematopoietic stem cell transplant (allo-HSCT) after CAR-T therapy can improve long-term survival remains controversial. We retrospectively analyzed long-term follow-up data of B-ALL patients who relapsed post-transplant and received CAR-T therapy followed by consolidation second allo-HSCT to investigate whether such a treatment sequence could improve long-term survival. Methods A single-center, retrospective study was performed between October 2017 and March 2022, involving 95 patients who received a consolidation second transplant after achieving CR from CAR-T therapy. Results The median age of patients was 22.8 years (range: 3.3-52.8) at the second transplant. After the first transplant, 71 patients (74.7%) experienced bone marrow relapse, 16 patients (16.8%) had extramedullary relapse, 5 patients (5.3%) had both bone marrow and extramedullary relapse and 3/95 patients (3.2%) had positive minimal residual disease (MRD) only. Patients received autologous (n=57, 60.0%) or allogeneic (n=28, 29.5%) CAR-T cells, while 10 patients (10.5%) were unknown. All patients achieved CR after CAR-T therapy. Before second HSCT, 86 patients (90.5%) were MRD-negative, and 9 (9.5%) were MRD-positive. All second transplant donors were different from the first transplant donors. The median follow-up time was 623 days (range: 33-1901) after the second HSCT. The 3-year overall survival (OS) and leukemia-free survival (LFS) were 55.3% (95%CI, 44.3-66.1%) and 49.8% (95%CI, 38.7-60.9%), respectively. The 3-year relapse incidence (RI) and non-relapse mortality (NRM) were 10.5% (95%CI, 5.6-19.6%) and 43.6% (95%CI, 33.9-56.2%), respectively. In multivariate analysis, the interval from CAR-T to second HSCT ≤90 days was associated with superior LFS(HR, 4.10, 95%CI,1.64-10.24; p=0.003) and OS(HR, 2.67, 95%CI, 1.24-5.74, p=0.012), as well as reduced NRM (HR, 2.45, 95%CI, 1.14-5.24, p=0.021). Conclusions Our study indicated that CAR-T therapy followed by consolidation second transplant could significantly improve long-term survival in B-ALL patients who relapsed post-transplant. The second transplant should be considered in suitable patients and is recommended to be performed within 90 days after CAR-T treatment.
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Affiliation(s)
- Xing-yu Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jian-ping Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yan-li Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Min Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jia-rui Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yue Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Rui-juan Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Zhi-jie Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - De-yan Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xian Zhang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jun-fang Yang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Peihua Lu
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
- Beijing Lu Daopei Institute of Hematology, Beijing, China
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18
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Gudsoorkar P, Abudayyeh A, Tchakarov A, Hanna R. Onconephrology and Thrombotic Microangiopathy: Looking Beyond the Horizon. Semin Nephrol 2023; 42:151345. [PMID: 37196461 DOI: 10.1016/j.semnephrol.2023.151345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Thrombotic microangiopathies (TMAs) represent a complex interaction of endothelial and podocyte biology, nephron physiology, complement genetics, and oncologic therapies with host immunology. The complexity of various factors, such as molecular causes, genetic expressions, and immune system mimicking, along with incomplete penetrance, make it difficult to find a straightforward solution. As a result, there may be variations in diagnosis, study, and treatment approaches, and achieving a consensus can be challenging. Here, we review the molecular biology, pharmacology, immunology, molecular genetics, and pathology of the various TMA syndromes in the setting of cancer. Controversies in etiology, nomenclature, and points requiring further clinical, translational, and bench research are discussed. Complement-mediated TMAs, chemotherapy drug-mediated TMAs, TMAs in monoclonal gammopathy, and other TMAs central to onconephrology practice are reviewed in detail. In addition, established and emerging therapies within the US Food and Drug Administration pipeline subsequently are discussed. Finally, a comprehensive review of critical areas of onconephrology clinical practice is presented as practical value to the clinical practitioner and seeds of investigation to be sown among the community of atypical hemolytic uremic syndrome researchers.
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Affiliation(s)
- Prakash Gudsoorkar
- Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, OH
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Amanda Tchakarov
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine Medical Center, Orange, CA.
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19
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Zhang Z, Hong W, Wu Q, Tsavachidis S, Li JR, Amos CI, Cheng C, Sartain SE, Afshar-Kharghan V, Dong JF, Bhatraju P, Martin PJ, Makar RS, Bendapudi PK, Li A. Pathway-driven rare germline variants associated with transplant-associated thrombotic microangiopathy (TA-TMA). Thromb Res 2023; 225:39-46. [PMID: 36948020 PMCID: PMC10147584 DOI: 10.1016/j.thromres.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023]
Abstract
The significance of rare germline mutations in transplant-associated thrombotic microangiopathy (TA-TMA) is not well studied. We performed a genetic association study in 100 adult TA-TMA patients vs. 98 post-transplant controls after matching by race, sex, and year. We focused on 5 pathways in complement, von Willebrand factor (VWF) function and related proteins, VWF clearance, ADAMTS13 function and related proteins, and endothelial activation (3641variants in 52 genes). In the primary analysis focused on 189 functional rare variants, no differential variant enrichment was observed in any of the pathways; specifically, 29 % TA-TMA and 33 % controls had at least 1 rare complement mutation. In the secondary analysis focused on 37 rare variants predicted to be pathogenic or likely pathogenic by ClinVar, Complement Database, or REVEL in-silico prediction tool, rare variants in the VWF clearance pathway were found to be significantly associated with TA-TMA (p = 0.008). On the gene level, LRP1 was the only one with significantly increased variants in TA-TMA in both analyses (p = 0.025 and 0.015). In conclusion, we did not find a significant association between rare variants in the complement pathway and TA-TMA; however, we discovered a new signal in the VWF clearance pathway driven by the gene LRP1 among likely pathogenic variants.
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Affiliation(s)
- Zhihui Zhang
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Wei Hong
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Qian Wu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Spiridon Tsavachidis
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, TX, United States of America
| | - Jian-Rong Li
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Christopher I Amos
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America; Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, TX, United States of America
| | - Chao Cheng
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, TX, United States of America
| | - Sarah E Sartain
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States of America
| | - Vahid Afshar-Kharghan
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Jing-Fei Dong
- BloodWorks Northwest Research Institute, Seattle, WA, United States of America
| | - Pavan Bhatraju
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Robert S Makar
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, United States of America; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Pavan K Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, United States of America; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Ang Li
- Section of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America.
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20
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Mahmoudjafari Z, Alencar MC, Alexander MD, Johnson DJ, Yeh J, Evans MD. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy and the role of advanced practice providers and pharmacists. Bone Marrow Transplant 2023:10.1038/s41409-023-01951-3. [PMID: 37059738 DOI: 10.1038/s41409-023-01951-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a severe and potentially life-threatening complication. HSCT-TMA is often underdiagnosed due to multifactorial pathophysiology and a historic lack of standard diagnostic criteria. Identification of the multi-hit hypothesis and the key role of the complement system, particularly the lectin pathway of complement, has led to development of treatments targeting the underlying pathogenesis of HSCT-TMA. Additional research is ongoing to investigate the efficacy and safety of these targeted therapies in patients with HSCT-TMA. Advanced practice providers (APPs; nurse practitioners and physician assistants) and pharmacists are critical members of the multidisciplinary HSCT team and ensure management of patients throughout the continuum of care. Additionally, pharmacists and APPs can improve patient care through medication management of complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives to improve outcomes. Understanding the presentation, prognosis, pathophysiology, and treatment options for HSCT-TMA can improve each of these efforts. Collaborative practice model for monitoring and care of HSCT-TMA. Advanced practice providers and pharmacists contribute to many aspects of patient care in transplant centers, including medication management for complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives. HSCT-TMA is a severe and potentially life-threatening complication that is often underdiagnosed. The collaboration of a multidisciplinary team of advanced practice providers, pharmacists, and physicians can optimize recognition, diagnosis, management, and monitoring of patients with HSCT-TMA, thereby improving outcomes for these patients.
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Affiliation(s)
- Zahra Mahmoudjafari
- Department of Pharmacy, University of Kansas Cancer Center, Kansas City, KS, USA.
| | - Maritza C Alencar
- Oncology Service Line, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Darren J Johnson
- Pediatric Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jason Yeh
- Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | - Misty D Evans
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- Sarah Cannon Pediatric Hematology/Oncology & Cellular Therapy at TriStar Centennial, Nashville, TN, USA
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21
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Dandoy CE, Tsong WH, Sarikonda K, McGarvey N, Perales MA. Systematic Review of Signs and Symptoms Associated with Hematopoietic Stem Cell Transplantation-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2023; 29:282.e1-282.e9. [PMID: 36592719 PMCID: PMC11284894 DOI: 10.1016/j.jtct.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a serious complication of the transplantation process that has been consistently associated with substantially greater morbidity and mortality compared with HSCT recipients who do not develop TMA. This study aimed to systematically review published signs and symptoms of HSCT-TMA and compare patients with HSCT-TMA and HSCT recipients who do not develop TMA. Publications were identified using multiple search term variations for stem cell transplantation that were entered into the PubMed, Embase, and CINAHL databases. Two reviewers screened references at the abstract level before reviewing full texts against inclusion and exclusion criteria using a PICOS-T framework. Complication proportions were grouped by organ class and then by complication type. Meta-analyses were conducted using a random-effects model in RevMan 5.4. After 2338 references were screened, a total of 30 studies were included in our analyses. The majority of studies (n = 23; 14 adult, 5 pediatric, 4 both) examined allogeneic transplantations only. Four studies examined autologous transplantation only (all pediatric), and 3 studies included both transplantation types (all pediatric). HSCT-TMA was associated with renal dysfunction (odds ratio [OR], 11.04 for adult, allogeneic and 7.35 for pediatric, all transplantations), renal failure (OR, 2.41 for adult and pediatric, allogeneic), renal replacement therapy (OR, 6.99 for pediatric, all transplantations and 60.85 for adult, allogeneic), and hypertension (OR, 5.44 for adult, allogeneic). HSCT-TMA was associated with respiratory failure (OR, 8.00 for adult and pediatric, allogeneic), pulmonary hypertension (OR, 9.86 for adult and pediatric, allogeneic), need for pleurocentesis (OR, 5.45 for pediatric, all transplantations), noninvasive ventilation (OR, 6.15 for pediatric, all transplantations), and invasive mechanical ventilation (OR, 5.18 for pediatric, all transplantations). Additionally, HSCT-TMA was associated with neurologic symptoms (OR, 2.28 for adult and pediatric, allogeneic), pericardial effusion (OR, 2.56 for adult and pediatric, allogeneic and 8.76 for pediatric, all transplantations), liver injury (OR, 3.87 for adult, allogeneic), infection (OR, 9.25 for adult, allogeneic; 2.06 for pediatric, all transplantations), gastrointestinal (GI) bleeding (OR, 7.78 for adult and pediatric, allogeneic), and acute graft-versus-host disease grade III-IV (OR, 3.29 for adult and pediatric, allogeneic). This study represents the first systematic review of HSCT-TMA signs and symptoms. Current diagnostic criteria systems involve laboratory markers for multiorgan dysfunction, including renal dysfunction, liver injury, and general tissue damage. Diagnostic criteria include neurologic symptoms, increased need for transfusions, and hypertension. This study identified additional associations with HSCT-TMA, including increased pulmonary hypertension, respiratory failure, fever, GI bleeding, and pericardial effusion. These symptoms might be included for evaluation in future diagnostic criteria and current practice.
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Affiliation(s)
- Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Wan H Tsong
- Omeros Corporation, Health Economics and Outcomes Research, Medical Affairs, Seattle, Washington
| | - Kaushik Sarikonda
- BluePath Solutions, Strategic Health Economics and Outcomes Research, Los Angeles, California
| | - November McGarvey
- BluePath Solutions, Strategic Health Economics and Outcomes Research, Los Angeles, California
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
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Luo L, Xiong H, Chen Z, Yang L, Sun M, Lu W, Tao F, Wang Z, Li J, Li Z, Tang S. Clinical characteristics of pediatric allogeneic hematopoietic stem cell transplantation-associated thrombotic microangiopathy (TA-TMA): a retrospective single-center analysis. Clin Transl Oncol 2023:10.1007/s12094-023-03129-1. [PMID: 36973479 DOI: 10.1007/s12094-023-03129-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To investigate the clinical features of thrombotic microangiopathy associated with allogeneic hematopoietic stem cell transplantation in children. METHODS A retrospective analysis of continuous clinical data from HSCT received in the Department of Hematology and Oncology of Wuhan Children's Hospital from August 1, 2016 to December 31, 2021. RESULTS During this period, 209 patients received allo-HSCT in our department, 20 (9.6%) of whom developed TA-TMA. TA-TMA was diagnosed at a median of 94 (7-289) days post-HSCT. Eleven (55%) patients had early TA-TMA within 100 days post-HSCT, while the other 9 (45%) patients had TA-TMA thereafter. The most common symptom of TA-TMA was ecchymosis (55%), while the main signs were refractory hypertension (90%) and multi-cavity effusion (35%). Five (25%) patients had central nervous system symptoms (convulsions and lethargy). All 20 patients had progressive thrombocytopenia, with 16 patients receiving transfusion of platelets that was ineffective. Ruptured red blood cells were visible in only two patients with peripheral blood smears. Cyclosporine A or Tacrolimus (CNI) dose was reduced once TA-TMA was diagnosed. Nineteen cases were treated with low-molecular-weight heparin, 17 patients received plasma exchange, and 12 patients were treated with rituximab. TA-TMA-related mortality percentage in this study was 45% (9/20). CONCLUSION Platelet decline and/or ineffective transfusion post-HSCT should be considered an early indicator of TA-TMA in pediatric patients. TA-TMA in pediatric patients may occur without evidence of peripheral blood schistocytes. Aggressive treatment is required once diagnosis is confirmed, but the long-term prognosis is poor.
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Affiliation(s)
- Linlin Luo
- Medical College of Jianghan University, Wuhan, 430056, Hubei Province, China
| | - Hao Xiong
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China.
| | - Zhi Chen
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Li Yang
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Ming Sun
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Wenjie Lu
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Fang Tao
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Zhuo Wang
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Jianxin Li
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Zuofeng Li
- Medical College of Wuhan University of Science and Technology, Wuhan, 430065, Hubei Province, China
| | - Sujie Tang
- Medical College of Jianghan University, Wuhan, 430056, Hubei Province, China
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23
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Ilan U, Brivio E, Algeri M, Balduzzi A, Gonzalez-Vincent M, Locatelli F, Zwaan CM, Baruchel A, Lindemans C, Bautista F. The Development of New Agents for Post-Hematopoietic Stem Cell Transplantation Non-Infectious Complications in Children. J Clin Med 2023; 12:2149. [PMID: 36983151 PMCID: PMC10054172 DOI: 10.3390/jcm12062149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/12/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is often the only curative treatment option for patients suffering from various types of malignant diseases and some non-cancerous conditions. Nevertheless, it is associated with a high risk of complications leading to transplant-related mortality and long-term morbidity. An increasing number of therapeutic and prevention strategies have been developed over the last few years to tackle the complications arising in patients receiving an HSCT. These strategies have been mainly carried out in adults and some are now being translated into children. In this manuscript, we review the recent advancements in the development and implementation of treatment options for post-HSCT non-infectious complications in pediatric patients with leukemia and other non-malignant conditions, with a special attention on the new agents available within clinical trials. We focused on the following conditions: graft failure, prevention of relapse and early interventions after detection of minimal residual disease positivity following HSCT in acute lymphoblastic and myeloid leukemia, chronic graft versus host disease, non-infectious pulmonary complications, and complications of endothelial origin.
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Affiliation(s)
- Uri Ilan
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Erica Brivio
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Mattia Algeri
- Department of Hematology/Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, 00165 Rome, Italy
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, 20900 Monza, Italy
| | - Marta Gonzalez-Vincent
- Department of Stem Cell Transplantation, Hospital Infantil Universitario Nino Jesus, 28009 Madrid, Spain
| | - Franco Locatelli
- Department of Hematology/Oncology and Cell and Gene Therapy, Bambino Gesù Children Hospital, 00165 Rome, Italy
| | | | - Andre Baruchel
- Department of Pediatric Hematology, AP-HP, Robert Debré Hospital, 75019 Paris, France
| | - Caroline Lindemans
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
- Division of Pediatrics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Stem Cell Transplantation, Regenerative Medicine Center, University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Francisco Bautista
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
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24
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A Fatal Case of Neuroblastoma Complicated by Posterior Reversible Encephalopathy with Rapidly Evolving Transplantation-Associated Thrombotic Microangiopathy. CHILDREN 2023; 10:children10030506. [PMID: 36980064 PMCID: PMC10047442 DOI: 10.3390/children10030506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/13/2023] [Accepted: 02/24/2023] [Indexed: 03/08/2023]
Abstract
Background: Transplantation-associated thrombotic microangiopathy (TA-TMA) is a severe complication of hematopoietic stem cell transplantation and is sometimes fatal. Observations: A 4-year-old, male patient with stage M neuroblastoma (NBL) who had received an allogeneic bone marrow transplantation (BMT) from his sibling five months previously presented with rapidly progressive posterior reversible encephalopathy (PRES) complicated with TA-TMA. Although the patient was transferred to the pediatric intensive care unit, he died within one week after the onset of the latest symptoms. Conclusions: This is the first description of a fatal case of NBL complicated by PRES with rapidly evolving TA-TMA after an allogenic BMT.
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25
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Schoettler ML, Carreras E, Cho B, Dandoy CE, Ho VT, Jodele S, Moissev I, Sanchez-Ortega I, Srivastava A, Atsuta Y, Carpenter P, Koreth J, Kroger N, Ljungman P, Page K, Popat U, Shaw BE, Sureda A, Soiffer R, Vasu S. Harmonizing Definitions for Diagnostic Criteria and Prognostic Assessment of Transplantation-Associated Thrombotic Microangiopathy: A Report on Behalf of the European Society for Blood and Marrow Transplantation, American Society for Transplantation and Cellular Therapy, Asia-Pacific Blood and Marrow Transplantation Group, and Center for International Blood and Marrow Transplant Research. Transplant Cell Ther 2023; 29:151-163. [PMID: 36442770 PMCID: PMC10119629 DOI: 10.1016/j.jtct.2022.11.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic cell transplantation (HCT) associated with significant morbidity and mortality. However, TA-TMA is a clinical diagnosis, and multiple criteria have been proposed without universal application. Although some patients have a self-resolving disease, others progress to multiorgan failure and/or death. Poor prognostic features also are not uniformly accepted. The lack of harmonization of diagnostic and prognostic markers has precluded multi-institutional studies to better understand incidence and outcomes. Even current interventional trials use different criteria, making it challenging to interpret the data. To address this urgent need, the American Society for Transplantation and Cellular Therapy, Center for International Bone Marrow Transplant Research, Asia-Pacific Blood and Marrow Transplantation, and European Society for Blood and Marrow Transplantation nominated representatives for an expert panel tasked with reaching consensus on diagnostic and prognostic criteria. The panel reviewed literature, generated consensus statements regarding diagnostic and prognostic features of TA-TMA using the Delphi method, and identified future directions of investigation. Consensus was reached on 4 key concepts: (1) TA-TMA can be diagnosed using clinical and laboratory criteria or tissue biopsy of kidney or gastrointestinal tissue; however, biopsy is not required; (2) consensus diagnostic criteria are proposed using the modified Jodele criteria with additional definitions of anemia and thrombocytopenia. TA-TMA is diagnosed when ≥4 of the following 7 features occur twice within 14 days: anemia, defined as failure to achieve transfusion independence despite neutrophil engraftment; hemoglobin decline by ≥1 g/dL or new-onset transfusion dependence; thrombocytopenia, defined as failure to achieve platelet engraftment, higher-than-expected transfusion needs, refractory to platelet transfusions, or ≥50% reduction in baseline platelet count after full platelet engraftment; lactate dehydrogenase (LDH) exceeding the upper limit of normal (ULN); schistocytes; hypertension; soluble C5b-9 (sC5b-9) exceeding the ULN; and proteinuria (≥1 mg/mg random urine protein-to-creatinine ratio [rUPCR]); (3) patients with any of the following features are at increased risk of nonrelapse mortality and should be stratified as high-risk TA-TMA: elevated sC5b-9, LDH ≥2 times the ULN, rUPCR ≥1 mg/mg, multiorgan dysfunction, concurrent grade II-IV acute graft-versus-host disease (GVHD), or infection (bacterial or viral); and (4) all allogeneic and pediatric autologous HCT recipients with neuroblastoma should be screened weekly for TA-TMA during the first 100 days post-HCT. Patients diagnosed with TA-TMA should be risk-stratified, and those with high-risk disease should be offered participation in a clinical trial for TA-TMA-directed therapy if available. We propose that these criteria and risk stratification features be used in data registries, prospective studies, and clinical practice across international settings. This harmonization will facilitate the investigation of TA-TMA across populations diverse in race, ethnicity, age, disease indications, and transplantation characteristics. As these criteria are widely used, we expect continued refinement as necessary. Efforts to identify more specific diagnostic and prognostic biomarkers are a top priority of the field. Finally, an investigation of the impact of TA-TMA-directed treatment, particularly in the setting of concurrent highly morbid complications, such as steroid-refractory GVHD and infection, is critically needed.
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Affiliation(s)
- M L Schoettler
- Department Blood and Marrow Transplantation, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Atlanta, Georgia
| | - E Carreras
- Spanish Bone Marrow Donor Registry, Josep Carreras Foundation and Leukemia Research Institute, Barcelona, Catalunya, Spain
| | - B Cho
- Department of Internal Medicine, Catholic Blood and Marrow Transplantation Center, Seoul, Korea
| | - C E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - V T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - S Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - I Moissev
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | | | - A Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Y Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
| | - P Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - J Koreth
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - N Kroger
- Division of Hematology, Ohio State University, Columbus, Ohio
| | - P Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - K Page
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - U Popat
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - B E Shaw
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A Sureda
- Clinical Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - R Soiffer
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - S Vasu
- Division of Hematology, Ohio State University, Columbus, Ohio.
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26
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Aklilu AM, Shirali AC. Chemotherapy-Associated Thrombotic Microangiopathy. KIDNEY360 2023; 4:409-422. [PMID: 36706238 PMCID: PMC10103319 DOI: 10.34067/kid.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023]
Abstract
Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as antiangiogenesis agents and proteasome inhibitors have been implicated in oncotherapy-associated TMA. Among TMA subtypes, drug-induced TMA is less well-understood. Treatment generally involves withdrawal of the offending agent and supportive care targeting blood pressure and proteinuria reduction. Immunosuppression and therapeutic plasma exchange have not shown clear benefit. The terminal complement inhibitor, eculizumab, has shown promising results in some cases of chemotherapy-associated TMA including in re-exposure. However, the data are limited, and unlike in primary atypical hemolytic uremic syndrome, the role of complement in the pathogenesis of drug-induced TMA is unclear. Larger multicenter studies and unified definitions are needed to elucidate the extent of the problem and potential treatment strategies.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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Lazana I. Transplant-Associated Thrombotic Microangiopathy in the Context of Allogenic Hematopoietic Stem Cell Transplantation: Where We Stand. Int J Mol Sci 2023; 24:ijms24021159. [PMID: 36674666 PMCID: PMC9863862 DOI: 10.3390/ijms24021159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) constitutes a significant contributor to the increased morbidity and mortality after allogenic hematopoietic stem cell transplantation (allo-HSCT). TA-TMA is a heterogenous disease, characterized by the triad of endothelial cell activation, complement dysregulation and microvascular hemolytic anemia, which may affect all organs. The lack of consensus diagnostic criteria, along with the common clinical features mimicking other diseases that complicate allo-HSCT, make the diagnosis of TA-TMA particularly challenging. Significant effort has been made to recognize specific risk factors predisposing to the development of TA-TMA and to identify serum biomarkers predicting the development of the disease. With regard to treatment, therapeutic plasma exchange (TPE) has been traditionally used, although with doubtful efficacy. On the other hand, the pivotal role of complement activation in the pathophysiology of TA-TMA has led to the exploration of the therapeutic potential of complement inhibitors in this setting. Eculizumab has been proposed as a first-line therapeutic agent in TA-TMA, owing to the very promising results in both pediatric and adult clinical trials. Pharmacokinetic and pharmacodynamic studies and CH50 levels are of paramount importance in the allo-HSCT setting, as a different dosing schedule (more intensive-in dose and frequency-at the beginning) seems to be required for successful outcomes. Furthermore, Narsoplimab, a MASP-2 inhibitor, recently received a Breakthrough Therapy Designation from the FDA for the treatment of TA-TMA after allo-HSCT. Finally, the decision to withdraw the CNIs, although initially advised by the Bone and Marrow Transplant Clinical Trials Network Committee, remains debatable owing to the controversial results of recent clinical trials. This review summarizes the current updates on pathophysiology, diagnosis and therapeutic approaches and emphasizes future goals and perspectives.
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Affiliation(s)
- Ioanna Lazana
- Cell and Gene Therapy Laboratory, Biomedical Research Foundation of the Academy of Athens, 11527 Athens, Greece;
- Hematology Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
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How I prevent GVHD in high-risk patients: posttransplant cyclophosphamide and beyond. Blood 2023; 141:49-59. [PMID: 35405017 DOI: 10.1182/blood.2021015129] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/09/2022] [Accepted: 03/21/2022] [Indexed: 01/10/2023] Open
Abstract
Advances in conditioning, graft-versus-host disease (GVHD) prophylaxis and antimicrobial prophylaxis have improved the safety of allogeneic hematopoietic cell transplantation (HCT), leading to a substantial increase in the number of patients transplanted each year. This influx of patients along with progress in remission-inducing and posttransplant maintenance strategies for hematologic malignancies has led to new GVHD risk factors and high-risk groups: HLA-mismatched related (haplo) and unrelated (MMUD) donors; older recipient age; posttransplant maintenance; prior checkpoint inhibitor and autologous HCT exposure; and patients with benign hematologic disorders. Along with the changing transplant population, the field of HCT has dramatically shifted in the past decade because of the widespread adoption of posttransplantation cyclophosphamide (PTCy), which has increased the use of HLA-mismatched related donors to levels comparable to HLA-matched related donors. Its success has led investigators to explore PTCy's utility for HLA-matched HCT, where we predict it will be embraced as well. Additionally, combinations of promising new agents for GVHD prophylaxis such as abatacept and JAK inhibitors with PTCy inspire hope for an even safer transplant platform. Using 3 illustrative cases, we review our current approach to transplantation of patients at high risk of GVHD using our modern armamentarium.
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Guo M, Qi J, Hou Q, Li X, Han Y. Risk factors for transplant-associated thrombotic microangiopathy (TA-TMA): a systematic review and meta-analysis. Expert Rev Hematol 2023; 16:191-203. [PMID: 36588482 DOI: 10.1080/17474086.2023.2162501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe hematopoietic stem cell transplantation complication with high mortality and a poor patient prognosis. The pathogenesis of TA-TMA is not yet clear. In previous studies, the conclusions of different centers remain controversial. We conducted a systematic review and meta-analysis of nine selected risk factors that might be associated with the onset of TA-TMA. MATERIALS AND METHODS PubMed databases were searched from their inception up to 15 September 2021, for relevant studies. The articles included unprocessed data related to one or more of the risk factors discussed in this meta-analysis, including recipient gender, donor type, graft source, pretreatment, infection, aGVHD, diagnosis, total body irradiation (TBI), and CMV infection. The outcome is the incidence rate (IR) of TA-TMA. RESULTS AND CONCLUSIONS According to the sixteen articles included, risk factors included in this Meta-analysis included gender, unrelated donor source (95% CI: 1.29-2.01), graft source from peripheral blood stem cell (PBSC)(95% CI: 0.48-0.97), RIC/NMA, class II-IV aGVHD (95% CI: 2.22-4.78), nonmalignant disease, TBI. However, inconsistent diagnostic criteria for TA-TMA and the limited number of studies have an impact on the results of the study. More prospective cohort studies and More accurate diagnostic criteria are needed.
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Affiliation(s)
- Mengting Guo
- 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
| | - 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
| | - Qixiu Hou
- 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
| | - Xueqian Li
- 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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High-dose thiotepa, in conjunction with melphalan, followed by autologous hematopoietic stem cell transplantation in patients with pediatric solid tumors, including brain tumors. Bone Marrow Transplant 2023; 58:123-128. [PMID: 36329150 PMCID: PMC9902273 DOI: 10.1038/s41409-022-01820-5] [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: 08/05/2021] [Revised: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
Among pediatric malignancies, solid tumors, particularly within the central nervous system (CNS), are common. Thiotepa, a myeloablative, high-dose chemotherapeutic (HDT) treatment administered prior to autologous hematopoietic stem cell transplantation (HSCT), can cross the blood-brain barrier and rapidly penetrate the CNS. We evaluated thiotepa HDT in conjunction with melphalan in Japanese patients with pediatric CNS/non-CNS solid tumors in a multicenter, open-label, non-comparative study. Thiotepa (200 mg/m2/day) was administered intravenously (IV) over 24 h on days -12, -11, -5, and -4 before scheduled HSCT. Melphalan (70 mg/m2/day) was administered IV over 1 h on days -11, -5, and -4. The safety analysis population comprised 41 patients, of whom 16 (39.0%) had solid tumors and 25 (61.0%) had brain tumors. The most frequently reported adverse events were diarrhea (40/41 [97.6%] patients) and febrile neutropenia (34/41 [82.9%]). No unexpected safety events were observed, and no events resulted in death or treatment discontinuation. All patients experienced bone marrow suppression and 39/41 (95.1%) achieved engraftment (neutrophil count ≥500/mm3 for 3 consecutive days after HSCT). The survival rate at day 100 post-autologous HSCT was 100%. These data confirm the safety of IV thiotepa plus melphalan HDT prior to autologous HSCT for patients with pediatric CNS/non-CNS solid tumors. Trial registration: JapicCTI-173654.
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31
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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Madsen K, Pelletier K, Côté G, Kitchlu A, Chen S, Mattsson J, Pasic I. Acute kidney injury within 100 days post allogeneic hematopoietic cell transplantation is associated with increased risk of post-transplant complications and poor transplant outcomes. Bone Marrow Transplant 2022; 57:1411-1420. [PMID: 35752740 DOI: 10.1038/s41409-022-01744-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/01/2022] [Accepted: 06/14/2022] [Indexed: 11/09/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) offers cure for some patients with hematological diseases but is associated with significant risk of morbidity and mortality. We investigated the incidence of AKI and its impact on transplant outcomes among 408 patients transplanted at Princess Margaret Hospital Cancer Centre, Toronto, Canada. The overall incidence of AKI at 100 days was 64.2%. Compared to those with no AKI, patients who developed AKI had inferior 2-y overall survival (OS), 44.7% vs. 62.4% (P = 0.0004), higher 2-y transplant related mortality (TRM) 36.8% vs. 18.7% (P = 0.0003), lower 2-y graft-vs-host disease (GVHD)- and relapse-free survival (GRFS), 21.0% vs. 39.8% (P = 0.0002), and higher 100-day grade 3-4 acute GVHD (aGVHD), 12.4% vs. 6.3% (P = 0.01). There was no difference in 2-y incidence of relapse between the AKI and non-AKI groups, 24.2% vs. 24.3% (P = 0.84), 100-day grade 2-4 aGVHD, 27.7% vs. 25.7 (P = 0.41) or 2-y moderate-severe chronic GVHD, 24.0% vs. 21.6% (P = 0.79). Patients who develop AKI within 100 days of HCT have inferior OS and GRFS with higher rates of TRM and grade 3-4 aGVHD. These results highlight the importance of close monitoring of renal function, multidisciplinary collaboration, and implementation of protective strategies throughout HCT to optimize transplant and kidney outcomes.
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Affiliation(s)
- Kayla Madsen
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Karyne Pelletier
- Division of Nephrology, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Gabrielle Côté
- Division of Nephrology, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Shiyi Chen
- Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Toronto, Canada
| | - Ivan Pasic
- Hans Messner Allogeneic Transplant Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada.
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Blasco M, Guillén-Olmos E, Diaz-Ricart M, Palomo M. Complement Mediated Endothelial Damage in Thrombotic Microangiopathies. Front Med (Lausanne) 2022; 9:811504. [PMID: 35547236 PMCID: PMC9082680 DOI: 10.3389/fmed.2022.811504] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
Thrombotic microangiopathies (TMA) constitute a group of different disorders that have a common underlying mechanism: the endothelial damage. These disorders may exhibit different mechanisms of endothelial injury depending on the pathological trigger. However, over the last decades, the potential role of the complement system (CS) has gained prominence in their pathogenesis. This is partly due to the great efficacy of complement-inhibitors in atypical hemolytic syndrome (aHUS), a TMA form where the primary defect is an alternative complement pathway dysregulation over endothelial cells (genetic and/or adquired). Complement involvement has also been demonstrated in other forms of TMA, such as thrombotic thrombocytopenic purpura (TTP) and in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (STEC-HUS), as well as in secondary TMAs, in which complement activation occurs in the context of other diseases. However, at present, there is scarce evidence about the efficacy of complement-targeted therapies in these entities. The relationship between complement dysregulation and endothelial damage as the main causes of TMA will be reviewed here. Moreover, the different clinical trials evaluating the use of complement-inhibitors for the treatment of patients suffering from different TMA-associated disorders are summarized, as a clear example of the entry into a new era of personalized medicine in its management.
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Affiliation(s)
- Miquel Blasco
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Elena Guillén-Olmos
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Marta Palomo
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain.,Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
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34
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Higham CS, Shimano KA, Melton A, Kharbanda S, Chu J, Dara J, Winestone LE, Hermiston ML, Huang JN, Dvorak CC. A pilot trial of prophylactic defibrotide to prevent serious thrombotic microangiopathy in high-risk pediatric patients. Pediatr Blood Cancer 2022; 69:e29641. [PMID: 35253361 DOI: 10.1002/pbc.29641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial injury complication of hematopoietic stem cell transplant (HSCT) leading to end-organ damage and high morbidity and mortality. Defibrotide is an anti-inflammatory and antithrombotic agent that may protect the endothelium during conditioning. PROCEDURE We hypothesized that prophylactic use of defibrotide during HSCT conditioning and acute recovery could prevent TA-TMA. A pilot single-arm phase II trial (NCT#03384693) evaluated the safety and feasibility of administering prophylactic defibrotide to high-risk pediatric patients during HSCT and assessed if prophylactic defibrotide prevented TA-TMA compared to historic controls. Patients received defibrotide 6.25 mg/kg IV q6h the day prior to the start of conditioning through day +21. Patients were prospectively monitored for TA-TMA from admission through week 24 post transplant. Potential biomarkers of endothelial injury (suppression of tumorigenicity 2 [ST2], angiopoietin-2 [ANG-2], plasminogen activator inhibitor-1 [PAI-1], and free hemoglobin) were analyzed. RESULTS Twenty-five patients were enrolled, 14 undergoing tandem autologous HSCT for neuroblastoma and 11 undergoing allogeneic HSCT. Defibrotide was discontinued early due to possibly related clinically significant bleeding in 12% (3/25) of patients; no other severe adverse events occurred due to the study intervention. The other 22 patients missed a median of 0.7% of doses (0%-5.2%). One patient developed nonsevere TA-TMA 12 days post HSCT. This observed TA-TMA incidence of 4% was below the historic rate of 18%-40% in a similar population of allogeneic and autologous patients. CONCLUSIONS Our study provides evidence that defibrotide prophylaxis is feasible in pediatric patients undergoing HSCT at high risk for TA-TMA and preliminary data indicating that defibrotide may reduce the risk of TA-TMA.
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Affiliation(s)
- Christine S Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Julia Chu
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Michelle L Hermiston
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - James N Huang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
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35
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Abou‐Ismail MY, Kapoor S, Citla Sridhar D, Nayak L, Ahuja S. Thrombotic microangiopathies: An illustrated review. Res Pract Thromb Haemost 2022; 6:e12708. [PMID: 35615754 PMCID: PMC9027164 DOI: 10.1002/rth2.12708] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 11/11/2022] Open
Abstract
The thrombotic microangiopathies (TMAs) are a heterogenous group of disorders with distinct pathophysiologies that cause occlusive microvascular or macrovascular thrombosis, and are characterized by microangiopathic hemolytic anemia, thrombocytopenia, and/or end-organ ischemia. TMAs are associated with significant morbidity and mortality, and data on the management of certain TMAs are often lacking. The nomenclature, classification, and management of various TMAs is constantly evolving as we learn more about these rare syndromes. Thorough clinical and laboratory evaluation is essential to distinguish various TMAs and arrive at an accurate diagnosis, which is key for appropriate management. In this illustrated review, we focus on thrombotic thrombocytopenic purpura (TTP), Shiga toxin-associated hemolytic uremic syndrome, complement-mediated hemolytic uremic syndrome, hematopoietic cell transplant-associated TMA, and drug-induced TMA, and describe their incidence, pathophysiology, diagnosis, and management. We also highlight emerging complement-directed therapies under investigation for the management of complement-mediated TMAs.
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Affiliation(s)
- Mouhamed Yazan Abou‐Ismail
- Division of Hematology and Hematologic Malignancies Department of Internal Medicine University of Utah Health Sciences Center Salt Lake City Utah USA
| | - Sargam Kapoor
- Department of Hematology & Oncology Alaska Native Medical Center Anchorage Alaska USA
| | - Divyaswathi Citla Sridhar
- Department of Pediatric Hematology & Oncology University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Lalitha Nayak
- Department of Hematology & Oncology University Hospitals Cleveland Medical Center Cleveland Ohio USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology University Hospitals Rainbow Babies and Children’s Hospital Cleveland Ohio USA
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36
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Yang LP, Zhao P, Wu YJ, Fu HX, He Y, Mo XD, Lv M, Wang FR, Yan CH, Chen YH, Chang YJ, Xu LP, Liu KY, Huang XJ, Zhang XH. 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. [PMID: 35079139 DOI: 10.1038/s41409-022-01581-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/09/2022]
Abstract
The efficacy and outcome of therapeutic plasma exchange (TPE) for transplant-associated thrombotic microangiopathy (TA-TMA) remain controversial. We therefore sought to evaluate the outcome and efficacy of TPE in patients with TA-TMA and to identify TA-TMA patients who would benefit from TPE management. Eighty-two patients with TA-TMA were treated with TPE. We reported a response rate of 52% and overall survival rates of 20% and 15% at 100 days and 1 year after TA-TMA, respectively, in TPE-treated patients, with a significantly lower survival in gastrointestinal (GI) bleeding patients (5% vs. 41% in non-GI bleeding patients, P = 0.003). Multivariate analysis revealed that patients with GI bleeding, grade III-IV aGVHD, severe anemia, and a lower cumulative volume of TPE were less likely to respond to TPE. GI bleeding, a lower initial volume of TPE, and elevated total bilirubin were independently associated with 100-day mortality. The leading causes of death were infection, active TA-TMA, and MODS. The results of this large cohort of real-world practice indicate that the efficacy and outcome of TPE for TA-TMA patients without GI bleeding are encouraging, and a higher volume of TPE is warranted to achieve favorable outcomes.
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Affiliation(s)
- Li-Ping Yang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ye-Jun Wu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yun He
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Meng Lv
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.
- National Clinical Research Center for Hematologic Disease, Beijing, China.
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China.
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Miyata M, Ichikawa K, Matsuki E, Watanabe M, Peltier D, Toubai T. Recent Advances of Acute Kidney Injury in Hematopoietic Cell Transplantation. Front Immunol 2022; 12:779881. [PMID: 35058924 PMCID: PMC8763685 DOI: 10.3389/fimmu.2021.779881] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/02/2021] [Indexed: 12/30/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication of allogeneic hematopoietic cell transplantation (allo-HCT) and is associated with non-relapse mortality (NRM) and quality of life (QOL). Multiple factors may contribute to AKI during allo-HCT and are often present at the same time making it difficult to determine the cause of AKI in each patient. Nephrotoxic drugs, infections, thrombotic microangiopathy (TMA), and sinusoidal obstruction syndrome (SOS) are well described causes of AKI during allo-HCT. Acute graft-versus-host disease (aGVHD) is a major complication of allo-HCT that mainly targets the intestines, liver, and skin. However, recent studies suggest aGVHD may also attack the kidney and contribute to AKI following allo-HCT. For example, severe aGVHD is associated with AKI, suggesting a link between the two. In addition, animal models have shown donor immune cell infiltration and increased expression of inflammatory cytokines in recipient kidneys after allo-HCT. Therefore, aGVHD may also target the kidney and contribute to AKI following allo-HCT. Herein, we describe the etiology, diagnosis, risk factors, pathophysiology, prevention, and treatment of renal injury after allo-HCT. In addition, we highlight emerging evidence that aGVHD may contribute to the development of AKI after allo-HCT.
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Affiliation(s)
- Masahiro Miyata
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Kazunobu Ichikawa
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Eri Matsuki
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Daniel Peltier
- Department of Pediatric Hematology/Oncology, University Michigan Medical School, Ann Arbor, MI, United States
| | - Tomomi Toubai
- Department of Internal Medicine III, Division of Hematology and Cell Therapy, Faculty of Medicine, Yamagata University, Yamagata, Japan
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Andronesi A, Sorohan B, Burcea A, Lipan L, Stanescu C, Craciun O, Stefan L, Ranete A, Varady Z, Ungureanu O, Lupusoru G, Agrigoroaei G, Andronesi D, Iliuta L, Obrisca B, Tanase A. Incidence and Risk Factors for Acute Kidney Injury after Allogeneic Stem Cell Transplantation: A Prospective Study. Biomedicines 2022; 10:biomedicines10020262. [PMID: 35203472 PMCID: PMC8869231 DOI: 10.3390/biomedicines10020262] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 01/11/2023] Open
Abstract
(1) Background: Acute kidney injury (AKI) is a serious complication of hematopoietic stem cell transplantation (HSCT). (2) Methods: The aim was to identify the incidence, severity, and risk factors for AKI during the first 100 days after allo-HSCT; we performed a prospective observational study on 135 consecutive patients. (3) Results: The mean age was 38.3 ± 11.9 years (50.6% females), AKI developed in 93 patients (68.9%), the median time of appearance was 28 days, and the mean serum creatinine at the time of AKI was 1.8 ± 0.8 mg/dL. A total of 36 (38.7%) patients developed stage 1 AKI, 33 (35.5%) patients developed stage 2, and 24 (25.8%) patients developed stage 3; eight (8.6%) patients required temporary hemodialysis, and the mortality rate in these patients was 87.5%. Death was twice as frequent in the AKI subgroup, without statistical significance. Cyclosporine overdose (HR = 2.36, 95% CI: 1.45-3.85, p = 0.001), tacrolimus overdose (HR = 4.72, 95% CI: 2.22-10.01, p < 0.001), acute graft-versus-host disease (aGVHD) (HR = 1.96, 95% CI: 1.13-3.40, p = 0.01), and CRP level (HR = 1.009, 95% CI: 1.007-1.10, p < 0.001) were independent risk factors for AKI. Sepsis (HR = 5.37, 95% CI: 1.75-16.48, p = 0.003) and sinusoidal obstruction syndrome (HR = 5.10, 95% CI: 2.02-12.85, p = 0.001) were found as independent risk factors for AKI stage 3. (4) Conclusions: AKI occurs with high incidence and increased severity after allo-HSCT. Careful monitoring of calcineurin inhibitors and proper management of sepsis may reduce this risk.
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Affiliation(s)
- Andreea Andronesi
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (G.L.); (G.A.); (B.O.)
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
- Correspondence: ; Tel.: +40-723-361-457
| | - Bogdan Sorohan
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (G.L.); (G.A.); (B.O.)
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
| | - Andreea Burcea
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
| | - Lavinia Lipan
- Bone Marrow Transplant Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.L.); (O.C.); (L.S.); (A.R.); (Z.V.); (A.T.)
| | - Cristina Stanescu
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
| | - Oana Craciun
- Bone Marrow Transplant Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.L.); (O.C.); (L.S.); (A.R.); (Z.V.); (A.T.)
| | - Laura Stefan
- Bone Marrow Transplant Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.L.); (O.C.); (L.S.); (A.R.); (Z.V.); (A.T.)
| | - Adela Ranete
- Bone Marrow Transplant Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.L.); (O.C.); (L.S.); (A.R.); (Z.V.); (A.T.)
| | - Zsofia Varady
- Bone Marrow Transplant Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.L.); (O.C.); (L.S.); (A.R.); (Z.V.); (A.T.)
| | - Oana Ungureanu
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
| | - Gabriela Lupusoru
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (G.L.); (G.A.); (B.O.)
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
| | - Gabriela Agrigoroaei
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (G.L.); (G.A.); (B.O.)
| | - Danut Andronesi
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania;
| | - Luminita Iliuta
- Department of Biostatistics, Marketing and Medical Technology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Bogdan Obrisca
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (B.S.); (G.L.); (G.A.); (B.O.)
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.B.); (C.S.); (O.U.)
| | - Alina Tanase
- Bone Marrow Transplant Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.L.); (O.C.); (L.S.); (A.R.); (Z.V.); (A.T.)
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Van Benschoten V, Roy C, Gupta R, Ouellette L, Hingorani S, Li A. Incidence and risk factors of transplant-associated thrombotic microangiopathy (TA-TMA): a systematic review and meta-analysis. Transplant Cell Ther 2022; 28:266.e1-266.e8. [PMID: 35042011 DOI: 10.1016/j.jtct.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized post-transplant complication, yet the overall incidence of the disease remains debated. OBJECTIVES To determine the pooled incidence of TA-TMA in a systematic review of literature and to identify consistent risk factors. STUDY DESIGN We performed a systematic review using Medline, Embase, and CENTRAL databases to identify cohort studies that reported incidence of and risk factors for TA-TMA from 2004 to 2020. We conducted a meta-analysis of proportion to estimate the pooled incidence of TA-TMA using a random-effects model. We assessed moderators of heterogeneity through subgroup analysis, risk of bias through ROBINS-I, and publication bias through funnel plot. RESULTS Among 21 cohort studies with 36,163 adult and pediatric patients that underwent allogeneic transplant, the pooled incidence of TA-TMA was 12% (95% CI 9-16). The diagnostic criteria used to define the disease was the most significant contributor identified to the high inter-study heterogeneity (I2 98%). Studies using provider/clinician diagnosis instead of laboratory diagnosis reported the lowest incidence at 3%. The most salient risk factor for TA-TMA reported in 14 studies was preceding acute graft-versus-host disease (GVHD). Other risk predictors described in 5 or more studies included preceding infection, prior transplant, mismatched donor, and myeloablative conditioning. CONCLUSION With a pooled incidence at 12% among a significantly heterogeneous population, TA-TMA is an important but relatively uncommon post-transplant complication. Given the divergence between laboratory-based and provider-based incidence, as well as the multitude of risk factors beyond acute GVHD, future studies should focus on risk stratifying the subset of TA-TMA patients who would benefit from therapeutic intervention.
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Affiliation(s)
| | - Cayla Roy
- School of Medicine, Baylor College of Medicine, Houston, TX
| | - Rohit Gupta
- School of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Sangeeta Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Nephrology, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Ang Li
- Section of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX.
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Palma LMP, Vaisbich-Guimarães MH, Sridharan M, Tran CL, Sethi S. Thrombotic microangiopathy in children. Pediatr Nephrol 2022; 37:1967-1980. [PMID: 35041041 PMCID: PMC8764494 DOI: 10.1007/s00467-021-05370-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
The syndrome of thrombotic microangiopathy (TMA) is a clinical-pathological entity characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end organ involvement. It comprises a spectrum of underlying etiologies that may differ in children and adults. In children, apart from ruling out shigatoxin-associated hemolytic uremic syndrome (HUS) and other infection-associated TMA like Streptococcus pneumoniae-HUS, rare inherited causes including complement-associated HUS, cobalamin defects, and mutations in diacylglycerol kinase epsilon gene must be investigated. TMA should also be considered in the setting of solid organ or hematopoietic stem cell transplantation. In this review, acquired and inherited causes of TMA are described with a focus on particularities of the main causes of TMA in children. A pragmatic approach that may help the clinician tailor evaluation and management is provided. The described approach will allow for early initiation of treatment while waiting for the definitive diagnosis of the underlying TMA.
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Affiliation(s)
- Lilian Monteiro P. Palma
- grid.411087.b0000 0001 0723 2494Department of Pediatrics, Pediatric Nephrology, State University of Campinas (UNICAMP), Rua Tessalia Vieira de Camargo, 126, Cidade Universitaria, Campinas, SP 13,083–887 Brazil
| | | | - Meera Sridharan
- grid.66875.3a0000 0004 0459 167XHematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Cheryl L. Tran
- grid.66875.3a0000 0004 0459 167XPediatric Nephrology, Department of Pediatrics, Mayo Clinic, Rochester, MN USA
| | - Sanjeev Sethi
- grid.66875.3a0000 0004 0459 167XDepartment of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
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Acute GVHD, BK hemorrhagic cystitis and age are risk factors for transplant-associated thrombotic microangiopathy in adults. Blood Adv 2021; 6:1342-1349. [PMID: 34932790 PMCID: PMC8864665 DOI: 10.1182/bloodadvances.2021004933] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 11/18/2021] [Indexed: 11/30/2022] Open
Abstract
Clinically actionable thrombotic microangiopathy (CA-TMA) occurring in the absence of aGVHD occurs earlier than day 100. aGVHD is a key and consistent risk factor for late-onset CA-TMA.
Hematopoietic cell transplantation–associated thrombotic microangiopathy (TMA) is a complication associated with higher nonrelapse mortality (NRM) in patients who undergo allogeneic transplant (HCT). Current classification criteria are not generally agreed on or validated, and the presence of confounding factors after transplant contribute to underdiagnosis or delayed diagnosis of TMA. We studied risk factors, incidence, and biomarkers of TMA in 119 adult allogeneic HCT recipients. Twenty-seven patients developed a clinically actionable phenotype of TMA (CA-TMA) and the incidence of CA-TMA was 22% by day 180. Among the 27 patients who developed CA-TMA, 10 developed it before the onset of acute graft-versus-host disease (aGVHD), and 17 patients developed it after the onset of aGVHD. We report for the first time that age >50 years, BK hemorrhagic cystitis, and other viral infections (CMV, HHV-6, or adenovirus) are risk factors for adult CA-TMA. Even after adjustment for aGVHD, CA-TMA was independently associated with significantly higher NRM. These data illustrate relationships between CA-TMA and aGVHD, describe new risk factors for CA-TMA and emphasizes the need to develop validated set of criteria for timely diagnosis.
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42
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Luo YH, Yang J, Wei A, Zhu GH, Wang B, Zhang R, Jia CG, Yan Y, Wang K, Li S, Zhou X, Qin MQ, Wang TY. Haploidentical hematopoietic stem cell transplantation for pediatric patients with chronic active Epstein-Barr virus infection: a retrospective analysis of a single center. World J Pediatr 2021; 17:626-636. [PMID: 34739695 DOI: 10.1007/s12519-021-00470-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate the feasibility and clinical effect of haploidentical hematopoietic stem cell transplantation (haplo-HSCT) for the treatment of pediatric patients with chronic active Epstein-Barr virus infection (CAEBV). METHODS Children with CAEBV who did not have matched donors and underwent haplo-HSCT in Beijing Children's Hospital, Capital Medical University, from October 2016 to June 2020 were analyzed retrospectively. Data relating to the clinical manifestations, engraftment, and prognosis of the children were extracted from medical records. RESULTS Twenty-five patients, including 16 males and 9 females, with an onset age of 5.0 ± 2.6 years and a transplantation age of 6.9 ± 2.9 years, were enrolled in this study. The mean time from diagnosis to transplantation was 3.8 (2.0-40.2) months. The mean observation time was 19.0 ± 12.0 months. Three patients received the reduced intensity conditioning regimen, and the remaining patients all received the modified myeloablative conditioning regimen. By the end of the follow-up, 23 patients were characterized by disease-free survival (DFS), 22 were characterized by event-free survival (EFS), and two died. One of the patients died of thrombotic microangiopathy (TMA), and another died of graft versus host disease (GVHD); this patient discontinued the treatment for economic reasons. The 3-year overall survival (OS) rate was estimated to be 92.0% ± 5.4%, and the 3-year EFS rate was estimated to be 87.4% ± 6.8%. All active patients survived after HSCT event-free. Acute GVHD degrees 1-3 were observed in ten patients (40.0%), and degree IV was observed in six (24.0%), who were all cured except for one patient. Chronic GVHD was observed in nine (36.0%), and most of these cases were mild. The incidence of TMA and veno-occlusive disease (VOD) was 28.0% and 4.0%. CONCLUSIONS Haploidentical hematopoietic stem cell transplantation is safe and effective in the treatment of pediatric CAEBV and can be used as an alternative therapy without matched donors or emergency transplantation. Patients with active disease before HSCT also benefited from haplo-HSCT. Haplo-HSCT requires careful monitoring for complications, such as GVHD and TMA. Early detection of TMA and timely treatment can reduce mortality and can improve the survival rate.
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Affiliation(s)
- Yan-Hui Luo
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Jun Yang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Ang Wei
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Guang-Hua Zhu
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Bin Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Rui Zhang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Chen-Guang Jia
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Yan Yan
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Kai Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Sidan Li
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Xuan Zhou
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Mao-Quan Qin
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China
| | - Tian-You Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Hematology Oncology Center, Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nanlishi Road No. 56, Beijing 100045, China.
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Kaya AH, Tekgunduz E. Management of thrombotic microangiopathy after hematopoietic cell transplantation: A position statement of ThREG (Turkish Hematology Research and Education Group). Transfus Apher Sci 2021; 60:103313. [PMID: 34785151 DOI: 10.1016/j.transci.2021.103313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hematopoietic stem cell transplantation associated-thrombotic microangiopathy (TA-HCT) is one of the early complications of endothelial origin in the course of HCT. Endothelial damage to the microvascular structure and the platelet-rich microthrombi, which are formed as a result of accompanying complement activation, constitute the main pathological conditions resulting TA-TMA. Early diagnosis and management are of utmost importance to prevent multi-organ failure and death. This review summarizes the current understanding of TA-TMA regarding pathogenesis, definition, differential diagnosis, risk factors, surveillance for early diagnosis and management.
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Affiliation(s)
- Ali Hakan Kaya
- Maltepe University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul, Turkey.
| | - Emre Tekgunduz
- Maltepe University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul, Turkey; Memorial Bahcelievler Hospital, Adult Hematology and BMT Clinic, Istanbul, Turkey
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44
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Schoettler M, Chonat S, Williams K, Lehmann L. Emerging therapeutic and preventive approaches to transplant-associated thrombotic microangiopathy. Curr Opin Hematol 2021; 28:408-416. [PMID: 34534983 PMCID: PMC9908033 DOI: 10.1097/moh.0000000000000687] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW Transplant-associated thrombotic microangiopathy (TA-TMA) is a complication that can occur in both allogeneic and autologous haematopoietic cellular therapy (HCT) recipients and is associated with significant morbidity and mortality. Although TA-TMA is a complex disease, there is emerging evidence that complement activation and endothelial dysfunction play a key role in the pathophysiology of the disease. The use of eculizumab has improved survival in patients with high risk and severe disease, but mortality rates in treated patients still exceed 30%, highlighting the need for novel approaches. RECENT FINDINGS There are multiple ongoing and planned clinical trials investigating novel complement agents in TA-TMA and other TMAs. Drugs vary by targets of the complement system, mechanism, and form of administration. Clinical trial designs include single arm studies that span across multiple age groups including children, and double-blind, randomized, placebo-controlled studies. These studies will provide robust data to inform the care of patients with TA-TMA in the future. In addition to multiple promising therapeutic agents, preventing TA-TMA is an emerging strategy. Agents known to protect the endothelium from damage and augment endothelial function by promoting anti-inflammatory and antithrombotic effects may have a role in preventing TA-TMA or ameliorating the severity, though additional studies are needed. SUMMARY Novel therapeutic agents for TA-TMA inhibition of the complement system are under investigation and prophylactic strategies of endothelial protection are emerging. Further understanding of the pathophysiology of the disease may identify additional therapeutic targets. Multiinstitutional, collaborative clinical trials are needed to determine the safety and efficacy of these agents going forward.
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Affiliation(s)
- Michelle Schoettler
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Pediatric Hematopoietic Cellular Therapy, Atlanta, GA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Department of Pediatrics, Pediatric Hematology, Emory University, Atlanta, GA
| | - Kirsten Williams
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Pediatric Hematopoietic Cellular Therapy, Atlanta, GA
| | - Leslie Lehmann
- Boston Children’s/Dana Farber Cancer and Blood Disorders Center, Pediatric Hematopoietic Cellular Therapies
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A prognostic model (BATAP) with external validation for patients with transplant-associated thrombotic microangiopathy. Blood Adv 2021; 5:5479-5489. [PMID: 34507352 PMCID: PMC8714708 DOI: 10.1182/bloodadvances.2021004530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a potentially life-threatening complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Information on markers for early prognostication remains limited, and no predictive tools for TA-TMA are available. We attempt to develop and validate a prognostic model for TA-TMA. A total of 507 patients who developed TA-TMA following allo-HSCT were retrospectively identified and separated into a derivation cohort and a validation cohort according to the time of transplantation to perform external temporal validation. Patient age (OR 2.371, 95% CI 1.264-4.445), anemia (OR 2.836, 95% CI 1.566-5.138), severe thrombocytopenia (OR 3.871, 95% CI 2.156-6.950), elevated total bilirubin (OR 2.716, 95% CI 1.489-4.955) and proteinuria (OR 2.289, 95% CI 1.257-4.168) were identified as independent prognostic factors for the 6-month outcome of TA-TMA. A risk score model termed BATAP (Bilirubin, Age, Thrombocytopenia, Anemia, Proteinuria) was then constructed according to the regression coefficients. The validated c-statistics were 0.816 (95% CI 0.766-0.867) and 0.756 (95% CI 0.696-0.817) in the internal and external validation, respectively. Calibration plots indicated that the model-predicted probabilities correlated well with the actual observed frequencies. This predictive model may facilitate the prognostication of TA-TMA and contribute to the early identification of high-risk patients.
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Jodele S, Sabulski A. Transplant-associated thrombotic microangiopathy: elucidating prevention strategies and identifying high-risk patients. Expert Rev Hematol 2021; 14:751-763. [PMID: 34301169 DOI: 10.1080/17474086.2021.1960816] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (TA-TMA) is a severe complication of transplant. TA-TMA is a multifactorial disease where generalized endothelial dysfunction leads to microangiopathic hemolytic anemia, intravascular platelet activation, and formation of microthrombi leading to end-organ injury. It is essential to identify patients at risk for this complication and to implement early interventions to improve TA-TMA associated transplant outcomes. AREAS COVERED Recognition of TA-TMA and associated multi-organ injury, risk predictors, contributing factors, differential diagnosis and targeting complement pathway in TA-TMA by summarizing peer reviewed manuscripts. EXPERT OPINION TA-TMA is an important transplant complication. Diagnostic and risk criteria are established in children and young adults and risk-based targeted therapies have been proposed using complement blockers. The immediate goal is to extend this work into adult stem cell transplant recipients by implementing universal TA-TMA screening practices. This will facilitate early TA-TMA diagnosis and targeted interventions, which will further improve survival. While complement blocking therapy is effective, about one third of patients are refractory to treatment and those patients commonly die. The next hurdle for the field is identifying reasons for failure, optimizing strategies for complement modifying therapy and searching for additional targetable pathways of endothelial injury.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Li A, Gupta R, Amos CI, Davis C, Pao E, Lee SJ, Hingorani SR. Thrombotic microangiopathy increases the risk of chronic kidney disease but not overall mortality in long-term transplant survivors. Transplant Cell Ther 2021; 27:864.e1-864.e5. [PMID: 34217847 DOI: 10.1016/j.jtct.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/14/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
Thrombotic microangiopathy (TMA) after allogeneic hematopoietic cell transplant (HCT) is associated with acute kidney injury (AKI) and increased mortality. The impact of TMA on chronic kidney disease (CKD) and long-term mortality among HCT survivors has not been fully examined. To assess the risk of CKD and mortality in HCT survivors with and without history of TMA, we conducted a retrospective cohort study among adult allogeneic HCT recipients who survived to at least 1 year post-transplantation. We examined the association between the history of TMA within 1 year and the onset of CKD longitudinally for 5 years with generalized estimating equation (GEE) while adjusting for other key confounders. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 using the CKD-EPI formula with outpatient creatinine values collected during the annual long-term follow-up unit follow-up visits. Kaplan Meier curves landmarked at 1 year were used for survival analyses. Among 2091 adult patients who underwent allogeneic HCT, we identified 1151 patients who survived at least 1 year and had available long-term follow-up data. Among them, 57 patients developed TMA within 1 year and 1094 did not have TMA. There was no pretransplantation baseline difference in eGFR between groups. After adjusting for confounders, history of TMA was associated with an odds ratio of 2.83 (95% confidence interval 1.33-6.03) for CKD development over 5 years after transplantation. The conditional 5-year survival was 78% in the TMA survivors and 80% in the non-TMA survivors (log rank P = .122). HCT survivors with a history of TMA had increased risk of CKD development. Although TMA was associated with high risk of mortality within 1 year after transplantation, long-term survival was comparable with non-TMA survivors. Future therapeutic interventions should focus on not only short-term mortality outcomes, but also short- and long-term kidney outcomes for HCT patients with TMA.
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Affiliation(s)
- Ang Li
- Section of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Rohit Gupta
- School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Christopher I Amos
- Division of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas; Institute of Clinical and Translational Medicine, Baylor College of Medicine, Houston, Texas
| | - Chris Davis
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Emily Pao
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Sangeeta R Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Nephrology, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Gabelli M, Ademokun C, Cooper N, Amrolia PI. Pathogenesis, risk factors and therapeutic options for autoimmune haemolytic anaemia in the post-transplant setting. Br J Haematol 2021; 196:45-62. [PMID: 34195990 DOI: 10.1111/bjh.17648] [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] [Received: 03/17/2021] [Accepted: 05/26/2021] [Indexed: 11/27/2022]
Abstract
Autoimmune haemolytic anaemia (AIHA) is a rare complication of allogeneic haematopoietic stem cell transplantation (HSCT), observed with an incidence of 1-5%. Paediatric age, diagnosis of non-malignant disease, lympho-depleting agents in the conditioning regimen, use of unrelated donor, graft versus host disease and infections have been associated with a higher risk of AIHA post HSCT. Post-HSCT AIHA is associated with high mortality and morbidity, and it is often very difficult to treat. Steroids and rituximab are used with a response rate around 30-50%. These and other therapeutic strategies are mainly derived from data on primary AIHA, although response rates in post-HSCT AIHA have been generally lower. Here we review the currently available data on risk factors and therapeutic options. There is a need for prospective studies in post-HSCT AIHA to guide clinicians in managing these complex patients.
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Affiliation(s)
- Maria Gabelli
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Christine Ademokun
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College, London, UK
| | - Persis I Amrolia
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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Transplant-associated thrombotic microangiopathy in pediatric patients: pre-HSCT risk stratification and prophylaxis. Blood Adv 2021; 5:2106-2114. [PMID: 33877298 DOI: 10.1182/bloodadvances.2020003988] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/08/2021] [Indexed: 12/19/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial injury syndrome that complicates hematopoietic stem cell transplant (HSCT). Morbidity and mortality from TA-TMA remain high, making prevention critical. We describe our retrospective single-center experience of TA-TMA after pediatric allogeneic HSCT and present a novel pre-HSCT risk-stratification system and prophylaxis regimen. From January 2012 through October 2019, 257 patients underwent 292 allogeneic HSCTs. Prospective risk stratification was introduced in December 2016. High-risk (HR) patients were treated with combination prophylaxis with eicosapentaenoic acid and N-acetylcysteine. The 1-year cumulative incidence of TA-TMA was 6.3% (95% confidence interval [CI], 3.2-9.4). Age ≥10 years, myeloablative conditioning with total body irradiation, HLA mismatch, diagnosis of severe aplastic anemia or malignancy, prior calcineurin inhibitor exposure, and recipient cytomegalovirus seropositivity were found to be pre-HSCT risk factors for development of TA-TMA. Before routine prophylaxis, TA-TMA rates were significantly different between the HR and standard-risk groups, at 28.2% (95% CI, 0-12.7) vs 3.2% (0.1-6.3), respectively (P < .001). After introduction of prophylaxis, the 1-year cumulative incidence of TA-TMA in the HR group decreased to 4.5% (95% CI, 0-13.1; P = .062, compared with the incidence before prophylaxis). Multicenter pediatric studies are needed to validate these risk criteria and to confirm the efficacy of the prophylactic regimen.
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Thrombotic Microangiopathy: Multi-Institutional Review of Pediatric Patients Who Underwent HSCT. J Pers Med 2021; 11:jpm11060467. [PMID: 34070379 PMCID: PMC8226470 DOI: 10.3390/jpm11060467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 12/03/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but serious complication of hematopoietic stem cell transplantation (HSCT). The purpose of our study is to estimate the incidence, prevalence, and analyze the risk factors and outcome of TMA in children receiving HSCT. Patients under the age of 21 who underwent HSCT at one of the 42 Pediatric Health Information System (PHIS) hospitals from 2000–2012 were analyzed, including demographics, hospitalizations, TMA, and other HSCT-related complications. From 2000 to 2012, a total of 12,369 unique pediatric patients who received HSCT were identified. Among these, 93 (0.8%) children were identified to have the diagnosis of TMA. TMA was significantly associated with allogeneic HSCT, peripheral blood stem cell trasnplants (PBSCT), cytomegalovirus (CMV), human herpes virus 6 (HHV6), fungal infection, graft-versus-host disease (GVHD), and veno-occlusive disease (VOD) (p = 0.01). Multivariate logistic regression analysis of mortality showed only HHV6 was an independent risk factor associated with increased mortality in patients with TMA (hazard ratio: 2.86 [1.01, 8.39], p = 0.05). The prevalence of TMA in our study is 0.8% with a mortality in our pediatric TMA cohort of 30%, which is in contrast to the higher mortality reported in previously published, small-case series. HHV6 emerged as not only a risk factor for TMA but also as associated with increased mortality in these patients.
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