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Therapeutic plasma exchange-free treatment for first-episode TTP: A systematic review. Transfus Apher Sci 2023:103661. [PMID: 36878741 DOI: 10.1016/j.transci.2023.103661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA), and therapeutic plasma exchange (TPE) is currently the standard treatment. However, TPE sometimes cannot be implemented. The aim of this study was to systematically review patients with a first TTP episode who were treated without TPE. METHOD The PubMed, Embase, Web of Science and Cochrane Library databases were searched by two investigators independently to collect case reports and clinical studies on TTP patients treated without TPE. After removing duplicate records and records that did not meet the inclusion criteria, the patients' data of eligible studies, including the basic characteristics, treatment regimens, and outcomes were extracted for further analysis. RESULTS A total of 5338 potentially relevant original studies were identified, from which 21 studies, including 14 cases, 3 case series and 4 retrospective studies, met eligibility requirements and were included. Treatment regimens in the absence of TPE were found to vary based on individual information. Most patients recovered, with normal platelet counts and ADAMT13 activity at discharge. In the meta-analysis of retrospective studies, the TPE-free group had no higher mortality than the TPE-treated group. CONCLUSION Our study shows that TPE-free treatment may not increase the mortality of TTP patients, which provides a new treatment concept for patients with first episodes of TTP. However, the current evidence is not high due to the lack of randomized controlled trials, so more well-designed prospective clinical trials are warranted to investigate the safety and efficacy of TPE-free treatment regimens in TTP patients.
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2
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Delaney M, Karam O, Lieberman L, Steffen K, Muszynski JA, Goel R, Bateman ST, Parker RI, Nellis ME, Remy KE. What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e1-e13. [PMID: 34989701 PMCID: PMC8769352 DOI: 10.1097/pcc.0000000000002854] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection? CONCLUSIONS The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.
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Affiliation(s)
- Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children’s National Hospital; Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Katherine Steffen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Jennifer A. Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Scot T. Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Robert I. Parker
- Emeritus, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Marianne E. Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Kenneth E. Remy
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
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3
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AlHejazi A, AlBeihany A, AlHashmi H, Alzahrani H, Motabi I, El-Hemaidi I, Alsaleh K, El Tayeb K, Rabea M, Khallaf M, Qari M. Approaches to acquired thrombotic thrombocytopenic purpura management in Saudi Arabia. JOURNAL OF APPLIED HEMATOLOGY 2022. [DOI: 10.4103/joah.joah_46_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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4
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[Treatment of immune-mediated thrombotic thrombocytopenic purpura: A decisive turning point]. Transfus Clin Biol 2021; 28:380-385. [PMID: 34464709 DOI: 10.1016/j.tracli.2021.08.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening thrombotic microangiopathy characterized by severe deficiency of ADAMTS13, the enzyme that cleaves von Willebrand factor multimers. Recent insights into iTTP pathophysiology have led to the development of new therapies targeting ADAMTS13 replacement, anti-ADAMTS13 antibodies, and von Willebrand factor-platelet interactions. New maximalist therapeutic strategies are emerging based on triple therapy. While plasma exchange remains the cornerstone therapy of the acute phase, the introduction of front-line immunosuppressive treatments, corticosteroids and rituximab, has led to a reduction in exacerbations and relapses but without any significant improvement in survival. Caplacizumab, a bivalent humanized anti-von Willebrand factor nanobody, is poised to revolutionize the treatment of the acute phase. By inhibiting the interaction between von Willebrand factor multimers and platelets, caplacizumab prevents platelets adhesion, prevents the formation of new microthrombi and protects organs from ischemia. Its early combination with plasma exchange and immunosuppressive therapy prevents unfavorable outcomes and reduces the burden of care. Supported by repeated ADAMTS13 assays, rituximab prevents relapse in patients with persistent or recurrent ADAMTS13 deficiency in clinical remission. This review examines how advances in diagnostics and targeted therapies are changing the current treatment paradigm in both the acute and remission phases and are contributing to dramatically improve the iTTP prognosis.
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5
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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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6
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Sukumar S, Lämmle B, Cataland SR. Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med 2021; 10:536. [PMID: 33540569 PMCID: PMC7867179 DOI: 10.3390/jcm10030536] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and ischemic end organ injury due to microvascular platelet-rich thrombi. TTP results from a severe deficiency of the specific von Willebrand factor (VWF)-cleaving protease, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13). ADAMTS13 deficiency is most commonly acquired due to anti-ADAMTS13 autoantibodies. It can also be inherited in the congenital form as a result of biallelic mutations in the ADAMTS13 gene. In adults, the condition is most often immune-mediated (iTTP) whereas congenital TTP (cTTP) is often detected in childhood or during pregnancy. iTTP occurs more often in women and is potentially lethal without prompt recognition and treatment. Front-line therapy includes daily plasma exchange with fresh frozen plasma replacement and immunosuppression with corticosteroids. Immunosuppression targeting ADAMTS13 autoantibodies with the humanized anti-CD20 monoclonal antibody rituximab is frequently added to the initial therapy. If available, anti-VWF therapy with caplacizumab is also added to the front-line setting. While it is hypothesized that refractory TTP will be less common in the era of caplacizumab, in relapsed or refractory cases cyclosporine A, N-acetylcysteine, bortezomib, cyclophosphamide, vincristine, or splenectomy can be considered. Novel agents, such as recombinant ADAMTS13, are also currently under investigation and show promise for the treatment of TTP. Long-term follow-up after the acute episode is critical to monitor for relapse and to diagnose and manage chronic sequelae of this disease.
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Affiliation(s)
- Senthil Sukumar
- Division of Hematology, Department of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, CH 3010 Bern, Switzerland;
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
- Haemostasis Research Unit, University College London, London WC1E 6BT, UK
| | - Spero R. Cataland
- Division of Hematology, Department of Medicine, The Ohio State University, Columbus, OH 43210, USA;
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7
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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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8
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Redant S, De Bels D, Ismaili K, Honoré PM. Membrane-Based Therapeutic Plasma Exchange in Intensive Care. Blood Purif 2020; 50:290-297. [PMID: 33091920 DOI: 10.1159/000510983] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022]
Abstract
The principles and use of plasmapheresis are often little understood by intensivists. We propose to review the principles, the main indications, and the methods of using this technique.
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Affiliation(s)
- Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Bruxelles, Belgium,
| | - David De Bels
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Khalid Ismaili
- Division of Nephrology, Hôpital Universitaire des Enfants Reine Fabiola (HUDERF), Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Patrick M Honoré
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
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9
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Gui RY, Huang QS, Cai X, Wu J, Liu HX, Liu Y, Yang LH, Zhang JY, Cheng YF, Jiang M, Mao M, Fang MY, Liu H, Wang LR, Wang Z, Zhou HB, Lan H, Jiang ZX, Shen XL, Zhang L, Fan SJ, Li Y, Wang QF, Huang XJ, Zhang XH. Development and validation of a prediction model (AHC) for early identification of refractory thrombotic thrombocytopenic purpura using nationally representative data. Br J Haematol 2020; 191:269-281. [PMID: 32452543 DOI: 10.1111/bjh.16767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening haematological emergency. Although therapeutic plasma exchange together with corticosteroids achieve successful outcomes, a considerable number of patients remain refractory to this treatment and require early initiation of intensive therapy. However, a method for the early identification of refractory iTTP is not available. To develop and validate a model for predicting the probability of refractory iTTP, a cohort of 265 consecutive iTTP patients from 17 large medical centres was retrospectively identified. The derivation cohort included 94 patients from 11 medical centres. For the validation cohort, we included 40 patients from the other six medical centres using geographical validation. An easy-to-use risk score system was generated, and its performance was assessed using internal and external validation cohorts. In the multivariable logistic analysis of the derivation cohort, three candidate predictors were entered into the final prediction model: age, haemoglobin and creatinine. The prediction model had an area under the curve of 0.886 (95% CI: 0.679-0.974) in the internal validation cohort and 0.862 (95% CI: 0.625-0.999) in the external validation cohort. The calibration plots showed a high agreement between the predicted and observed outcomes. In conclusion, we developed and validated a highly accurate prediction model for the early identification of refractory iTTP. It has the potential to guide tailored therapy and is a step towards more personalized medicine.
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Affiliation(s)
- Ruo-Yun Gui
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xuan Cai
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Wu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People's Hospital, Beijing, China
| | - Yi Liu
- Department of Hematology, Navy General Hospital, Beijing, China
| | - Lin-Hua Yang
- Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jing-Yu Zhang
- The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun-Feng Cheng
- Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Min Mao
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang Uygur Autonomous Region, China
| | - Mei-Yun Fang
- Zhongshan Hospital Affiliated to Dalian University, Dalian, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Beijing, China
| | - Li-Ru Wang
- Department of Hematology, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - He-Bing Zhou
- Department of Hematology, Beijing LuHe Hospital, Capital Medical University, Beijing, China
| | - Hai Lan
- Department of Hematology, ShunDe Hospital of GuangZhou University of Chinese Medicine, GuangZhou, China
| | - Zhong-Xing Jiang
- Department of Hematology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xu-Liang Shen
- Department of Hematology, He Ping Central Hospital of the Changzhi Medical College, Changzhi, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Sheng-Jin Fan
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yueying Li
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China.,China National Center for Bioinformation, Beijing, China
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China.,China National Center for Bioinformation, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
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10
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Hou R, Tian W, Qiao R, Zhang J. Efficacy of albumin and compounded plasma for plasma exchange in acquired thrombotic thrombocytopenic purpura. J Clin Apher 2020; 35:154-162. [PMID: 32110837 DOI: 10.1002/jca.21771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening thrombotic microangiopathy. Therapeutic plasma exchange (TPE) is the first-line treatment for TTP. In our institution, albumin plus plasma (fresh frozen plasma [FFP] and/or cryoprecipitate-reduced plasma [CRP]) has been used as replacement fluid since 2014. We aimed to evaluate the efficacy of albumin combined with plasma as TPE for TTP. MATERIAL AND METHODS We retrospectively evaluated 20 patients admitted to our institution due to an acute episode of TTP between January 1, 2014 and February 1, 2019. They were divided into two groups according to the replacement fluid protocols: (a) albumin plus FFP (1:1) and (b) albumin plus mixed plasma [ie, albumin and FFP with CRP (2:1:1)] groups. Data on patient characteristics, replacement parameters, outcome, and hemorrhage risk were collected and analyzed. RESULTS There were no significant differences in treatment outcomes between the two groups (P > .05). However, the albumin plus mixed plasma group tended to require fewer plasma exchanges (median, 4) and shorter time to response (median, 15 days) compared to albumin plus FFP group (median, 6; 31 days). Although the cumulative survival of the albumin plus mixed plasma group was higher than the other group starting from day 23 after treatment, we did not observe significant difference (P = .50). No significant increase in the risk for hemorrhage was observed in either group. CONCLUSIONS The therapeutic efficacy of albumin and mixed plasma (2:1:1) is not inferior to that of albumin and FFP (1:1), and it can be used in treating TTP.
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Affiliation(s)
- Ruiqin Hou
- Laboratory Medicine Department, Peking University Third Hospital, Beijing, People's Republic of China
| | - Wenqin Tian
- Department of Blood Transfusion, Peking University People's Hospital, Beijing, People's Republic of China
| | - Rui Qiao
- Laboratory Medicine Department, Peking University Third Hospital, Beijing, People's Republic of China
| | - Jie Zhang
- Laboratory Medicine Department, Peking University Third Hospital, Beijing, People's Republic of China
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11
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Poullin P, Delmotte N, Sanderson F, Roche M, Gensollen S. Efficacy and safety of plasma exchange using a double viral inactivated and prion reduced solvent/detergent fresh frozen plasma for the treatment of thrombotic microangiopathy: The first French experience in a single center. Transfus Apher Sci 2020; 59:102587. [DOI: 10.1016/j.transci.2019.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/02/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022]
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12
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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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13
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Garraud O, Malot S, Herbrecht R, Ojeda-Uribe M, Lin JS, Veyradier A, Payrat JM, Liu K, Corash L, Coppo P. Amotosalen-inactivated fresh frozen plasma is comparable to solvent-detergent inactivated plasma to treat thrombotic thrombocytopenic purpura. Transfus Apher Sci 2019; 58:102665. [PMID: 31740165 DOI: 10.1016/j.transci.2019.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Therapeutic Plasma Exchange (TPE) is the primary therapy of immune-mediated Thrombotic Thrombocytopenic Purpura (iTTP). Efficacy and safety data for TPE of iTTP have been assessed with Quarantine and Solvent-Detergent inactivated (SD) plasma. Here, amotosalen-UVA pathogen inactivated (AI) plasma, also in routine use, was evaluated in iTTP. METHODS We conducted a retrospective review of iTTP cases prospectively reported to the French national registry (2010-2013). Cases reviewed underwent TPE with ≥70% of either AI or SD plasma. The primary endpoint was time to platelet count recovery; secondary endpoints were related to follow-up (sustained remission, relapses, flare-ups and refractoriness). RESULTS 30 Test patients were identified in the AI group which could be timely matched to 40 Control patients in the SD group. The groups were fairly comparable for clinical presentation. Major findings were: (i) iTTP patients were exposed to lower plasma volumes in the AI group than in the SD group; (ii) Recovery rates were comparable between the groups. Median time to platelet count recovery (>150 × 109/L) trended to be shorter in the AI group though non significantly. Tolerance of AI vs SD plasma was of comparable frequency and severity in either group. CONCLUSION TPE with Amotosalen-inactivated plasma demonstrated therapeutic efficacy and tolerability for iTTP patients. In view of the retrospective design, confirmation of these results is required in larger prospective studies.
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Affiliation(s)
- Olivier Garraud
- Reference Center for Thrombotic Microangiopathies, Assistance Publique des Hôpitaux de Paris, Paris, France; Institut National de la Transfusion Sanguine, Paris, France; Faculty of Medicine of Saint-Etienne, University of Lyon, Saint-Etienne, France.
| | - Sandrine Malot
- Reference Center for Thrombotic Microangiopathies, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Raoul Herbrecht
- Reference Center for Thrombotic Microangiopathies, Assistance Publique des Hôpitaux de Paris, Paris, France; University Hospitals of Strasbourg, Strasbourg, France; Université de Strasbourg, INSERM U_S1113/IRFaC, Strasbourg, France
| | - Mario Ojeda-Uribe
- Reference Center for Thrombotic Microangiopathies, Assistance Publique des Hôpitaux de Paris, Paris, France; Centre Hospitalier Emile-Muller, Mulhouse, France
| | | | - Agnès Veyradier
- Reference Center for Thrombotic Microangiopathies, Assistance Publique des Hôpitaux de Paris, Paris, France; Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Kathy Liu
- Cerus Corporation, Concord, CA, United States
| | | | - Paul Coppo
- Reference Center for Thrombotic Microangiopathies, Assistance Publique des Hôpitaux de Paris, Paris, France; Service d'Hématologie, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France; Sorbonne Universités, Paris, France.
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Atreya C, Glynn S, Busch M, Kleinman S, Snyder E, Rutter S, AuBuchon J, Flegel W, Reeve D, Devine D, Cohn C, Custer B, Goodrich R, Benjamin RJ, Razatos A, Cancelas J, Wagner S, Maclean M, Gelderman M, Cap A, Ness P. Proceedings of the Food and Drug Administration public workshop on pathogen reduction technologies for blood safety 2018 (Commentary, p. 3026). Transfusion 2019; 59:3002-3025. [PMID: 31144334 PMCID: PMC6726584 DOI: 10.1111/trf.15344] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Chintamani Atreya
- US Food and Drug Administration, Center for Biologics Evaluation and ResearchOffice of Blood Research and ReviewSilver SpringMaryland
| | - Simone Glynn
- National Heart Lung and Blood InstituteBethesdaMarylandUSA
| | | | | | - Edward Snyder
- Blood BankYale‐New Haven HospitalNew HavenConnecticut
| | - Sara Rutter
- Department of Pathology and Laboratory MedicineYale School of MedicineNew HavenConnecticut
| | - James AuBuchon
- Department of PathologyDartmouth‐Hitchcock Medical CenterLebanonNew Hampshire
| | - Willy Flegel
- Department of Transfusion MedicineNIH Clinical CenterBethesdaMaryland
| | - David Reeve
- Blood ComponentsAmerican Red CrossRockvilleMaryland
| | - Dana Devine
- Department of Lab Medicine and PathologyUniversity of Minnesota Medical CenterMinneapolisMinnesota
| | - Claudia Cohn
- Department of Lab Medicine and PathologyUniversity of Minnesota Medical CenterMinneapolisMinnesota
| | - Brian Custer
- Vitalant Research InstituteSan FranciscoCalifornia
| | - Raymond Goodrich
- Department of Microbiology, Immunology and PathologyColorado State UniversityFort CollinsColorado
| | | | | | - Jose Cancelas
- Hoxworth Blood CenterUniversity of Cincinnati HealthCincinnatiOhio
| | | | - Michelle Maclean
- The Robertson Trust Laboratory for Electronic Sterilisation Technologies (ROLEST)University of StrathclydeGlasgowScotland
| | - Monique Gelderman
- Department of HematologyCenter for Biologics Evaluation and Research, US Food and Drug AdministrationSilver SpringMaryland
| | - Andrew Cap
- U.S. Army Institute of Surgical ResearchSan AntonioTexas
| | - Paul Ness
- Blood BankJohns Hopkins HospitalBaltimoreMaryland
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15
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Cushing MM, Pagano MB, Jacobson J, Schwartz J, Grossman BJ, Kleinman S, Han MA, Cohn CS. Pathogen reduced plasma products: a clinical practice scientific review from the AABB. Transfusion 2019; 59:2974-2988. [DOI: 10.1111/trf.15435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Melissa M. Cushing
- Department of Pathology and Laboratory MedicineWeill Cornell Medicine New York New York
| | - Monica B. Pagano
- Department of Laboratory MedicineUniversity of Washington Medical Center Seattle Washington
| | | | - Joseph Schwartz
- Department of Pathology & Cell BiologyColumbia University Vagelos College of Physicians and Surgeons New York New York
| | - Brenda J. Grossman
- Department of Pathology & ImmunologyWashington University School of Medicine in St. Louis St. Louis Missouri
| | - Steven Kleinman
- Department of Pathology & Laboratory MedicineThe University of British Columbia Vancouver British Columbia
| | - Mi Ah Han
- Department of Preventive MedicineCollege of Medicine Chosun University Gwangju Republic of Korea
| | - Claudia S. Cohn
- Department of Laboratory Medicine and PathologyUniversity of Minnesota Minneapolis Minnesota
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16
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Abstract
Contrary to economically comparable countries, France has had a versatile policy to process and manufacture therapeutic plasma, and to apply safety measures. This has principally affected the origin of plasma (whole blood supernatant versus apheresis), and the application or not of a chemical process. At the time being, the civilian and Army Forces blood establishments produce more than 99% of the plasma issued for patients in need; safety means consist in a large part of quarantine and, to a lesser extent, to a pathogen reduction technology process (Amotosalen-HCl-UVA). The blood establishments ship plasma to the national manufacturer of blood derivatives. Plasma in France is strictly within the Voluntary Non-Remunerated pathway with no breach to this principle to be expected for both labile components and source plasma. The constant hemovigilance allows reflection to make policies evolving, with respect to safety measures particularly to reduce cases of allergy.
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Affiliation(s)
- O Garraud
- EA3064, faculty of medicine of Saint-Etienne, University of Lyon, 42023, Saint-Etienne, France; Palliative Care, the Ruffec Hospital, 16700, Ruffec, France; The National Institute for Blood Transfusion INTS, 75015, Paris, France.
| | - C Martinaud
- CTSA, département des activités cliniques, 92140, Clamart, France; INSERM UMRS-MD 1197, CTSA, 92140, Clamart, France
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17
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Garraud O, Coppo P. Types of fresh plasma with focus on therapeutic plasma exchange. Transfus Apher Sci 2019; 58:258-261. [DOI: 10.1016/j.transci.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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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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19
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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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20
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Garraud O, Aubron C, Ozier Y, Coppo P, Tissot JD. Plasma for direct therapeutic use, for today and tomorrow: A short critical overview. Transfus Clin Biol 2018; 25:281-286. [PMID: 30131289 DOI: 10.1016/j.tracli.2018.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Plasma for direct therapeutic use is a fast-evolving blood component in terms of its production and presentation. More than a dozen forms are available worldwide, which is often overlooked since most countries apply policies making only one or very few forms available for treating patients in need. It is most often reserved for the same three clinical indications, i.e. overall clotting-factor deficiency, reversal of vitamin K antagonists in the context of active bleeding or prior to urgent surgery, and therapeutic plasma exchange. The level of evidence is often less robust than generally acknowledged for such major indications while novel indications are tending to emerge in medical and trauma settings. This short review explores classical views and new prospects opened up by novel presentations and statuses for therapeutic plasma.
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Affiliation(s)
- O Garraud
- EA3064, university of Lyon, faculty of medicine, 42023 Saint-Étienne cedex 2, France; Institut national de la transfusion sanguine, 75039 Paris cedex 15, France.
| | - C Aubron
- Medical intensive care unit, centre hospitalier et universitaire de Brest, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest, France; Université de Bretagne Occidentale, 29009 Brest, France
| | - Y Ozier
- Medical intensive care unit, centre hospitalier et universitaire de Brest, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest, France; Université de Bretagne Occidentale, 29009 Brest, France
| | - P Coppo
- CNR-MAT, groupe hospitalier Cochin, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex, France; Université Paris Pierre-et-Marie-Curie, 75006 Paris, France; Faculté de médecine de Sorbonne université, 91-105, boulevard de l'Hôpital, 75013 Paris, France; Inserm_U1009, Institut Gustave Roussy, rue Edouard Vaillant, 94800 Villejuif, France
| | - J-D Tissot
- Faculté de Biologie et de Médecine de Lausanne, 1011 Lausanne, Switzerland
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21
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Herbrecht R, Ojeda-Uribe M, Kientz D, Fohrer C, Bohbot A, Hinschberger O, Liu KL, Remy E, Ernst C, Lin JS, Corash L, Cazenave JP. Characterization of efficacy and safety of pathogen inactivated and quarantine plasma in routine use for treatment of acquired immune thrombotic thrombocytopenic purpura. Vox Sang 2018; 113:459-467. [PMID: 29786866 DOI: 10.1111/vox.12663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Auto-immune thrombotic thrombocytopenic purpura (TTP) is a morbid multi-organ disorder. Cardiac involvement not recognized in initial disease descriptions is a major cause of morbidity. Therapeutic plasma exchange (TPE) requires exposure to multiple plasma donors with risk of transfusion-transmitted infection (TTI). Pathogen inactivation (PI) with amotosalen-UVA, the INTERCEPT Blood System for Plasma (IBSP) is licensed to reduce TTI risk. METHODS An open-label, retrospective study evaluated the efficacy of quarantine plasma (QP) and IBSP in TTP and defined treatment emergent cardiac abnormalities. Medical record review of sequential patient cohorts treated with QP and IBSP characterized efficacy by remission at 30 and 60 days (d) of treatment, time to remission, and volume (L/kg) of plasma required. Safety outcomes focused on cardiac adverse events (AE), relapse rates, and mortality. RESULTS Thirty-one patients (18 IBSP and 13 QP) met study criteria for auto-immune TTP. The proportions (%) of patients in remission at 30 d (IBSP = 61·1, QP = 46·2, P = 0·570) and 60 d (IBSP = 77·8, QP = 76·9, P = 1·00) were not different. Median days to remission were less for IBSP (15·0 vs. 24·0, P = 0·003). Relapse rates (%) 60 d after remission were not different between cohorts (IBSP = 7·1, QP = 40·0, P = 0·150). ECG abnormalities before and during TPE were frequent; however, cardiac AE and mortality were not different between treatment cohorts. CONCLUSIONS Cardiac and a spectrum of ECG findings are common in TTP. In this study, IBSP and QP had similar therapeutic profiles for TPE.
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Affiliation(s)
- R Herbrecht
- Centre de Competence des Microangiopathies d'Alsace, Strasbourg, France
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - M Ojeda-Uribe
- Centre de Competence des Microangiopathies d'Alsace, Strasbourg, France
- CH Emile Muller, Mulhouse, France
| | | | - C Fohrer
- Centre de Competence des Microangiopathies d'Alsace, Strasbourg, France
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - A Bohbot
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - K-L Liu
- CH Emile Muller, Mulhouse, France
| | - E Remy
- EFS Alsace, Strasbourg, France
| | - C Ernst
- Cerus Corporation, Concord, CA, USA
| | - J-S Lin
- Cerus Corporation, Concord, CA, USA
| | - L Corash
- Cerus Corporation, Concord, CA, USA
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22
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Lee LJ, Roland KJ, Sreenivasan GM, Zypchen LN, Ambler KL, Yenson PR. Solvent-Detergent Plasma for the Treatment of Thrombotic Microangiopathies: A Canadian Tertiary Care Centre Experience. Transfus Apher Sci 2018; 57:233-235. [DOI: 10.1016/j.transci.2018.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 01/12/2018] [Accepted: 02/14/2018] [Indexed: 12/01/2022]
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23
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Abstract
PURPOSE OF REVIEW Acquired thrombotic thrombocytopenic purpura is an immune-mediated thrombotic microangiopathy caused by antibodies to ADAMTS13 (A Disintegrin And Metalloproteinase with a ThromboSpondin type 1 motif, member 13). Standard treatment with therapeutic plasma exchange and immunosuppression with steroids results in high remission and low mortality rates. However, a number of patients remain refractory to frontline therapy and/or experience multiple relapses. This study reviews emerging therapies for thrombotic thrombocytopenic purpura. RECENT FINDINGS Studies indicate that reducing anti-ADAMTS13 antibody levels through B-cell depletion or proteasome inhibition is effective for the management of refractory disease. Preliminary reports examining anti-CD20 therapy for the treatment of initial disease or as maintenance therapy for seropositive patients suggest the addition of immunosuppression in other disease phases may delay relapse. Exciting developments in targeted therapies to von Willebrand Factor and recombinant ADAMTS13 hold promise for transforming disease management. SUMMARY Approximately half of patients diagnosed with acquired thrombotic thrombocytopenic purpura experience refractory and/or relapsing disease. For these patients, a hematologic remission may be an insufficient therapeutic goal. With recent developments, it is now possible to envision a multifaceted approach targeting disease mechanisms that may dramatically improve outcomes for this otherwise debilitating disease.
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24
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Abstract
There are numerous congenital and acquired causes of thrombocytopenia. Thrombocytopenia could be a result of decreased bone marrow production, increased consumption, increased destruction, splenic sequestration or a combination of these causes. In this review, we have focused on some of the serious acquired causes of thrombocytopenia. There have been some significant advances in our understanding of the pathophysiology, diagnostic testing, and treatment of immune thrombocytopenia, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome over the past five years. These advances have resulted in a significant decrease in mortality and morbidity of patients with these disorders. Despite these advances, we are still faced with numerous unanswered questions in the pathophysiology and management of these complex thrombocytopenic disorders.
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Affiliation(s)
- Srikanth Nagalla
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ravindra Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
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25
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Garraud O. Are all therapeutic plasma preparations the same: Is it worth assessing them in clinical trials? Transfus Apher Sci 2017; 56:920-923. [DOI: 10.1016/j.transci.2017.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Guignier C, Benamara A, Oriol P, Coppo P, Mariat C, Garraud O. Amotosalen-inactivated plasma is as equally well tolerated as quarantine plasma in patients undergoing large volume therapeutic plasma exchange. Transfus Clin Biol 2017; 25:73-77. [PMID: 29102655 DOI: 10.1016/j.tracli.2017.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A retrospective - single center - survey compared tolerance of individual donor therapeutic plasma in a series of 88 patients principally presenting with thrombotic microangiopathy; all patients underwent therapeutic plasma exchange (TPE) performed with more than 90% of either of two types of plasma preparations. One plasma type used in TPE was prepared with pathogen reduction by amotosalen addition and UVA illumination, and the other one was non-manipulated (quarantine plasma). Both types of plasma were single donor. Occurrences of adverse reactions were equally low in either arm (amotosalen: 9 in 4689 bags of ∼200mL [0.019] versus quarantine: 2 in 828 bags [0.024]), confirming the safe use of amotosalen inactivated therapeutic plasma for TPE.
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Affiliation(s)
- C Guignier
- Department of Family Practice, Faculty of Medicine of Saint-Étienne, 42023 Saint-Étienne, France
| | - A Benamara
- Établissement français du sang Rhône-Alpes-Auvergne, 42023 Saint-Étienne, France
| | - P Oriol
- Hemovigilance Unit, University Hospital of Saint-Étienne, 42055 Saint-Étienne, France
| | - P Coppo
- National Registry of Microangiopathies, Department of Hematology, Saint-Antoine Hospital, 75011 Paris, France; Faculty of Medicine, University Paris-Pierre-et-Marie-Curie, 75012 Paris, France
| | - C Mariat
- Department of Nephrology, University Hospital of Saint-Étienne, 42055 Saint-Étienne, France; EA3064, Faculty of Medicine of Saint-Étienne, University of Lyon, 42023 Saint-Étienne, France
| | - O Garraud
- EA3064, Faculty of Medicine of Saint-Étienne, University of Lyon, 42023 Saint-Étienne, France; Institut national de la transfusion sanguine, 6, rue Alexandre-Cabanel, 75015 Paris, France.
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27
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Abstract
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and organ ischemia linked to disseminated microvascular platelet rich-thrombi. TTP is specifically related to a severe deficiency in ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13), the specific von Willebrand factor-cleaving protease. ADAMTS13 deficiency is most frequently acquired via ADAMTS13 autoantibodies, but rarely, it is inherited via mutations of the ADAMTS13 gene. The first acute episode of TTP usually occurs during adulthood, with a predominant anti-ADAMTS13 autoimmune etiology. In rare cases, however, TTP begins as soon as childhood, with frequent inherited forms. TTP is ∼2-fold more frequent in women, and its outcome is characterized by a relapsing tendency. Rapid recognition of TTP is crucial to initiate appropriate treatment. The first-line therapy for acute TTP is based on daily therapeutic plasma exchange supplying deficient ADAMTS13, with or without steroids. Additional immune modulators targeting ADAMTS13 autoantibodies are mainly based on steroids and the humanized anti-CD20 monoclonal antibody rituximab. In refractory or unresponsive TTP, more intensive therapies including twice-daily plasma exchange; pulses of cyclophosphamide, vincristine, or cyclosporine A; or salvage splenectomy are considered. New drugs including N-acetylcysteine, bortezomib, recombinant ADAMTS13, and caplacizumab show promise in the management of TTP. Also, long-term follow-up of patients with TTP is crucial to identify the occurrence of other autoimmune diseases, to control relapses, and to evaluate psychophysical sequelae. Further development of both patients’ registries worldwide and innovative drugs is still needed to improve TTP management.
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28
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Scully M, Cataland S, Coppo P, de la Rubia J, Friedman KD, Kremer Hovinga J, Lämmle B, Matsumoto M, Pavenski K, Sadler E, Sarode R, Wu H. Consensus on the standardization of terminology in thrombotic thrombocytopenic purpura and related thrombotic microangiopathies. J Thromb Haemost 2017; 15:312-322. [PMID: 27868334 DOI: 10.1111/jth.13571] [Citation(s) in RCA: 301] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Indexed: 12/11/2022]
Abstract
Essentials An international collaboration provides a consensus for clinical definitions. This concerns thrombotic microangiopathies and thrombotic thrombocytopenic purpura (TTP). The consensus defines diagnosis, disease monitoring and response to treatment. Requirements for ADAMTS-13 are given. SUMMARY Background Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) are two important acute conditions to diagnose. Thrombotic microangiopathy (TMA) is a broad pathophysiologic process that leads to microangiopathic hemolytic anemia and thrombocytopenia, and involves capillary and small-vessel platelet aggregates. The most common cause is disseminated intravascular coagulation, which may be differentiated by abnormal coagulation. Clinically, a number of conditions present with microangiopathic hemolytic anemia and thrombocytopenia, including cancer, infection, transplantation, drug use, autoimmune disease, and pre-eclampsia and hemolysis, elevated liver enzymes and low platelet count syndrome in pregnancy. Despite overlapping clinical presentations, TTP and HUS have distinct pathophysiologies and treatment pathways. Objectives To present a consensus document from an International Working Group on TTP and associated thrombotic microangiopathies (TMAs). Methods The International Working Group has proposed definitions and terminology based on published information and consensus-based recommendations. Conclusion The consensus aims to aid clinical decisions, but also future studies and trials, utilizing standardized definitions. It presents a classification of the causes of TMA, and criteria for clinical response, remission and relapse of congenital and immune-mediated TTP.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH, Cardiometabolic programme-NIHR UCLH/UCL BRC, London, UK
| | - S Cataland
- Department of Internal Medicine, Ohio State University Hospital, Columbus, OH, USA
| | - P Coppo
- Department of Hematology, Saint-Antoine University Hospital, Paris, France
| | - J de la Rubia
- Department of Hematology, University Hospital Dr Peset, Valencia, Spain
| | - K D Friedman
- Division of Benign Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Kremer Hovinga
- Department of Hematology, Bern University Hospital, Bern, Switzerland
| | - B Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - M Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - K Pavenski
- Department of Laboratory medicine, St Michael's Hospital/Research Institute, Toronto, Ontario, Canada
| | - E Sadler
- Department of Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - R Sarode
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - H Wu
- Department of Pathology, Ohio State University Hospital, Columbus, OH, USA
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Garraud O. La délivrance des plasmas. Les plasmas d’aujourd’hui et de demain. Transfus Clin Biol 2016; 23:240-244. [DOI: 10.1016/j.tracli.2016.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
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