1
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Silva de Avó Freixo H, Andrade Carvalho A, Marufuji Ogawa M, Simões E Silva Enokihara MM, Tomimori J. Lupus tumidus in kidney transplant recipient: a case of an autoimmune disease in an immunosuppressed patient. Int J Dermatol 2023; 62:e24-e25. [PMID: 36073250 DOI: 10.1111/ijd.16410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/17/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | | | - Jane Tomimori
- Department of Dermatology, Universidade Federal de São Paulo, São Paulo, Brasil
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2
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McCarthy MD, Fareeth AGM. Evans syndrome in a young man with rare autoimmune associations and transplanted liver. BMJ Case Rep 2022; 15:15/9/e251252. [PMID: 36171014 PMCID: PMC9528579 DOI: 10.1136/bcr-2022-251252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Evans syndrome is classically characterised by two or more cytopenias occurring either concomitantly or sequentially. Most commonly, these are autoimmune haemolytic anaemia and immune thrombocytopenia purpura. It is mostly associated with specific autoimmune conditions such as systemic lupus erythematosus and lymphoproliferative disorders. We present a case report of Evans syndrome in a young man with primary sclerosing cholangitis and Crohn’s disease, neither of which are classically associated with the condition. The case also further adds to the number of case reports of Evans syndrome occurring in patients following liver transplantation.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Humans
- Liver Transplantation/adverse effects
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Male
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Thrombocytopenia/complications
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Affiliation(s)
| | - A G Mohamed Fareeth
- Acute Medicine, East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, UK
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3
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Vakilian M. A review on the effect of prolyl isomerization on immune response aberration and hypersensitivity reactions: A unifying hypothesis. Clin Immunol 2021; 234:108896. [PMID: 34848356 DOI: 10.1016/j.clim.2021.108896] [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: 08/27/2021] [Revised: 11/19/2021] [Accepted: 11/21/2021] [Indexed: 12/01/2022]
Abstract
Little is known about the causes and mechanisms of ectopic immune responses, including different types of hypersensitivity, superantigens, and cytokine storms. Two of the most questionable phenomena observed in immunology are why the intensity and extent of immune responses to different antigens are different, and why some self-antigens are attacked as foreign. The secondary structure of the peptides involved in the immune system, such as the epitope-paratope interfaces plays a pivotal role in the resulting immune responses. Prolyl cis/trans isomerization plays a fundamental role in the form of the secondary structure and the folding of proteins. This review covers some of the emerging evidence indicating the impact of prolyl isomerization on protein conformation, aberration of immune responses, and the development of hypersensitivity reactions.
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Affiliation(s)
- Mehrdad Vakilian
- Department of Cell Biology, Genetics and Physiology, University of Malaga (UMA), The Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain.
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4
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Gipson DR, Larkin T, Seifert R, Black LV. Romiplostim as a Therapeutic Intervention for Tacrolimus-induced Immune Thrombocytopenia in a Pediatric Cardiac Transplant Patient. J Pediatr Hematol Oncol 2021; 43:e777-e779. [PMID: 33181586 DOI: 10.1097/mph.0000000000001994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/05/2020] [Indexed: 01/19/2023]
Abstract
Tacrolimus-induced immune thrombocytopenia (ITP) is a rare entity that can occur years after initiation of tacrolimus therapy following solid organ transplantation, and platelet recovery can be substantially delayed following discontinuation of tacrolimus. Romiplostim, a thrombopoietin receptor agonist approved by the FDA in 2018 for the treatment of chronic ITP in children, may be a useful therapy to hasten platelet recovery in the acute ITP setting in place of immunomodulating agents. We present a case of tacrolimus-induced ITP successfully treated with romiplostim in a child following cardiac transplantation.
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Affiliation(s)
| | - Trisha Larkin
- Department of Pediatrics
- Department of Pediatrics, Division of Pediatric Hematology-Oncology
| | - Robert Seifert
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL
| | - L Vandy Black
- Department of Pediatrics
- Department of Pediatrics, Division of Pediatric Hematology-Oncology
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5
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Kehar M, Grunebaum E, Jimenez-Rivera C, Mozer-Glassberg Y, Jamal A, Ng VL, Avitzur Y. Conversion from tacrolimus to sirolimus as a treatment modality in de novo allergies and immune-mediated disorders in pediatric liver transplant recipients. Pediatr Transplant 2020; 24:e13737. [PMID: 32428390 DOI: 10.1111/petr.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/31/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
De novo PTAID may develop in pediatric solid organ transplant recipients, have a diverse spectrum, and are occasionally treatment resistant. Previous reports showed resolution of immune cytopenias in solid organ transplant recipients following replacement of the calcineurin inhibitor tacrolimus with the mTOR inhibitor sirolimus. Herein we describe a retrospective review (2000-2017) of subjects who developed PTAID in whom immunosuppression was changed to sirolimus. Eight recipients (6 males) of either liver (n = 7) or multivisceral transplant (n = 1) suffered from severe, treatment-resistant PTAID and were switched from tacrolimus to sirolimus. The median age at transplant was 1 year (range 0.5-2.4 years). Six (75%) recipients developed de novo allergy and 2 immune-mediated diseases. The median age at presentation of PTAID was 2.7 (1.4-9) years at a median of 1.3 (0.25-8) years after transplantation. The median time from PTAID presentation to conversion to sirolimus was 1.8 (0.45-10) years. Complete resolution of symptoms was seen in 4 (50%) patients after a median of 12 (range 4-24) months including 2 patients with immune-mediated disease, 1 eczema, and 1 with eosinophilic colitis. One patient with multiple food allergies had a partial response and 3 (38%) had no response. None of the 8 recipients developed sirolimus-attributed adverse events or acute rejection during a median follow-up of 5 (0.6-8) years after the conversion. Immunosuppression conversion from tacrolimus to sirolimus can be an effective therapy in patients suffering severe or treatment-resistant PTAID, suggesting a potential role for tacrolimus in the pathogenesis of PTAID.
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Affiliation(s)
- Mohit Kehar
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Queens University, Kingston, ON, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carolina Jimenez-Rivera
- Division of Gastroenterology Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petah-Tikva, Israel
| | - Alisha Jamal
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vicky Lee Ng
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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6
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Knops N, Emonds MP, Herman J, Levtchenko E, Mekahli D, Pirenne J, Van Geet C, Dierickx D. Bortezomib for autoimmune hemolytic anemia after intestinal transplantation. Pediatr Transplant 2020; 24:e13700. [PMID: 32166874 DOI: 10.1111/petr.13700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/03/2019] [Accepted: 02/24/2020] [Indexed: 01/19/2023]
Abstract
AIHA is rare in the general population and associated with a mortality of 8%. In contrast, AIHA occurs in up to 12.2% of cases after intestinal transplantation and is associated with mortality up to 50%. Treatment entails a "step-up" approach including corticosteroids, IvIg, plasmapheresis, and rituximab. However, AIHA after transplantation often is refractory to this strategy, contributing to a poor outcome. We describe a child with microvillous inclusion disease who developed AIHA 1 year after multivisceral transplantation that was refractory to standard therapy and was subsequently treated with bortezomib.We observed remission of AIHA within 1 week after the start of bortezomib. Bortezomib was associated with transient diarrhea, leucopenia, and elevated liver enzymes. Three years later, he remains in remission without important complications. Published data on bortezomib for autoimmune cytopenias outside SOT are discussed. This is the first report to support bortezomib as an important therapeutic alternative for AIHA after SOT. The occurrence and treatment of AIHA after SOT, and specifically intestinal transplantation, should be the subject of future registry studies to collect additional experience and explore the optimal therapeutic approach.
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Affiliation(s)
- Noël Knops
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jean Herman
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Elena Levtchenko
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Djalila Mekahli
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Pediatrics (Pediatric Hemato-Oncology), University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Daan Dierickx
- Hematology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology (Laboratorium of Experimental Hematology), KU Leuven, Leuven, Belgium
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7
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Grunebaum E, Avitzur Y. Liver-associated immune abnormalities. Autoimmun Rev 2018; 18:15-20. [PMID: 30408587 DOI: 10.1016/j.autrev.2018.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 06/30/2018] [Indexed: 01/19/2023]
Abstract
In recent years, the cross talk between the liver and the immune system is being uncovered, in part by studying liver involvement in primary immune deficiencies (PID) and in part by investigating the alterations of the immune system following orthotopic liver transplantation (OLT). Here we review some of the reciprocal interactions between the liver and the immune system. Patients with PID, particularly those involving inherited defects in T and B cells or innate immunity are prone to infections and inflammatory responses that often involve the liver. Omenn's syndrome, familial hemophagocytic lymphohistiocytosis, AIRE, FOXP3 and CD25 deficiencies, common variable immunodeficiency, CD40 ligand deficiency, chronic granulomatous disease and autoimmune lymphoproliferative syndrome are some of the notable PID associated with typical hepatobiliary abnormalities. Knowledge gained from studying these PID together with laboratory and histological evaluations can assist in managing PID-associated liver dysfunction. The liver itself also has important effects on the immune system, as evident from the growing experience with patients surviving OLT. Up to 40% of pediatric patients who receive OLT suffer from post transplantation allergy, autoimmunity, and immune-mediated disorders (PTAA). PTAA is more common after liver and heart transplantations than kidney transplantations. Potential contributing factors for the increased frequency of PTAA after OLT include the age of the patients, the prolonged use of tacrolimus and the reduced regulatory immune function with a shift towards a TH2 immune response. Better understanding of the mechanisms leading to the development of PTAA after OLT will also improve the management of these conditions.
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Affiliation(s)
- Eyal Grunebaum
- Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada; The Food Allergy and Anaphylaxis Program, Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | - Yaron Avitzur
- University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
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8
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Jarchin L, Chu J, Januska M, Merola P, Arnon R. Autoimmune hemolytic anemia: An unusual presentation of hemophagocytic lymphohistiocytosis in a pediatric post-liver transplant patient. Pediatr Transplant 2018; 22:e13281. [PMID: 30129086 DOI: 10.1111/petr.13281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/09/2018] [Accepted: 07/24/2018] [Indexed: 01/19/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), a rare condition characterized by immune dysfunction with uncontrolled activation of macrophages and hypersecretion of cytokines, has only been reported in a small number of pediatric patients following solid organ transplant (SOT). The diagnosis of HLH after SOT is especially difficult, as several of the diagnostic criteria, including fever, splenomegaly, and cytopenias, are nonspecific and can be seen with other post-transplant complications. Autoimmune hemolytic anemia (AIHA) has also been reported after pediatric SOT and is thought to be related to immunosuppression, specifically tacrolimus. Although HLH and AIHA have been separately described following SOT, there have been no reports of them occurring together in post-liver transplant (LT) patients. We report the first case of autoimmune hemolysis as the presenting symptom of HLH in a pediatric post-LT patient.
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Affiliation(s)
- Lauren Jarchin
- Division of Pediatric Gastroenterology, Mount Sinai Medical Center, New York City, New York
| | - Jaime Chu
- Recanati/Miller Transplantation Institute at Mount Sinai, Mount Sinai Medical Center, New York City, New York
| | - Megan Januska
- Department of Pediatrics, Mount Sinai Medical Center, New York City, New York
| | - Pamela Merola
- Division of Pediatric Hematology-Oncology, Mount Sinai Medical Center, New York City, New York
| | - Ronen Arnon
- Recanati/Miller Transplantation Institute at Mount Sinai, Mount Sinai Medical Center, New York City, New York
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9
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Avdimiretz N, Seitz S, Kim T, Murdoch F, Urschel S. Allergies and autoimmune disorders in children after heart transplantation. Clin Transplant 2018; 32:e13400. [PMID: 30176068 DOI: 10.1111/ctr.13400] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 08/07/2018] [Accepted: 08/29/2018] [Indexed: 12/15/2022]
Abstract
Pediatric heart transplantation requires lifelong immune suppression and may require thymectomy, both of which alter T-cell repertoires. We hypothesized that atopic and autoimmune diseases are more common in pediatric heart transplant patients than the general population, and that transplantation in early childhood increases the risk of development or worsening of atopic or autoimmune disease. A cross-sectional single-center study including 21 heart transplant patients aged ≤18 years was conducted. Data collected included age at transplant, induction, thymectomy, and development and severity of atopic or autoimmune disease. A majority (67%) reported having any atopic disease post-transplant, all of whom reported onset or worsening post-transplantation. Thymectomized patients were significantly more likely to have asthma (P = 0.018) and report asthma worsening post-transplant (P = 0.045). Patients with worsening of asthma post-transplant were transplanted at a significantly younger age (P = 0.040). ABO incompatible and ABO compatible recipients presented similarly. Anemia was common (38%) but not always clearly of autoimmune origin. Atopic diseases are common in children following heart transplantation: Compared to the general population, there is a higher prevalence of eczema (43% vs 11%) and asthma (33% vs 9%). Both thymectomy and younger age at transplant are associated with atopic disorders, possibly due to altered T-cell repertoires.
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Affiliation(s)
- Nicholas Avdimiretz
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.,Division of Pediatric Respirology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Tiffany Kim
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Faye Murdoch
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.,Alberta Transplant Institute, University of Alberta, Edmonton, Canada
| | - Simon Urschel
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.,Alberta Transplant Institute, University of Alberta, Edmonton, Canada.,Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Alberta, Canada
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10
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Rotz SJ, Ware RE, Kumar A. Diagnosis and management of chronic and refractory immune cytopenias in children, adolescents, and young adults. Pediatr Blood Cancer 2018; 65:e27260. [PMID: 29856527 DOI: 10.1002/pbc.27260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/26/2018] [Accepted: 05/06/2018] [Indexed: 12/13/2022]
Abstract
Children, adolescents, and young adults with chronic refractory autoimmune cytopenias represent a rare but challenging group of patients, who are managed frequently by pediatric hematologists. Novel diagnostic tests and genomic discoveries are refining historical diagnoses of Evans syndrome and common variable immunodeficiency, while also elucidating the cellular and molecular basis for these disorders. Genetic characterization of chronic and refractory autoimmune cytopenias has led to targeted therapies with improved clinical outcomes and fewer off-target toxicities. In this review, we focus on the appropriate diagnostic workup, expanded genetic testing, and novel treatment opportunities that are available for these challenging patients.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Russell E Ware
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish Kumar
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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11
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Rock N, Ansari M, Villard J, Ferrari-Lacraz S, Waldvogel S, McLin VA. Factors associated with immune hemolytic anemia after pediatric liver transplantation. Pediatr Transplant 2018; 22:e13230. [PMID: 29885007 DOI: 10.1111/petr.13230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 01/27/2023]
Abstract
Immune-mediated hemolytic anemia following SOT is a rare disorder, the risk factors for which are unknown. Our purpose was to analyze a seemingly increased incidence in our center with the aim to identify predisposing factors. This recipients single-center retrospective study reviewed the medical records of 96 pediatric LT between 2000 and 2013. IHA was defined as acute anemia with a positive direct antiglobulin test. Seven cases of immune-mediated hemolytic anemia were identified (incidence 8.5%). Three cases presented during the first 3 months following LT (early IHA), and 4 presented later (late IHA). All patients with late IHA required rituximab. Using univariate analysis, the following factors were associated with IHA onset: BA (P = .04), younger age (P = .04), and the use of IGL-1 preservation solution (P = .05). Late IHA was associated with viral infections occurring beyond 3 months following LT, younger age, and BA (P = .01). Overall, CMV infection was associated with the development of both early and late IHA: CMV-negative recipients who received an organ from a CMV-positive donor were more likely to develop IHA (P = .035), and de novo CMV infection during the first year post-LT was associated with late IHA (P = .03). IHA is a rare complication following pediatric LT, occurring more frequently in younger patients and patients with an initial diagnosis of BA. CMV-negative recipients and patients who experience a de novo CMV infection in the first year following LT seem particularly vulnerable. IGL-1 preservation solution may be associated with an increased likelihood of developing IHA, a novel finding which warrants further investigation.
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Affiliation(s)
- Nathalie Rock
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
| | - Marc Ansari
- Pediatric Hematology and Oncology Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Jean Villard
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sylvie Ferrari-Lacraz
- Transplant Immunology Unit, Division of Immunology and Allergy, University Hospitals Geneva, Geneva, Switzerland
| | - Sophie Waldvogel
- Immunology and Hematology Laboratory, University Hospitals Geneva, Geneva, Switzerland
| | - Valérie Anne McLin
- Swiss Center for Liver Disease in Children, University Hospitals Geneva, Geneva, Switzerland
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12
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Badawy A, Kaido T, Atsushi Y, Yagi S, Hata K, Kamo N, Fukumitsu K, Okajima H, Uemoto S. Evans Syndrome After Successful Immunosuppressant-Free Living-Donor Liver Transplant. EXP CLIN TRANSPLANT 2018; 18:258-260. [PMID: 29911962 DOI: 10.6002/ect.2018.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Evans syndrome is an uncommon disease characterized by a combination of autoimmune hemolytic anemia and autoimmune thrombocytopenia concomitantly or sequentially with a positive direct Coombs test in the absence of any underlying known cause. Here, we present a case of an adult patient who underwent living-donor liver transplant that was preceded by bone marrow transplant 20 years earlier from the same HLA identical donor and who received a single-agent immunosuppressive therapy for only 2 months as prophylaxis against graft-versus-host disease. Two months after transplant, he developed Evans syndrome with severe anemia and thrombocytopenia. After administration of steroids and intravenous immunoglobulin, the patient's anemia and thrombocytopenia improved dramatically. Through the 7 years of follow-up, the patient has not developed graft-versus-host disease or acute or chronic rejection. This case demonstrates a rare complication posttransplant and the possibility of functional tolerance of liver grafts after a combined liver and bone marrow transplant from the same donor.
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Affiliation(s)
- Amr Badawy
- >From the Hepato-Biliary-Pancreatic Surgery and Transplantation Department, Kyoto University, Kyoto, Japan; and the General Surgery Department, Alexandria University, Alexandria, Egypt
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13
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Marcus N, Amir AZ, Grunebaum E, Dipchand A, Hebert D, Ng VL, Walters T, Avitzur Y. De Novo Allergy and Immune-Mediated Disorders Following Solid-Organ Transplantation-Prevalence, Natural History, and Risk Factors. J Pediatr 2018; 196:154-160.e2. [PMID: 29395171 DOI: 10.1016/j.jpeds.2017.11.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/11/2017] [Accepted: 11/15/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To describe the prevalence, natural course, outcome, and risk factors of post-transplant de novo allergy and autoimmunity. STUDY DESIGN A cross-sectional, cohort study of all children (<18 years) who underwent a solid-organ transplantation, between 2000 and 2012, in a single transplant center, with a follow-up period of 6 months or more post-transplant and without history of allergy or immune-mediated disorder pretransplant. RESULTS A total of 626 eligible patients were screened, and 273 patients (160 males; 59%) met the inclusion criteria; this included 111 liver, 103 heart, 52 kidney, and 7 multivisceral recipients. Patients were followed for a median period of 3.6 years. A total of 92 (34%) patients (42 males, 46%) developed allergy or autoimmune disease after transplantation, with a high prevalence among liver (41%), heart (40%), and multivisceral (57%) transplant recipients compared with kidney recipients (4%; P < .001). Post-transplant allergies included eczema (n = 44), food allergy (22), eosinophilic gastrointestinal disease (11), and asthma (28). Autoimmunity occurred in 18 (6.6%) patients, presenting mainly as autoimmune cytopenia (n = 10). In a multivariate analysis, female sex, young age at transplantation, family history of allergy, Epstein-Barr virus infection, and elevated eosinophil count >6 months post-transplantation were associated with an increased risk for allergy or autoimmunity. Two patients (0.7%) died from autoimmune hemolytic anemia and hemophagocytic lymphohistiocytosis, and 52 episodes of post-transplant allergy, autoimmunity, and immune-mediated disorders (37%) did not improve over time. CONCLUSIONS Allergy and autoimmunity are common in pediatric liver, heart, and multivisceral transplant recipients and pose a significant health burden. Further studies are required to clarify the mechanisms behind this post-transplant immune dysregulation.
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Affiliation(s)
- Nufar Marcus
- Division of Immunology and Allergy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Kipper Institute for Allergy and Immunology, Schneider Children's Medical Center of Israel, University of Tel-Aviv, Tel-Aviv, Israel
| | - Achiya Z Amir
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; The Pediatric Gastroenterology, Hepatology & Nutrition Clinic, Tel-Aviv Medical Center, University of Tel-Aviv, Tel-Aviv, Israel
| | - Eyal Grunebaum
- Division of Immunology and Allergy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Diane Hebert
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Walters
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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14
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Kaya Z, Egritas O, Dalgic B. Tacrolimus-Induced Autoimmune Hemolytic Anemia in a Previously Reported Child With History of Thrombocytopenia Following Liver Transplant. EXP CLIN TRANSPLANT 2018; 16:355-356. [PMID: 29633932 DOI: 10.6002/ect.2017.0289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Zühre Kaya
- >From the Department of Pediatric Hematology, Gazi University, Faculty of Medicine, Ankara, Turkey
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Park JA, Lee HH, Kwon HS, Baik CR, Song SA, Lee JN. Sirolimus for Refractory Autoimmune Hemolytic Anemia after Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report and Literature Review of the Treatment of Post-Transplant Autoimmune Hemolytic Anemia. Transfus Med Rev 2016; 30:6-14. [DOI: 10.1016/j.tmrv.2015.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/18/2015] [Accepted: 09/18/2015] [Indexed: 12/18/2022]
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Abstract
PURPOSE OF REVIEW Successful outcomes in patient, graft survival, and quality of life depend on the prevention, early detection, and treatment of possible complications. The aim of the study was to highlight the common outcomes focusing on the unique features in children. Medical follow-up of children after liver transplantation includes monitoring of surgical complications: biliary and vascular, rejection, infections, posttransplant lymphoproliferative disease, other malignancies, recurrent disease, graft function, hypertension, diabetes, renal failure, among other conditions. The goal is to maintain normal graft function on minimal immunosuppression to avoid medication-induced side-effects. RECENT FINDINGS Recent findings include the importance of meticulous follow-up of Epstein-Barr virus and Cytomegalic virus viral load, leading to early diagnosis and improved prognosis, increased prevalence of renal toxicity, cognitive dysfunction, autoimmune, atopic and eosinophilic disease, oral hygiene and chronic hepatitis, and fibrosis of allografts. SUMMARY Caring for children after liver transplantation is extremely rewarding; however, careful attention must be paid to a variety of systems with understanding of the distinctiveness of pediatrics to assure optimal outcomes.
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Schoettler M, Elisofon SA, Kim HB, Blume ED, Rodig N, Boyer D, Neufeld EJ, Grace RF. Treatment and outcomes of immune cytopenias following solid organ transplant in children. Pediatr Blood Cancer 2015; 62:214-218. [PMID: 25308853 PMCID: PMC4394012 DOI: 10.1002/pbc.25215] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/10/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune cytopenias are a recognized life-threatening complication following pediatric solid organ transplants (SOT), but treatment responses and overall outcome are not well described. The aim of this study was to evaluate the demographic characteristics, response to treatments, and outcomes of a cohort of patients who developed immune cytopenias following SOT. PROCEDURE In this single center retrospective review, patients with immune cytopenias after SOT were identified by electronic medical record (EMR) search and transplant databases from 1995-2012. RESULTS Of 764 SOT patients, 19 (2.4%) developed immune cytopenias. Incidence varied widely by transplant type from 1.2% (renal) to 23.5% (multivisceral). Autoimmune hemolytic anemia (AIHA) was the most common immune cytopenia. Overall median time from transplant to immune cytopenia was 8 m and varied by transplant type from 3 m (liver) to 74 m (heart). Standard therapies for immune cytopenias were often used and ineffective. The most effective therapy for the immune cytopenia was changing immunosuppression from tacrolimus to another agent. Three of 19 patients died; none directly attributed to the immune cytopenia. CONCLUSIONS Immune cytopenias are not rare after SOT, and patients usually do not respond well to traditional first line therapies. Provided that the risk of organ rejection is otherwise manageable, temporary cessation of tacrolimus could be more widely explored in this challenging clinical context. Pediatr Blood Cancer 2015;62:214-218. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Michelle Schoettler
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Scott A Elisofon
- The Division of Gastroenterology, Boston Children's Hospital, Boston, MA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Nancy Rodig
- Division of Nephrology, Boston Children's Hospital, Boston, MA
| | - Debra Boyer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - Ellis J Neufeld
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
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19
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Ünlüsoy Aksu A, Eğritaş Gürkan Ö, Sarı S, Yenicesu İ, Dalgıç B. Immune thrombocytopenic purpura in a liver transplant patient. EXP CLIN TRANSPLANT 2014; 12 Suppl 1:175-177. [PMID: 24635822 DOI: 10.6002/ect.25liver.p49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Thrombocytopenia is common during the early posttransplant period. Most cases are mild and recover in 1 month. Occasionally, severe thrombocytopenia may occur in the late posttransplant period. We report a 10-year-old boy with severe thrombocytopenia 3.5 years after liver transplant. We exclude secondary causes of thrombocytopenia. Bone marrow aspiration findings and treatment response were suggestive for immune thrombocytopenic purpura. The patient was treated with intravenous immunoglobulin at thrombocytopenia periods successfully. We continued tacrolimus, but preferred a reduced dose. In conclusion, immune thrombocytopenic purpura should be borne in mind as a reason of late onset, severe thrombocytopenia after liver transplant.
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Affiliation(s)
- Aysel Ünlüsoy Aksu
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gazi University, Ankara, Turkey
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Turner DL, Gordon CL, Farber DL. Tissue-resident T cells,in situimmunity and transplantation. Immunol Rev 2014; 258:150-66. [DOI: 10.1111/imr.12149] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Damian L. Turner
- Columbia Center for Translational Immunology; Columbia University Medical Center; New York NY USA
- Department of Medicine; Columbia University Medical Center; New York NY USA
| | - Claire L. Gordon
- Columbia Center for Translational Immunology; Columbia University Medical Center; New York NY USA
- Department of Medicine; Columbia University Medical Center; New York NY USA
- Department of Medicine; University of Melbourne; Melbourne Vic. Australia
| | - Donna L. Farber
- Columbia Center for Translational Immunology; Columbia University Medical Center; New York NY USA
- Department of Surgery; Columbia University Medical Center; New York NY USA
- Department of Microbiology and Immunology; Columbia University Medical Center; New York NY USA
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Abstract
The diagnosis and management of children with autoimmune cytopenias can be challenging. Children can present with immune-mediated destruction of a single-cell lineage or multiple cell lineages, including platelets (immune thrombocytopenia [ITP]), erythrocytes (autoimmune hemolytic anemia), and neutrophils (autoimmune neutropenia). Immune-mediated destruction can be primary or secondary to a comorbid immunodeficiency, malignancy, rheumatologic condition, or lymphoproliferative disorder. Treatment options generally consist of nonspecific immune suppression or modulation. This nonspecific approach is changing as recent insights into disease biology have led to targeted therapies, including the use of thrombopoietin mimetics in ITP and sirolimus for cytopenias associated with autoimmune lymphoproliferative syndrome.
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