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Fang W, Sun W, Fang W, Zhao S, Wang C. Clinical features, treatment, and outcomes of patients with carfilzomib induced thrombotic microangiopathy. Int Immunopharmacol 2024; 134:112178. [PMID: 38728883 DOI: 10.1016/j.intimp.2024.112178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is associated with carfilzomib, and knowledge of carfilzomib-induced TMA is based mainly on case reports. This study investigated the clinical characteristics of patients with carfilzomib-induced TMA and provided a reference for the rational use of carfilzomib. METHODS Reports of carfilzomib-induced TMA were collected for retrospective analysis by searching the Chinese and English databases from inception to January 31, 2024. RESULTS Sixty-six patients were included, with a median age of 63 years (range 39, 85). The median time to onset of TMA was 42 days (range 1, 1825) from initial administration, and the median number of cycles was 3 cycles (range 1, 15). Hemolytic anemia was recorded in 64 patients, with a median of 8.3 g/dL (range 4.6, 13). Sixty-three patients had thrombocytopenia with a median of 18 × 109/L (range 1, 139). The median value of increased LDH was 1192 IU/L (range 141, 5378). ADAMTS13 activity was normal in 41 (62.1 %) of the 42 patients. Mutations were found in 9 (13.6 %) of the 15 patients. Fifty-seven patients achieved a clinical response after discontinuing carfilzomib and receiving therapeutic plasma exchange (53.0 %), eculizumab (24.2 %), or hemodialysis (39.4 %). CONCLUSION Carfilzomib-induced TMA is an important adverse event that should be considered in patients receiving carfilzomib for multiple myeloma with anemia, thrombocytopenia, and acute kidney injury. Withdrawal of carfilzomib and treatment with eculizumab have proven successful in some patients.
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Affiliation(s)
- Weilun Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China; College of Pharmacy, Changsha Medical University, Changsha, Hunan 410219, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Shaoli Zhao
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China.
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [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: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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Largeau B, Thoreau B, Grangé S, Jonville-Béra AP, Halimi JM. Thrombotic microangiopathy associated with anticancer and immune system targeting drugs: New insights from real-world data using the WHO pharmacovigilance database. J Intern Med 2023; 294:665-678. [PMID: 37538031 DOI: 10.1111/joim.13703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND The worldwide development of immune system targeting/anticancer drugs has revolutionized immuno-oncology, but their implication in thrombotic microangiopathy syndromes (TMA) is increasingly suspected. Using real-world data, the aim of this study was to identify drugs associated with TMA reporting and to describe the evolution of TMA reporting over time with a focus on these drugs. METHODS A global disproportionality study was performed using the individual case safety reports (ICSRs) extracted from the World Health Organization (WHO) pharmacovigilance database (VigiBase) from its inception (1968) to April 30, 2022. RESULTS Of the 31,251,040 ICSRs, 6946 cases of suspected drug-induced TMA were included from 55 countries. The outcome was fatal in 18.2% of cases. A total of 72 immune system targeting/anticancer drugs were associated with significant overreporting, including 17 drugs with a potential new safety concern for TMA. Although the rate of TMA reporting per million of ICSRs has remained fairly stable, an absolute increase in reported cases of suspected drug-induced TMA has been observed over the last decade. The pattern of drugs reported in TMA has evolved with a substantial increase in the proportion of cases involving immune system-targeting drugs/anticancer drugs from 47.3% (205/433) in the period 1992-2001 to 80.7% (3819/4730) in the period 2012-2021. CONCLUSION Several recently marketed immune system targeting/anticancer drugs have been identified as potential new drugs associated with TMA, which will require confirmatory studies. The number of drugs associated with TMA reporting markedly increased within the past 10 years, primarily due to innovative anticancer drugs.
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Affiliation(s)
- Bérenger Largeau
- Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Benjamin Thoreau
- Service de Médecine Interne-Immunologie Clinique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Steven Grangé
- Centre National de Référence pour les microangiopathies thrombotiques, Hôpital Saint-Antoine, Université de la Sorbonne, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Bois-Guillaume, CHU Rouen, Rouen, France
| | - Annie-Pierre Jonville-Béra
- Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Jean-Michel Halimi
- Centre National de Référence pour les microangiopathies thrombotiques, Hôpital Saint-Antoine, Université de la Sorbonne, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Bretonneau, CHU Tours, Tours, France
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Uruski P, Matuszewska J, Leśniewska A, Rychlewski D, Niklas A, Mikuła-Pietrasik J, Tykarski A, Książek K. An integrative review of nonobvious puzzles of cellular and molecular cardiooncology. Cell Mol Biol Lett 2023; 28:44. [PMID: 37221467 DOI: 10.1186/s11658-023-00451-y] [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: 02/22/2023] [Accepted: 04/17/2023] [Indexed: 05/25/2023] Open
Abstract
Oncologic patients are subjected to four major treatment types: surgery, radiotherapy, chemotherapy, and immunotherapy. All nonsurgical forms of cancer management are known to potentially violate the structural and functional integrity of the cardiovascular system. The prevalence and severity of cardiotoxicity and vascular abnormalities led to the emergence of a clinical subdiscipline, called cardiooncology. This relatively new, but rapidly expanding area of knowledge, primarily focuses on clinical observations linking the adverse effects of cancer therapy with deteriorated quality of life of cancer survivors and their increased morbidity and mortality. Cellular and molecular determinants of these relations are far less understood, mainly because of several unsolved paths and contradicting findings in the literature. In this article, we provide a comprehensive view of the cellular and molecular etiology of cardiooncology. We pay particular attention to various intracellular processes that arise in cardiomyocytes, vascular endothelial cells, and smooth muscle cells treated in experimentally-controlled conditions in vitro and in vivo with ionizing radiation and drugs representing diverse modes of anti-cancer activity.
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Affiliation(s)
- Paweł Uruski
- Department of Hypertensiology, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Julia Matuszewska
- Department of Pathophysiology of Ageing and Civilization Diseases, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Aleksandra Leśniewska
- Department of Pathophysiology of Ageing and Civilization Diseases, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Daniel Rychlewski
- Department of Pathophysiology of Ageing and Civilization Diseases, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Arkadiusz Niklas
- Department of Hypertensiology, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Justyna Mikuła-Pietrasik
- Department of Pathophysiology of Ageing and Civilization Diseases, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Andrzej Tykarski
- Department of Hypertensiology, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland
| | - Krzysztof Książek
- Department of Pathophysiology of Ageing and Civilization Diseases, Poznań University of Medical Sciences, Długa ½ Str., 61-848, Poznan, Poland.
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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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Moscvin M, Liacos CI, Chen T, Theodorakakou F, Fotiou D, Hossain S, Rowell S, Leblebjian H, Regan E, Czarnecki P, Bagnoli F, Bolli N, Richardson P, Rennke HG, Dimopoulos MA, Kastritis E, Bianchi G. Mutations in the alternative complement pathway in multiple myeloma patients with carfilzomib-induced thrombotic microangiopathy. Blood Cancer J 2023; 13:31. [PMID: 36849497 PMCID: PMC9971259 DOI: 10.1038/s41408-023-00802-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 02/28/2023] Open
Abstract
Thrombotic microangiopathy (TMA) has been reported to occur in multiple myeloma (MM) patients in association with treatment with carfilzomib, an irreversible proteasome inhibitor (PI). The hallmark of TMA is vascular endothelial damage leading to microangiopathic hemolytic anemia, platelet consumption, fibrin deposition and small-vessel thrombosis with resultant tissue ischemia. The molecular mechanisms underlying carfilzomib-associated TMA are not known. Germline mutations in the complement alternative pathway have been recently shown to portend increased risk for the development of atypical hemolytic uremic syndrome (aHUS) and TMA in the setting of allogeneic stem cell transplant in pediatric patients. We hypothesized that germline mutations in the complement alternative pathway may similarly predispose MM patients to carfilzomib-associated TMA. We identified 10 MM patients with a clinical diagnosis of TMA in the context of carfilzomib treatment and assessed for the presence of germline mutations in the complement alternative pathway. Ten, matched MM patients exposed to carfilzomib but without clinical TMA were used as negative controls. We identified a frequency of deletions in the complement Factor H genes 3 and 1 (delCFHR3-CFHR1) and genes 1 and 4 (delCFHR1-CFHR4) in MM patients with carfilzomib-associated TMA that was higher as compared to the general population and matched controls. Our data suggest that complement alternative pathway dysregulation may confer susceptibility to vascular endothelial injury in MM patients and predispose to development of carfilzomib-associated TMA. Larger, retrospective studies are needed to evaluate whether screening for complement mutations may be indicated to properly counsel patients about TMA risk with carfilzomib use.
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Affiliation(s)
- Maria Moscvin
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
- Stanford Health Care, Stanford, CA, USA
| | - Christine Ivy Liacos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Tianzeng Chen
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Shahrier Hossain
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Sean Rowell
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Houry Leblebjian
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eileen Regan
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Peter Czarnecki
- Renal Division, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Filippo Bagnoli
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
- Hematology Division, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Niccolo' Bolli
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
- Hematology Division, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Helmut G Rennke
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Athens, Greece
| | - Giada Bianchi
- Amyloidosis Program, Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA.
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7
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Carfilzomib Induced Microangiopathy due to Accumulation With Paxlovid. Kidney Int Rep 2022; 7:2746-2749. [PMID: 36506224 PMCID: PMC9727521 DOI: 10.1016/j.ekir.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022] Open
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Gavriilaki E, Dalampira D, Theodorakakou F, Liacos CI, Kanellias N, Eleutherakis-Papaiakovou E, Terpos E, Gavriatopoulou M, Verrou E, Triantafyllou T, Sevastoudi A, Koravou EE, Touloumenidou T, Varelas C, Papalexandri A, Sakellari I, Dimopoulos MA, Kastritis E, Katodritou E. Genetic and Functional Evidence of Complement Dysregulation in Multiple Myeloma Patients with Carfilzomib-Induced Thrombotic Microangiopathy Compared to Controls. J Clin Med 2022; 11:3355. [PMID: 35743426 PMCID: PMC9225266 DOI: 10.3390/jcm11123355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Carfilzomib, an irreversible proteasome inhibitor approved for the treatment of relapsed/refractory Multiple Myeloma (MM) has been associated with Thrombotic Microangiopathy (TMA). Several pathogenetic mechanisms of carfilzomib-induced TMA have been proposed; however, recently, there has been a shift of focus on the potential contribution of complement dysregulation. Our aim was to explore whether patients with carfilzomib-induced TMA harbor germline variants of complement-related genes, which have been characterized as risk factors for TMA. METHODS We retrospectively recruited consecutive MM patients with carfilzomib-induced TMA and compared them to MM patients who received ≥4 cycles of carfilzomib and did not develop signs/symptoms of TMA, in a 1:2 ratio. Genomic DNA from peripheral blood was analyzed using next generation sequencing (NGS) with a complement-related gene panel; ADAMTS13 activity and soluble C5b-9 were measured using ELISA. RESULTS Complement-related variants were more common in patients with carfilzomib-induced TMA compared to non-TMA controls, regardless of patient and treatment characteristics; ADAMTS13 activity and C5b-9 were compatible with the phenotype of complement-related TMA. CONCLUSIONS We confirmed the previous findings that implicated complement-related genes in the pathogenesis of carfilzomib-induced TMA. Most importantly, by incorporating a control group of non-TMA MM patients treated with carfilzomib-based regimens and functional complement assays, we enhanced the credibility of our findings.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department—BMT Unit, G. Papanicolaou Hospital, 570 10 Thessaloniki, Greece; (E.G.); (E.-E.K.); (T.T.); (C.V.); (A.P.); (I.S.)
| | - Dimitra Dalampira
- Hematology Department, Theagenio Cancer Hospital, 546 39 Thessaloniki, Greece; (E.V.); (T.T.); (A.S.); (E.K.)
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Christine-Ivy Liacos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Evgenia Verrou
- Hematology Department, Theagenio Cancer Hospital, 546 39 Thessaloniki, Greece; (E.V.); (T.T.); (A.S.); (E.K.)
| | - Theodora Triantafyllou
- Hematology Department, Theagenio Cancer Hospital, 546 39 Thessaloniki, Greece; (E.V.); (T.T.); (A.S.); (E.K.)
| | - Aggeliki Sevastoudi
- Hematology Department, Theagenio Cancer Hospital, 546 39 Thessaloniki, Greece; (E.V.); (T.T.); (A.S.); (E.K.)
| | - Evaggelia-Evdoxia Koravou
- Hematology Department—BMT Unit, G. Papanicolaou Hospital, 570 10 Thessaloniki, Greece; (E.G.); (E.-E.K.); (T.T.); (C.V.); (A.P.); (I.S.)
| | - Tasoula Touloumenidou
- Hematology Department—BMT Unit, G. Papanicolaou Hospital, 570 10 Thessaloniki, Greece; (E.G.); (E.-E.K.); (T.T.); (C.V.); (A.P.); (I.S.)
| | - Christos Varelas
- Hematology Department—BMT Unit, G. Papanicolaou Hospital, 570 10 Thessaloniki, Greece; (E.G.); (E.-E.K.); (T.T.); (C.V.); (A.P.); (I.S.)
| | - Apostolia Papalexandri
- Hematology Department—BMT Unit, G. Papanicolaou Hospital, 570 10 Thessaloniki, Greece; (E.G.); (E.-E.K.); (T.T.); (C.V.); (A.P.); (I.S.)
| | - Ioanna Sakellari
- Hematology Department—BMT Unit, G. Papanicolaou Hospital, 570 10 Thessaloniki, Greece; (E.G.); (E.-E.K.); (T.T.); (C.V.); (A.P.); (I.S.)
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (F.T.); (C.-I.L.); (N.K.); (E.E.-P.); (E.T.); (M.G.); (M.A.D.); (E.K.)
| | - Eirini Katodritou
- Hematology Department, Theagenio Cancer Hospital, 546 39 Thessaloniki, Greece; (E.V.); (T.T.); (A.S.); (E.K.)
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Meuleman MS, Duval A, Fremeaux-Bacchi V, Roumenina LT, Chauvet S. Ex Vivo Test for Measuring Complement Attack on Endothelial Cells: From Research to Bedside. Front Immunol 2022; 13:860689. [PMID: 35493497 PMCID: PMC9041553 DOI: 10.3389/fimmu.2022.860689] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/21/2022] [Indexed: 01/04/2023] Open
Abstract
As part of the innate immune system, the complement system plays a key role in defense against pathogens and in host cell homeostasis. This enzymatic cascade is rapidly triggered in the presence of activating surfaces. Physiologically, it is tightly regulated on host cells to avoid uncontrolled activation and self-damage. In cases of abnormal complement dysregulation/overactivation, the endothelium is one of the primary targets. Complement has gained momentum as a research interest in the last decade because its dysregulation has been implicated in the pathophysiology of many human diseases. Thus, it appears to be a promising candidate for therapeutic intervention. However, detecting abnormal complement activation is challenging. In many pathological conditions, complement activation occurs locally in tissues. Standard routine exploration of the plasma concentration of the complement components shows values in the normal range. The available tests to demonstrate such dysregulation with diagnostic, prognostic, and therapeutic implications are limited. There is a real need to develop tools to demonstrate the implications of complement in diseases and to explore the complex interplay between complement activation and regulation on human cells. The analysis of complement deposits on cultured endothelial cells incubated with pathologic human serum holds promise as a reference assay. This ex vivo assay most closely resembles the physiological context. It has been used to explore complement activation from sera of patients with atypical hemolytic uremic syndrome, malignant hypertension, elevated liver enzymes low platelet syndrome, sickle cell disease, pre-eclampsia, and others. In some cases, it is used to adjust the therapeutic regimen with a complement-blocking drug. Nevertheless, an international standard is lacking, and the mechanism by which complement is activated in this assay is not fully understood. Moreover, primary cell culture remains difficult to perform, which probably explains why no standardized or commercialized assay has been proposed. Here, we review the diseases for which endothelial assays have been applied. We also compare this test with others currently available to explore complement overactivation. Finally, we discuss the unanswered questions and challenges to overcome for validating the assays as a tool in routine clinical practice.
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Affiliation(s)
- Marie-Sophie Meuleman
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Anna Duval
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | | | - Lubka T Roumenina
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Sophie Chauvet
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
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Terao T, Tsushima T, Miura D, Ikeda D, Fukumoto A, Kuzume A, Tabata R, Narita K, Takeuchi M, Matsue K. Carfilzomib-induced thrombotic microangiopathy is underestimated in clinical practice: A report of five patients and literature review. Leuk Lymphoma 2022; 63:1102-1110. [PMID: 35373680 DOI: 10.1080/10428194.2022.2057485] [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] [Indexed: 10/18/2022]
Abstract
Carfilzomib (Cfz) is widely used to treat multiple myeloma. However, real-world data of the incidence of thrombotic microangiopathy (TMA) caused by Cfz is inconsistent (<1-5%). We evaluated 96 consecutive patients who received Cfz to evaluate the incidence of TMA in clinical practice. TMA developed in five patients (5.2%) who were mainly receiving high-dose Cfz (≥56 mg/m2). Based on a literature review, precaution should be taken for Cfz-induced TMA in male patients receiving high-dose Cfz irrespective of the combination therapy, Cfz administration period, and complement level. In conclusion, Cfz-induced TMA might be underestimated in clinical practice, and early intervention should be considered.
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Affiliation(s)
- Toshiki Terao
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Takafumi Tsushima
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Daisuke Miura
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Daisuke Ikeda
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Ami Fukumoto
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Ayumi Kuzume
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Rikako Tabata
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kentaro Narita
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Masami Takeuchi
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kosei Matsue
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
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11
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How I treat microangiopathic hemolytic anemia in patients with cancer. Blood 2021; 137:1310-1317. [PMID: 33512445 PMCID: PMC8555418 DOI: 10.1182/blood.2019003810] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.
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12
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Freyer CW, Bange EM, Skuli S, Hsu M, Lin J, Cuker A, Cohen AD, Garfall A. Carfilzomib-Induced Atypical Hemolytic Uremic Syndrome in a Patient With Heterozygous CFHR3/CFHR1 Deletion Treated With Eculizumab. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e845-e849. [PMID: 34366267 DOI: 10.1016/j.clml.2021.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Craig W Freyer
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Erin M Bange
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sarah Skuli
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Miles Hsu
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John Lin
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam D Cohen
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alfred Garfall
- Hospital of the University of Pennsylvania, Philadelphia, PA
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13
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Camilleri M, Cuadrado M, Phillips E, Wilson W, Jenner R, Pang G, Kamora S, Streetly M, Popat R, Bygrave C, Owen R, Cavenagh J, Chapman M, Sive J, Eccersley L, Sheaff M, Benjamin R, Ramasamy K, Cook G, Virchis A, Chavda SJ, Clifton-Hadley L, Scully MA, Yong K. Thrombotic microangiopathy in untreated myeloma patients receiving carfilzomib, cyclophosphamide and dexamethasone on the CARDAMON study. Br J Haematol 2021; 193:750-760. [PMID: 33650100 DOI: 10.1111/bjh.17377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
Proteasome inhibitors have been associated with thrombotic microangiopathy (TMA) - a group of disorders characterised by occlusive microvascular thrombosis causing microangiopathic haemolytic anaemia, thrombocytopenia and end-organ damage. To date, carfilzomib-associated TMA has predominantly been described in relapsed/refractory myeloma patients. We report eight patients with newly diagnosed myeloma who experienced TMA events while receiving carfilzomib on the phase II CARDAMON trial. The first three occurred during maintenance single-agent carfilzomib, two occurred at induction with carfilzomib given with cyclophosphamide and dexamethasone (KCd) and three occurred during KCd consolidation. At TMA presentation 6/8 were hypertensive; 7/8 had acute kidney injury and in three, renal impairment persisted after resolution of TMA in other respects. The mechanism of carfilzomib-associated TMA remains unclear, though patients with known hypertension seem particularly susceptible. Given the first three cases occurred during maintenance after a longer than five-week treatment break, a protocol amendment was instituted with: aggressive hypertension management, carfilzomib step-up dosing (20 mg/m2 on day 1) at start of maintenance before dose escalation to 56 mg/m2 maximum, and adding 10 mg dexamethasone as premedication to maintenance carfilzomib infusions. No further TMA events occurred during maintenance following this amendment and the TMA incidence reduced from 4·2 to 1·6 per 1 000 patient cycles.
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Affiliation(s)
- Marquita Camilleri
- Haematology Department, University College Hospitals, London, UK
- Cancer Institute, University College London, London, UK
| | - Maria Cuadrado
- Haematology Department, University College Hospitals, London, UK
| | - Elizabeth Phillips
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester, UK
| | - William Wilson
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Richard Jenner
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Gavin Pang
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Sumaiya Kamora
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Matthew Streetly
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
| | - Rakesh Popat
- Haematology Department, University College Hospitals, London, UK
- Cancer Institute, University College London, London, UK
| | | | - Roger Owen
- HMDS Laboratory, St James' Institute of Oncology, Leeds, UK
| | - James Cavenagh
- Haematology Department, Barts Health NHS Trust, London, UK
| | - Mike Chapman
- Haematology Department, Cambridge Institute for Medical Research, Cambridge, UK
| | - Jonathan Sive
- Haematology Department, University College Hospitals, London, UK
| | | | - Michael Sheaff
- Cellular Pathology Department, Barts Health NHS Trust, London, UK
| | | | - Karthik Ramasamy
- Haematology Department, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Gordon Cook
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Andres Virchis
- Haematology Department, Royal Free Hospitals NHS Trust, London, UK
| | - Selina J Chavda
- Haematology Department, University College Hospitals, London, UK
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
| | - Laura Clifton-Hadley
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester, UK
| | - Marie Anne Scully
- Haematology Department, University College Hospitals, London, UK
- Cardiometabolic Programme, NIHR UCLH/UCL Biomedical Research Centre, London, UK
| | - Kwee Yong
- Haematology Department, University College Hospitals, London, UK
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
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14
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Venner CP, LeBlanc R, Sandhu I, White D, Belch AR, Reece DE, Chen C, Dolan S, Lalancette M, Louzada M, Kew A, McCurdy A, Monteith B, Reiman T, McDonald G, Sherry M, Gul E, Chen BE, Hay AE. Weekly carfilzomib plus cyclophosphamide and dexamethasone in the treatment of relapsed/refractory multiple myeloma: Final results from the MCRN-003/MYX.1 single arm phase II trial. Am J Hematol 2021; 96:552-560. [PMID: 33650179 DOI: 10.1002/ajh.26147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/14/2021] [Indexed: 11/09/2022]
Abstract
The MCRN-003/CCTGMYX.1 is a single arm phase II trial of weekly carfilzomib, cyclophosphamide and dexamethasone (wKCd), exploring a convenient immunomodulator (IMiD)-free regimen in relapsed myeloma. Weekly carfilzomib (20/70 mg/m2 ), dexamethasone 40 mg and cyclophosphamide 300 mg/m2 was delivered over 28-day cycles. The primary endpoint was overall response after four cycles. Secondary endpoints included toxicity, response depth, PFS and OS. Exploratory endpoints included the impact of cytogenetics, prior therapy exposure and serum free light chain (sFLC) escape; 76 patients were accrued. The ORR was 85% (68% ≥very good partial response [VGPR] and 29% ≥complete response [CR]). The median OS and PFS were 27 and 17 months respectively. High-risk cytogenetics conferred a worse ORR (75% vs. 97%, p = .013) and median OS (18 months vs. NR, p = .002) with a trend toward a worse median PFS (14 vs. 22 months, p = .06). Prior proteasome inhibitor (PI) or lenalidomide did not influence OS or PFS. The sFLC was noted in 15% of patients with a median PFS of 17 months when included as a progression event. The most common ≥ grade 3 non-hematologic adverse events were infectious (40%), vascular (17%) and cardiac (15%). The wKCD is a safe and effective regimen in relapse, especially for patients ineligible for lenalidomide-based therapies.
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Affiliation(s)
| | - Richard LeBlanc
- CIUSSS de lʼEst de lʼIle de Montréal Université de Montréal Montreal Quebec Canada
| | - Irwindeep Sandhu
- The Cross Cancer Institute University of Alberta Edmonton Alberta Canada
| | - Darrell White
- Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax Nova Scotia Canada
| | - Andrew R. Belch
- The Cross Cancer Institute University of Alberta Edmonton Alberta Canada
| | | | | | - Sean Dolan
- University of New Brunswick Saint John Regional Hospital Saint John New Brunswick Canada
| | | | - Martha Louzada
- London Regional Cancer Centre University of Western Ontario London Ontario Canada
| | - Andrea Kew
- The Ottawa Hospital University of Ottawa Ottawa Ontario Canada
| | - Arleigh McCurdy
- The Ottawa Hospital University of Ottawa Ottawa Ontario Canada
| | - Bethany Monteith
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Tony Reiman
- University of New Brunswick Saint John Regional Hospital Saint John New Brunswick Canada
| | - Gail McDonald
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Max Sherry
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Engin Gul
- Canadian Myeloma Research Group (formerly the Myeloma Canada Research Network) Vaughan Ontario Canada
| | - Bingshu E. Chen
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Annette E. Hay
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
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15
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Rassner M, Baur R, Wäsch R, Schiffer M, Schneider J, Mackensen A, Engelhardt M. Two cases of carfilzomib-induced thrombotic microangiopathy successfully treated with Eculizumab in multiple myeloma. BMC Nephrol 2021; 22:32. [PMID: 33461512 PMCID: PMC7814610 DOI: 10.1186/s12882-020-02226-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/25/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Treatment with proteasome inhibitors like carfilzomib in patients with multiple myeloma (MM) can induce thrombotic microangiopathy (TMA) characterized by neurological symptoms, acute kidney injury, hemolysis and thrombocytopenia. Successful treatment with the monoclonal antibody eculizumab was described for these patients, but reports of ideal management and definitive treatment protocols are lacking. CASE PRESENTATION The first case describes a 43-years-old IgG-kappa-MM patient that developed TMA during the first course of carfilzomib-lenalidomide-dexamethasone (KRd) consolidation after autologous stem cell transplantation (ASCT). In the second case, a 59-years-old IgG-kappa-MM patient showed late-onset TMA during the fourth and last cycle of elotuzumab-KRd consolidation within the DSMM XVII study of the German study group MM (DSMM; clinicalTrials.gov Identifier: NCT03948035). Concurrently, he suffered from influenza A/B infection. Both patients had a high TMA-index for a poor prognosis of TMA. Therapeutically, in both patients plasma exchange (TPE) was initiated as soon as TMA was diagnosed. In patient #1, dialysis became necessary. For both patients, only when the complement inhibitor eculizumab was administered, kidney function and blood values impressively improved. CONCLUSION In this small case series, two patients with MM developed TMA due to carfilzomib treatment (CFZ-TMA), the second patient as a late-onset form. Even though TMA could have been elicited by influenza in the second patient and occurred after ASCT in both patients, with cases of TMA post-transplantation in MM being described, a relation of TMA and carfilzomib treatment was most likely. In both patients, treatment with eculizumab over two months efficiently treated TMA without recurrence and with both patients remaining responsive months after TMA onset. Taken together, we describe two cases of TMA in MM patients on carfilzomib-combination treatment, showing similar courses of this severe adverse reaction, with good responses to two months of eculizumab treatment.
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Affiliation(s)
- Michael Rassner
- Department of Medicine I (Hematology, Oncology and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 53, D-79106, Freiburg, Germany
| | - Rebecca Baur
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 53, D-79106, Freiburg, Germany
| | - Mario Schiffer
- Department of Internal Medicine 4 - Nephrology, University Hospital of Erlangen, Erlangen, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5 - Hematology/Oncology, University Hospital of Erlangen, Erlangen, Germany
| | - Monika Engelhardt
- Department of Medicine I (Hematology, Oncology and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 53, D-79106, Freiburg, Germany.
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