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Glenthøj A, Grace RF, Lander C, van Beers EJ, Glader B, Kuo KHM, Yan Y, McGee B, Boscoe AN, Li J, Bianchi P. Comorbidities and complications in adult and paediatric patients with pyruvate kinase deficiency: Analysis from the Peak Registry. Br J Haematol 2024; 205:613-623. [PMID: 39118415 DOI: 10.1111/bjh.19601] [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: 08/25/2023] [Accepted: 06/06/2024] [Indexed: 08/10/2024]
Abstract
Pyruvate kinase (PK) deficiency, a rare, congenital haemolytic anaemia caused by mutations in the PKLR gene, is associated with many clinical manifestations, but the full disease burden has yet to be characterised. The Peak Registry (NCT03481738) is an observational, longitudinal registry of adult and paediatric patients with PK deficiency. Here, we described comorbidities and complications in these patients by age at most recent visit and PKLR genotype. As of 13 May 2022, 241 patients were included in the analysis. In total, 48.3% had undergone splenectomy and 50.5% had received chelation therapy. History of iron overload (before enrolment/during follow-up) was common (52.5%), even in never-transfused patients (20.7%). Neonatal complications and symptoms included jaundice, splenomegaly and hepatomegaly, with treatment interventions required in 41.5%. Among adults, osteopenia/osteoporosis occurred in 19.0% and pulmonary hypertension in 6.7%, with median onset ages of 37, 33 and 22 years, respectively. Biliary events and bone health problems were common across PKLR genotypes. Among 11 patients who had thromboembolic events, eight had undergone prior splenectomy. Patients with PK deficiency may have many complications, which can occur early in and throughout life. Awareness of their high disease burden may help clinicians better provide appropriate monitoring and management of these patients.
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MESH Headings
- Humans
- Registries
- Pyruvate Kinase/deficiency
- Pyruvate Kinase/genetics
- Male
- Female
- Adult
- Child
- Anemia, Hemolytic, Congenital Nonspherocytic/genetics
- Anemia, Hemolytic, Congenital Nonspherocytic/epidemiology
- Pyruvate Metabolism, Inborn Errors/genetics
- Pyruvate Metabolism, Inborn Errors/epidemiology
- Adolescent
- Child, Preschool
- Infant
- Comorbidity
- Middle Aged
- Splenectomy
- Young Adult
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/epidemiology
- Iron Overload/etiology
- Iron Overload/epidemiology
- Bone Diseases, Metabolic/etiology
- Bone Diseases, Metabolic/epidemiology
- Infant, Newborn
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Affiliation(s)
- Andreas Glenthøj
- Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Carl Lander
- Thrive with PK Deficiency, Bloomington, Minnesota, USA
| | - Eduard J van Beers
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bertil Glader
- Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | - Yan Yan
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Bryan McGee
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Audra N Boscoe
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Junlong Li
- Agios Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Paola Bianchi
- Hematology Unit, Pathophysiology of Anemia Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Al-Samkari H, Shehata N, Lang-Robertson K, Bianchi P, Glenthøj A, Sheth S, Neufeld EJ, Rees DC, Chonat S, Kuo KHM, Rothman JA, Barcellini W, van Beers EJ, Pospíšilová D, Shah AJ, van Wijk R, Glader B, Mañú Pereira MDM, Andres O, Kalfa TA, Eber SW, Gallagher PG, Kwiatkowski JL, Galacteros F, Lander C, Watson A, Elbard R, Peereboom D, Grace RF. Diagnosis and management of pyruvate kinase deficiency: international expert guidelines. Lancet Haematol 2024; 11:e228-e239. [PMID: 38330977 DOI: 10.1016/s2352-3026(23)00377-0] [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: 10/20/2023] [Revised: 12/04/2023] [Accepted: 12/13/2023] [Indexed: 02/10/2024]
Abstract
Pyruvate kinase (PK) deficiency is the most common cause of chronic congenital non-spherocytic haemolytic anaemia worldwide, with an estimated prevalence of one in 100 000 to one in 300 000 people. PK deficiency results in chronic haemolytic anaemia, with wide ranging and serious consequences affecting health, quality of life, and mortality. The goal of the International Guidelines for the Diagnosis and Management of Pyruvate Kinase Deficiency was to develop evidence-based guidelines for the clinical care of patients with PK deficiency. These clinical guidelines were developed by use of GRADE methodology and the AGREE II framework. Experts were invited after consideration of area of expertise, scholarly contributions in PK deficiency, and country of practice for global representation. The expert panel included 29 expert physicians (including adult and paediatric haematologists and other subspecialists), geneticists, laboratory specialists, nurses, a guidelines methodologist, patients with PK deficiency, and caregivers from ten countries. Five key topic areas were identified, the panel prioritised key questions, and a systematic literature search was done to generate evidence summaries that were used in the development of draft recommendations. The expert panel then met in person to finalise and vote on recommendations according to a structured consensus procedure. Agreement of greater than or equal to 67% among the expert panel was required for inclusion of a recommendation in the final guideline. The expert panel agreed on 31 total recommendations across five key topics: diagnosis and genetics, monitoring and management of chronic complications, standard management of anaemia, targeted and advanced therapies, and special populations. These new guidelines should facilitate best practices and evidence-based PK deficiency care into clinical practice.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nadine Shehata
- Departments of Medicine and Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Paola Bianchi
- Hematology Unit, Pathophysiology of Anemias Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas Glenthøj
- Danish Red Blood Cell Center, Department of Hematology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Sujit Sheth
- Division of Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Ellis J Neufeld
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - David C Rees
- Department of Paediatric Haematology, King's College London, King's College Hospital, London, UK
| | - Satheesh Chonat
- Pediatric Hematology/Oncology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Kevin H M Kuo
- Division of Medical Oncology and Hematology, University Health Network, University of Toronto, ON, Canada
| | | | - Wilma Barcellini
- Hematology Unit, Pathophysiology of Anemias Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eduard J van Beers
- Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, Netherlands
| | - Dagmar Pospíšilová
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Ami J Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucile Packard Children Hospital, Stanford School of Medicine, Palo Alto, CA, USA
| | - Richard van Wijk
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Bertil Glader
- Division of Pediatric Hematology/Oncology, Lucile Packard Children Hospital, Stanford School of Medicine, Palo Alto, CA, USA
| | - Maria Del Mar Mañú Pereira
- Rare Anaemia Disorders Research Laboratory, Institut de Recerca - Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Oliver Andres
- Centre of Inherited Blood Cell Disorders, University Hospital Würzburg, Würzburg, Germany
| | - Theodosia A Kalfa
- Division of Hematology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stefan W Eber
- Department of Pediatrics, Practice for Pediatric Hematology and Hemostaseology, University Children's Hospital, Technical University, Munich, Germany
| | - Patrick G Gallagher
- Department of Pediatrics, Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Janet L Kwiatkowski
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carl Lander
- Thrive with Pyruvate Kinase Deficiency Foundation, Bloomington, MN, USA
| | | | - Riyad Elbard
- Thalassemia International Federation, Nicosia, Cyprus
| | | | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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Andrae DA, Grace RF, Jewett A, Foster B, Klaassen RJ, Salek S, Li J, Tai F, Boscoe AN, Zagadailov E. Psychometric validation of the Pyruvate Kinase Deficiency Diary and Pyruvate Kinase Deficiency Impact Assessment in adults in the phase 3 ACTIVATE trial. J Patient Rep Outcomes 2023; 7:112. [PMID: 37943362 PMCID: PMC10636000 DOI: 10.1186/s41687-023-00650-3] [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: 03/30/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Pyruvate kinase (PK) deficiency is a rare hereditary disorder characterized by chronic hemolytic anemia and serious sequalae which negatively affect patient quality of life. This study aimed to psychometrically validate the first disease-specific patient-reported outcome (PRO) instruments: the 7-item PK Deficiency Diary (PKDD) and 12-item PK Deficiency Impact Assessment (PKDIA), designed to assess signs, symptoms, and impacts of PK deficiency in patients enrolled in the ACTIVATE global phase 3 study of mitapivat versus placebo (NCT03548220). METHODS All validation analyses for the PKDD and PKDIA were performed on blinded data, with analyses on item integrity, scoring, reliability, and validity conducted on data from screening and baseline. Completion rates and baseline response distributions were characterized using descriptive statistics. Item response modelling was used to inform a weighted scoring system. Reliability was assessed by internal consistency and test-retest reliability; and validity by convergent and known-groups analyses. RESULTS Of the 80 adults enrolled, baseline data were available for 77 (96.3%) and 78 (97.5%) patients for the PKDD and PKDIA, respectively. Item responses skewed right, indicating that mean values exceeded median values, especially for items utilizing a 0-10 numeric scale, which were subsequently recoded to a 0-4 scale; 4 items were removed from the PKDIA due to redundancy or low relevance to the trial population. Both the PKDD and PKDIA demonstrated high internal consistency (McDonald's coefficient ω = 0.86 and 0.90, respectively), test-retest reliability (intra-class coefficients of 0.94 and 0.87, respectively), and convergent validity with other PROs (linear correlation coefficients [|r|] between 0.30-0.73 and 0.50-0.82, respectively). CONCLUSIONS The findings provide evidence of validity and reliability for the PKDD and PKDIA, the first disease-specific PRO measures for PK deficiency, and can therefore increase understanding of, and more accurately capture, the wider impact of PK deficiency on health-related quality of life. Trial registration ClinicalTrials.gov, NCT03548220. Registered June 07, 2018; https://www. CLINICALTRIALS gov/ct2/show/NCT03548220 .
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Affiliation(s)
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Robert J Klaassen
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Sam Salek
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Junlong Li
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Feng Tai
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Audra N Boscoe
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA.
| | - Erin Zagadailov
- Agios Pharmaceuticals, Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
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Grace RF, van Beers EJ, Vives Corrons JL, Glader B, Glenthøj A, Kanno H, Kuo KHM, Lander C, Layton DM, Pospíŝilová D, Viprakasit V, Li J, Yan Y, Boscoe AN, Bowden C, Bianchi P. The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry: rationale and study design. BMJ Open 2023; 13:e063605. [PMID: 36958777 PMCID: PMC10040033 DOI: 10.1136/bmjopen-2022-063605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION Pyruvate kinase (PK) deficiency is a rare, under-recognised, hereditary condition that leads to chronic haemolytic anaemia and potentially serious secondary complications, such as iron overload, cholecystitis, pulmonary hypertension and extramedullary haematopoiesis. It is an autosomal recessive disease caused by homozygous or compound heterozygous mutations in the PKLR gene. Due to its rarity and clinical heterogeneity, information on the natural history and long-term clinical course of PK deficiency is limited, presenting major challenges to patient management, the development of new therapies and establishing disease-specific treatment recommendations. The Pyruvate Kinase Deficiency Global Longitudinal (Peak) Registry is an initiative to address the gaps in the knowledge of PK deficiency. This manuscript describes the objectives, study design and methodology for the Peak Registry. METHODS AND ANALYSIS The Peak Registry is an observational, longitudinal, global registry of adult and paediatric patients with a genetically confirmed diagnosis of PK deficiency. The Peak Steering Committee is composed of 11 clinicians and researchers with experience in the diagnosis and management of PK deficiency from 10 countries, a patient representative and representatives from the sponsor (Agios Pharmaceuticals). The registry objective is to foster an understanding of the longitudinal clinical implications of PK deficiency, including its natural history, treatments and outcomes, and variability in clinical care. The aim is to enrol up to 500 participants from approximately 60 study centres across 20 countries over 7 years, with between 2 and 9 years of follow-up. Data will include demographics, diagnosis history, genotyping, transfusion history, relevant clinical events, medications, emergency room visits and hospitalisations. ETHICS AND DISSEMINATION Registry protocol and informed consent forms are approved by institutional review boards/independent ethics committees at each study site. The study is being conducted in accordance with the Declaration of Helsinki. Registry data will be published in peer-reviewed journal articles and conference publications. TRIAL REGISTRATION NUMBER NCT03481738.
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Affiliation(s)
- Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Eduard J van Beers
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Joan-Lluis Vives Corrons
- Institute for Leukaemia Research Josep Carreras ENERCA Coordinator, University of Barcelona, Barcelona, Spain
| | - Bertil Glader
- Stanford University School of Medicine, Stanford, California, USA
| | - Andreas Glenthøj
- Danish Red Blood Cell Center, Department of Hematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Hitoshi Kanno
- Department of Transfusion Medicine and Cell Processing, Tokyo Women's Medical University, Tokyo, Japan
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | | | - D Mark Layton
- Hammersmith Hospital, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Dagmar Pospíŝilová
- Department of Pediatrics, Palacky University and University Hospital, Olomouc, Czech Republic
| | - Vip Viprakasit
- Siriaj Hospital, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Junlong Li
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Yan Yan
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Audra N Boscoe
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Chris Bowden
- Agios Pharmaceuticals Inc, Cambridge, Massachusetts, USA
| | - Paola Bianchi
- Hematology Unit, Pathophysiology of Anemias Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Pyruvate kinase activator: A major breakthrough in the world of Hematology. Ann Med Surg (Lond) 2022; 82:104631. [PMID: 36268365 PMCID: PMC9577647 DOI: 10.1016/j.amsu.2022.104631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
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Mitapivat in adult patients with pyruvate kinase deficiency receiving regular transfusions (ACTIVATE-T): a multicentre, open-label, single-arm, phase 3 trial. THE LANCET HAEMATOLOGY 2022; 9:e724-e732. [DOI: 10.1016/s2352-3026(22)00214-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023]
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Fattizzo B, Cavallaro F, Marcello APML, Vercellati C, Barcellini W. Pyruvate Kinase Deficiency: Current Challenges and Future Prospects. J Blood Med 2022; 13:461-471. [PMID: 36072510 PMCID: PMC9444143 DOI: 10.2147/jbm.s353907] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/23/2022] [Indexed: 01/19/2023] Open
Abstract
Pyruvate kinase deficiency (PKD) is a rare autosomal recessive disease marked by chronic hemolytic anemia of various severity and frequent complications including gallstones, splenomegaly, iron overload, and others. Disease phenotype is highly heterogeneous and changes over time with children, adolescents and adult patients displaying different transfusion requirement and rates of complications. The diagnosis relies on the initial clinical suspicion in a patient with chronic hemolysis and exclusion of other more common congenital forms of hemolytic anemias; it is supported by the demonstration of reduced PK enzyme activity, and further confirmed by the detection of (homozygous or compound heterozygous) mutations of PKLR gene. Therapy is mainly supportive, with vitamin supplementation and transfusions (based on symptoms and patient growth rather than on fixed Hb thresholds). Splenectomy is widely performed, although it is less effective than in membrane defects and carries thrombotic and infectious risk. In the last decade, the allosteric PK enzyme activator mitapivat showed dramatic clinical benefit in clinical trials and gene therapy is also being studied to substitute the defective enzyme. In this review, we provide an insight in the current challenges of PKD diagnosis and management and discuss the future application of novel drugs and gene therapy, including a focus on quality of life.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Correspondence: Bruno Fattizzo, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Hematology Unit, Via F. Sforza 35, Milan, 20122, Italy, Tel +39 0255033477, Email
| | - Francesca Cavallaro
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Cristina Vercellati
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Johnson S, Grace RF, Despotovic JM. Diagnosis, monitoring, and management of pyruvate kinase deficiency in children. Pediatr Blood Cancer 2022; 69:e29696. [PMID: 35452178 DOI: 10.1002/pbc.29696] [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] [Received: 07/06/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase (PK) deficiency is a rare, congenital red blood cell disorder caused by a single gene defect. The spectrum of genotypes, variants, and phenotypes are broad, commonly requiring a multimodal approach including enzyme and genetic testing for accurate and reliable diagnosis. Similarly, management of primary and secondary sequelae of PK deficiency varies, mainly including supportive care with transfusions and surgical interventions to improve symptoms and quality of life. Given the risk of acute and long-term complications of PK deficiency and its treatment, regular monitoring and management of iron burden and organ dysfunction is critical. Therefore, all children and adolescents with PK deficiency should receive regular hematology care with visits at least every 6 months regardless of transfusion status. We continue to learn more about the spectrum of symptoms and complications of PK deficiency and best practice for monitoring and management through registry efforts (NCT03481738). The treatment of PK deficiency has made strides over the last few years with newer disease-modifying therapies being developed and studied, with the potential to change the course of disease in childhood and beyond.
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Affiliation(s)
- Shaniqua Johnson
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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Al-Samkari H, Galactéros F, Glenthøj A, Rothman JA, Andres O, Grace RF, Morado-Arias M, Layton DM, Onodera K, Verhovsek M, Barcellini W, Chonat S, Judge MP, Zagadailov E, Xu R, Hawkins P, Beynon V, Gheuens S, van Beers EJ. Mitapivat versus Placebo for Pyruvate Kinase Deficiency. N Engl J Med 2022; 386:1432-1442. [PMID: 35417638 DOI: 10.1056/nejmoa2116634] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pyruvate kinase deficiency is a rare, hereditary, chronic condition that is associated with hemolytic anemia. In a phase 2 study, mitapivat, an oral, first-in-class activator of erythrocyte pyruvate kinase, increased the hemoglobin level in patients with pyruvate kinase deficiency. METHODS In this global, phase 3, randomized, placebo-controlled trial, we evaluated the efficacy and safety of mitapivat in adults with pyruvate kinase deficiency who were not receiving regular red-cell transfusions. The patients were assigned to receive either mitapivat (5 mg twice daily, with potential escalation to 20 or 50 mg twice daily) or placebo for 24 weeks. The primary end point was a hemoglobin response (an increase from baseline of ≥1.5 g per deciliter in the hemoglobin level) that was sustained at two or more scheduled assessments at weeks 16, 20, and 24. Secondary efficacy end points were the average change from baseline in the hemoglobin level, markers of hemolysis and hematopoiesis, and the change from baseline at week 24 in two pyruvate kinase deficiency-specific patient-reported outcome measures. RESULTS Sixteen of the 40 patients (40%) in the mitapivat group had a hemoglobin response, as compared with none of the 40 patients in the placebo group (adjusted difference, 39.3 percentage points; 95% confidence interval, 24.1 to 54.6; two-sided P<0.001). Patients who received mitapivat had a greater response than those who received placebo with respect to each secondary end point, including the average change from baseline in the hemoglobin level. The most common adverse events were nausea (in 7 patients [18%] in the mitapivat group and 9 patients [23%] in the placebo group) and headache (in 6 patients [15%] and 13 patients [33%], respectively). Adverse events of grade 3 or higher occurred in 10 patients (25%) who received mitapivat and 5 patients (13%) who received placebo. CONCLUSIONS In patients with pyruvate kinase deficiency, mitapivat significantly increased the hemoglobin level, decreased hemolysis, and improved patient-reported outcomes. No new safety signals were identified in the patients who received mitapivat. (Funded by Agios Pharmaceuticals; ACTIVATE ClinicalTrials.gov number, NCT03548220.).
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Affiliation(s)
- Hanny Al-Samkari
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Frédéric Galactéros
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Andreas Glenthøj
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Jennifer A Rothman
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Oliver Andres
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Rachael F Grace
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Marta Morado-Arias
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - D Mark Layton
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Koichi Onodera
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Madeleine Verhovsek
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Wilma Barcellini
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Satheesh Chonat
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Malia P Judge
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Erin Zagadailov
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Rengyi Xu
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Peter Hawkins
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Vanessa Beynon
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Sarah Gheuens
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
| | - Eduard J van Beers
- From the Division of Hematology Oncology, Massachusetts General Hospital (H.A.-S.) and the Dana-Farber/Boston Children's Cancer and Blood Disorders Center (R.F.G.), Harvard Medical School, Boston, and Agios Pharmaceuticals, Cambridge (M.P.J., E.Z., R.X., P.H., V.B., S.G.) - all in Massachusetts; Unité des Maladies Génétiques du Globule Rouge, Centre Hospitalier Universitaire Henri Mondor, Créteil, France (F.G.); the Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen (A.G.); Duke University Medical Center, Durham, NC (J.A.R.); the Department of Pediatrics, University of Würzburg, Würzburg, Germany (O.A.); the Hematology Department, Hospital Universitario La Paz, Madrid (M.M.-A.); Hammersmith Hospital, Imperial College Healthcare NHS Trust, London (D.M.L.); Tohoku University Hospital, Sendai, Japan (K.O.); McMaster University, Hamilton, ONT, Canada (M.V.); Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.); Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and the Department of Pediatrics, Emory University, Atlanta (S.C.); and the Benign Hematology Center, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands (E.J.B.)
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Chueh HW, Kim N. Molecular genetic testing enabled the diagnosis of otherwise undiagnosable cases of pyruvate kinase deficiency. Pediatr Hematol Oncol 2022; 39:166-173. [PMID: 34281465 DOI: 10.1080/08880018.2021.1950877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The gold standard for the diagnosis of pyruvate kinase (PK) deficiency, the most frequent red blood cell enzymopathy, is an enzymatic activity assay. However, this assay is rather unreliable in a clinical setting, often leading to misdiagnosis or missed diagnosis. This report presented the cases of two patients diagnosed with PK deficiency using molecular genetic testing, even though conventional laboratory tests, including the PK activity assay, failed to detect any abnormalities. Genetic analysis of the patients and their asymptomatic parents revealed the presence of variants in both alleles of the PKLR gene that were assessed as "likely pathogenic" or "pathogenic" in the form of compound heterozygotes. One of the mutations detected was common in both patients. Our results suggested that genetic testing might be required for the reliable diagnosis of suspected congenital hemolytic anemia cases displaying atypical presentation.
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Affiliation(s)
- Hee Won Chueh
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Namhee Kim
- Department of Laboratory Medicine, Donga-A University College of Medicine, Busan, Republic of Korea
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Chonat S, Eber SW, Holzhauer S, Kollmar N, Morton DH, Glader B, Neufeld EJ, Yaish HM, Rothman JA, Sharma M, Ravindranath Y, Wang H, Breakey VR, Sheth S, Bradeen HA, Al-Sayegh H, London WB, Grace RF. Pyruvate kinase deficiency in children. Pediatr Blood Cancer 2021; 68:e29148. [PMID: 34125488 DOI: 10.1002/pbc.29148] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/08/2021] [Accepted: 05/13/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Pyruvate kinase deficiency (PKD) is a rare, autosomal recessive red blood cell enzyme disorder, which leads to lifelong hemolytic anemia and associated complications from the disease and its management. METHODS An international, multicenter registry enrolled 124 individuals younger than 18 years old with molecularly confirmed PKD from 29 centers. Retrospective and prospective clinical data were collected. RESULTS There was a wide range in the age at diagnosis from 0 to 16 years. Presentation in the newborn period ranged from asymptomatic to neonatal jaundice to fulminant presentations of fetal distress, myocardial depression, and/or liver failure. Children <5 years old were significantly more likely to be transfused than children >12 to <18 years (53% vs. 14%, p = .0006), which correlated with the timing of splenectomy. Regular transfusions were most common in children with two severe PKLR variants. In regularly transfused children, the nadir hemoglobin goal varied considerably. Impact on quality of life was a common reason for treatment with regular blood transfusions and splenectomy. Splenectomy increased the hemoglobin and decreased transfusion burden in most children but was associated with infection or sepsis (12%) and thrombosis (1.3%) even during childhood. Complication rates were high, including iron overload (48%), perinatal complications (31%), and gallstones (20%). CONCLUSIONS There is a high burden of disease in children with PKD, with wide practice variation in monitoring and treatment. Clinicians must recognize the spectrum of the manifestations of PKD for early diagnostic testing, close monitoring, and management to avoid serious complications in childhood.
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Affiliation(s)
- Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Stefan W Eber
- Schwerpunktpraxis für Pädiatrische Hämatologie-Onkologie, Munich, Germany
| | - Susanne Holzhauer
- Charité, University Medicine, Pediatric Hematology and Oncology, Berlin, Germany
| | | | - D Holmes Morton
- Central Pennsylvania Clinic for Special Children & Adults, Belleville, Pennsylvania, USA.,Lancaster General Hospital, Lancaster, Pennsylvania, USA
| | - Bertil Glader
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, California, USA
| | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Hassan M Yaish
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | | | - Mukta Sharma
- Children's Mercy, School of Medicine University of Missouri, Kansas City, Missouri, USA
| | - Yaddanapudi Ravindranath
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Heng Wang
- DDC Clinic for Special Needs Children, Middlefield, Ohio, USA
| | | | - Sujit Sheth
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Heather A Bradeen
- The University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Hasan Al-Sayegh
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
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Health-Related Quality of Life and Fatigue in Children and Adults with Pyruvate Kinase Deficiency. Blood Adv 2021; 6:1844-1853. [PMID: 34470054 PMCID: PMC8941458 DOI: 10.1182/bloodadvances.2021004675] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/29/2021] [Indexed: 01/19/2023] Open
Abstract
The impact of PKD on HRQoL and fatigue is described in 254 children and adults using 6 validated instruments. Severe anemia, regular transfusion, iron chelation, and nonmissense mutations are associated with worse patient-reported outcomes.
Pyruvate kinase deficiency (PKD) is the most common cause of congenital nonspherocytic hemolytic anemia. Although recognition of the disease spectrum has recently expanded, data describing its impact on health-related quality of life (HRQoL) are limited. In this prospective international cohort of 254 patients (131 adults and 123 children) with PKD, we used validated measures to assess the impact of disease on HRQoL (EuroQol 5-Dimension Questionnaire, Pediatric Quality of Life Inventory Generic Core Scale version 4.0, and Functional Assessment of Cancer Therapy-Anemia) and fatigue (Patient Reported Outcomes Measurement Information System Fatigue and Pediatric Functional Assessment of Chronic Illness Therapy-Fatigue). Significant variability in HRQoL and fatigue was reported for adults and children, although individual scores were stable over a 2-year interval. Although adults who were regularly transfused reported worse HRQoL and fatigue compared with those who were not (EuroQol-visual analog scale, 58 vs 80; P = .01), this difference was not seen in children. Regularly transfused adults reported lower physical, emotional, and functional well-being and more anemia symptoms. HRQoL and fatigue significantly differed in children by genotype, with the worst scores in those with 2 severe PKLR mutations; this difference was not seen in adults. However, iron chelation was associated with significantly worse HRQoL scores in children and adults. Pulmonary hypertension was also associated with significantly worse HRQoL. Additionally, 59% of adults and 35% of children reported that their jaundice upset them, identifying this as an important symptom for consideration. Although current treatments for PKD are limited to supportive care, new therapies are in clinical trials. Understanding the impact of PKD on HRQoL is important to assess the utility of these treatments. This trial was registered at www.clinicaltrials.gov as #NCT02053480.
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Management of pyruvate kinase deficiency in children and adults. Blood 2021; 136:1241-1249. [PMID: 32702739 DOI: 10.1182/blood.2019000945] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/18/2019] [Indexed: 01/19/2023] Open
Abstract
Pyruvate kinase deficiency (PKD) is an autosomal-recessive enzyme defect of the glycolytic pathway that causes congenital nonspherocytic hemolytic anemia. The diagnosis and management of patients with PKD can be challenging due to difficulties in the diagnostic evaluation and the heterogeneity of clinical manifestations, ranging from fetal hydrops and symptomatic anemia requiring lifelong transfusions to fully compensated hemolysis. Current treatment approaches are supportive and include transfusions, splenectomy, and chelation. Complications, including iron overload, bilirubin gallstones, extramedullary hematopoiesis, pulmonary hypertension, and thrombosis, are related to the chronic hemolytic anemia and its current management and can occur at any age. Disease-modifying therapies in clinical development may decrease symptoms and findings associated with chronic hemolysis and avoid the complications associated with current treatment approaches. As these disease-directed therapies are approved for clinical use, clinicians will need to define the types of symptoms and findings that determine the optimal patients and timing for initiating these therapies. In this article, we highlight disease manifestations, monitoring approaches, strategies for managing complications, and novel therapies in development.
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Boscoe AN, Yan Y, Hedgeman E, van Beers EJ, Al-Samkari H, Barcellini W, Eber SW, Glader B, Yaish HM, Chonat S, Sharma M, Kuo KHM, Neufeld EJ, Wang H, Verhovsek M, Sheth S, Grace RF. Comorbidities and complications in adults with pyruvate kinase deficiency. Eur J Haematol 2021; 106:484-492. [PMID: 33370479 PMCID: PMC7985869 DOI: 10.1111/ejh.13572] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/19/2023]
Abstract
Objectives Pyruvate kinase (PK) deficiency is caused by PKLR gene mutations, leading to defective red blood cell glycolysis and hemolytic anemia. Rates of comorbidities and complications by transfusion history and relative to the general population remain poorly quantified. Methods Data for patients aged ≥ 18 years with two confirmed PKLR mutations were obtained from the PK deficiency Natural History Study (NCT02053480). Frequencies of select conditions were compared with an age‐ and sex‐matched cohort from a general insured US population without PK deficiency. Results Compared with the matched population (n = 1220), patients with PK deficiency (n = 122) had significantly higher lifetime rates of osteoporosis, liver cirrhosis, and pulmonary hypertension; splenectomy and cholecystectomy rates were also significantly higher in the 8 years before the index date. Sixty‐five (53.3%) patients with PK deficiency were classified as regularly transfused, 30 (24.6%) as occasionally transfused, and 27 (22.1%) as never transfused. Regularly transfused patients were significantly more likely than never transfused patients to have had splenectomy, cholecystectomy, and/or thrombosis. Liver iron overload was reported in 62% of patients and occurred regardless of transfusion cohort. Conclusions Even never transfused patients with PK deficiency had higher rates of select comorbidities and complications than individuals without PK deficiency.
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Affiliation(s)
| | - Yan Yan
- Agios Pharmaceuticals, Inc., Cambridge, MA, USA
| | | | - Eduard J van Beers
- Van Creveldkliniek, University Medical Center Utrecht, University of Utrecht, The Netherlands
| | - Hanny Al-Samkari
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefan W Eber
- Special Praxis for Pediatric Hematology and University Children's Hospital, Technical University, Munich, Germany
| | - Bertil Glader
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hassan M Yaish
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mukta Sharma
- Children's Mercy, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | | | - Heng Wang
- DDC Clinic for Special Needs Children, Middlefield, OH, USA
| | | | - Sujit Sheth
- Weill Cornell Medical College, New York, NY, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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15
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Agarwal AM, Rets A. Laboratory approach to investigation of anemia with a focus on pyruvate kinase deficiency. Int J Lab Hematol 2021; 42 Suppl 1:107-112. [PMID: 32543069 DOI: 10.1111/ijlh.13200] [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: 01/23/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 01/19/2023]
Abstract
Anemia is a major health burden worldwide and affects approximately one-third of world's population. It is not a diagnosis; it is a manifestation of an underlying pathophysiology leading to either decreased hemoglobin (Hb), hematocrit (Hct), or red blood cells (RBCs). Iron deficiency anemia is still the most common cause of anemia worldwide. The symptoms are usually due to the underlying compensatory responses to decrease in oxygen delivery to the tissues. Laboratory investigation should start with complete blood count (CBC), reticulocyte count (RC), and peripheral smear evaluation. Further testing depends on these indices, that is, iron parameters and hemoglobinopathies/thalassemia evaluation in microcytic hypochromic anemia, vitamin B12, and folic acid level in macrocytic anemia. Increased RC denotes adequate bone marrow response and points toward hemolytic process and vice versa. Anemia diagnosis can be complex and confusing for the practicing physician. This review tries to give a practical simplistic approach to the diagnosis, focusing mainly on the basic parameters, that is, CBC, RC, and peripheral smear etc. Moreover, we have also tried to provide an update on the pyruvate kinase deficiency, as there has been recent exciting development in the management of these patients.
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Affiliation(s)
- Archana M Agarwal
- University of Utah-Pathology, Salt Lake City, Utah.,ARUP Laboratories - Pathology, Salt Lake City, Utah
| | - Anton Rets
- University of Utah-Pathology, Salt Lake City, Utah.,ARUP Laboratories - Pathology, Salt Lake City, Utah
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16
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Al-Samkari H, Van Beers EJ, Kuo KHM, Barcellini W, Bianchi P, Glenthøj A, Del Mar Mañú Pereira M, Van Wijk R, Glader B, Grace RF. The variable manifestations of disease in pyruvate kinase deficiency and their management. Haematologica 2020; 105:2229-2239. [PMID: 33054048 PMCID: PMC7556504 DOI: 10.3324/haematol.2019.240846] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/20/2020] [Indexed: 01/19/2023] Open
Abstract
Pyruvate kinase deficiency (PKD) is the most common cause of chronic hereditary non-spherocytic hemolytic anemia and results in a broad spectrum of disease. The diagnosis of PKD requires a high index of suspicion and judicious use of laboratory tests that may not always be informative, including pyruvate kinase enzyme assay and genetic analysis of the PKLR gene. A significant minority of patients with PKD have occult mutations in non-coding regions of PKLR which are missed on standard genetic tests. The biochemical consequences of PKD result in hemolytic anemia due to red cell pyruvate and ATP deficiency while simultaneously causing increased red cell 2,3-diphosphoglycerate, which facilitates oxygen unloading. This phenomenon, in addition to numerous other factors such as genetic background and differences in splenic function result in a poor correlation between symptoms and degree of anemia from patient to patient. Red cell transfusions should, therefore, be symptom-directed and not based on a hemoglobin threshold. Patients may experience specific complications, such as paravertebral extramedullary hematopoiesis and chronic debilitating icterus, which require personalized treatment. The decision to perform splenectomy or hematopoietic stem cell transplantation is nuanced and depends on disease burden and long-term outlook given that targeted therapeutics are in development. In recognition of the complicated nature of the disease and its management and the limitations of the PKD literature, an international working group of ten PKD experts convened to better define the disease burden and manifestations. This article summarizes the conclusions of this working group and is a guide for clinicians and investigators caring for patients with PKD.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Eduard J Van Beers
- Van Creveldkliniek, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Wilma Barcellini
- UOS Ematologia, Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Bianchi
- UOS Ematologia, Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas Glenthøj
- Department of Hematology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - María Del Mar Mañú Pereira
- Translational Research in Rare Anaemia Disorders, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Richard Van Wijk
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Bertil Glader
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rachael F Grace
- Dana/Farber Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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Bianchi P, Fermo E, Lezon‐Geyda K, Beers EJ, Morton HD, Barcellini W, Glader B, Chonat S, Ravindranath Y, Newburger PE, Kollmar N, Despotovic JM, Verhovsek M, Sharma M, Kwiatkowski JL, Kuo KHM, Wlodarski MW, Yaish HM, Holzhauer S, Wang H, Kunz J, Addonizio K, Al‐Sayegh H, London WB, Andres O, Wijk R, Gallagher PG, Grace RFF. Genotype-phenotype correlation and molecular heterogeneity in pyruvate kinase deficiency. Am J Hematol 2020; 95:472-482. [PMID: 32043619 DOI: 10.1002/ajh.25753] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase (PK) deficiency is a rare recessive congenital hemolytic anemia caused by mutations in the PKLR gene. This study reports the molecular features of 257 patients enrolled in the PKD Natural History Study. Of the 127 different pathogenic variants detected, 84 were missense and 43 non-missense, including 20 stop-gain, 11 affecting splicing, five large deletions, four in-frame indels, and three promoter variants. Within the 177 unrelated patients, 35 were homozygous and 142 compound heterozygous (77 for two missense, 48 for one missense and one non-missense, and 17 for two non-missense variants); the two most frequent mutations were p.R510Q in 23% and p.R486W in 9% of mutated alleles. Fifty-five (21%) patients were found to have at least one previously unreported variant with 45 newly described mutations. Patients with two non-missense mutations had lower hemoglobin levels, higher numbers of lifetime transfusions, and higher rates of complications including iron overload, extramedullary hematopoiesis, and pulmonary hypertension. Rare severe complications, including lower extremity ulcerations and hepatic failure, were seen more frequently in patients with non-missense mutations or with missense mutations characterized by severe protein instability. The PKLR genotype did not correlate with the frequency of complications in utero or in the newborn period. With ICCs ranging from 0.4 to 0.61, about the same degree of clinical similarity exists within siblings as it does between siblings, in terms of hemoglobin, total bilirubin, splenectomy status, and cholecystectomy status. Pregnancy outcomes were similar across genotypes in PK deficient women. This report confirms the wide genetic heterogeneity of PK deficiency.
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Affiliation(s)
- Paola Bianchi
- U.O.C. EmatologiaU.O.S. Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan Italy
| | - Elisa Fermo
- U.O.C. EmatologiaU.O.S. Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan Italy
| | | | - Eduard J. Beers
- Division Internal Medicine and DermatologyVan Creveldkliniek, University Medical Center Utrecht Utrecht The Netherlands
| | - Holmes D. Morton
- Central Pennsylvania Clinic for Special Children & AdultsBelleville, PA; Lancaster General Hospital Lancaster PA
| | - Wilma Barcellini
- U.O.C. EmatologiaU.O.S. Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan Italy
| | - Bertil Glader
- Lucile Packard Children's HospitalStanford University Palo Alto CA
| | - Satheesh Chonat
- Department of PediatricsEmory University School of Medicine, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta Atlanta GA
| | - Yaddanapudi Ravindranath
- School of MedicinePediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine Detroit MI
| | - Peter E. Newburger
- Department of PediatricsUniversity of Massachusetts Medical School Worcester MA
| | - Nina Kollmar
- Department of Pediatric Hematology/OncologyKlinikum Kassel GmbH Kassel Germany
| | | | | | - Mukta Sharma
- Department of PediatricsChildren's Mercy, School of Medicine University of Missouri Kansas City MO
| | - Janet L. Kwiatkowski
- Division of HematologyChildren's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Kevin H. M. Kuo
- Division of Hematology, Department of MedicineUniversity Health Network, University of Toronto Toronto Ontario Canada
| | | | - Hassan M. Yaish
- Primary Children's HospitalUniversity of Utah Salt Lake City UT
| | - Susanne Holzhauer
- CharitéUniversity Medicine, Pediatric Hematology and Oncology Berlin Germany
| | - Heng Wang
- DDC Clinic for Special Needs Children Middlefield OH
| | - Joachim Kunz
- Zentrumfür Kinder‐und Jugendmedizin Heidelberg Germany
| | - Kathryn Addonizio
- Dana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston MA
| | - Hasan Al‐Sayegh
- Dana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston MA
| | - Wendy B. London
- Dana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston MA
| | - Oliver Andres
- Department of PediatricsUniversity of Würzburg Würzburg Germany
| | - Richard Wijk
- Central Diagnostic LaboratoryUniversity Medical Center Utrecht Utrecht The Netherlands
| | - Patrick G. Gallagher
- Department of Pediatrics, Department of Genetics, Department of PathologyYale University School of Medicine New Haven CT
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18
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Salek S, Boscoe AN, Piantedosi S, Egan S, Evans CJ, Wells T, Cohen J, Klaassen RJ, Grace R, Storm M. Development of the pyruvate kinase deficiency diary and pyruvate kinase deficiency impact assessment: Disease-specific assessments. Eur J Haematol 2019; 104:427-434. [PMID: 31880847 PMCID: PMC7216839 DOI: 10.1111/ejh.13376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 01/19/2023]
Abstract
Introduction Currently recommended patient‐reported outcome (PRO) measures for patients with pyruvate kinase (PK) deficiency are non‐disease‐specific. The PK Deficiency Diary (PKDD) and PK Deficiency Impact Assessment (PKDIA) were developed to be more targeted measures for capturing the symptoms and impacts of interest to this patient population. Methods The instruments were developed based on concept elicitation interviews with 21 adults and modified based on 20 cognitive interviews. The domain structure and item concepts of the PKDD and PKDIA were compared with currently recommended measures, the EORTC QLQ‐C30 and the SF‐36v2®. Results The PKDD is a seven‐item measure of the core signs and symptoms of PK deficiency. The PKDIA is a 14‐item measure of the impacts of PK deficiency on patients’ health‐related quality of life (HRQoL). Minimal similarities were found between the new measures and the EORTC QLQ‐C30 (eg, 43% of concepts were similar to the PKDD; 42% were similar to the PKDIA) and SF‐36v2® (57% of concepts were similar to the PKDD; 17% were similar to the PKDIA). Conclusions The PKDD and PKDIA fill a gap in the existing outcomes measurement strategy for PK deficiency. Future work includes psychometric evaluation of these newly developed measures.
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Affiliation(s)
- Sam Salek
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | | | | | | | | | | | | | - Robert J Klaassen
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Rachael Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Program, Boston, MA, USA
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Grace RF, Mark Layton D, Barcellini W. How we manage patients with pyruvate kinase deficiency. Br J Haematol 2019; 184:721-734. [PMID: 30681718 DOI: 10.1111/bjh.15758] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Novel therapies in development have brought a new focus on pyruvate kinase deficiency (PKD), the most common congenital haemolytic anaemia due to a glycolytic enzyme deficiency. With an improved recognition of its clinical presentation and understanding of the diagnostic pathway, more patients are likely to be identified with this anaemia. Complications, including gallstones and non-transfusion-related iron overload, require monitoring for early diagnosis and management. Current management remains supportive with red cell transfusions, chelation and splenectomy. Decisions to transfuse and/or splenectomise must be individualised. Haematopoietic stem cell transplant has been pursued in a small number of patients with mixed outcomes. Novel treatment approaches, which range from a small molecule pyruvate kinase activator to gene therapy, may transform the way in which PKD is managed in the future. In this review, we discuss the pathophysiology of PKD and present our approaches to diagnosis, monitoring and management of patients with this anaemia.
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Affiliation(s)
- Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - D Mark Layton
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Salek MS, Ionova T, Johns JR, Oliva EN. Appraisal of patient-reported outcome measures in analogous diseases and recommendations for use in phase II and III clinical trials of pyruvate kinase deficiency. Qual Life Res 2018; 28:399-410. [PMID: 30456713 PMCID: PMC6373289 DOI: 10.1007/s11136-018-2025-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE Pyruvate kinase deficiency (PKD) is a rare disease and understanding of its epidemiology and associated burden remains limited. With no current curative therapy, clinical manifestations can be life threatening, clinically managed by maintaining adequate hemoglobin levels through transfusion and subsequent support, but with frequent complications. Treatment goals are to maintain/improve the patient's quality of life. With new therapies, reliable, valid, and relevant patient-reported outcome (PRO) tools are required for use in clinical trials. METHODS Systematic literature search identified no current PRO tools for capturing/measuring the impact of PKD and treatments in clinical trials. Therefore, the search strategy was revised to consider conditions analogous to PKD in terms of symptoms and impacts that might serve as parallels to the experience in PKD; this included sickle cell anemia, thalassemia, and hemolytic anemia. Psychometric properties, strengths, and weakness of selected appropriate PRO instruments were compared, and recommendations made for choice of PRO tools. RESULTS In adult populations, EORTC QLQ C30 and SF-36v2 are recommended, the former being a basic minimum, covering generic HRQoL, and core symptoms such as fatigue. In pediatric populations, PedsQL Generic Core Scale to measure HRQoL and PedsQL MFS scale to measure fatigue are recommended. CONCLUSIONS Some symptoms/life impacts may be unique to PKD and not observable in analogous conditions. A 'Physico-Psychosocial Model' derived from the 'Medical Model' is proposed to form the basis for a hypothesized conceptual framework to address the development of PKD-specific PRO instruments.
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Affiliation(s)
- M S Salek
- School of Life and Medical Sciences, University of Hertfordshire, College Lane, Hatfield, AL10 9AB, UK.
| | - T Ionova
- University Clinic St. Petersburg State University and Multinational Centre for Quality of Life Research, St. Petersburg, Russia
| | - J R Johns
- Institute for Medicines Development, Cardiff, UK
| | - E N Oliva
- Haematology Unit, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy
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