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Trisolini SM, Laganà A, Capria S. Immune Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, Therapy and Open Issues. Mediterr J Hematol Infect Dis 2024; 16:e2024060. [PMID: 38984099 PMCID: PMC11232686 DOI: 10.4084/mjhid.2024.060] [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: 11/21/2023] [Accepted: 06/19/2024] [Indexed: 07/11/2024] Open
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury due to microvascular platelet-rich thrombi. iTTP pathophysiology is based on a severe ADAMTS13 deficiency, the specific von Willebrand factor (vWF)-cleaving protease, due to anti-ADAMTS13 autoantibodies. Early diagnosis and treatment reduce the mortality. Frontline therapy includes daily plasma exchange (PEX) with fresh frozen plasma replacement and immunosuppression with corticosteroids. Caplacizumab has recently been added to frontline therapy. Caplacizumab is a nanobody that binds to the A1 domain of vWF, blocking the interaction of ultra-large vWF multimers with the platelet and thereby preventing the formation of platelet-rich thrombi. Caplacizumab reduces mortality due to ischemic events, refractoriness, and exacerbations after PEX discontinuation. Until now, the criteria for response to treatment mainly took into account the normalization of platelet count and discontinuation of PEX; with the use of caplacizumab leading to rapid normalization of platelet count, it has been necessary to redefine the response criteria, taking into account also the underlying autoimmune disease. Monitoring of ADAMTS13 activity is important to identify cases with a low value of activity (<10IU/L), requiring the optimization of immunosuppressive therapy with the addition of Rituximab. Rituximab is effective in patients with refractory disease or relapsing disease. Currently, the use of Rituximab has expanded, both in frontline treatment and during follow-up, as a pre-emptive approach. Some patients do not achieve ADAMTS13 remission following the acute phase despite steroids and rituximab treatment, requiring an individualized immunosuppressive approach to prevent clinical relapse. In iTTP, there is an increased risk of venous thrombotic events (VTEs) as well as arterial thrombotic events, and most occur after platelet normalization. Until now, there has been no consensus on the use of pharmacological thromboprophylaxis in patients on caplacizumab because the drug is known to increase bleeding risk.
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Affiliation(s)
- Silvia Maria Trisolini
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
| | - Alessandro Laganà
- Resident Doctor at the Department of Hematology, University "Sapienza" of Rome, Rome, Italy
| | - Saveria Capria
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
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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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Underwood MI, Alwan F, Thomas MR, Scully MA, Crawley JTB. Autoantibodies enhance ADAMTS-13 clearance in patients with immune thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:1544-1552. [PMID: 36813118 DOI: 10.1016/j.jtha.2023.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/20/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Severe deficiency in ADAMTS-13 (<10%) and the loss of von Willebrand factor-cleaving function can precipitate microvascular thrombosis associated with thrombotic thrombocytopenic purpura (TTP). Patients with immune-mediated TTP (iTTP) have anti-ADAMTS-13 immunoglobulin G antibodies that inhibit ADAMTS-13 function and/or increase ADAMTS-13 clearance. Patients with iTTP are treated primarily by plasma exchange (PEX), often in combination with adjunct therapies that target either the von Willebrand factor-dependent microvascular thrombotic processes (caplacizumab) or the autoimmune components (steroids or rituximab) of the disease. OBJECTIVES To investigate the contributions of autoantibody-mediated ADAMTS-13 clearance and inhibition in patients with iTTP at presentation and through the course of the PEX therapy. PATIENTS/METHODS Anti-ADAMTS-13 immunoglobulin G antibodies, ADAMTS-13 antigen, and activity were measured before and after each PEX in 17 patients with iTTP and 20 acute TTP episodes. RESULTS At presentation, 14 out of 15 patients with iTTP had ADAMTS-13 antigen levels of <10%, suggesting a major contribution of ADAMTS-13 clearance to the deficiency state. After the first PEX, both ADAMTS-13 antigen and activity levels increased similarly, and the anti-ADAMTS-13 autoantibody titer decreased in all patients, revealing ADAMTS-13 inhibition to be a modest modifier of the ADAMTS-13 function in iTTP. Analysis of ADAMTS-13 antigen levels between consecutive PEX treatments revealed that the rate of ADAMTS-13 clearance in 9 out of 14 patients analyzed was 4- to 10-fold faster than the estimated normal rate of clearance. CONCLUSION These data reveal, both at presentation and during PEX treatment, that antibody-mediated clearance of ADAMTS-13 is the major pathogenic mechanism that causes ADAMTS-13 deficiency in iTTP. Understanding the kinetics of ADAMTS-13 clearance in iTTP may now enable further optimization of treatment of patients with iTTP.
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Affiliation(s)
- Mary I Underwood
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Ferras Alwan
- Haemophilia Centre, Imperial College Healthcare Trust, London, United Kingdom; University College Hospital, London, United Kingdom
| | | | | | - James T B Crawley
- Centre for Haematology, Imperial College London, London, United Kingdom.
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4
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Binns TC, Sostin N, Tormey CA. State of the Evidence: Drug Removal via Apheresis. Transfus Med Rev 2023; 37:16-20. [PMID: 36604194 DOI: 10.1016/j.tmrv.2022.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
Therapeutic apheresis refers to a diversity of procedures in which specific hematologic components (e.g., plasma, erythrocytes, leukocytes, etc.) with pathological associations are removed from circulation (with possible replacement) in order to treat a variety of disease processes. As pharmacologic agents also circulate with these components, their removal is sometimes incidental, or in the scenario of drug toxicity, a therapeutic goal. The corpus of published manuscripts on this subject has grown immensely over the past few decades; however, the breadth of diseases, methods, and drugs that co-exist in this space make it challenging to generate generalizable evidence regarding drug removal via apheresis. This review discusses factors worth considering when interpreting literature-reported data on drug removal by apheresis with examples from several notable studies and highlights topics in need of evidential improvement and growth as our palette of therapeutic agents continues to expand.
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Affiliation(s)
- Thomas C Binns
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Nataliya Sostin
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
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Chen M, Shortt J. Plasma-cell directed therapy for immune thrombotic thrombocytopenic purpura (iTTP). Transfus Med Rev 2022; 36:204-214. [DOI: 10.1016/j.tmrv.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
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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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7
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Subhan M, Scully M. Advances in the management of TTP. Blood Rev 2022; 55:100945. [DOI: 10.1016/j.blre.2022.100945] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
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Plasma exchange in the intensive care unit: a narrative review. Intensive Care Med 2022; 48:1382-1396. [PMID: 35960275 PMCID: PMC9372988 DOI: 10.1007/s00134-022-06793-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023]
Abstract
In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine.
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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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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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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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12
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Rituximab leads to early elimination of circulating CD20+ T and B lymphocytes in patients with iTTP despite ongoing TPEx. Blood Adv 2021; 4:477-481. [PMID: 32027742 DOI: 10.1182/bloodadvances.2019001148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/30/2019] [Indexed: 11/20/2022] Open
Abstract
Key Points
How TPEx impacts rituximab effectiveness in iTTP patients is not fully understood. In iTTP patients on therapeutic plasma exchange, rituximab eliminates circulating CD20+ B and T cells in 24 hours for at least 1 week.
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13
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Cost savings to hospital of rituximab use in severe autoimmune acquired thrombotic thrombocytopenic purpura. Blood Adv 2021; 4:539-545. [PMID: 32045473 DOI: 10.1182/bloodadvances.2019000827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022] Open
Abstract
Patients with severe autoimmune thrombotic thrombocytopenic purpura (TTP) experience acute hematologic emergencies during disease flares and a lifelong threat for relapse. Rituximab, in addition to steroids and therapeutic plasma exchange (TPE), has been shown to mitigate relapse risk. A barrier to care in initiating rituximab in the inpatient setting has been the presumed excessive cost of medication to the hospital. Retrospectively reviewing TTP admissions from 2004 to 2018 at our academic center, we calculated the actual inpatient cost of care. We then calculated the theoretical cost to the hospital of initiating rituximab in the inpatient setting for both initial TTP and relapse TTP cohorts, with the hypothesis that preventing sufficient future TTP admissions offsets the cost of initiating rituximab in all patients with TTP. At a median follow-up of 55 months in the initial TTP cohort, rituximab use produced a projected cost savings of $905 906 and would have prevented 185 inpatient admission days and saved 137 TPE procedures. In the relapse TTP setting, rituximab use produced a projected cost savings of $425 736 and would have prevented 86 inpatient admission days and saved 64 TPE procedures. From a hospital cost standpoint, cost of rituximab should no longer be a barrier to initiating inpatient rituximab in both initial and relapse TTP settings.
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14
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How I treat thrombotic thrombocytopenic purpura in pregnancy. Blood 2021; 136:2125-2132. [PMID: 32797178 DOI: 10.1182/blood.2019000962] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/20/2020] [Indexed: 12/22/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an acute, life-threatening thrombotic microangiopathy (TMA) caused by acquired or congenital severe deficiency of ADAMTS13. Pregnancy is a recognized risk factor for precipitating acute (first or recurrent) episodes of TTP. Differential diagnosis with other TMAs is particularly difficult when the first TTP event occurs during pregnancy; a high index of suspicion and prompt recognition of TTP are essential for achieving a good maternal and fetal outcome. An accurate distinction between congenital and acquired cases of pregnancy-related TTP is mandatory for safe subsequent pregnancy planning. In this article, we summarize the current knowledge on pregnancy-associated TTP and describe how we manage TTP during pregnancy in our clinical practice.
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Perrone S, Passucci M, Ortu La Barbera E, Capriata M, Ferretti A, Mecozzi A, Giovangrossi P, Equitani F, Cimino G. Early response to caplacizumab and rituximab after anaphylaxis to Octaplas plasma in a patient with thrombotic thrombocytopenic purpura. J Clin Apher 2021; 36:499-504. [PMID: 33459440 DOI: 10.1002/jca.21877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/07/2020] [Accepted: 01/07/2021] [Indexed: 01/14/2023]
Abstract
Management of aTTP in patients who refuse or are intolerant to plasma remains challenging, but new drugs can be implemented with success. A 39-year-old woman presented to the Emergency department for bruises at the upper and lower limbs together with worsening anemia and thrombocytopenia; PLASMIC score was seven, indicative of high risk to have a thrombotic microangiopathy due to severe ADAMTS-13 deficiency: indeed, it was 1.4%. We immediately started Plasma Exchange, but after the third procedure she developed severe anaphylaxis to Octaplas plasma, so PEXs were discontinued. We proceeded to a salvage strategy with rituximab and caplacizumab that was rapidly effective to resolve symptoms and hemolysis. It has been already reported a case in which a patient developed severe reactions to fresh-frozen plasma that required discontinuation of PEX. Differently from this case, our patient was already using the less immunogenic pooled plasma units Octaplas, therefore a strategy with caplacizumab was the only available option. Moreover, rituximab is associated with a shorter time to obtain a durable remission in aTTP and a faster time (15 days) to final ADAMTS13 activity recovery >10%. To our knowledge, this is the first case of early discontinuation of caplacizumab in a patient allergic to PEX by actively monitoring ADAMTS13 activity, allowing optimization of healthcare resources during COVID-19 pandemic.
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Affiliation(s)
- Salvatore Perrone
- Hematology, Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy
| | - Mauro Passucci
- Department of Translational and Precision Medicine, University "La Sapienza", Rome, Italy
| | | | - Marcello Capriata
- Department of Translational and Precision Medicine, University "La Sapienza", Rome, Italy
| | - Antonietta Ferretti
- Haemorrhagic and Thrombotic Diseases Service, Area of Hematology, Fondazione Policlinico Universitario "A. Gemelli", IRCCS, Rome, Italy
| | - Alessandra Mecozzi
- Pharmacy, Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy
| | - Piera Giovangrossi
- Transfusion Medicine and Immuno-Hematology Unit, S. M. Goretti Hospital, Latina, Italy
| | - Francesco Equitani
- Transfusion Medicine and Immuno-Hematology Unit, S. M. Goretti Hospital, Latina, Italy
| | - Giuseppe Cimino
- Hematology, Polo Universitario Pontino, S.M. Goretti Hospital, Latina, Italy.,Department of Translational and Precision Medicine, University "La Sapienza", Rome, Italy
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Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
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Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Abou-Ismail MY, Arafah Y, Fu P, Cao S, Schmaier AH, Nayak L. Outcomes of Immune Thrombotic Thrombocytopenic Purpura (iTTP) With Upfront Cyclophosphamide vs. Rituximab. Front Med (Lausanne) 2020; 7:588526. [PMID: 33195351 PMCID: PMC7657267 DOI: 10.3389/fmed.2020.588526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Immune thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disorder managed with plasma exchange (PLEX) and steroids. Addition of rituximab (RTX) to initial disease treatment has been shown to lower future relapse rates. Information as to whether upfront cyclophosphamide (CTX) treatment is helpful in reducing relapse is not known. Methods: In a retrospective cohort study, we identified all patients at our institution diagnosed with iTTP between 2010 and 2019. We analyzed outcomes of cumulative incidence of relapse (CIR) and duration of remission. Results: Thirty Nine patients were studied. Group A (n = 10) included patients who received upfront PLEX and steroids alone, and Group B (n = 28) included those who received either upfront RTX (n = 23) or CTX (n = 5) in addition to PLEX and steroids. The 2-year CIR was 50% in Group A and 27.7% in Group B, with a median duration of remission of 43.6 months vs. 108.3 months, respectively (p = 0.04). Group A was associated with a HR=8.7 (95% CI: 1.27, 59.45), p = 0.027 for duration of remission. There was no significant difference between CTX and RTX in both outcomes of CIR and duration of remission. We observed a potential impact on remission duration based on the presenting absolute neutrophil count (HR = 0.74, 95% CI: 0.58, 0.96) and serum creatinine (HR = 1.42, 95% CI: 1.03, 1.94). Conclusion: There was no significant difference in iTTP relapse outcomes between upfront RTX and CTX. Absolute neutrophil count and serum creatinine may have a role in predicting relapse. Larger, prospective studies are needed to evaluate these findings.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Yasmin Arafah
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Pingfu Fu
- Case Western Reserve University, Cleveland, OH, United States
| | - Shufen Cao
- Case Western Reserve University, Cleveland, OH, United States
| | - Alvin H Schmaier
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Lalitha Nayak
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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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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19
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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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20
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Prendecki M, McAdoo SP, Pusey CD. Is There a Role for Plasma Exchange in ANCA-Associated Vasculitis? CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00161-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of review
This review summarises the evidence for the use of therapeutic plasma exchange (TPE) in anti-neutrophil cytoplasm antibody (ANCA)–associated vasculitis. TPE is an extra-corporeal treatment which efficiently removes IgG and other pathogenic small molecules from the blood. There are several mechanistic reasons why this should be of benefit in AAV including the well-described pathogenicity of ANCA.
Recent findings
The recently published PEXIVAS trial is the largest study of TPE in AAV to date. It did not show a benefit for adjunctive TPE on a primary end point of ESRD or death. There was no difference in serious adverse events between those treated with TPE and those treated with immunosuppressive drugs alone.
Conclusions
Based on the results of PEXIVAS, most patients with AAV should not be treated with adjunctive TPE. However, there are subgroups of patients with AAV for whom TPE may still be of benefit, including those with double positivity for anti-GBM antibodies and ANCA.
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21
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Reddy MS, Hofmann S, Shen YM, Nagalla S, Rambally S, Usmani A, Sarode R. Comparison of low fixed dose versus standard-dose rituximab to treat thrombotic thrombocytopenic purpura in the acute phase and preemptively during remission. Transfus Apher Sci 2020; 59:102885. [PMID: 32739120 DOI: 10.1016/j.transci.2020.102885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 11/18/2022]
Abstract
The standard dose of rituximab used in B-cell hematological malignancies, 375 mg/m2 weekly, may be excessive for autoimmune conditions. Successful use of a low, fixed dose of 100-200 mg of rituximab, weekly for 4 weeks, has been reported in the literature in the treatment of autoimmune thrombotic thrombocytopenic purpura (aTTP). We retrospectively analyzed our rituximab data in aTTP over a 13-year-period for 39 patients, with the aim of comparing response and outcomes with a standard lymphoma-dose course versus a low fixed 100 mg-dose course. Compared to the standard dose (17 patients, 17 courses of 4 infusions), our patients who received a low dose (8 patients, 9 courses of 4 infusions) had a possibly lower baseline risk but did achieve a similar time to remission and number of plasma exchange procedures to remission. Preemptive low-dose courses for ADAMTS13 activity <50 % during remission (6 patients, 10 courses of 4 infusions) achieved a median peak ADAMTS13 activity of 99 %, in a median of 1 month, with no clinical relapses. Our results provide additional evidence for the efficacy of low-dose rituximab, with the benefit of much lower cost, less infusion time, and theoretically lower risk of toxicity.
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Affiliation(s)
- Manasa S Reddy
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
| | - Sandra Hofmann
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Yu Min Shen
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Srikanth Nagalla
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Siayareh Rambally
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Amena Usmani
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Ravi Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA; Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
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22
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Abstract
Therapeutic plasma exchange (TPE) is an extracorporeal process in which a large volume of whole blood is taken from the patient's vein. Plasma is then separated from the other cellular components of the blood and discarded while the remaining blood components may then be returned to the patient. Replacement fluids such as albumin or fresh-frozen plasma may or may not be used. TPE has been used clinically for the removal of pathologic targets in the plasma in a variety of conditions, such as pathogenic antibodies in autoimmune disorders. TPE is becoming more common in the neurointensive care space as autoimmunity has been shown to play an etiological role in many acute neurological disorders. It is important to note that not only does TPE removes pathologic elements from the plasma, but may also remove drugs, which may be an intended or unintended consequence. The objective of the current review is to provide an up-to-date summary of the available evidence pertaining to drug removal via TPE and provide relevant clinical suggestions where applicable. This review also aims to provide an easy-to-follow clinical tool in order to determine the possibility of a drug removal via TPE given the procedure-specific and pharmacokinetic drug properties.
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23
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Gómez-De León A, Villela-Martínez LM, Yáñez-Reyes JM, Gómez-Almaguer D. Advances in the treatment of thrombotic thrombocytopenic purpura: repurposed drugs and novel agents. Expert Rev Hematol 2020; 13:461-470. [DOI: 10.1080/17474086.2020.1750361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Andrés Gómez-De León
- Hematology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario ‘Dr. José Eleuterio González’, Monterrey, México
| | - Luis Mario Villela-Martínez
- Centro Médico “Dr. Ignacio Chavez”. ISSSTESON, Hermosillo, México
- Universidad del Valle de México. Campus Hermosillo, Hermosillo, México
| | - José Miguel Yáñez-Reyes
- Hematology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario ‘Dr. José Eleuterio González’, Monterrey, México
| | - David Gómez-Almaguer
- Hematology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario ‘Dr. José Eleuterio González’, Monterrey, México
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24
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Gauckler P, Leierer J, Kocher F, Feistritzer C, Willenbacher W, Gunsilius E, Wolf D, Neuwirt H, Mayer G, Kronbichler A. Lessons learned from immunoadsorption for hyperviscosity in IgM multiple myeloma-A case report. J Clin Apher 2020; 35:227-230. [PMID: 32142176 PMCID: PMC7383619 DOI: 10.1002/jca.21775] [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: 01/04/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/12/2022]
Abstract
We report the case of a 63‐year‐old Caucasian woman with multiple relapsed IgM multiple myeloma (MM) and elevated free kappa light chains (fκLC). Due to hyperviscosity syndrome with visual impairment, regular plasma exchanges were performed. As part of her 11th line of therapy, an experimental protocol consisting of pembrolizumab, pomalidomide, and dexamethasone was initiated. To reduce fκLC and immunoglobulin (Ig) M, we performed immunoadsorption (IA) using columns containing recombinant single domain camelid antibody fragments as ligands. We measured pembrolizumab (humanized IgG4 kappa anti‐PD1 antibody) levels before and after each IA session and found a 98.1% reduction from baseline with five sessions of IA. Comparable elimination kinetics were observed for serum IgG, whereas fκLC and IgM were eliminated to a substantially lesser extent. These findings highlight that in hyperviscosity syndrome due to IgM MM, broad spectrum IA columns might be only moderately effective compared to total plasma exchange or double filtration plasmapheresis. Monoclonal antibodies are efficiently reduced by extracorporeal therapies and re‐dosing is necessary to provide sufficient efficacy. In the case of serious adverse events such as immune‐related adverse events, IA might be used to eliminate the monoclonal antibody. Measuring IgG levels might be a reasonable strategy for monitoring drug levels of monoclonal antibodies during IA.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Johannes Leierer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Florian Kocher
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Willenbacher
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria.,Oncotyrol, Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Eberhard Gunsilius
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Internal Medicine V (Hematology and Oncology), Medical University Innsbruck, Innsbruck, Austria
| | - Hannes Neuwirt
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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25
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Lu J, Zhong H, Jing S, Wang L, Xi J, Lu J, Zhou L, Zhao C. Low-dose rituximab every 6 months for the treatment of acetylcholine receptor-positive refractory generalized myasthenia gravis. Muscle Nerve 2020; 61:311-315. [PMID: 31875994 DOI: 10.1002/mus.26790] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION In this prospective, open-label study we explore the effectiveness of low-dose rituximab every 6 months in treating refractory generalized myasthenia gravis (GMG). METHODS Twelve patients with acetylcholine receptor (AChR)-positive refractory GMG were enrolled for the study. The primary endpoint was the change in quantitative myasthenia gravis (QMG) score from baseline to the study end. Secondary endpoints included changes in manual muscle testing (MMT), MG-Related Activities of Daily Living (MG-ADL), and 15-item Quality-of-Life (MGQOL-15) scores, as well as prednisolone reduction. RESULTS MG decreased from 18.25 ± 4.03 to 8.42 ± 3.99 (P = .0001), MMT from 27.50 ± 17.78 to 4.58 ± 4.34 (P = .0001), ADL from 8.50 ± 2.84 to 1.17 ± 1.27 (P < .0001), MGQOL-15 from 37.25 ± 13.78 to 17.50 ± 9.73 (P = .0015), and prednisolone dose from 29.38 ± 11.92 mg/day to 8.86 ± 1.88 mg/day (P ≤ .01). DISCUSSION Low-dose rituximab every 6 months is effective in treating refractory GMG patients.
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Affiliation(s)
- Jun Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Huahua Zhong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Sisi Jing
- Department of Neurology, Jing'an District Centre Hospital of Shanghai, Fudan University, Shanghai, China
| | - Liang Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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26
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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27
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Picod A, Provôt F, Coppo P. Therapeutic plasma exchange in thrombotic thrombocytopenic purpura. Presse Med 2019; 48:319-327. [PMID: 31759790 DOI: 10.1016/j.lpm.2019.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease related to the formation of microvascular thrombosis and subsequent organ failure. The disease is accompanied with microangiopathic haemolytic anaemia, consumptive thrombocytopenia and lies on a severe deficiency in ADAMTS13, the von Willebrand factor-cleaving protease. In the acquired, immune-mediated form, this deficiency is due to the production of autoantibodies directed against the enzyme. Therapeutic plasma exchange has been used empirically for decades and still represents the cornerstone of TTP treatment. However, a better understanding of pathophysiological mechanisms underlying the disease has led these last years to the development of highly effective targeted therapies that might in the future restraint the use of therapeutic plasma exchange.
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Affiliation(s)
- Adrien Picod
- Centre national de référence des microangiopathies thrombotiques, 75000 Paris, France
| | - François Provôt
- Centre national de référence des microangiopathies thrombotiques, 75000 Paris, France; Hôpital Albert-Calmette, service de néphrologie, 59000 Lille, France
| | - Paul Coppo
- Centre national de référence des microangiopathies thrombotiques, 75000 Paris, France; Assistance publique-Hôpitaux de Paris, hôpital Saint-Antoine, service d'hématologie, 75012 Paris, France; Sorbonne-Université, 75006 Paris, France.
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28
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Prendecki M, Pusey C. Plasma exchange in anti-glomerular basement membrane disease. Presse Med 2019; 48:328-337. [DOI: 10.1016/j.lpm.2019.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/11/2019] [Indexed: 12/31/2022] Open
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29
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Indications of plasma exchanges in combination with intravenous immunoglobulins or therapeutic monoclonal antibodies. How to combine them? Presse Med 2019; 48:354-359. [DOI: 10.1016/j.lpm.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/02/2019] [Indexed: 11/21/2022] Open
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30
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Mazepa MA, Park YA, Raval JS. Taking Empiricism out of Immune Thrombotic Thrombocytopenic Purpura: Current and Future Treatment Strategies. Transfus Med Rev 2019; 33:248-255. [DOI: 10.1016/j.tmrv.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/10/2019] [Accepted: 06/29/2019] [Indexed: 01/05/2023]
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31
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Picod A, Coppo P. Developments in the use of plasma exchange and adjunctive therapies to treat immune-mediated thrombotic thrombocytopenic purpura. Expert Rev Hematol 2019; 12:461-471. [PMID: 31092093 DOI: 10.1080/17474086.2019.1619170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening disease characterized by a severe functional deficit in the von-Willebrand cleaving protease ADAMTS13, due to autoantibody production. The once-dismal prognosis of the disease has been changed by the discovery of the dramatic efficiency of therapeutic plasma exchange (TPE). Areas covered: This review focuses on the history and recent developments in the use of TPE for iTTP with a special emphasis on the consequences for TPE practice of the recent introduction of new highly effective immunosuppressive strategies and anti-von Willebrand factor (vWF) therapies. Expert opinion: Although TPE still represents the cornerstone, emergency treatment of iTTP, their duration, and associated complications could be dramatically reduced in the future by the systematic addition of early immunosuppression using corticosteroids and rituximab as well as an anti-vWF therapy with caplacizumab.
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Affiliation(s)
- Adrien Picod
- a Centre National de Référence des MicroAngiopathies Thrombotiques, Assistance Publique - Hôpitaux de Paris , Paris , France
| | - Paul Coppo
- a Centre National de Référence des MicroAngiopathies Thrombotiques, Assistance Publique - Hôpitaux de Paris , Paris , France.,b Service d'hématologie, Hôpital Saint-Antoine , Assistance publique - Hôpitaux de Paris , France.,c Sorbonne-Université , Paris , France
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32
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Hamasaki Y, Aikawa A, Itabashi Y, Muramatsu M, Hyoudou Y, Shinoda K, Takahashi Y, Sakurabayashi K, Mizutani T, Oguchi H, Kawamura T, Sakai K, Shishido S. Efficacy of 2 Doses of Rituximab on B-Cell and Antidonor Antibody and Outcomes of ABO-Incompatible Living-Donor Pediatric Kidney Transplant. EXP CLIN TRANSPLANT 2019; 17:105-109. [PMID: 30777532 DOI: 10.6002/ect.mesot2018.o43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Rituximab treatment strategies vary in ABOincompatible pediatric kidney transplant recipients. Here, we present the efficacy of 2 doses of rituximab and subsequent outcomes in ABO-incompatible pediatric kidney transplant patients. MATERIALS AND METHODS Our study of ABO-incompatible pediatric kidney transplant recipients included 21 who were pretreated with desensitization that included 2 doses of 100 mg rituximab (rituximab group) at 10 and 1 day pretransplant and 14 who received splenectomy without rituximab (splenectomy group). Both groups received immunosuppression. Basiliximab was administered during transplant and 4 days posttransplant. Double-filtration plasmapheresis and/or plasma exchange procedures were performed pretransplant in those with higher antidonor antibody titers. CD19-positive and CD20-positive B cells were measured sequentially in the rituximab group. Maximum titers of antidonor antibody pre- and posttransplant, patient and graft survival, biopsy-proven rejection, and complications/infections were compared between groups. RESULTS In the rituximab group, CD19- and CD20-positive B cells were depleted on transplant, persistently depleted at 3 months, and under 5% until 1 year posttransplant. Maximum titers of antidonor antibodies decreased significantly posttranplant in the rituximab (P < .001) but not in the splenectomy group (P = .174), with maximum titers posttransplant significantly lower than shown in the splenectomy group (P < .001). No rituximab patients had clinical rejection, but 5 splenectomy group patients had clinical T-cell-mediated rejection, with 2 also having antibody-mediated rejection. Six in the rituximab group had cytomegalovirus viremia but no cytomegalovirus disease; however, 5 splenectomy group recipients had cytomegalovirus disease and viremia. In the rituximab group, 3 had late-onset neutropenia. One child died of hypertrophic cardio myopathy with a functioning graft; all others survived with no failed grafts. All splenectomy group children survived, although 2 had deteriorated graft function. CONCLUSIONS Two doses of rituximab were effective in long-term B-cell depletion to suppress antidonor antibodies. The possibility of late-onset neutropenia must be considered.
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Affiliation(s)
- Yuko Hamasaki
- From the Department of Nephrology and the Department of Pediatric Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
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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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Dane K, Chaturvedi S. Beyond plasma exchange: novel therapies for thrombotic thrombocytopenic purpura. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:539-547. [PMID: 30504355 PMCID: PMC6246029 DOI: 10.1182/asheducation-2018.1.539] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The advent of plasma exchange has dramatically changed the prognosis of acute thrombotic thrombocytopenic purpura (TTP). Recent insights into TTP pathogenesis have led to the development of novel therapies targeting pathogenic anti-ADAMTS13 antibody production, von Willebrand factor (VWF)-platelet interactions, and ADAMTS13 replacement. Retrospective and prospective studies have established the efficacy of rituximab as an adjunct to plasma exchange for patients with acute TTP, either upfront or for refractory disease. Relapse prevention is a major concern for survivors of acute TTP, and emerging data support the prophylactic use of rituximab in patients with persistent or recurrent ADAMTS13 deficiency in clinical remission. Capalcizumab, a nanobody directed against domain A1 of VWF that prevents the formation of VWF-platelet aggregates, recently completed phase 2 (TITAN) and 3 (HERCULES) trials with encouraging results. Compared with placebo, caplacizumab shortened the time to platelet recovery and may protect against microthrombotic tissue injury in the acute phase of TTP, though it does not modify the underlying immune response. Other promising therapies including plasma cell inhibitors (bortezomib), recombinant ADAMTS13, N-acetyl cysteine, and inhibitors of the VWF-glycoprotein Ib/IX interaction (anfibatide) are in development, and several of these agents are in prospective clinical studies to evaluate their efficacy and role in TTP. In the coming years, we are optimistic that novel therapies and international collaborative efforts will usher in even more effective, evidence-based approaches to address refractory acute TTP and relapse prevention.
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Affiliation(s)
- Kathryn Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD; and
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Al-Husban N, Al-Kuran O. Post-Partum Thrombotic Thrombocytopenic Purpura (TTP) in a Patient with known Idiopathic (Immune) Thrombocytopenic Purpura: a case report and review of the literature. J Med Case Rep 2018; 12:147. [PMID: 29855343 PMCID: PMC5984346 DOI: 10.1186/s13256-018-1692-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/17/2018] [Indexed: 01/02/2023] Open
Abstract
Background Incidences of immune thrombocytopenic purpura occur in 1 in every 1000–10,000 pregnancies accounting for 3% of all thrombocytopenic pregnancies. A pre-existing immune thrombocytopenic purpura is known to be a risk factor for developing thrombocytopenia during pregnancy. We present here the treatment regime and management of a patient with known immune thrombocytopenic purpura who developed postpartum thrombotic thrombocytopenia with atypical response to traditional therapy. Pregnant women are more vulnerable to immune thrombocytopenic purpura or thrombotic thrombocytopenia. Pregnancy or postpartum thrombotic thrombocytopenia accounts for 10–25% of all thrombotic thrombocytopenia. Case presentation This case report deals with the treatment regime and management of a patient with known immune thrombocytopenic purpura who developed postpartum thrombotic thrombocytopenia. A 30-year-old Middle Eastern woman, with a prior diagnosis of chronic immune thrombocytopenic purpura had remained off-the-treatment for many years. After primary unexplained infertility for 8 years, for which she underwent six failed trials of in vitro fertilization, she delivered a healthy baby through caesarean section. Two days post-surgery, she had persistent thrombocytopenia, ecchymoses, bruises, and hemolysis. Her blood film revealed leukoerythroblastic anemia. Her blood tests also revealed a very low level of haptoglobin, and low level of ADAMTS13. A diagnosis of thrombotic thrombocytopenia was suspected. Plasma exchange therapy was started with partial response. We showed that rituximab in conjunction with mycophenolate mofetil following plasma exchange therapy was effective in controlling the low platelet count in our patient. Conclusions Rituximab in conjunction with mycophenolate mofetil following plasma exchange therapy was effective in controlling the low platelet count in our patient. Only two doses of rituximab were sufficient to normalize our patient. We present here a case of safe and effective use of rituximab in pregnancy-induced thrombotic thrombocytopenia.
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Affiliation(s)
- Naser Al-Husban
- Faculty of Medicine, University of Jordan and Jordan University Hospital, PO Box 2194, Amman, 11941, Jordan.
| | - Oqba Al-Kuran
- Faculty of Medicine, University of Jordan and Jordan University Hospital, PO Box 2194, Amman, 11941, Jordan
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Gastaldi M, Nosadini M, Spatola M, Sartori S, Franciotta D. N-methyl-D-aspartate receptor encephalitis: laboratory diagnostics and comparative clinical features in adults and children. Expert Rev Mol Diagn 2018; 18:181-193. [DOI: 10.1080/14737159.2018.1431124] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Matteo Gastaldi
- Laboratory of Neuroimmunology and Department of Brain and Behavioral Sciences, IRCCS Mondino Foundation and University of Pavia, Pavia, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padua, Padova, Italy
| | - Marianna Spatola
- Department of Clinical Neuroscience, University of Lausanne (UNIL), Switzerland and IDIBAPS (Institut d’Investigacions Biomèdiques August Pi i Sunyer) Barcelona, Spain, Barcelona, Spain
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padua, Padova, Italy
| | - Diego Franciotta
- Laboratory of Neuroimmunology, IRCCS Mondino Foundation, Pavia, Italy
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Kronbichler A. Biological Agents and Therapeutic Plasma Exchange: Can They Coexist in the Future? Ther Apher Dial 2017; 21:553-555. [DOI: 10.1111/1744-9987.12639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 09/14/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension); Medical University Innsbruck; Innsbruck Austria
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Relapse of nephrotic syndrome during post-rituximab peripheral blood B-lymphocyte depletion. Clin Exp Nephrol 2017; 22:110-116. [DOI: 10.1007/s10157-017-1415-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/16/2017] [Indexed: 12/21/2022]
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Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
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Tandan R, Hehir MK, Waheed W, Howard DB. Rituximab treatment of myasthenia gravis: A systematic review. Muscle Nerve 2017; 56:185-196. [DOI: 10.1002/mus.25597] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Rup Tandan
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Michael K. Hehir
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Waqar Waheed
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Diantha B. Howard
- Center for Clinical and Translational Science; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Burlington Vermont USA
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Abstract
Thrombotic thrombocytopenia purpura (TTP) and the hemolytic uremic syndrome (HUS) are rare thrombotic microangiopathies that can be rapidly fatal. Although the acquired versions of TTP and HUS are generally highest on this broad differential, multiple rarer entities can produce a clinical picture similar to TTP/HUS, including microangiopathic hemolysis, renal failure, and neurologic compromise. More recent analysis has discovered a host of genetic factors that can produce microangiopathic hemolytic syndromes. This article discusses the current understanding of thrombotic microangiopathy and outlines the pathophysiology and causative agents associated with each distinct syndrome as well as the most accepted treatments.
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Affiliation(s)
- Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Jason A Taylor
- Division of Hematology and Medical Oncology, The Hemophilia Center, Portland VA Medical Center, Knight Cancer Institute, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, L586, Portland, OR 97239, USA.
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Benhamou Y, Paintaud G, Azoulay E, Poullin P, Galicier L, Desvignes C, Baudel J, Peltier J, Mira J, Pène F, Presne C, Saheb S, Deligny C, Rousseau A, Féger F, Veyradier A, Coppo P. Efficacy of a rituximab regimen based on B cell depletion in thrombotic thrombocytopenic purpura with suboptimal response to standard treatment: Results of a phase II, multicenter noncomparative study. Am J Hematol 2016; 91:1246-1251. [PMID: 27643485 DOI: 10.1002/ajh.24559] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 12/30/2022]
Abstract
The standard four-rituximab infusions treatment in acquired thrombotic thrombocytopenic purpura (TTP) remains empirical. Peripheral B cell depletion is correlated with the decrease in serum concentrations of anti-ADAMTS13 and associated with clinical response. To assess the efficacy of a rituximab regimen based on B cell depletion, 24 TTP patients were enrolled in this prospective multicentre single arm phase II study and then compared to patients from a previous study. Patients with a suboptimal response to a plasma exchange-based regimen received two infusions of rituximab 375 mg m-2 within 4 days, and a third dose at day +15 of the first infusion if peripheral B cells were still detectable. Primary endpoint was the assessment of the time required to platelet count recovery from the first plasma exchange. Three patients died after the first rituximab administration. In the remaining patients, the B cell-driven treatment hastened remission and ADAMTS13 activity recovery as a result of rapid anti-ADAMTS13 depletion in a similar manner to the standard four-rituximab infusions schedule. The 1-year relapse-free survival was also comparable between both groups. A rituximab regimen based on B cell depletion is feasible and provides comparable results than with the four-rituximab infusions schedule. This regimen could represent a new standard in TTP. This trial was registered at www.clinicaltrials.gov (NCT00907751). Am. J. Hematol. 91:1246-1251, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ygal Benhamou
- Service de Médecine Interne, CHU Charles NicolleRouen
- Inserm U1096Rouen France
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
| | - Gilles Paintaud
- Université François‐Rabelais de Tours, CNRS, GICC UMR 7292, CHRU de Tours, Laboratoire de Pharmacologie‐ToxicologieTours France
| | - Elie Azoulay
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Hôpital Saint‐Louis, AP‐HPService de Réanimation MédicaleParis France
- Université Paris Diderot, Sorbonne Paris CitéParis France
| | - Pascale Poullin
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Hôpital de Marseille ConceptionService d'HémaphérèseMarseille France
| | - Lionel Galicier
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Université Paris Diderot, Sorbonne Paris CitéParis France
- Hôpital Saint‐Louis, AP‐HPService d'Immunologie CliniqueParis France
| | - Céline Desvignes
- Université François‐Rabelais de Tours, CNRS, GICC UMR 7292, CHRU de Tours, Laboratoire de Pharmacologie‐ToxicologieTours France
| | - Jean‐Luc Baudel
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- CHU Saint‐Antoine, AP‐HPService de Réanimation MédicaleParis France
- Sorbonne Université, UPMC Univ Paris 06Paris France
| | - Julie Peltier
- Urgences néphrologiques et transplantation rénale, Hôpital Tenon, AP‐HPParis France
| | - Jean‐Paul Mira
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Hôpital Cochin, AP‐HPService de Réanimation PolyvalenteParis France
- Université Paris 5Paris France
| | - Frédéric Pène
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Hôpital Cochin, AP‐HPService de Réanimation PolyvalenteParis France
- Université Paris 5Paris France
| | - Claire Presne
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Hôpital SudService de Néphrologie—Médecine InterneAmiens France
| | - Samir Saheb
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Service de Médecine interne 1, Hôpital La Pitié‐Salpêtrière, AP‐HPParis France
| | | | - Alexandra Rousseau
- Sorbonne Université, UPMC Univ Paris 06Paris France
- Hôpital Saint‐Antoine, AP‐HPUnité de Recherche Clinique de l'Est Parisien (URC‐Est)Paris France
| | - Frédéric Féger
- Sorbonne Université, UPMC Univ Paris 06Paris France
- CHU Saint‐Antoine, AP‐HPService d'Immunologie et Hématologie biologiqueParis France
| | - Agnès Veyradier
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Université Paris Diderot, Sorbonne Paris CitéParis France
- Hôpital Lariboisière, AP‐HPService d'Hématologie BiologiqueParis France
| | - Paul Coppo
- Hôpital Saint‐Antoine, AP‐HPCentre de Référence des Microangiopathies Thrombotiques Paris, France
- Inserm U1009, Institut Gustave RoussyVillejuif, Paris France
- Hôpital Saint‐Antoine, AP‐HPService d'HématologieParis France
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Go RS, Winters JL, Leung N, Murray DL, Willrich MA, Abraham RS, Amer H, Hogan WJ, Marshall AL, Sethi S, Tran CL, Chen D, Pruthi RK, Ashrani AA, Fervenza FC, Cramer CH, Rodriguez V, Wolanskyj AP, Thomé SD, Hook CC. Thrombotic Microangiopathy Care Pathway: A Consensus Statement for the Mayo Clinic Complement Alternative Pathway-Thrombotic Microangiopathy (CAP-TMA) Disease-Oriented Group. Mayo Clin Proc 2016; 91:1189-211. [PMID: 27497856 DOI: 10.1016/j.mayocp.2016.05.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/12/2016] [Accepted: 05/27/2016] [Indexed: 12/15/2022]
Abstract
Thrombotic microangiopathies (TMAs) comprise a heterogeneous set of conditions linked by a common histopathologic finding of endothelial damage resulting in microvascular thromboses and potentially serious complications. The typical clinical presentation is microangiopathic hemolytic anemia accompanied by thrombocytopenia with varying degrees of organ ischemia. The differential diagnoses are generally broad, while the workup is frequently complex and can be confusing. This statement represents the joint recommendations from a multidisciplinary team of Mayo Clinic physicians specializing in the management of TMA. It comprises a series of evidence- and consensus-based clinical pathways developed to allow a uniform approach to the spectrum of care including when to suspect TMA, what differential diagnoses to consider, which diagnostic tests to order, and how to provide initial empiric therapy, as well as some guidance on subsequent management.
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Affiliation(s)
- Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Maria A Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | - Carl H Cramer
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN
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Thomas MR, Robinson S, Scully MA. How we manage thrombotic microangiopathies in pregnancy. Br J Haematol 2016; 173:821-30. [DOI: 10.1111/bjh.14045] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 01/17/2016] [Accepted: 01/17/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Mari R. Thomas
- Department of Haematology; UCLH; Cardiometabolic programme- NIHR UCLH/UCL BRC; London UK
| | | | - Marie A. Scully
- Department of Haematology; UCLH; Cardiometabolic programme- NIHR UCLH/UCL BRC; London UK
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Vazquez-Mellado A, Pequeño-Luévano M, Cantu-Rodriguez OG, Villarreal-Martínez L, Jaime-Pérez JC, Gomez-De-Leon A, De La Garza-Salazar F, Gonzalez-Llano O, Colunga-Pedraza P, Sotomayor-Duque G, Gomez-Almaguer D. More about low-dose rituximab and plasma exchange as front-line therapy for patients with thrombotic thrombocytopenic purpura. ACTA ACUST UNITED AC 2016; 21:311-6. [PMID: 26907228 DOI: 10.1080/10245332.2015.1133008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is characterized by a reduction in the von Willebrand cleavage protein ADAMTS-13, mainly as a consequence of autoimmunity. Plasma exchange (PEx) is standard, achieving complete remission (CR) in 77-83% of cases, but rates are variable depending on ADAMTS-13 activity and relapse is frequent in patients with <10%. Thus, an effective front-line immunosuppressive treatment is needed. MATERIALS AND METHODS We administered PEx daily until CR and rituximab 100 mg/dose/week for 4 consecutive weeks to 10 patients with a first TTP episode and 1 relapsed patient (8 females (72%) and 3 males (28%)). Median age was 34 years (15-46) and laboratory parameters at diagnosis were as follows: platelets 11 × 10(9)/l (range 7-27.4 × 10(9)/l), lactate dehydrogenase 1822 U/l (range 705-8220 U/l, normal 70-180 U/l), and haemoglobin 6 g/dl (range 4.2-11.8 g/dl). ADAMTS-13 activity was determined in eight patients and was <10% in all. ADAMTS-13 autoantibody titre was determined in seven patients and was >15 units/ml in all (ref: negative <12, undetermined 12-15, positive >15 units/ml); Shiga toxin was negative in all patients. The median number of PEx until CR was 7 (range 4-12); prednisone 1 mg/kg was administered to six patients. RESULTS The median follow-up was 22 months (range 4-49) and the estimated 2-year relapse-free survival was 89%; one HIV+ patient relapsed at 8 months follow-up. No complications related to PEx or rituximab were reported. CONCLUSIONS Our study suggests that low-dose rituximab and PEx are effective as front-line treatment for acute TTP; however, a prospective trial is needed to demonstrate whether low-dose rituximab is as effective as the conventional dose.
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Affiliation(s)
- Alberto Vazquez-Mellado
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Myrna Pequeño-Luévano
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Olga Graciela Cantu-Rodriguez
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Laura Villarreal-Martínez
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - José Carlos Jaime-Pérez
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Andres Gomez-De-Leon
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Fernando De La Garza-Salazar
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Oscar Gonzalez-Llano
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Perla Colunga-Pedraza
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - Guillermo Sotomayor-Duque
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
| | - David Gomez-Almaguer
- a Haematology Department, Hospital Universitario Jose Eleuterio Gonzalez , Autonomous University of Nuevo Leon , Monterrey , Mexico
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Blombery P, Kivivali L, Pepperell D, McQuilten Z, Engelbrecht S, Polizzotto M, Phillips L, Wood E, Cohney S. Diagnosis and management of thrombotic thrombocytopenic purpura (TTP) in Australia: findings from the first 5 years of the Australian TTP/thrombotic microangiopathy registry. Intern Med J 2016; 46:71-9. [DOI: 10.1111/imj.12935] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/20/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
Affiliation(s)
- P. Blombery
- Department of Haematology; Peter MacCallum Cancer Centre; Melbourne Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - L. Kivivali
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - D. Pepperell
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Fiona Stanley Hospital; Perth Australia
| | - Z. McQuilten
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - S. Engelbrecht
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Gold Coast University Hospital; Queensland Australia
| | - M. N. Polizzotto
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- St Vincent's Hospital; Sydney Australia
- The Kirby Institute; University of New South Wales; Sydney Australia
| | - L. E. Phillips
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - E. Wood
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Monash Medical Centre; Melbourne Australia
| | - S. Cohney
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Department of Medicine; University of Melbourne; Melbourne Australia
- Departments of Nephrology; Western and Royal Melbourne Hospitals; Melbourne Australia
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Wang J, Wu T, Shen H, Ren C, Chen H, She Z, Wang Z. [Clinical study on Rituximab in the treatment of idiopathic thrombotic thrombocytopenic purpura]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 36:316-20. [PMID: 25916294 PMCID: PMC7342611 DOI: 10.3760/cma.j.issn.0253-2727.2015.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
目的 观察利妥昔单抗(RTX)在特发性血栓性血小板减少性紫癜(ITTP)治疗中的价值。 方法 17例ITTP患者中9例采用RTX+血浆置换+糖皮质激素治疗(RTX组),8例采用血浆置换+糖皮质激素±免疫抑制剂(对照组)。RTX用法为375 mg/m2每周1次连续4次。监测患者血常规、LDH、ADAMTS13活性及抑制物、外周血B淋巴细胞百分比。观察两组患者的血浆置换次数/总量、缓解时间、复发率及不良反应发生情况。 结果 RTX组、对照组血浆置换次数中位数分别为5(2~8)、6(4~9)次,血浆置换总量中位数分别为9.6(4.0~15.4)、11.2(7.5~14.6)L。RTX组、对照组达到血液学缓解中位时间分别为15(5~20)d、22(7~36)d,达到免疫学缓解中位时间分别为2(2~8)、2(2~4)周。两组患者ADAMTS13活性均在2周后显著回升。RTX组随访期内无复发,对照组4例患者复发。RTX给药前及治疗后1周患者外周血B淋巴细胞百分比差异有统计学意义[(18.39±7.15)%对(2.19±5.11)%,P<0.001], 9个月后逐渐回升,治疗中未观察到RTX相关严重不良反应,但该组1例患者持续免疫学缓解7个月后死于肺部感染。 结论 RTX联合血浆置换和糖皮质激素治疗ITTP,能快速获得血液学甚至免疫学缓解,降低复发率,不良反应少,但需注意防治感染。
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Affiliation(s)
- Jing Wang
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
| | - Tianqin Wu
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
| | - Hongshi Shen
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
| | - Chuanlu Ren
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
| | - Haifei Chen
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
| | - Ziqiang She
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
| | - Zhaoyue Wang
- Department of Hematology, 100th Hospital of PLA, Suzhou 215007, China
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48
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Soucemarianadin M, Benhamou Y, Delmas Y, Pichereau C, Maury E, Pène F, Halimi JM, Presne C, Thouret JM, Veyradier A, Coppo P. Twice-daily therapeutical plasma exchange-based salvage therapy in severe autoimmune thrombotic thrombocytopenic purpura: the French TMA Reference Center experience. Eur J Haematol 2016; 97:183-91. [DOI: 10.1111/ejh.12706] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Myriam Soucemarianadin
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Réanimation; Centre Hospitalier Métropole Savoie; Chambéry France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Inserm U1096; Rouen France
- Service de Médecine Interne; CHU Charles Nicolle; Rouen France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Néphrologie Transplantation Dialyse; Centre Hospitalier Universitaire; Bordeaux France
| | - Claire Pichereau
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Service de Réanimation Médicale; CHU Saint-Antoine; Paris France
| | - Eric Maury
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Service de Réanimation Médicale; CHU Saint-Antoine; Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Réanimation Polyvalente; Hôpital Cochin; Paris France
- Université Paris 5; Paris France
| | - Jean-Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de néphrologie-immunologie clinique; hôpital Bretonneau; Tours France
- EA 4245; université François-Rabelais 2; boulevard Tonnellé; Tours France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Néphrologie - Médecine Interne; Hôpital Sud; Amiens France
| | - Jean-Marc Thouret
- Service de Réanimation; Centre Hospitalier Métropole Savoie; Chambéry France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service d'Hématologie Biologique; Hôpital Lariboisière; Paris France
- Univ. Paris Diderot; Sorbonne Paris Cité; Paris France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Inserm U1009; Institut Gustave Roussy; Villejuif France
- Service d'Hématologie; Hôpital Saint-Antoine; Paris France
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49
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Song GW, Lee SG, Hwang S, Kim KH, Ahn CS, Moon DB, Ha TY, Jung DH, Park GC, Kim WJ, Sin MH, Yoon YI, Kang WH, Kim SH, Tak EY. ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab. Am J Transplant 2016; 16:157-70. [PMID: 26372830 DOI: 10.1111/ajt.13444] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/29/2015] [Accepted: 06/24/2015] [Indexed: 01/25/2023]
Abstract
ABO incompatibility is no longer considered a contraindication for adult living donor liver transplantation (ALDLT) due to various strategies to overcome the ABO blood group barrier. We report the largest single-center experience of ABO-incompatible (ABOi) ALDLT in 235 adult patients. The desensitization protocol included a single dose of rituximab and total plasma exchange. In addition, local graft infusion therapy, cyclophosphamide, or splenectomy was used for a certain time period, but these treatments were eventually discontinued due to adverse events. There were three cases (1.3%) of in-hospital mortality. The cumulative 3-year graft and patient survival rates were 89.2% and 92.3%, respectively, and were comparable to those of the ABO-compatible group (n = 1301). Despite promising survival outcomes, 17 patients (7.2%) experienced antibody-mediated rejection that manifested as diffuse intrahepatic biliary stricture; six cases required retransplantation, and three patients died. ABOi ALDLT is a feasible method for expanding a living liver donor pool, but the efficacy of the desensitization protocol in targeting B cell immunity should be optimized.
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Affiliation(s)
- G-W Song
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-G Lee
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Hwang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - K-H Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C-S Ahn
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-B Moon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - T-Y Ha
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - D-H Jung
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - G-C Park
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W-J Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - M-H Sin
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Y-I Yoon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - W-H Kang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S-H Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - E-Y Tak
- Asan Center for Life Science, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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50
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Froissart A, Veyradier A, Hié M, Benhamou Y, Coppo P. Rituximab in autoimmune thrombotic thrombocytopenic purpura: A success story. Eur J Intern Med 2015; 26:659-65. [PMID: 26293834 DOI: 10.1016/j.ejim.2015.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 11/20/2022]
Abstract
Despite a significant improvement of thrombotic thrombocytopenic purpura (TTP) prognosis since the use of plasma exchange, morbidity and mortality remained significant because of poor response to standard treatment or exacerbations and relapses. Rituximab, a chimeric monoclonal antibody directed against the B-lymphocyte CD20 antigen, has shown a particular interest in this indication. Recent studies also reported strong evidence for its efficiency in the prevention of relapses. This review addresses these recent progresses and still opened questions in this topic: should rituximab be proposed in all patients at the acute phase? Should all patients benefit from a preemptive treatment? Is the infectious risk acceptable in this context?
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Affiliation(s)
- Antoine Froissart
- Service de médecine interne, CHI, Créteil, France; Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Miguel Hié
- Service de Médecine Interne, Hôpital la Pitié-Salpétrière, Paris, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service de médecine interne, CHU Charles Nicolle, Rouen, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1009, Institut Gustave Roussy, Villejuif, France.
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