1
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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2
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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3
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Oliver M, Patriquin CJ, Pavenski K. Predictors of relapse and prophylactic management of immune thrombotic thrombocytopenic purpura. Transfus Apher Sci 2023; 62:103749. [PMID: 37344323 DOI: 10.1016/j.transci.2023.103749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Affiliation(s)
- Monika Oliver
- Department of Medicine, University of Alberta, Canada; Division of Hematology, University of Alberta Hospital, Canada
| | - Christopher J Patriquin
- Department of Medicine, University of Toronto, Canada; Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
| | - Katerina Pavenski
- Department of Medicine, University of Toronto, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, Canada; Departments of Medicine and Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Canada.
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4
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How I treat immune-mediated thrombotic thrombocytopenic purpura after hospital discharge. Blood 2022; 140:438-444. [PMID: 35667044 DOI: 10.1182/blood.2021014514] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/14/2022] [Indexed: 11/20/2022] Open
Abstract
Immune-mediated thrombocytopenic purpura (iTTP) is a thrombotic microangiopathy characterized by an acquired ADAMTS13 deficiency as a result of the presence of an antibody inhibitor of ADAMTS13 leading to the formation of ultralarge von Willebrand multimers. Treatment of iTTP includes plasma exchange, high-dose glucocorticoids, rituximab, and, more recently, caplacizumab, to prevent the development of exacerbations. There is the risk of both relapse and long-term complications that include neurocognitive deficits and cardiovascular events that occur in patients in remission after recovery from an acute iTTP episode. Data on the risk factors for the development of these complications, the appropriate screening, and treatment are limited due to the paucity of research. This article is a review of the current understanding on the risk factors for exacerbation, relapse, and long-term complications of iTTP and discusses an approach to observing patients with iTTP after hospital discharge and during the long-term follow-up in the outpatient setting.
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5
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Westwood JP, Scully M. Management of acquired, immune thrombocytopenic purpura (iTTP): beyond the acute phase. Ther Adv Hematol 2022; 13:20406207221112217. [PMID: 35923772 PMCID: PMC9340390 DOI: 10.1177/20406207221112217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Modern therapy for acute TTP has resulted in a dramatic improvement in
outcomes, with the combination of plasma exchange, immunosuppression,
and caplacizumab being associated with >90% survival rates
following an acute episode. TTP is no longer associated with just the
acute episode, but requires long-term follow-up. There remains
significant morbidity associated with acute TTP, and many patients
suffer marked neuropsychological sequelae, including impairment in
cognitive functioning, affective disorders, and reduction in
health-related quality of life measures. The focus of management
beyond the acute phase centres on relapse prevention,
via careful monitoring of patients and the use
of either ad hoc or regular immunosuppressive therapies. The main
therapy used is rituximab, but despite more limited evidence, other
immunosuppressive therapies may be required to aim for normalisation
of ADAMTS 13 activity. Follow-up with a reduction in ADAMTS 13
activity levels (ADAMTS 13 relapse), rituximab is central to
normalisation of activity levels and prevention of a clinical relapse.
Fundamental to elective therapy is the role of ADAMTS 13 activity
monitoring, and impact of reduced ADAMTS13 activity on end organ
damage. This review discusses monitoring and treatment strategy for
long-term management of TTP, including the variety of therapies
available to maintain remission, prevent relapse and a summary of a
long-term treatment pathway.
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Affiliation(s)
| | - Marie Scully
- Department of Haematology, UCLH, London, UK
- National Institute for Health Research Cardiometabolic Programme, UCLH/UCL Cardiovascular BRC, 250 Euston Road, NW1 2PG London, UK
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6
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Updates on thrombotic thrombocytopenic purpura: Recent developments in pathogenesis, treatment and survivorship. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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7
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Pavenski K, Huang SHS, Patriquin CJ. Predictors of relapse and preventative strategies in immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:1027-1040. [PMID: 34747320 DOI: 10.1080/17474086.2021.2003703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare autoimmune blood disorder, which presents with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis and is caused by severe deficiency of ADAMTS13. iTTP may result in both acute and chronic complications and is rapidly fatal without expedient treatment. Life-time risk of relapse is approximately 40%. AREAS COVERED A number of predictors of relapse has been described in the literature. The most well-studied predictor of relapse is persistent ADAMTS13 deficiency; however, it is not a perfect marker. Relapse can be prevented by treatment with immunosuppressive medications, with rituximab being the most studied. EXPERT OPINION Patients who recover from iTTP should be regularly assessed, including with ADAMTS13 activity testing. The optimal frequency of assessments has not been established, but every 3 months is recommended. Considering the potential for significant organ damage and mortality associated with iTTP relapse, patients in remission and with persistent ADAMTS13 activity of 10-20% should be prophylactically treated with immunosuppression. Additional markers to precisely identify patients at higher risk of relapse are needed.
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Affiliation(s)
- Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Shih-Han Susan Huang
- Department of Medicine, Division of Nephrology, Western University, London, Canada
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
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8
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Blood-brain barrier permeability in survivors of immune-mediated thrombotic thrombocytopenic purpura: a pilot study. Blood Adv 2021; 5:4211-4218. [PMID: 34521110 PMCID: PMC8945621 DOI: 10.1182/bloodadvances.2021005317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disorder of systemic microthrombosis and organ ischemia. The etiology of chronic cerebrovascular outcomes in iTTP survivors is largely unknown. In this pilot study, we measured blood-brain barrier (BBB) permeability in patients with iTTP at the start of remission and 6 months later. This prospective pilot study included 7 adult patients with incident iTTP. Eligibility criteria included ADAMTS13 activity < 10% and detectable inhibitor at diagnosis. Patients were recruited from London Health Sciences Centre in Canada (2017-2019) within 3 days of hospital admission and followed for 6 months after remission (defined as normalization of platelet count and lactate dehydrogenase with no clinical signs or symptoms of microvascular injury for more than 30 days after the last plasma exchange). All patients had cerebral computed tomography perfusion scans with BBB permeability surface product measurements. Patients (5 women, 2 men) had a mean age of 48 years (range, 21-77 years). At diagnosis, patients had a mean platelet count of 22 (standard deviation [SD], 25) × 109/L. At the start of remission, mean BBB permeability surface product was 0.91 (0.30) mL/min/100 g. Six months later, the mean permeability surface product was 0.56 (0.22) mL/min/100 g, with a mean difference of -0.312 mL/min/100 g (95% confidence interval: -0.4729 to -0.1510; P = .0032). In this pilot study of patients with iTTP, pathologically increased BBB permeability was evident, and although there was some improvement, this persisted 6 months after remission. Future work will explore the chronicity of these findings and their clinical implications.
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9
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Gómez-Seguí I, Pascual Izquierdo C, de la Rubia Comos J. Best practices and recommendations for drug regimens and plasma exchange for immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:707-719. [PMID: 34275393 DOI: 10.1080/17474086.2021.1956898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. TTP pathophysiology is based on a severe ADAMTS13 deficiency, and is a medical emergency with fatal outcome if appropriate treatment is not initiated promptly. AREAS COVERED Authors will review the best options currently available to minimize mortality, prevent relapses, and obtain the best clinical response in patients with immune TTP (iTTP). Available bibliography about iTTP treatment has been searched in Library's MEDLINE/PubMed database from January 1990 until April 2021. EXPERT OPINION The generalized use of plasma exchange marked a paradigm in the management of iTTP. In recent years, strenuous efforts have been done for a better understanding of the pathophysiology of this disease, improve diagnosis, optimize treatment, reduce mortality, and prevent recurrences. The administration of front-line rituximab and, more recently, the availability of caplacizumab, the first targeted therapy for iTTP, have been steps toward a further reduction in early mortality and for the prevention of relapses.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio De Hematología Y Hemoterapia, Hospital General , Universitario Gregorio Marañón. Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier de la Rubia Comos
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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10
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [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: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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11
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Lemiale V, Valade S, Mariotte E. Unresponsive Thrombotic Thrombocytopenic Purpura (TTP): Challenges and Solutions. Ther Clin Risk Manag 2021; 17:577-587. [PMID: 34113115 PMCID: PMC8185636 DOI: 10.2147/tcrm.s205632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/14/2021] [Indexed: 01/20/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy secondary to a severely decreased A Disintegrin And Metalloprotease with ThromboSpondin type 1 repeats 13 (ADAMTS13) activity, resulting in the formation of widespread von Willebrand factor - and platelet-rich microthrombi. ADAMTS13 deficiency is mainly acquired through anti-ADAMTS13 autoantibodies in adults. With modern standards of care, unresponsive TTP has become rarer with a frequency of refractory/relapsing forms dropping from >40% to <10%. As patients with unresponsive TTP are at increased risk of mortality, prompt recognition and early therapeutic intensification are mandatory. Therapeutic options at the disposal of clinicians caring for patients with refractory TTP consist of increased ADAMTS13 supplementation, increased immunosuppression, and inhibition of von Willebrand factor adhesion to platelets. In this work, we focus on possible therapies for the management of patients with unresponsive TTP, and propose an algorithm for the management of these difficult cases.
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Affiliation(s)
- Virginie Lemiale
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Sandrine Valade
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
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12
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Successful Treatment With Bortezomib for Refractory and Complicated Acquired Thrombotic Thrombocytopenic Purpura in an Adolescent Girl. J Pediatr Hematol Oncol 2021; 43:e587-e591. [PMID: 33306607 DOI: 10.1097/mph.0000000000002026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/31/2020] [Indexed: 01/19/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare, dangerous, life-threatening disease characterized by microangiopathic hemolytic anemia and thrombocytopenia, along with organ dysfunction due to microangiopathy-related ischemia. Plasma exchange and steroids are used for initial treatment, and rituximab is often used in refractive patients. Caplacizumab, cyclophosphamide, and splenectomy are among other treatment options. It has been reported that bortezomib, a proteasome inhibitor, can be used in the management of refractory acquired TTP. Herein, we present a 16-year-old female patient who was monitored for acquired TTP and treated with high-dose steroids, plasma exchange, rituximab, cyclophosphamide, and N-acetylcysteine but developed renal, cardiac, gastrointestinal, and neurologic complications. The girl was then successfully treated with bortezomib, and she has been monitored in remission for 6 months. We consider that bortezomib is a beneficial treatment, especially in patients with refractory TTP.
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13
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Nichols MM, Crane GM. Educational Case: Differentiating Thrombotic Thrombocytopenic Purpura From Other Thrombotic Microangiopathies and Potential Role of the Spleen. Acad Pathol 2021; 8:23742895211001312. [PMID: 33855171 PMCID: PMC8013907 DOI: 10.1177/23742895211001312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 01/23/2021] [Accepted: 02/19/2021] [Indexed: 11/17/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Meredith M Nichols
- Robert J. Tomsich Department of Pathology and Laboratory Medicine, Cleveland Clinic Foundation, OH, USA
| | - Genevieve M Crane
- Robert J. Tomsich Department of Pathology and Laboratory Medicine, Cleveland Clinic Foundation, OH, USA
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14
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Sukumar S, Lämmle B, Cataland SR. Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med 2021; 10:536. [PMID: 33540569 PMCID: PMC7867179 DOI: 10.3390/jcm10030536] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and ischemic end organ injury due to microvascular platelet-rich thrombi. TTP results from a severe deficiency of the specific von Willebrand factor (VWF)-cleaving protease, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13). ADAMTS13 deficiency is most commonly acquired due to anti-ADAMTS13 autoantibodies. It can also be inherited in the congenital form as a result of biallelic mutations in the ADAMTS13 gene. In adults, the condition is most often immune-mediated (iTTP) whereas congenital TTP (cTTP) is often detected in childhood or during pregnancy. iTTP occurs more often in women and is potentially lethal without prompt recognition and treatment. Front-line therapy includes daily plasma exchange with fresh frozen plasma replacement and immunosuppression with corticosteroids. Immunosuppression targeting ADAMTS13 autoantibodies with the humanized anti-CD20 monoclonal antibody rituximab is frequently added to the initial therapy. If available, anti-VWF therapy with caplacizumab is also added to the front-line setting. While it is hypothesized that refractory TTP will be less common in the era of caplacizumab, in relapsed or refractory cases cyclosporine A, N-acetylcysteine, bortezomib, cyclophosphamide, vincristine, or splenectomy can be considered. Novel agents, such as recombinant ADAMTS13, are also currently under investigation and show promise for the treatment of TTP. Long-term follow-up after the acute episode is critical to monitor for relapse and to diagnose and manage chronic sequelae of this disease.
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Affiliation(s)
- Senthil Sukumar
- Division of Hematology, Department of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, CH 3010 Bern, Switzerland;
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
- Haemostasis Research Unit, University College London, London WC1E 6BT, UK
| | - Spero R. Cataland
- Division of Hematology, Department of Medicine, The Ohio State University, Columbus, OH 43210, USA;
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15
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Barba C, Peyre M, Galicier L, Cathebras P, Ranta D, Malot S, Veyradier A, Coppo P. Intensive rituximab regimen in immune-mediated thrombotic thrombocytopenic purpura can circumvent unresponsiveness to standard rituximab treatment. Br J Haematol 2020; 192:e21-e25. [PMID: 33216951 DOI: 10.1111/bjh.17170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Christophe Barba
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, AP-HP. Sorbonne-Université, Paris, France
| | - Marion Peyre
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, AP-HP. Sorbonne-Université, Paris, France
| | - Lionel Galicier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Immunopathologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Pascal Cathebras
- Service de Médecine Interne, Centre Hospitalier Universitaire de St Etienne, Paris, France
| | - Dana Ranta
- Service d'Hématologie, Centre Hospitalier Universitaire de Nancy, Paris, France
| | - Sandrine Malot
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Hématologie Biologique - Hémostase, Hôpital Lariboisière, Paris, AP-HP, France
| | - Paul Coppo
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, AP-HP. Sorbonne-Université, Paris, France.,INSERM UMRS 1138, Paris, France
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16
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Mellaza C, Henry N, Fayolle PM, Mortaza S, Subra JF, Veyradier A, Coppo P, Augusto JF. Refractory Auto-Immune Thrombotic Thrombocytopenic Pupura Successfully Treated With Caplacizumab. Front Med (Lausanne) 2020; 7:549931. [PMID: 33195299 PMCID: PMC7649819 DOI: 10.3389/fmed.2020.549931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/14/2020] [Indexed: 01/23/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy characterized by mechanical hemolytic anemia, profound thrombocytopenia, and neurological manifestations. Acquired auto-immune TTP, the most prevalent cause of TTP, is induced by the presence of inhibitory anti-ADAMTS13 auto-antibodies. Modern treatment of acquired TTP relies on plasma exchange, rituximab, and steroids. Caplacizumab (Cablivi®), a humanized single-variable domain immunoglobulin that targets the A1 domain of the ultra-large von Willebrand factor, inhibits the interaction between ultra-large vWFand platelets. In two clinical trials, caplacizumab, in addition to conventional treatment, shortened the delay to platelet count normalization in comparison to conventional treatment plus placebo, without increasing significantly hemorrhagic complications. Moreover, caplacizumab was associated with reduced occurrence of a secondary endpoint associating death, TTP recurrence, and major thromboembolic events. Here, we report the off-label use of caplacizumab in a 68-year-old patient with confirmed acquired TTP, severe thrombocytopenia, and generalized tonic–clonic seizures requiring mechanical ventilation and admission in the intensive care unit. Conventional treatment was rapidly started. Despite the intensification of plasma exchange treatment with twice-daily sessions, steroid continuation, and a second rituximab infusion on day 6, thrombotic microangiopathy worsened with thrombocytopenia at 21 g/L on day 8 from admission. We also considered using caplacizumab, which we could obtain and start on day 12 from admission, as it was available under a temporary authorization use in France. As soon as 12 h after caplacizumab initiation, we observed a significant increase of platelet count and improvement of other hemolytic parameters. We observed resolution of encephalopathy and complete recovery of motor paralysis, allowing us to stop mechanical ventilation on day 14. Caplacizumab was maintained for 128 days until day 139 from initial admission. The patient is going well 10 months after initial admission, without any neurological sequelae, and TTP did not relapse. To the best of our knowledge, this is the first reported use of caplacizumab in such a condition. This case report suggests that caplacizumab use may help to reduce the rate of refractory TTP episodes.
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Affiliation(s)
- Chloé Mellaza
- Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire Angers, Angers, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire Angers, Angers, France
| | - Pierre-Marie Fayolle
- Département de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Angers, France
| | - Satar Mortaza
- Département de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Angers, France
| | - Jean-François Subra
- Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire Angers, Angers, France.,Université d'Angers, Angers, France
| | - Agnès Veyradier
- Service d'Hématologie Biologique, Hôpital Lariboisière and EA3518, Hôpital Saint Louis, Groupe Hospitalier Saint Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Center de Référence des Microangiopathies Thrombotiques, Paris, France
| | - Paul Coppo
- Center de Référence des Microangiopathies Thrombotiques, Paris, France.,Service d'Hématologie Hôpital Saint-Antoine AP-HP, Paris, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire Angers, Angers, France.,Université d'Angers, Angers, France
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. Good practice statements (GPS) for the clinical care of patients with thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2503-2512. [PMID: 32914535 PMCID: PMC7880820 DOI: 10.1111/jth.15009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its management. METHODS In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to both immune-mediated TTP (iTTP) and hereditary/congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations. RESULTS The panel agreed on eleven recommendations based on evidence ranging from very low to moderate certainty. For first episode and relapses of acute iTTP, the panel made a strong recommendation for the addition of corticosteroids to therapeutic plasma exchange (TPE), and a conditional recommendation for addition of rituximab and caplacizumab. For asymptomatic iTTP with low ADAMTS13, the panel made a conditional recommendation for rituximab outside of pregnancy, and for prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, but a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy. CONCLUSIONS The panel's recommendations are based on all the available evidence for the treatment effects of various approaches including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing ADAMTS13 antibody production. There was insufficient evidence for further comparison of different treatment approaches, for which future high-quality studies in iTTP (e.g., rituximab, corticosteroids, recombinant ADAMTS13, and caplacizumab) and in cTTP (eg, recombinant ADAMTS13) are needed.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique, Hôpitaux de Paris, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, The University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Kucukyurt S, Eskazan AE. Assessment and Monitoring of Patients with Immune-Mediated Thrombotic Thrombocytopenic Purpura (iTTP): Strategies to Improve Outcomes. J Blood Med 2020; 11:319-326. [PMID: 33061729 PMCID: PMC7532071 DOI: 10.2147/jbm.s205630] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acquired or immune-mediated TTP (iTTP) is a life-threatening thrombotic microangiopathy, characterized by the presence of microangiopathic hemolytic anemia and severe thrombocytopenia, and a variable degree of ischemic organ damage, related to a severe deficiency of ADAMTS13, which is a serine metalloprotease necessary for cleavage of large vWF multimers. There has been a dramatic decrease in mortality rates with the recognition of the pathophysiology of iTTP over the years. Although therapeutic plasma exchange (TPE) together with corticosteroids are the backbone of the upfront treatment of patients with iTTP with successful outcomes, patients may remain refractory and/or relapse following an initial response to this treatment. Methods We performed a review regarding the pathogenesis, diagnosis, treatment strategies, monitoring, and prognosis of iTTP. Results There are several new treatment strategies, which can be used among these patients, helping in improving outcomes of iTTP. Rituximab has been shown to be a safe and effective adjunct to TPE, especially in patients with refractory and/or relapse as well as it is increasingly used preemptively to prevent exacerbation or recurrence. Recently, caplacizumab, a nanobody targeting vWF, was approved as an addition to the current regimen of TPE and immunomodulation for patients of iTTP. Conclusion Specific predictors of relapse in patients in remission can be relevant for an optimal patient management. Different models including ADAMTS13 biomarkers can provide a new screening strategy to identify patients who may predict outcomes and the risk of relapse, benefit from preemptive therapy prior to relapse.
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Affiliation(s)
- Selin Kucukyurt
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Thrombotic thrombocytopenic purpura and defective apoptosis due to CASP8/10 mutations: the role of mycophenolate mofetil. Blood Adv 2020; 3:3432-3435. [PMID: 31714957 DOI: 10.1182/bloodadvances.2019000575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/17/2019] [Indexed: 01/19/2023] Open
Abstract
Key Points
Immunological dysregulation may underlie unusual autoimmune diseases, which also deserve to be investigated from a genetic point of view.
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Elverdi T, Eskazan AE. Caplacizumab as an emerging treatment option for acquired thrombotic thrombocytopenic purpura. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:1251-1258. [PMID: 31118566 PMCID: PMC6475094 DOI: 10.2147/dddt.s134470] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disease with a mortality rate of over 90% if left untreated. Therapeutic plasma exchange (PEX) is the mainstay of treatment of acquired TTP (aTTP), and with the introduction of PEX, the mortality rate declined dramatically below 20%. Although PEX together with corticosteroids are the backbone of the upfront management of patients with aTTP with successful outcomes, patients may remain refractory and/or relapse following an initial response to this treatment. There are some therapeutic options, which can be used among these patients, helping in improving outcomes of aTTP. Caplacizumab (formerly ALX-0081 or ALX-0681) is a humanized single-variable domain immunoglobulin that recognizes the human von Willebrand factor (vWF) A1 domain and inhibits the vWF-platelet glycoprotein 1b-alpha (GP1b-α) interaction. The drug was first developed for the prevention of thrombosis in high-risk patients with acute coronary syndrome undergoing percutaneous coronary intervention; however, drug development for this indication has been discontinued. Recently, caplacizumab received its first approval following Phase II TITAN and Phase III HERCULES trials in the European Union (EU) for the treatment of acute episode of aTTP in adult patients, in addition to PEX and immunosuppression. This review focuses on the use of caplacizumab as an emerging treatment option in patients with aTTP.
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Affiliation(s)
- Tugrul Elverdi
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey,
| | - Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey,
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Nicholson MC, Pavenski K, Trinkaus M. A case for consideration by apheresis practitioners: Melanoma and PD-1 inhibitor treatment in a patient with multiple relapses of immune thrombotic thrombocytopenic purpura. Transfus Apher Sci 2019; 58:123-124. [PMID: 30917902 DOI: 10.1016/j.transci.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a rare life-threatening disease caused by ADAMTS-13 deficiency. Up to forty percent of patients with TTP relapse, and most relapse within eight years of their first presentation. This case report describes a patient with an aggressive course of TTP who subsequently developed metastatic melanoma while receiving prophylactic rituximab. Limited data exists regarding the potential for malignancy in patients receiving Rituximab for benign conditions. This is the first published case of melanoma in a TTP patient treated with rituximab. Melanoma treatment with PD-1 inhibitors is also associated with worsening of pre-existing autoimmune conditions. In this case, a splenectomy resulted in a durable remission despite treatment with PD-1 inhibitor.
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Affiliation(s)
- Matthew C Nicholson
- Division of Hematology, Department of Medicine, University of British Columbia, Canada
| | - Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital and University of Toronto, Canada.
| | - Martina Trinkaus
- Departments of Medicine, St. Michael's Hospital and University of Toronto, Canada
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Coppo P, Cuker A, George JN. Thrombotic thrombocytopenic purpura: Toward targeted therapy and precision medicine. Res Pract Thromb Haemost 2019; 3:26-37. [PMID: 30656273 PMCID: PMC6332733 DOI: 10.1002/rth2.12160] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy characterized by severe congenital or immune-mediated deficiency in ADAMTS13, the enzyme that cleaves von Willebrand factor multimers. This rare condition leads invariably and rapidly to a fatal outcome in the absence of treatment, and therefore raises multiple diagnostic and therapeutic challenges. The novel concepts and mechanisms identified in the laboratory for this disease have been rapidly and successfully translated into the clinic for the benefit of patients, making TTP an archetypal disease that has benefited from targeted therapies. After decades of empirical treatment with plasma exchange, identification of ADAMTS13 as the key enzyme involved in TTP pathophysiology provided an explanation for the remarkable efficacy of plasma administration, in which the missing enzyme is replenished, and paved the way for development of a recombinant form of the enzyme. Similarly, the demonstration of a major role of anti-ADAMTS13 antibodies through models of passive transfer of autoimmunity spurred development of immunomodulatory strategies based on B-cell depletion. More recently, an inhibitor of the platelet-von Willebrand factor interaction demonstrated efficacy in large clinical trials through prevention of formation of further microthrombi and protection of organs from ischemia. These translational breakthroughs in TTP are described in our review.
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Affiliation(s)
- Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesParisFrance
- Service d'HématologieHôpital Saint‐AntoineAP‐HPParisFrance
- Sorbonne UniversitésParisFrance
| | - Adam Cuker
- Departments of Medicine and Pathology & Laboratory MedicinePerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvania
| | - James N. George
- Departments of Epidemiology & Biostatistics, MedicineUniversity of Oklahoma Health Sciences CenterOklahoma CityOklahoma
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Saleem R, Rogers ZR, Neunert C, George JN. Maintenance rituximab for relapsing thrombotic thrombocytopenic purpura: a case report. Transfusion 2018; 59:921-926. [DOI: 10.1111/trf.15093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/09/2018] [Accepted: 10/26/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Rabia Saleem
- Department of Internal Medicine, College of Medicine, Department of Biostatistics & Epidemiology, College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City Oklahoma
| | - Zora R. Rogers
- Division of Hematology/Oncology, Department of PediatricsThe University of Texas Southwestern Medical Center Dallas Texas
| | - Cindy Neunert
- Hematology Division, Department of PediatricsNew York‐Presbyterian Hospital, Columbia University College of Physicians & Surgeons New York New York
| | - James N. George
- Department of Internal Medicine, College of Medicine, Department of Biostatistics & Epidemiology, College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City Oklahoma
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Sun R, Gu W, Ma Y, Wang J, Wu M. Relapsed/refractory acquired thrombotic thrombocytopenic purpura in a patient with Sjögren syndrome: Case report and review of the literature. Medicine (Baltimore) 2018; 97:e12989. [PMID: 30412131 PMCID: PMC6221612 DOI: 10.1097/md.0000000000012989] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
RATIONALE Thrombotic thrombocytopenic purpura (TTP) is a rare, fatal disorder which could be caused by autoimmune diseases. However, TTP secondary to Sjögren syndrome (SS) is extremely rare. PATIENT CONCERNS A 47-year- old woman with an 8-year history of SS was admitted due to skin ecchymosis and bleeding gums. Then she gradually developed fever and headache. DIAGNOSES Laboratory investigations suggested anemia, thrombocytopenia, increased lactic dehydrogenase, and a disintegrin-like metalloproteinase with thrombospondin motif type 1 member 13 (ADAMTS13) activity deficiency with high inhibitor titers. Acquired TTP was thus diagnosed. INTERVENTIONS Plasma exchange (PE) was the first choice for treatment, while glucocorticoid, cyclosporine A (CSA), rituximab, and intravenous immunoglobulin (IVIG) were used simultaneously. Bortezomib, a selective proteasome inhibitor and thereby inducing apoptosis in both B-cells and plasma cells, was added. OUTCOMES She was discharged from the hospital and then treated with prednisone of 40 mg/d and hydroxychloroquine. The patient remained in full remission. LESSONS We conclude that bortezomib should be considered for patients with TTP refractory to PE, steroids, and rituximab due to its efficacy and relatively favorable side effect profile.
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Affiliation(s)
- Rurong Sun
- Department of Immunology and Rheumatology
| | - Weiying Gu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | | | - Jing Wang
- Department of Immunology and Rheumatology
| | - Min Wu
- Department of Immunology and Rheumatology
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Knöbl P. Treatment of thrombotic microangiopathy with a focus on new treatment options. Hamostaseologie 2018; 33:149-59. [DOI: 10.5482/hamo-13-01-0004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 04/12/2013] [Indexed: 11/05/2022] Open
Abstract
SummaryThe thrombotic microangiopathies (TMA) are a heterogeneous group of disorders, characterized by microangiopathic haemolytic anaemia with red cell fragmentation, thrombocytopenia and signs of organ dysfunction due to disturbed microcirculation. Current laboratory methods can be used to better distinguish some of these entities. Organ dysfunction can be severe and life-threatening, and immediate start of sufficient therapy is necessary to avoid permanent damage or death. The therapeutic options, however, are often limited to symptomatic measures, and are not standardized or based on high scientific evidence. During the preceding years, not only considerable progress has been made in better diagnosis of TMA, but also new therapeutic strategies have been established. Initial treatment still is based on plasma exchange and symptomatic measures to protect organ function. New concepts (immunosuppression, targeted anti-von Willebrand factor or anti-complement therapy, replacement with recombinant enzymes) are discussed in this article.
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Studt JD, Voorberg J, Hovinga JA, Schaller M. Acquired thrombotic thrombocytopenic purpura. Hamostaseologie 2018; 33:121-30. [DOI: 10.5482/hamo-12-12-0023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 01/17/2013] [Indexed: 01/16/2023] Open
Abstract
SummaryThe von Willebrand factor (VWF)-cleaving metalloprotease, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs-13) is the only known target of the dysregulated immune response in acquired TTP. Autoantibodies to ADAMTS13 either neutralize its activity or accelerate its clearance, thereby causing a severe deficiency of ADAMTS13 in plasma. As a consequence, size regulation of VWF is impaired and the persistence of ultra-large VWF (ULVWF) multimers facilitates micro vascular platelet aggregation causing microangiopathic haemolytic anaemia and ischaemic organ damage. Autoimmune TTP although a rare disease with an annual incidence of 1.72 cases has a mortality rate of 20% even with adequate therapy.We describe the mechanisms involved in ADAMTS13 autoimmunity with a focus on the role of B- and T-cells in the pathogenesis of this disorder. We discuss the potential translation of recent experimental findings into future therapeutic concepts for the treatment of acquired TTP.
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Masias C, Cataland SR. Novel therapies in thrombotic thrombocytopenic purpura. Res Pract Thromb Haemost 2018; 2:19-26. [PMID: 30046703 PMCID: PMC6055500 DOI: 10.1002/rth2.12066] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/13/2017] [Indexed: 12/25/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia and a consumptive thrombocytopenia, as a result of severe deficiency of ADAMTS13. The standard of care of the acute episode is treatment with plasma exchange and immunosuppression. After the acute episode is resolved, patients face a significant risk of relapse and long-term complications associated with significant morbidity and even mortality. Novel treatments have been under development and will be discussed in this review. Caplacizumab, a nanobody that blocks the interaction between VWF and platelets, has shown promising results in decreasing the time to recover from the acute events that will hopefully translate into long-term clinical benefit for patients. In addition, identifying biomarkers to allow us to better predict the risk for relapse and the development of these long-term complications in patients with TTP are a few of the challenges that require our attention moving forward.
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Affiliation(s)
- Camila Masias
- Department of MedicineOhio State UniversityColumbusOHUSA
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Bonnet S, Guédon A, Ribeil JA, Suarez F, Tamburini J, Gaujoux S. Indications and outcome of splenectomy in hematologic disease. J Visc Surg 2017; 154:421-429. [PMID: 28757383 DOI: 10.1016/j.jviscsurg.2017.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Splenectomy is part of the therapeutic arsenal for benign or malignant hematological disorders that constitute the main indication for elective splenectomy. With the development of minimally invasive approaches, and in particular, laparoscopy, as well as the advent of monoclonal antibody therapy, the indications and the outcomes of splenectomy for hematologic disease have changed in recent years. Nonetheless, splenectomy has its place in hemoglobinopathies and hemolytic diseases, improves thrombocytopenia in refractory immune thrombocytopenic purpura, can reverse sequelae linked to voluminous splenomegaly secondary to myelofibrosis, or can be used for diagnostic purposes or for splenomegaly in lymphoproliferative syndromes.
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Affiliation(s)
- S Bonnet
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital Cochin, université Paris Descartes, AP-HP, 75014 Paris, France
| | - A Guédon
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital Cochin, université Paris Descartes, AP-HP, 75014 Paris, France
| | - J-A Ribeil
- Université Paris Descartes, 75005 Paris, France; Département de biothérapie, hôpital universitaire Necker-Enfants-Malades, AP-HP, 75015 Paris, France
| | - F Suarez
- Université Paris Descartes, 75005 Paris, France; Service d'hématologie adulte, hôpital universitaire Necker-Enfants-Malades, AP-HP, Paris, France
| | - J Tamburini
- Service d'hématologie clinique, hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Descartes, 75005 Paris, France
| | - S Gaujoux
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital Cochin, université Paris Descartes, AP-HP, 75014 Paris, France; Université Paris Descartes, 75005 Paris, France.
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Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) 2017 in Japan. Int J Hematol 2017; 106:3-15. [DOI: 10.1007/s12185-017-2264-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/21/2017] [Accepted: 05/21/2017] [Indexed: 01/12/2023]
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Abstract
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and organ ischemia linked to disseminated microvascular platelet rich-thrombi. TTP is specifically related to a severe deficiency in ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13), the specific von Willebrand factor-cleaving protease. ADAMTS13 deficiency is most frequently acquired via ADAMTS13 autoantibodies, but rarely, it is inherited via mutations of the ADAMTS13 gene. The first acute episode of TTP usually occurs during adulthood, with a predominant anti-ADAMTS13 autoimmune etiology. In rare cases, however, TTP begins as soon as childhood, with frequent inherited forms. TTP is ∼2-fold more frequent in women, and its outcome is characterized by a relapsing tendency. Rapid recognition of TTP is crucial to initiate appropriate treatment. The first-line therapy for acute TTP is based on daily therapeutic plasma exchange supplying deficient ADAMTS13, with or without steroids. Additional immune modulators targeting ADAMTS13 autoantibodies are mainly based on steroids and the humanized anti-CD20 monoclonal antibody rituximab. In refractory or unresponsive TTP, more intensive therapies including twice-daily plasma exchange; pulses of cyclophosphamide, vincristine, or cyclosporine A; or salvage splenectomy are considered. New drugs including N-acetylcysteine, bortezomib, recombinant ADAMTS13, and caplacizumab show promise in the management of TTP. Also, long-term follow-up of patients with TTP is crucial to identify the occurrence of other autoimmune diseases, to control relapses, and to evaluate psychophysical sequelae. Further development of both patients’ registries worldwide and innovative drugs is still needed to improve TTP management.
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Sys J, Provan D, Schauwvlieghe A, Vanderschueren S, Dierickx D. The role of splenectomy in autoimmune hematological disorders: Outdated or still worth considering? Blood Rev 2017; 31:159-172. [DOI: 10.1016/j.blre.2017.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/12/2016] [Accepted: 01/03/2017] [Indexed: 01/26/2023]
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Abstract
Thrombotic thrombocytopenic purpura (TTP; also known as Moschcowitz disease) is characterized by the concomitant occurrence of often severe thrombocytopenia, microangiopathic haemolytic anaemia and a variable degree of ischaemic organ damage, particularly affecting the brain, heart and kidneys. Acute TTP was almost universally fatal until the introduction of plasma therapy, which improved survival from <10% to 80-90%. However, patients who survive an acute episode are at high risk of relapse and of long-term morbidity. A timely diagnosis is vital but challenging, as TTP shares symptoms and clinical presentation with numerous conditions, including, for example, haemolytic uraemic syndrome and other thrombotic microangiopathies. The underlying pathophysiology is a severe deficiency of the activity of a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), the protease that cleaves von Willebrand factor (vWF) multimeric strings. Ultra-large vWF strings remain uncleaved after endothelial cell secretion and anchorage, bind to platelets and form microthrombi, leading to the clinical manifestations of TTP. Congenital TTP (Upshaw-Schulman syndrome) is the result of homozygous or compound heterozygous mutations in ADAMTS13, whereas acquired TTP is an autoimmune disorder caused by circulating anti-ADAMTS13 autoantibodies, which inhibit the enzyme or increase its clearance. Consequently, immunosuppressive drugs, such as corticosteroids and often rituximab, supplement plasma exchange therapy in patients with acquired TTP.
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Coppo P. Treatment of autoimmune thrombotic thrombocytopenic purpura in the more severe forms. Transfus Apher Sci 2016; 56:52-56. [PMID: 28110841 DOI: 10.1016/j.transci.2016.12.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Daily therapeutic plasma exchange (TPE) transformed the historically fatal prognosis of acquired, anti-ADAMTS13 antibody-mediated thrombotic thrombocytopenic purpura (TTP), leading to the current overall survival rates of >80%. However, relapses occur in up to 40% of patients and refractory disease with fatal outcomes still occurs. In this context, the introduction of rituximab has probably been the second major breakthrough in TTP management. Rituximab is now routinely recommended during the acute phase, typically in patients with a suboptimal response to treatment, or even as frontline therapy, with high response rates. In more severe patients, salvage strategies may include twice daily TPE, pulses of cyclophosphamide, vincristine, as well as splenectomy in the more desperate cases. In this life-threatening disease, relapses can be efficiently prevented in patients with a severe acquired ADAMTS13 deficiency and otherwise in remission with the use of rituximab. In the coming years, the TTP therapeutic landscape should be enriched by original strategies stemming from clinical experience and new agents that are currently being evaluated in large, ideally international, clinical trials. Promising agents under evaluation include N-acetylcysteine, bortezomib, recombinant ADAMTS13 and caplacizumab, an inhibitor of the glycoprotein-Ib/IX-von Willebrand factor axis.
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Affiliation(s)
- Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1170, Institut Gustave Roussy, Villejuif, France; Université Pierre et Marie Curie (Univ Paris 6), France.
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Clark WF, Huang SHS, Walsh MW, Farah M, Hildebrand AM, Sontrop JM. Plasmapheresis for the treatment of kidney diseases. Kidney Int 2016; 90:974-984. [DOI: 10.1016/j.kint.2016.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 01/24/2023]
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Bortezomib therapy in patients with relapsed/refractory acquired thrombotic thrombocytopenic purpura. Ann Hematol 2016; 95:1751-6. [DOI: 10.1007/s00277-016-2804-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
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Ostertag EM, Kacir S, Thiboutot M, Gulendran G, Zheng XL, Cines DB, Siegel DL. ADAMTS13 autoantibodies cloned from patients with acquired thrombotic thrombocytopenic purpura: 1. Structural and functional characterization in vitro. Transfusion 2016; 56:1763-74. [PMID: 27040144 PMCID: PMC4938786 DOI: 10.1111/trf.13584] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/25/2016] [Accepted: 02/06/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acquired thrombotic thrombocytopenia purpura (TTP) is a life-threatening illness caused by autoantibodies that decrease the activity of ADAMTS13, the von Willebrand factor-cleaving protease. Despite efficacy of plasma exchange, mortality remains high and relapse is common. Improved therapies may come from understanding the diversity of pathogenic autoantibodies on a molecular or genetic level. Cloning comprehensive repertoires of patient autoantibodies can provide the necessary tools for studying immunobiology of disease and developing animal models. STUDY DESIGN AND METHODS Anti-ADAMTS13 antibodies were cloned from four patients with acquired TTP using phage display and characterized with respect to genetic origin, inhibition of ADAMTS13 proteolytic activity, and epitope specificity. Anti-idiotypic antisera raised to a subset of autoantibodies enabled comparison of their relatedness to each other and to polyclonal immunoglobulin (Ig)G in patient plasma. RESULTS Fifty-one unique antibodies were isolated comprising epitope specificities resembling the diversity found in circulating patient IgG. Antibodies directed both to the amino terminal domains and to those requiring the ADAMTS13 cysteine-rich/spacer region for binding inhibited proteolytic activity, while those solely targeting carboxy-terminal domains were noninhibitory. Anti-idiotypic antisera raised to a subset of antibody clones crossreacted with and reduced the inhibitory activity of polyclonal IgG from a set of unrelated patients. CONCLUSIONS Anti-ADAMTS13 autoantibodies isolated by repertoire cloning display the diversity of epitope specificities found in patient plasma and provide tools for developing animal models of acquired TTP. Shared idiotypes of inhibitory clones with circulating IgG from multiple patients suggest common features of pathogenic autoantibodies that could be exploited for developing more targeted therapies.
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Affiliation(s)
- Eric M. Ostertag
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Stephen Kacir
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Michelle Thiboutot
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Gayathri Gulendran
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - X. Long Zheng
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas B. Cines
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
| | - Don L. Siegel
- Departments of Pathology & Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania
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Cataland SR, Wu HM. Acquired thrombotic thrombocytopenic purpura: new therapeutic options and their optimal use. J Thromb Haemost 2015; 13 Suppl 1:S223-9. [PMID: 26149028 DOI: 10.1111/jth.12934] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Advances in our understanding of the pathophysiology of both congenital and acquired thrombotic thrombocytopenic purpura (TTP) have led to both an increased understanding of the disease and novel approaches to therapy. The efficacy of rituximab in acquired TTP has led to consideration of rituximab as a prophylactic therapy to prevent relapse of TTP. Novel therapies that target the A1 domain of von Willebrand factor (VWF) to block the formation of microthrombotic disease have also entered clinical study and have demonstrated promise as potential therapeutic options. Additionally, a recombinant ADAMTS13 protease has been developed which may be an important therapeutic option for both congenital and acquired TTP. The development of these new therapeutic options for patients diagnosed with TTP has increased the importance of conducting prospective, randomized studies with these agents to both confirm their efficacy and more importantly understand their most appropriate role in the treatment of patients with TTP.
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Affiliation(s)
- S R Cataland
- Department of Medicine, Ohio State University, Columbus, OH, USA
| | - H M Wu
- Department of Pathology, Ohio State University, Columbus, OH, USA
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Omri HE, Taha RY, Gamil A, Ibrahim F, Sabah HA, Mahmoud ZO, Pittari G, HIjji IA, Yassin MA. Efficacy and Safety of Rituximab for Refractory and Relapsing Thrombotic Thrombocytopenic Purpura: A Cohort of 10 Cases. PLASMATOLOGY 2015; 8:1-7. [PMID: 26052230 PMCID: PMC4451552 DOI: 10.4137/cmbd.s25326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Idiopathic thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder mediated by autoantibodies directed against ADAMTS13. This provides a rationale for the use of rituximab in this disorder. We report our experience and the outcome of 10 cases of TTP (9 refractory and 1 relapsing) successfully treated with rituximab in combination with plasma exchange (PE) and other immunosuppressive treatments. METHODS The diagnosis of TTP was based on clinical criteria and supported by severe deficiency of ADAMTS13 activity and presence of inhibitors in seven cases. Rituximab was started after a median of 18.6 sessions of PE (range: 5–35) at the dose of 375 mg/m2/week for 4–8 weeks. RESULTS Complete remission was achieved in all patients after a median time of 14.4 days of the first dose (range: 6–30). After a median follow-up of 30 months (range: 8–78), eight patients were still in remission and two developed multiple relapses, treated again with the same therapy, and achieved complete responses; they are alive, and in complete remission after a follow-up of 12 and 16 months. CONCLUSION Rituximab appears to be a safe and effective therapy for refractory and relapsing TTP. However, longer follow-up is recommended to assess relapse and detect possible long-term side effects of this therapy.
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Affiliation(s)
- Halima El Omri
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ruba Y Taha
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Amna Gamil
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Firyal Ibrahim
- Department of Laboratory Medicine and Pathology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Al Sabah
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Zeinab O Mahmoud
- Blood Bank Center, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Gianfranco Pittari
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Al HIjji
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed A Yassin
- Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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Wieland I, Kentouche K, Jentzsch M, Lothschütz D, Graf N, Sykora KW. Long-term remission of recurrent thrombotic thrombocytopenic purpura (TTP) after Rituximab in children and young adults. Pediatr Blood Cancer 2015; 62:823-9. [PMID: 25623397 DOI: 10.1002/pbc.25398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/18/2014] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Acquired thrombotic-thrombocytopenic purpura (TTP) is an autoimmune disorder characterized by autoantibodies directed against the von Willebrand metalloprotease. Depletion of B-cells can prevent synthesis of this antibody and presumably induce remission of the disease. In adults, Rituximab (RTX) was effective in relapsed or refractory acute idiopathic TTP. PROCEDURE We report the long-term follow-up of five children and two adolescents (age at diagnosis 6-19 years, median 15 years) who were treated with RTX for recurrent or refractory TTP. Some of the patients suffered from recurrent refractory TTP with long histories of previous unsuccessful treatments. One had TTP associated with pancreatitis. RESULTS Three patients have been in complete remission after one treatment course with RTX. Four relapsed after 1 to 5 years, respectively, and responded to additional courses of RTX. One of them is in long-term remission after a third course of RTX and splenectomy. Compared to literature reports with a median follow up of 1.4 years (3-46 month), follow-up of our patients after treatment with RTX was very long (2-12.7 years, median 7.7 years). RTX therapy could induce long-term remissions in children with refractory recurrent TTP. Median duration of remission was longer and relapses per patient-years less frequent in patients receiving RTX compared to patients not receiving it. Remissions were achieved in children within one week, much faster than in adults. CONCLUSION Because of the rapid induction of remissions, RTX may be suitable for first-line therapy in pediatric acquired antibody-mediated TTP.
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Affiliation(s)
- Ivonne Wieland
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
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How I treat refractory thrombotic thrombocytopenic purpura. Blood 2015; 125:3860-7. [PMID: 25784681 DOI: 10.1182/blood-2014-11-551580] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/07/2015] [Indexed: 01/01/2023] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA) without an obvious cause, and may include fever, mild renal failure, and neurologic deficits. It is characterized by a deficiency of the von Willebrand factor (VWF) cleaving enzyme, ADAMTS13 (a disintegrin and metalloproteinase, with a thrombospondin type 1 motif, member 13), resulting in formation of microthrombi in the high sheer environment of the microvasculature. This causes microvascular occlusion, MAHA, and organ ischemia. Diagnosis is based on the presence of clinical symptoms, laboratory aberrations consistent with MAHA, decreased ADAMTS13 activity, and possibly presence of anti-ADAMTS13 autoantibodies. Upfront treatment of acute TTP includes plasma exchange and corticosteroids. A significant number of patients are refractory to this treatment and will require further interventions. There are limited data and consensus on the management of the refractory TTP patient. Management involves simultaneously ruling out other causes of thrombocytopenia and MAHA, while also considering other treatments. In this article, we describe our management of the patient with refractory TTP, and discuss use of rituximab, increased plasma exchange, splenectomy, and immunosuppressive options, including cyclophosphamide, vincristine, and cyclosporine. We also review recent evidence for the potential roles of bortezomib and N-acetylcysteine, and explore new therapeutic approaches, including recombinant ADAMTS13 and anti-VWF therapy.
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von Auer C, von Krogh AS, Kremer Hovinga JA, Lämmle B. Current insights into thrombotic microangiopathies: Thrombotic thrombocytopenic purpura and pregnancy. Thromb Res 2015; 135 Suppl 1:S30-3. [DOI: 10.1016/s0049-3848(15)50437-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Coppo P, Froissart A. Treatment of thrombotic thrombocytopenic purpura beyond therapeutic plasma exchange. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:637-643. [PMID: 26637782 DOI: 10.1182/asheducation-2015.1.637] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Daily therapeutic plasma exchange (TPE) transformed the historically fatal prognosis of acquired, anti-ADAMTS13 antibody-mediated thrombotic thrombocytopenic purpura (TTP), leading to the current overall survival rates of 80%-85%. However, relapses occur in ~40% of patients and refractory disease with fatal outcomes still occurs. In this context, the introduction of rituximab has probably been the second major breakthrough in TTP management. Rituximab is now routinely recommended during the acute phase, typically in patients with a suboptimal response to treatment, or even as frontline therapy, with high response rates. In more severe patients, salvage strategies may include twice-daily TPE, pulses of cyclophosphamide, vincristine, as well as splenectomy in more desperate cases. In this life-threatening disease, relapse prevention represents a major goal. Persistent severe acquired ADAMTS13 deficiency in patients who are otherwise in remission is associated with a high risk of relapse and preemptive treatment with rituximab may be considered in this context. In the coming years, the TTP therapeutic landscape should be enriched by original strategies stemming from clinical experience and new agents that are currently being evaluated in large, ideally international, clinical trials. Promising agents under evaluation include N-acetylcysteine, bortezomib, recombinant ADAMTS13, and inhibitors of the glycoprotein-Ib/IX-von Willebrand factor axis.
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Affiliation(s)
- Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1170, Institut Gustave Roussy, Villejuif, France; Université Pierre et Marie Curie, Paris, France; and
| | - Antoine Froissart
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service de médecine interne, CHI Créteil, Paris, France
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The splenic autoimmune response to ADAMTS13 in thrombotic thrombocytopenic purpura contains recurrent antigen-binding CDR3 motifs. Blood 2014; 124:3469-79. [DOI: 10.1182/blood-2014-04-561142] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Key Points
The spleen harbors ADAMTS13-specific memory B cells following acute acquired TTP. The splenic anti-ADAMTS13 antibody repertoire is characterized by a set of unique and novel CDR3 motifs, 4 shared by 2 patients.
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Mujer de 64 años con ictericia y alteración del sensorio. Med Clin (Barc) 2014; 143:72-7. [DOI: 10.1016/j.medcli.2014.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 02/14/2014] [Accepted: 02/27/2014] [Indexed: 11/23/2022]
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Thrombotic microangiopathies. Semin Arthritis Rheum 2014; 43:797-805. [DOI: 10.1016/j.semarthrit.2013.11.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 11/03/2013] [Accepted: 11/07/2013] [Indexed: 12/24/2022]
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Preemptive rituximab infusions after remission efficiently prevent relapses in acquired thrombotic thrombocytopenic purpura. Blood 2014; 124:204-10. [PMID: 24869941 DOI: 10.1182/blood-2014-01-550244] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In acquired thrombotic thrombocytopenic purpura (TTP), the persistence of severe ADAMTS13 deficiency (<10%) during remission is associated with more relapse. Preemptive (ie, after remission) administration of rituximab in these patients to prevent relapses remains controversial. We performed a cross-sectional analysis of 12-year follow-up data to compare the relapse incidence with or without preemptive rituximab infusion. Among 48 patients who experienced at least one episode of acquired TTP followed by severe ADAMTS13 deficiency during remission, 30 received preemptive rituximab (group 1); the other 18 did not (group 2). After a median of 17 months (interquartile range [IQR], 11-29) following rituximab, the relapse incidence decreased from 0.57 episodes/year (IQR, 0.46-0.7) to 0 episodes/year (IQR, 0-0.81) (P < .01) in group 1. ADAMTS13 activity 3 months after the first rituximab infusion increased to 46% (IQR, 30%-68%). Nine patients required additional courses of rituximab. In 5 patients, ADAMTS13 activity failed to increase durably. Four patients experienced manageable adverse effects. In group 2, the relapse incidence was higher (0.5 relapses/year; IQR, 0.12-0.5; P < .01). Relapse-free survival was longer in group 1 (P = .049). A persistent severe ADAMTS13 deficiency during TTP remission should prompt consideration of preemptive rituximab to prevent relapses.
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Laparoscopic splenectomy for the treatment of refractory thrombotic thrombocytopenic purpura. Clin J Gastroenterol 2013; 6:420-3. [PMID: 26182130 DOI: 10.1007/s12328-013-0419-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 08/18/2013] [Indexed: 10/26/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a serious hematologic disorder with a high rate of morbidity and mortality. We report here on the surgical and homological outcomes of laparoscopic splenectomy (LS) in a patient with refractory TTP. A 69-year-old Japanese woman was referred to our hospital because of purpura in the lower extremities. In addition to the marked thrombocytopenia, hemolytic anemia and progressive mental disorder were noted. The ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif 13) activity was undetectable and ADAMTS13 inhibitor was extremely increased. The diagnosis of TTP was made based on the clinical features and laboratory abnormalities. She received steroid-pulse therapy for 3 days, low-dose methylprednisolone continuous infusion and plasma exchange (PE) daily for 14 days. However, the patient was found to be refractory TTP to PE. The LS was performed at 15 days after diagnosis. The ADAMTS13 inhibitor was not detected after LS, and in addition, the platelet count had increased to over 100,000/mm(3) on postoperative day 17. The patient remains in remission 24 months after surgery. The results of our case demonstrate that LS is a safe and reasonable treatment option for patients with TTP refractory to PE.
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van Balen T, Schreuder MF, de Jong H, van de Kar NCAJ. Refractory thrombotic thrombocytopenic purpura in a 16-year-old girl: successful treatment with bortezomib. Eur J Haematol 2013; 92:80-2. [PMID: 24118335 DOI: 10.1111/ejh.12206] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2013] [Indexed: 11/30/2022]
Abstract
We present a case of a 16-year-old girl with autoimmune thrombotic thrombocytopenic purpura (TTP), refractory to plasma exchange and high-dose prednisone. Despite the additional treatment with rituximab, she developed renal and neurological complications with ongoing hemolysis and thrombocytopenia. Bortezomib, a proteasome inhibitor and thereby blocking plasma cells, was added, and our patient recovered. We suggest that bortezomib can be of additional value in severe immunologically mediated TTP in adolescents. Its use may prevent the necessity of other invasive therapies, such as splenectomy, with significant side effects.
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Affiliation(s)
- Tessa van Balen
- Department of Pediatric Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Bennett M, Chubar Y, Gavish I, Aviv A, Stemer G, Chap-Marshak D. Experiences in a family with the Upshaw-Schulman syndrome over a 44-year period. Clin Appl Thromb Hemost 2013; 20:296-303. [PMID: 23872162 DOI: 10.1177/1076029613495309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A family with a novel c.717_del frameshift and a c.3655C > T missense mutation of a disintegrin and metalloproteinase with thrombospondin type I motif, member 13 protein (ADAMTS13) is described. Family members have been under observation for 44 years. Two double heterozygotes have severe early-onset Upshaw-Schulman syndrome and require prophylactic plasma infusions. Analysis reveals that 2 weekly plasma infusions are not sufficient in preventing laboratory evidence of a thrombotic thrombocytopenic purpura (TTP) attack. Both the double heterozygotes also have a heterozygous factor V Leiden G1291A mutation. One underwent splenectomy, which did not reduce the frequency of TTP episodes but resulted in a recurrent pulmonary embolism and has necessitated lifelong anticoagulant therapy. The other has mild chronic renal failure and has had episodes of atrial fibrillation and cerebral infarction. Of the 3 heterozygotes in the family, 1 has had episodes of mild thrombocytopenia.
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Affiliation(s)
- Michael Bennett
- 1Department of Haematology, The Emek Medical Centre, Afula, Israel
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Scully M, Hunt BJ, Benjamin S, Liesner R, Rose P, Peyvandi F, Cheung B, Machin SJ. Guidelines on the diagnosis and management of thrombotic thrombocytopenic purpura and other thrombotic microangiopathies. Br J Haematol 2012; 158:323-35. [PMID: 22624596 DOI: 10.1111/j.1365-2141.2012.09167.x] [Citation(s) in RCA: 510] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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