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Gebetsberger J, Streif W, Dame C. Update on the Use of Thrombopoietin-Receptor Agonists in Pediatrics. Hamostaseologie 2024. [PMID: 38925157 DOI: 10.1055/a-2247-4209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024] Open
Abstract
This review summarizes the rationale and current data on the use of thrombopoietin receptor agonists (TPO-RAs) for treating severe thrombocytopenia in infants, children, and adolescents. It focuses on substances that have been approved by the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) for pediatric patients. Romiplostim and eltrombopag are already established as second-line treatment for persistent or chronic immune thrombocytopenia (ITP). As in adults, TPO-RAs are currently also evaluated in severe aplastic anemia (SAA), chemotherapy-induced thrombocytopenia (CIT), myelodysplastic syndromes (MDS), and poor engraftment after hematopoietic stem cell transplantation in pediatric and adolescent patients. Moreover, studies on the implication of TPO-RA in treating rare inherited thrombocytopenias, such as Wiskott-Aldrich syndrome (WAS), congenital amegakaryocytic thrombocytopenia (CAMT), or MYH9-associated thrombocytopenia, deserve future attention. Current developments include testing of avatrombopag and lusutrombopag that are approved for the treatment of thrombocytopenia associated with chronic liver disease (CLD) in adult patients. In pediatric and adolescent medicine, we expect in the near future a broader use of TPO-RAs as first-line treatment in primary ITP, thereby considering immunomodulatory effects that increase the rate of sustained remission off-treatment, and a selective use in rare inherited thrombocytopenias based on current clinical trials.
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Affiliation(s)
| | - Werner Streif
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Christof Dame
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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2
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Zaninetti C, Wolff M, Greinacher A. Diagnosing Inherited Platelet Disorders: Modalities and Consequences. Hamostaseologie 2021; 41:475-488. [PMID: 34391210 DOI: 10.1055/a-1515-0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Inherited platelet disorders (IPDs) are a group of rare conditions featured by reduced circulating platelets and/or impaired platelet function causing variable bleeding tendency. Additional hematological or non hematological features, which can be congenital or acquired, distinctively mark the clinical picture of a subgroup of patients. Recognizing an IPD is challenging, and diagnostic delay or mistakes are frequent. Despite the increasing availability of next-generation sequencing, a careful phenotyping of suspected patients-concerning the general clinical features, platelet morphology, and function-is still demanded. The cornerstones of IPD diagnosis are clinical evaluation, laboratory characterization, and genetic testing. Achieving a diagnosis of IPD is desirable for several reasons, including the possibility of tailored therapeutic strategies and individual follow-up programs. However, detailed investigations can also open complex scenarios raising ethical issues in case of IPDs predisposing to hematological malignancies. This review offers an overview of IPD diagnostic workup, from the interview with the proband to the molecular confirmation of the suspected disorder. The main implications of an IPD diagnosis are also discussed.
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Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Martina Wolff
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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3
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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4
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Bastida JM, Gonzalez-Porras JR, Rivera J, Lozano ML. Role of Thrombopoietin Receptor Agonists in Inherited Thrombocytopenia. Int J Mol Sci 2021; 22:ijms22094330. [PMID: 33919295 PMCID: PMC8122256 DOI: 10.3390/ijms22094330] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 01/05/2023] Open
Abstract
In the last decade, improvements in genetic testing have revolutionized the molecular diagnosis of inherited thrombocytopenias (ITs), increasing the spectrum of knowledge of these rare, complex and heterogeneous disorders. In contrast, the therapeutic management of ITs has not evolved in the same way. Platelet transfusions have been the gold standard treatment for a long time. Thrombopoietin receptor agonists (TPO-RA) were approved for immune thrombocytopenia (ITP) ten years ago and there is evidence for the use of TPO-RA not only in other forms of ITP, but also in ITs. We have reviewed in the literature the existing evidence on the role of TPO-RAs in ITs from 2010 to February 2021. A total of 24 articles have been included, 4 clinical trials, 3 case series and 17 case reports. A total of 126 patients with ITs have received TPO-RA. The main diagnoses were Wiskott–Aldrich syndrome, MYH9-related disorder and ANKRD26-related thrombocytopenia. Most patients were enrolled in clinical trials and were treated for short periods of time with TPO-RA as bridging therapies towards surgical interventions, or other specific approaches, such as hematopoietic stem cell transplantation. Here, we have carried out an updated and comprehensive review about the efficacy and safety of TPO-RA in ITs.
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Affiliation(s)
- José María Bastida
- Department of Hematology, Instituto de Investigación Biomédica de Salamanca (IBSAL), Complejo Asistencial Universitario de Salamanca (CAUSA), Universidad de Salamanca (USAL), 37007 Salamanca, Spain;
- Correspondence:
| | - José Ramón Gonzalez-Porras
- Department of Hematology, Instituto de Investigación Biomédica de Salamanca (IBSAL), Complejo Asistencial Universitario de Salamanca (CAUSA), Universidad de Salamanca (USAL), 37007 Salamanca, Spain;
| | - José Rivera
- Department of Hematology and Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30008 Murcia, Spain; (J.R.); (M.L.L.)
| | - María Luisa Lozano
- Department of Hematology and Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30008 Murcia, Spain; (J.R.); (M.L.L.)
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5
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Downes K, Borry P, Ericson K, Gomez K, Greinacher A, Lambert M, Leinoe E, Noris P, Van Geet C, Freson K. Clinical management, ethics and informed consent related to multi-gene panel-based high throughput sequencing testing for platelet disorders: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:2751-2758. [PMID: 33079472 PMCID: PMC7589386 DOI: 10.1111/jth.14993] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
Abstract
Molecular diagnostics of inherited platelet disorders (IPD) has been revolutionized by the implementation of high-throughput sequencing (HTS) approaches. A conclusive diagnosis using HTS tests can be obtained quickly and cost-effectively in many, but not all patients. The expanding use of HTS tests has raised concerns regarding complex variant interpretation and the ethical implications of detecting unsolicited findings such as variants in IPD genes RUNX1, ETV6, and ANKRD26, which are associated with increased leukemic risk. This guidance document has been developed and written by a multidisciplinary team of researchers and clinicians, with expertise in hematology, clinical and molecular genetics, and bioethics, alongside a RUNX1 patient advocacy representative. We recommend that for clinical diagnostics, HTS for IPD should use a multigene panel of curated diagnostic-grade genes. Critically, we advise that an HTS test for clinical diagnostics should only be ordered by a clinical expert that is: (a) fully aware of the complexity of genotype-phenotype correlations for IPD; (b) able to discuss these complexities with a patient and family members before the test is initiated; and (c) able to interpret and appropriately communicate the results of a HTS diagnostic report, including the implication of variants of uncertain clinical significance. Each patient should know what an HTS test could mean for his or her clinical management before initiating a test. We hereby propose an exemplified informed consent document that includes information on these ethical concerns and can be used by the community for implementation of HTS of IPD in a clinical diagnostic setting. This paper does not include recommendations for HTS of IPD in a research setting.
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Affiliation(s)
- Kate Downes
- East Genomic Laboratory HubCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
| | - Pascal Borry
- Department of Public Health and Primary CareKU LeuvenLeuvenBelgium
| | | | - Keith Gomez
- Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Andreas Greinacher
- Institut für Immunologie und TransfusionsmedizinUniversitätsmedizin GreifswaldGreifswaldGermany
| | - Michele Lambert
- Division of HematologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - Eva Leinoe
- Department of HaematologyRigshospitaletNational University HospitalCopenhagenDenmark
| | - Patrizia Noris
- IRCCS Policlinico San Matteo Foundation and University of PaviaPaviaItaly
| | - Chris Van Geet
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Kathleen Freson
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
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6
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Wakefield BJ, Diehl R, Neff AT, Bakdash S, Pettersson GB, Mehta AR. Perioperative Management of a Patient With Profound Thrombocytopenia Secondary to MYH9-RD Presenting for Thoracic Aortic Aneurysm Repair and Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2020; 35:1154-1160. [PMID: 32861542 DOI: 10.1053/j.jvca.2020.07.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Brett J Wakefield
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.
| | - Rachel Diehl
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Anne T Neff
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Suzanne Bakdash
- Department of Laboratory Medicine, Section of Transfusion Medicine, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Gosta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Anand R Mehta
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
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7
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Zaninetti C, Gresele P, Bertomoro A, Klersy C, De Candia E, Veneri D, Barozzi S, Fierro T, Alberelli MA, Musella V, Noris P, Fabris F, Balduini CL, Pecci A. Eltrombopag for the treatment of inherited thrombocytopenias: a phase II clinical trial. Haematologica 2019; 105:820-828. [PMID: 31273088 PMCID: PMC7049343 DOI: 10.3324/haematol.2019.223966] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/28/2019] [Indexed: 12/17/2022] Open
Abstract
Patients with inherited thrombocytopenias often require platelet transfusions to raise their platelet count before surgery or other invasive procedures; moreover, subjects with clinically significant spontaneous bleeding may benefit from an enduring improvement of thrombocytopenia. The hypothesis that thrombopoietin-mimetics can increase platelet count in inherited thrombocytopenias is appealing, but evidence is scarce. We conducted a prospective, phase II clinical trial to investigate the efficacy of the oral thrombopoietin-mimetic eltrombopag in different forms of inherited thrombocytopenia. We enrolled 24 patients affected by MYH9-related disease, ANKRD26-related thrombocytopenia, X-linked thrombocytopenia/ Wiskott-Aldrich syndrome, monoallelic Bernard-Soulier syndrome, or ITGB3-related thrombocytopenia. The average pre-treatment platelet count was 40.4 ×109/L. Patients received a 3- to 6-week course of eltrombopag in a dose-escalated manner. Of 23 patients evaluable for response, 11 (47.8%) achieved a major response (platelet count >100 ×109/L), ten (43.5%) had a minor response (platelet count at least twice the baseline value), and two patients (8.7%) did not respond. The average increase of platelet count compared to baseline was 64.5 ×109/L (P<0.001). Four patients with clinically significant spontaneous bleeding entered a program of long-term eltrombopag administration (16 additional weeks): all of them obtained remission of mucosal hemorrhages, with the remission persisting throughout the treatment period. Treatment was globally well tolerated: five patients reported mild adverse events and one patient a moderate adverse event. In conclusion, eltrombopag was safe and effective in increasing platelet count and reducing bleeding symptoms in different forms of inherited thrombocytopenia. Despite these encouraging results, caution is recommended when using thrombopoietinmimetics in inherited thrombocytopenias predisposing to leukemia. ClinicalTrials.gov identifier: NCT02422394.
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Affiliation(s)
- Carlo Zaninetti
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia.,PhD course in Experimental Medicine, University of Pavia, Pavia
| | - Paolo Gresele
- Department of Medicine, University of Perugia, Perugia
| | | | - Catherine Klersy
- Service of Clinical Epidemiology & Biometry, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia
| | - Erica De Candia
- IRCCS Policlinico Universitario A. Gemelli Foundation, Roma.,Institute of Internal Medicine and Geriatrics, Catholic University of the Sacred Heart, Roma
| | - Dino Veneri
- Department of Medicine, Section of Hematology, University of Verona, Verona
| | - Serena Barozzi
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia
| | | | | | - Valeria Musella
- Service of Clinical Epidemiology & Biometry, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia
| | | | - Carlo L Balduini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia.,Ferrata-Storti Foundation, Pavia, Italy
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia
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8
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Rodeghiero F, Pecci A, Balduini CL. Thrombopoietin receptor agonists in hereditary thrombocytopenias. J Thromb Haemost 2018; 16:1700-1710. [PMID: 29956472 DOI: 10.1111/jth.14217] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 12/15/2022]
Abstract
Hereditary thrombocytopenias (HTPs) constitute a heterogeneous group of diseases characterized by a reduction in platelet count and a potential bleeding risk. As a result of advances in diagnostic methods, HTPs are increasingly being identified, and appear to be less rare than previously thought. Most HTPs do not have effective treatments, except for platelet transfusion when bleeding occurs and in preparation for procedures associated with a risk of bleeding. Preliminary clinical evidence suggests that thrombopoietin receptor agonists (TPO-RAs) with an established use in the treatment of certain acquired thrombocytopenias are well tolerated and provide clinical benefits in patients with some forms of HTP. These drugs may therefore be considered for the treatment of HTPs in clinical practice. However, caution and close monitoring are recommended, owing to the absence of long-term safety data and the potential risks posed by prolonged bone marrow stimulation in certain HTPs. In this review, we summarize the available clinical data on TPO-RAs in the treatment of HTPs, and discuss their use in patients with these disorders. We believe that TPO-RAs will play a major role in the treatment of HTPs, particularly myosin heavy chain 9-related disease, Wiskott-Aldrich syndrome, X-linked thrombocytopenia, and thrombocytopenia caused by THPO mutations.
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Affiliation(s)
- F Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Haematology, S. Bortolo Hospital, Vicenza, Italy
| | - A Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - C L Balduini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
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9
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Rabbolini DJ, Chun Y, Latimer M, Kunishima S, Fixter K, Valecha B, Tan P, Chew LP, Kile BT, Burt R, Radhakrishnan K, Bird R, Ockelford P, Gabrielli S, Chen Q, Stevenson WS, Ward CM, Morel-Kopp MC. Diagnosis and treatment of MYH9-RD in an Australasian cohort with thrombocytopenia. Platelets 2017; 29:793-800. [DOI: 10.1080/09537104.2017.1356920] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- David J. Rabbolini
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Yenna Chun
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | | | - Shinji Kunishima
- Department of Advanced Diagnosis, Clinical Research Center, Nagoya Medical Center, Nagoya, Japan
| | - Kathleen Fixter
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Bhavia Valecha
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Peter Tan
- Department of Haematology, Royal Perth Hospital, Perth, Australia
| | - Lee Ping Chew
- Clinical Research Malaysia, Sarawak General Hospital, Sarawak, Malaysia
| | - Benjamin T. Kile
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Rachel Burt
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Kottayam Radhakrishnan
- Children’s Cancer Centre Monash Children’s Hospital, Melbourne, Australia
- Department of Haematology, Monash Medical Centre, Melbourne, Australia
| | - Robert Bird
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Australia
| | - Paul Ockelford
- Department of Haematology, Auckland Hospital, Auckland, New Zealand
| | - Sara Gabrielli
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Qiang Chen
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - William S. Stevenson
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Christopher M. Ward
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Marie-Christine Morel-Kopp
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia
- Northern Blood Research Centre, Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
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10
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Eichel Y, Tormos LM, Squires JE. Preoperative use of platelets in a 6-year-old with acute appendicitis and a myosin heavy chain 9-related disorder: a case report and review of literature. Transfusion 2015; 56:349-53. [PMID: 26446054 DOI: 10.1111/trf.13366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/27/2015] [Accepted: 08/31/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mutations of nonmuscle myosin heavy chain 9 (MYH9) gene are an autosomal dominant cause of inherited thrombocytopenia in children. MYH9 spectrum disorders include May-Hegglin anomaly and Sebastian, Fechtner, and Epstein syndromes. Patients with these disorders often present with macroplatelets and thrombocytopenia and have a mild bleeding tendency; extrahematologic manifestations (nephropathy, deafness, and cataracts) correlate with specific mutations. No definitive guidelines exist for preoperative prophylactic platelet (PLT) transfusion in these patients. STUDY DESIGN AND METHODS This was a case study and literature review. RESULTS A 6-year-old male presented with appendicitis. Review of records revealed that he and his siblings had thrombocytopenia; polymerase chain reaction amplification with DNA sequence analysis showed a variation in the MYH9 gene previously reported as a known cause of MYH9-related disorders. Involvement of other organ systems was not found on initial work-up. The patient's PLT count on admission was 20 × 10(9) /L. The degree of thrombocytopenia prompted transfusion of apheresis PLTs and he had good response (73 × 10(9) /L). After infusion he developed hives, rash, itching, and nausea, which resolved after administration of epinephrine and hydrocortisone. Transfusion reaction work-up was negative and symptoms were interpreted as an allergic reaction. The appendectomy was uneventful. CONCLUSION This patient's PLT count was within guidelines to warrant transfusion; however, some patients with MYH9 mutations have counts above the transfusion threshold. To the authors' knowledge, there are no set guidelines for preoperative prophylaxis in a patient with an MYH9 deficiency. The management of the bleeding diathesis in these patients, especially in the setting of invasive procedures, is uncertain.
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Affiliation(s)
- Yekaterina Eichel
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Lee Marie Tormos
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jerry E Squires
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
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Yamanouchi J, Hato T, Kunishima S, Niiya T, Nakamura H, Yasukawa M. A novel MYH9 mutation in a patient with MYH9 disorders and platelet size-specific effect of romiplostim on macrothrombocytopenia. Ann Hematol 2015; 94:1599-600. [DOI: 10.1007/s00277-015-2416-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 05/30/2015] [Indexed: 11/29/2022]
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12
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Pecci A. Diagnosis and treatment of inherited thrombocytopenias. Clin Genet 2015; 89:141-53. [PMID: 25920516 DOI: 10.1111/cge.12603] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 12/26/2022]
Abstract
Knowledge in the field of inherited thrombocytopenias (ITs) has greatly improved over the last 15 years. Several new genes responsible for thrombocytopenia have been identified leading to the definition of novel nosographic entities and to a much better characterization of the phenotypes of these diseases. To date, ITs encompass 22 disorders caused by mutations in 24 genes and characterized by different degrees of complexity and great variability in prognosis. Making a definite diagnosis is important for setting an appropriate follow-up, choosing the best treatments and providing proper counseling. Despite the abovementioned progress, diagnosis of ITs remains difficult and these disorders are still underdiagnosed. The purpose of this review is to provide an updated guide to the diagnosis of ITs based on simple procedures. Moreover, the currently available therapeutic options for these conditions are recapitulated and discussed.
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Affiliation(s)
- A Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
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13
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Pecci A. Pathogenesis and management of inherited thrombocytopenias: rationale for the use of thrombopoietin-receptor agonists. Int J Hematol 2013; 98:34-47. [PMID: 23636669 DOI: 10.1007/s12185-013-1351-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 04/18/2013] [Accepted: 04/19/2013] [Indexed: 12/30/2022]
Abstract
Knowledge in the field of inherited thrombocytopenias (ITs) has considerably improved over the recent years. In the last 5 years, nine new genes whose mutations are responsible for thrombocytopenia have been identified, and this also led to the recognition of several novel nosographic entities, such as thrombocytopenias deriving from mutations in CYCS, TUBB1, FLNA, ITGA2B/ITGB3, ANKRD26 and ACTN1. The identification of novel molecular alterations causing thrombocytopenia together with improvement of methodologies to study megakaryopoiesis led to considerable advances in understanding pathophysiology of ITs, thus providing the background for proposing new treatments. Thrombopoietin-receptor agonists (TPO-RAs) represent an appealing therapeutic hypothesis for ITs and have been tested in a limited number of patients. In this review, we provide an updated description of pathogenetic mechanisms of thrombocytopenia in the different forms of ITs and recapitulate the current management of these disorders. Moreover, we report the available clinical and preclinical data about the role of TPO-RAs in ITs and discuss the rationale for the use of these molecules in view of pathogenesis of the different forms of thrombocytopenia of genetic origin.
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Affiliation(s)
- Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Piazzale Golgi, 27100 Pavia, Italy.
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Trautmann K, Jakob C, von Grünhagen U, Schleyer E, Brümmendorf TH, Siegert G, Ehninger G, Platzbecker U. Eltrombopag fails to improve severe thrombocytopenia in late-stage dyskeratosis congenita and diamond-blackfan-anaemia. Thromb Haemost 2012; 108:397-8. [PMID: 22739569 DOI: 10.1160/th12-02-0121] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 05/07/2012] [Indexed: 11/05/2022]
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