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Béranger N, Coppo P, Tsatsaris V, Boisseau P, Provôt F, Delmas Y, Poullin P, Vanhoorelbeke K, Veyradier A, Joly BS. Management and follow-up of pregnancy-onset thrombotic thrombocytopenic purpura: the French experience. Blood Adv 2024; 8:183-193. [PMID: 38039511 PMCID: PMC10805644 DOI: 10.1182/bloodadvances.2023011972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Abstract
ABSTRACT Pregnancy-onset thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening disease of which diagnosis and management requires experienced multidisciplinary teams. The mechanisms responsible for a deficiency in the disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13 (ADAMTS13) leading to pregnancy-onset TTP may be congenital or acquired, and studying ADAMTS13 conformation could be of interest. The differential diagnosis between TTP and other pregnancy-associated thrombotic microangiopathies (TMA) is often challenging. Our retrospective multicenter study highlights the significance and the challenges associated with pregnancy-onset TTP and childbirth in terms of diagnosis, obstetric management, and follow-up aspects. Among 1174 pregnancy-onset TMA enrolled in the French Registry for TMA from 2000 to 2020, we identified 108 pregnancy-onset TTP: 52 immune-mediated TTP (iTTP, 48.1%), 27 acquired TTP of unidentified mechanism (uTTP, 25%), and 29 congenital TTP (cTTP, 26.9%). Data show that maternal outcome is good (survival rate: 95%) and fetal outcome is linked to the gestational age at the onset of the disease (survival rate: 75.5%). Three distinct entities with different natural histories emerged: pregnancy-onset iTTP appears similar to idiopathic iTTP, with an open ADAMTS13 conformation, and is marked by a relapse risk independent of subsequent pregnancies; pregnancy-onset uTTP appears to have a different pathophysiology with an unexpected open ADAMTS13 conformation and a very low relapse risk independent of subsequent pregnancies; finally, pregnancy-onset cTTP is characterized by the necessity of pregnancy as a systematic and specific trigger and a need for prophylactic plasmatherapy for subsequent pregnancies. This trial was registered at www.clinicaltrials.gov as #NCT00426686, and at the Health Authority and the French Ministry of Health (P051064/PHRC AOM05012).
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Affiliation(s)
- Nicolas Béranger
- Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris.Nord, Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
| | - Paul Coppo
- Service d’Hématologie, Centre de référence des microangiopathies thrombotiques, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
| | - Vassilis Tsatsaris
- Maternité Port Royal, Hôpital Cochin, FHU PREMA, Assistance Publique-Hôpitaux de Paris.Centre, Université de Paris, Paris, France
- INSERM UMR-S 1139, Physiopathologie et pharmacotoxicologie placentaire humaine, Université de Paris, Paris, France
| | | | | | - Yahsou Delmas
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | - Pascale Poullin
- Service d’Hémaphérèse, Hôpital de la Conception, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Agnès Veyradier
- Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris.Nord, Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
| | - Bérangère S. Joly
- Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris.Nord, Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
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2
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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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3
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Hamroun A, Prouteau C, Lenain R, Roger C, Bauters A, Zawadzki C, Subtil D, Gibier JB, Stichelbout M, Coppo P, Lionet A, Maanaoui M, Hazzan M, Provôt F. The challenging follow-up of pregnancy in women with known thrombotic thrombocytopenic purpura: a single-center experience of a preemptive management protocol. J Nephrol 2023; 36:2519-2529. [PMID: 37816989 DOI: 10.1007/s40620-023-01790-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/30/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Although thrombotic thrombocytopenic purpura frequently affects women of childbearing age, there is no clear recommendation for the management of subsequent pregnancies in women with established thrombotic thrombocytopenic purpura. METHODS This single-center, retrospective, observational study included all women with hereditary thrombotic thrombocytopenic purpura or immune thrombotic thrombocytopenic purpura who had had at least one subsequent pregnancy after thrombotic thrombocytopenic purpura diagnosis between 2003 and 2022. The strategy comprised weekly surveillance of platelet count during pregnancy (and quarterly monitoring of ADAMTS13 activity) for women with immune thrombotic thrombocytopenic purpura, without any routine prophylactic treatment. In case of thrombocytopenia < 150,000/mm3 (with or without hemolysis relapse), women with hereditary thrombotic thrombocytopenic purpura systematically received plasma infusions twice weekly until platelet count normalized. RESULTS A total of 13 patients were included (7 with hereditary thrombotic thrombocytopenic purpura and 6 with immune thrombotic thrombocytopenic purpura, with 20 planned pregnancies (11 and 9, respectively). All pregnancies resulted in live births, and all mothers survived. There was a marked improvement in pregnancy terms in the hereditary thrombotic thrombocytopenic purpura group compared to index pregnancies (37 [35;39] versus 31 [24;38] weeks, p = 0.037) and birth weights (3265 [3029;3410] versus 2160 [1240;2705] grams, p = 0.016), with need for plasma support mostly starting during the third trimester (5/7 patients, 7/11 pregnancies). A single hereditary thrombotic thrombocytopenic purpura relapse occurred, with rapid resolution after plasma support intensification. There were no relapses in the immune thrombotic thrombocytopenic purpura group, with ADAMTS13 activity systematically above 40% during all monitored pregnancies. CONCLUSION These real-life data support the feasibility of a preemptive approach to pregnancy monitoring in women with known thrombotic thrombocytopenic purpura who undergo active surveillance within a multidisciplinary network.
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Affiliation(s)
- Aghiles Hamroun
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
- UMR1167 RID-AGE, Inserm, Institut Pasteur de Lille, Lille University, 59000, Lille, France
| | - Camille Prouteau
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Rémi Lenain
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Camille Roger
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Anne Bauters
- Department of Hematology and Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, Lille University, Lille, France
| | - Christophe Zawadzki
- Department of Hematology and Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, Lille University, Lille, France
| | - Damien Subtil
- CHU Lille, Hôpital Jeanne de Flandre, Lille University, 59000, Lille, France
- Lille University, EA 2694 Santé Publique, Épidémiologie Et Qualité Des Soins, F-59000, Lille, France
| | - Jean-Baptiste Gibier
- Regional and University Hospital Center of Lille, Department of Pathology, Pathology Institute, Lille University, 59037, Lille, France
| | - Morgane Stichelbout
- Regional and University Hospital Center of Lille, Department of Pathology, Pathology Institute, Lille University, 59037, Lille, France
| | - Paul Coppo
- French Reference Centre for Thrombotic Microangiopathies, Saint-Antoine Hospital, Paris, France
- Hematology Department, Saint-Antoine Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Arnaud Lionet
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Mehdi Maanaoui
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
- Inserm, CHU Lille, Institut Pasteur Lille, Lille University, U1190, EGID, F-59000, Lille, France
| | - Marc Hazzan
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - François Provôt
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France.
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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: 8] [Impact Index Per Article: 8.0] [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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5
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Sakai K, Matsumoto M. Clinical Manifestations, Current and Future Therapy, and Long-Term Outcomes in Congenital Thrombotic Thrombocytopenic Purpura. J Clin Med 2023; 12:3365. [PMID: 37240470 PMCID: PMC10219024 DOI: 10.3390/jcm12103365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is an extremely rare disease characterized by the severe deficiency of a disintegrin and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13), caused by ADAMTS13 mutations. While ADAMTS13 supplementation by fresh frozen plasma (FFP) infusion immediately corrects platelet consumption and resolves thrombotic symptoms in acute episodes, FFP treatment can lead to intolerant allergic reactions and frequent hospital visits. Up to 70% of patients depend on regular FFP infusions to normalize their platelet counts and avoid systemic symptoms, including headache, fatigue, and weakness. The remaining patients do not receive regular FFP infusions, mainly because their platelet counts are maintained within the normal range or because they are symptom-free without FFP infusions. However, the target peak and trough levels of ADAMTS13 to prevent long-term comorbidity with prophylactic FFP and the necessity of treating FFP-independent patients in terms of long-term clinical outcomes are yet to be determined. Our recent study suggests that the current volumes of FFP infusions are insufficient to prevent frequent thrombotic events and long-term ischemic organ damage. This review focuses on the current management of cTTP and its associated issues, followed by the importance of upcoming recombinant ADAMTS13 therapy.
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Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan;
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan;
- Department of Hematology, Nara Medical University, Kashihara 634-8521, Japan
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6
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Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol 2023; 141:85-108. [PMID: 36455925 DOI: 10.1097/aog.0000000000005024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 12/05/2022]
Abstract
The most common thrombotic microangiopathy (TMA) of pregnancy is the well-recognized syndrome of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, rare TMAs, including thrombotic thrombocytopenic purpura, complement-mediated hemolytic-uremic syndrome, and catastrophic antiphospholipid syndrome, may occur during pregnancy or postpartum and present with features similar to those of preeclampsia with severe features. Early recognition and treatment of these infrequently encountered conditions are key for avoiding serious maternal morbidities with long-term sequelae and possible maternal or fetal death. Differentiating between preeclampsia with severe features and these rare TMAs is diagnostically challenging as there is significant overlap in their clinical and laboratory presentation. Given the rarity of these TMAs, high-quality evidence-based recommendations on diagnosis and management during pregnancy are lacking. Using current objective information and recommendations from working groups, this report provides practical clinical approaches to diagnose and manage these rare TMAs. This report also discusses how to manage individuals with a history of these rare TMAs who are planning to conceive. To optimize favorable outcomes, a multidisciplinary approach including obstetricians, maternal-fetal medicine specialists, hematologists, and nephrologists alongside close clinical and laboratory monitoring is vital.
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Special Issue "Advances in Thrombocytopenia". J Clin Med 2022; 11:jcm11226679. [PMID: 36431157 PMCID: PMC9692737 DOI: 10.3390/jcm11226679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombocytopenia is a commonly encountered hematologic challenge in medicine [...].
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Mitranovici MI, Pușcașiu L, Oală IE, Petre I, Craina ML, Mager AR, Vasile K, Chiorean DM, Sabău AH, Turdean SG, Cotoi OS. A Race against the Clock: A Case Report and Literature Review Concerning the Importance of ADAMTS13 Testing in Diagnosis and Management of Thrombotic Thrombocytopenic Purpura during Pregnancy. Diagnostics (Basel) 2022; 12:diagnostics12071559. [PMID: 35885465 PMCID: PMC9323862 DOI: 10.3390/diagnostics12071559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/25/2022] Open
Abstract
Thrombocytopenic purpura (TTP) is a rare, potentially fatal pathology characterized by microangiopathic thrombotic syndrome and caused by an acute protease deficiency of von Willebrand factor, ADAMTS13. Moreover, ADAMTS13 deficiency promotes microthrombosis led by the persistence of ultra-large VWF multimers in the blood circulation. According to the few studies involving pregnant participants, the heterogeneity of manifestations has made this pathology difficult to diagnose, with an unexpected occurrence and increased risk of maternal and fetal morbidity and mortality. We reported on the case of a 28-year-old pregnant woman with an obstetric score of G2P0 who presented to the obstetrics and gynecology department of our clinic with the complaint of minimal vaginal bleeding. The evolution of our case was severe and life-threatening, a “race against the clock”, with our goal being to emphasize the importance and difficulty of diagnosing TTP in the absence of specific symptomatology. We faced a lack of technological support for a correct and complete diagnosis, and the first manifestation of this disease was the intrauterine death of the fetus. After completing all the necessary procedures, the placental tissue was sent for further histopathological evaluation. We highlighted the importance of monitoring ADAMTS13 for relapses monthly, with prophylaxis being essential for maternal and fetal mortality and morbidity.
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Affiliation(s)
- Melinda Ildiko Mitranovici
- Department of Obstetrics and Gynecology, Emergency County Hospital Hunedoara, 14 Victoriei Street, 331057 Hunedoara, Romania;
- Correspondence:
| | - Lucian Pușcașiu
- Department of Obstetrics and Gynecology, County Emergency Hospital, University of Medicine and Pharmacy Targu Mures, 38 Gh. Marinescu Str., 540142 Targu Mures, Romania;
| | - Ioan Emilian Oală
- Department of Obstetrics and Gynecology, Emergency County Hospital Hunedoara, 14 Victoriei Street, 331057 Hunedoara, Romania;
| | - Izabella Petre
- Department of Obstetrics and Gynecology, Victor Babeș University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (I.P.); (M.L.C.)
| | - Marius Lucian Craina
- Department of Obstetrics and Gynecology, Victor Babeș University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania; (I.P.); (M.L.C.)
| | - Antonia Rebeka Mager
- Department of Pathology, Emergency County Hospital Hunedoara, 14 Victoriei Street, 331057 Hunedoara, Romania;
| | - Kinga Vasile
- Department of Hematology, Emergency County Hospital Deva, 1 Decembrie Street, 330005 Deva, Romania;
| | - Diana Maria Chiorean
- Department of Pathology, County Clinical Hospital of Targu Mures, 540072 Targu Mures, Romania; (D.M.C.); (A.-H.S.); (S.G.T.); (O.S.C.)
| | - Adrian-Horațiu Sabău
- Department of Pathology, County Clinical Hospital of Targu Mures, 540072 Targu Mures, Romania; (D.M.C.); (A.-H.S.); (S.G.T.); (O.S.C.)
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania
| | - Sabin Gligore Turdean
- Department of Pathology, County Clinical Hospital of Targu Mures, 540072 Targu Mures, Romania; (D.M.C.); (A.-H.S.); (S.G.T.); (O.S.C.)
| | - Ovidiu Simion Cotoi
- Department of Pathology, County Clinical Hospital of Targu Mures, 540072 Targu Mures, Romania; (D.M.C.); (A.-H.S.); (S.G.T.); (O.S.C.)
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania
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Graça NAG, Joly BS, Voorberg J, Vanhoorelbeke K, Béranger N, Veyradier A, Coppo P. TTP: From empiricism for an enigmatic disease to targeted molecular therapies. Br J Haematol 2022; 197:156-170. [PMID: 35146746 PMCID: PMC9304236 DOI: 10.1111/bjh.18040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022]
Abstract
The 100th anniversary of the first description of Thrombotic Thrombocytopenic Purpura (TTP) as a disease by Dr. Eli Moschcowitz approaches. For many decades, TTP remained mostly a mysterious fatal condition, where diagnosis was often post-mortem. Initially a pentad of symptoms was identified, a pattern that later revealed to be fallible. Sporadic observations led to empiric interventions that allowed for the first impactful breakthrough in TTP treatment, almost 70 years after its first description: the introduction of plasma exchange and infusions as treatments. The main body of knowledge within the field was gathered in the latest three decades: patient registries were set and proved crucial for advancements; the general mechanisms of disease have been described; the diagnosis was refined; new treatments and biomarkers with improvements on prognosis and management were introduced. Further changes and improvements are expected in the upcoming decades. In this review, we provide a brief historic overview of TTP, as an illustrative example of the success of translational medicine enabling to rapidly shift from a management largely based on empiricism to targeted therapies and personalized medicine, for the benefit of patients. Current management options and present and future perspectives in this still evolving field are summarized.
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Affiliation(s)
- Nuno A. G. Graça
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
| | - Bérangère S. Joly
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Nicolas Béranger
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Agnès Veyradier
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
- Service d'HématologieHôpital Saint‐Antoine, AP‐HPParisFrance
- Sorbonne UniversitéUPMC Univ ParisParisFrance
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10
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Scully M. How to evaluate and treat the spectrum of TMA syndromes in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:545-551. [PMID: 34889427 PMCID: PMC8791125 DOI: 10.1182/hematology.2021000290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Thrombotic microangiopathy (TMA) is the broad definition for thrombocytopenia, microangiopathic hemolytic anemia, and end-organ damage. Two important categories are thrombotic thrombocytopenic purpura (TTP) and complement-mediated hemolytic-uremic syndrome (CM-HUS). Pregnancy and the immediate postpartum period are associated with TMAs specific to pregnancy in rare situations. These include pregnancy-induced hypertension, preeclampsia, and hemolysis, elevated liver enzymes, and low platelets. TTP and CM-HUS may present in pregnancy. However, the diagnosis may not be immediately obvious as they share characteristics of pregnancy-related TMAs. Within this review, we discuss investigations, differential diagnosis of TMAs in pregnancy, and management. The importance is a risk of maternal mortality but also poor fetal outcomes in relation to TTP and CM-HUS. Treatment of these disorders at presentation in pregnancy is discussed to achieve remission and prolong fetal viability if possible. In subsequent pregnancies, a treatment pathway is presented that has been associated with successful maternal and fetal outcomes. Critical to this is a multidisciplinary approach involving obstetricians, the fetal medicine unit, and neonatologists.
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Affiliation(s)
- Marie Scully
- Correspondence Marie Scully, Department of Haematology, University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UC BRC, 250 Euston Rd, London NW1 2PG, UK; e-mail:
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Zununi Vahed S, Rahbar Saadat Y, Ardalan M. Thrombotic microangiopathy during pregnancy. Microvasc Res 2021; 138:104226. [PMID: 34252400 DOI: 10.1016/j.mvr.2021.104226] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Pregnancy is a high-risk time for the development of different kinds of thrombotic microangiopathy (TMA). Three major syndromes including TTP (thrombotic thrombocytopenic purpura), PE/HELLP (preeclampsia/hemolysis, elevated liver function tests, low platelets), and aHUS (atypical hemolytic- uremic syndrome) should be sought in pregnancy-TMA. These severe disorders share multiple clinical features and overlaps and even the coexistence of more than one pathologic mechanism. Each of these disorders finally ends in endothelial damage and fibrin thrombi formation within the microcirculation that fragments RBCs (schystocytes), aggregates platelets, and creates ischemic injury in the targeted organs i.e.; kidney and brain. Although the mechanisms of these severe disorders have been revealed, pregnancy-related TMA still interfaces with diagnostic and therapeutic challenges. Here, we highlight the current knowledge of diagnosis and management of these complications during pregnancy.
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Sakai K, Fujimura Y, Miyata T, Isonishi A, Kokame K, Matsumoto M. Current prophylactic plasma infusion protocols do not adequately prevent long-term cumulative organ damage in the Japanese congenital thrombotic thrombocytopenic purpura cohort. Br J Haematol 2021; 194:444-452. [PMID: 34046888 DOI: 10.1111/bjh.17560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 01/02/2023]
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP), known as Upshaw-Schulman syndrome, is an ultrarare thrombotic disorder caused by ADAMTS13 gene mutations; however, its long-term outcomes have not been widely studied. A questionnaire survey was administered to physicians of patients in the Japanese cTTP registry to characterise these outcomes. We analysed 55 patients in remission, with 41 cases receiving prophylactic fresh frozen plasma (FFP; median dosage: 13·2 ml/kg per month) and 14 receiving on-demand FFP. Patients receiving prophylactic FFP were considered as having a more severe form of the disease and had lower platelet counts and higher serum creatinine levels than those receiving on-demand FFP (median 138 × 109 /l vs. 243 × 109 /l, P = 0·003 and 0·71 mg/dl vs 0·58 mg/dl, P = 0·009, respectively). Patients who received prophylactic FFP more commonly developed organ damage, including renal impairment, cerebral infarctions, and cardiac hypofunction, than those who did not. Adverse FFP-related events were seen in 78% of the prophylactic FFP group, with allergic reactions being most common. Since current protocols for FFP administration to the prophylactic FFP group in Japan may be insufficient for preventing cumulative organ damage, a higher dosage of ADAMTS13 supply using recombinant ADAMTS13 agent is needed in these patients.
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Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan.,Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ayami Isonishi
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
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