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Azadbakht S, Amidi B, Naderi N, Sharifaskari A, Hatami M. Concurrent myocardial infarction in the setting of thrombotic thrombocytopenic purpura secondary to systemic lupus erythematosus: A case report. Clin Case Rep 2024; 12:e8751. [PMID: 38617067 PMCID: PMC11009456 DOI: 10.1002/ccr3.8751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/15/2024] [Accepted: 03/27/2024] [Indexed: 04/16/2024] Open
Abstract
Key Clinical Message In acute thrombotic thrombocytopenic purpura (TTP), apart from urgent treatment, assessing the patient's medical history, especially conditions like systemic lupus erythematosus that could trigger TTP, is crucial. Rarely, TTP patients may experience cardiac conditions as severe as a myocardial infarction. Abstract A 45-year-old woman manifested severe and acute thrombotic thrombocytopenic purpura (TTP) of unknown origin. The patient's symptoms, the laboratory data, the detection of the reduction in ADAMTS13 activity, and the presence of schistocytes on the peripheral smear confirmed the diagnosis. The patient was then planned for therapeutic plasma exchange (TPE). Prior to the scheduled TPE, she suddenly experienced extreme shortness of breath and chest pain. An electrocardiogram was obtained immediately after reporting signs of an inferior myocardial infarction. Further examinations to acquire information about the patient's underlying medical conditions in order to study the secondary causes of TTP, combined with the results of the laboratory tests, resulted in the patient being diagnosed with systemic lupus erythematosus.
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Affiliation(s)
- Saleh Azadbakht
- Department of Internal Medicine, School of MedicineLorestan University of Medical SciencesKhorramabadIran
| | - Bardia Amidi
- Department of Internal Medicine, School of MedicineLorestan University of Medical SciencesKhorramabadIran
- Student Research CommitteeLorestan University of Medical SciencesKhorramabadIran
| | - Narges Naderi
- Department of Internal Medicine, School of MedicineLorestan University of Medical SciencesKhorramabadIran
- Student Research CommitteeLorestan University of Medical SciencesKhorramabadIran
| | - Anwar Sharifaskari
- Department of Internal Medicine, School of MedicineLorestan University of Medical SciencesKhorramabadIran
| | - Mahtab Hatami
- Department of Internal Medicine, School of MedicineLorestan University of Medical SciencesKhorramabadIran
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2
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Rose J. Autoimmune Connective Tissue Diseases: Systemic Lupus Erythematosus and Rheumatoid Arthritis. Immunol Allergy Clin North Am 2023; 43:613-625. [PMID: 37394263 DOI: 10.1016/j.iac.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Systemic lupus erythematosus and rheumatoid arthritis are just 2 of several autoimmune connective tissue diseases that are primarily chronic in nature but can present to the emergency department by virtue of an acute exacerbation of disease. Beyond an acute exacerbation of disease, their predilection for invading multiple organ systems lends itself to the potential for patients presenting to the emergency department with either a single or isolated symptom or a myriad of signs and/or symptoms indicative of a degree of disease complexity and severity that warrant timely recognition and resuscitation.
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Affiliation(s)
- Jonathan Rose
- Department of Emergency Medicine, Memorial Healthcare System, Memorial Hospital West, 703 N Flamingo Road, Pembroke Pines, FL 33028, USA.
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3
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Mutoh T, Ohashi K, Nagai T, Sugiura A, Kudo M, Fujii H. Upfront rituximab therapy for thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case-based review. Rheumatol Int 2023; 43:373-381. [PMID: 35962219 DOI: 10.1007/s00296-022-05182-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of various autoantibodies and deposition of immune complexes on tissues. Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematological disorder that rarely develops in SLE, mainly caused by inhibitory or clearing autoantibody against ADAMTS13. Although B cells play critical roles in the pathogenesis of two diseases, the role of B-cell depletion therapy using rituximab (RTX), a chimeric monoclonal antibody targeting CD20, in the management of TTP associated with SLE remains unclear. We present a 27-year-old woman who manifested TTP and nephritis simultaneously at diagnosis of SLE. This patient successfully responded to high-dose glucocorticoids combined with plasma exchange, and early administration of RTX-induced sustained remission of TTP without relapse over 16 months. This literature review in light of our case demonstrates relationship between early intervention with RTX and better treatment response despite the degree of ADAMTS13 activity. Moreover, we discuss the clinical features in TTP associated with SLE, risk factors for the development of TTP in SLE, and possible outcomes based on RTX dose. It is important to consider upfront RTX as a promising treatment strategy for SLE-associated secondary TTP to improve short-term response and long-term prognosis.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Keiichi Ohashi
- Department of Hematology, Ishinomaki Red Cross Hospital, Ishinomaki, Miyagi, Japan
| | - Taichi Nagai
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
| | - Akira Sugiura
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masataka Kudo
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital, Sendai, Miyagi, Japan
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4
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Successful Treatment with Bortezomib for Refractory Thrombotic Thrombocytopenic Purpura Associated with Systemic Lupus Erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2022; 3:208-210. [PMID: 36879832 PMCID: PMC9984934 DOI: 10.2478/rir-2022-0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/11/2022] [Indexed: 02/10/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life- threatening disease that can be secondary to systemic lupus erythematosus (SLE). The fist- line treatments of TTP are steroid, immunosuppressor and plasm exchange (PE). However, some patients may have a poor response to these treatments. Bortezomib is a selective proteasome inhibitor and widely used to treat patients with multiple myeloma (MM). In recent years, bortezomib has been used to treat patients with refractory TTP. Here we report a patient with refractory TTP associated with SLE and had a successful treatment with bortezomib.
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5
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Yoshida Y, Nishi H. The role of the complement system in kidney glomerular capillary thrombosis. Front Immunol 2022; 13:981375. [PMID: 36189215 PMCID: PMC9515535 DOI: 10.3389/fimmu.2022.981375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
The complement system is part of the innate immune system. The crucial step in activating the complement system is the generation and regulation of C3 convertase complexes, which are needed to generate opsonins that promote phagocytosis, to generate C3a that regulates inflammation, and to initiate the lytic terminal pathway through the generation and activity of C5 convertases. A growing body of evidence has highlighted the interplay between the complement system, coagulation system, platelets, neutrophils, and endothelial cells. The kidneys are highly susceptible to complement-mediated injury in several genetic, infectious, and autoimmune diseases. Atypical hemolytic uremic syndrome (aHUS) and lupus nephritis (LN) are both characterized by thrombosis in the glomerular capillaries of the kidneys. In aHUS, congenital or acquired defects in complement regulators may trigger platelet aggregation and activation, resulting in the formation of platelet-rich thrombi in the kidneys. Because glomerular vasculopathy is usually noted with immunoglobulin and complement accumulation in LN, complement-mediated activation of tissue factors could partly explain the autoimmune mechanism of thrombosis. Thus, kidney glomerular capillary thrombosis is mediated by complement dysregulation and may also be associated with complement overactivation. Further investigation is required to clarify the interaction between these vascular components and develop specific therapeutic approaches.
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Kasitanon N, Hamijoyo L, Li MT, Oku K, Navarra S, Tanaka Y, Mok CC. Management of non-renal manifestations of systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements. Int J Rheum Dis 2022; 25:1220-1229. [PMID: 35916201 DOI: 10.1111/1756-185x.14413] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/31/2022] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of systemic lupus erythematosus (SLE) is higher in Asians than Caucasians, with higher frequency of renal and other major organ manifestations that carry a poorer prognosis. The outcome of SLE is still unsatisfactory in many parts of the Asia Pacific region due to limited access to healthcare systems, poor treatment adherence and adverse reactions to therapies. The Asia Pacific League of Associations for Rheumatology (APLAR) SLE special interest group has recently published a set of consensus recommendation statements for the management of SLE in the Asia Pacific region. The current article is a supplement of systematic literature search (SLR) to the prevalence and treatment of non-renal manifestations of SLE in Asian patients.
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Affiliation(s)
- Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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7
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Lee CH, Huang YC, Li SS, Hsu YT, Chen YP, Chen TY. Application of PLASMIC Score in Risk Prediction of Thrombotic Thrombocytopenic Purpura: Real-World Experience From a Tertiary Medical Center in Taiwan. Front Med (Lausanne) 2022; 9:893273. [PMID: 35615090 PMCID: PMC9124890 DOI: 10.3389/fmed.2022.893273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) deficiency (activity <10%). Urgent intervention based on the timely evaluation of ADAMTS13 level is crucial to guide optimal therapy. The recently developed PLASMIC score based on seven items allows the rapid identification of patients at high risk for TTP due to severe ADAMTS13 deficiency. This retrospective study included 31 hospitalized patients with suspicious thrombotic microangiopathy in National Cheng Kung University Hospital from December 2016 to July 2021. Data on ADAMTS13 activity and medical and laboratory information were retrieved from medical records. The PLASMIC score could be calculated in 24 of the 31 patients with available data, and the final cohort was stratified according to the 7-point PLASMIC score. All patients with high PLASMIC score (6-7) exhibited severe ADAMTS13 deficiency (activity ≤10%). One patient with a brain tumor and a PLASMIC score of 6 did not have severe ADAMTS13 activity of ≤10%. The patients in the intermediate- and low risk groups (PLASMIC scores of 5 and 0-4, respectively) exhibited ADAMTS13 activities of above 10%. Given the role of prompt diagnosis in the timely delivery of appropriate therapy, these findings confirm and strengthen the predictive value of the PLASMIC score in patients at high risk for TTP due to severe ADAMTS13 deficiency.
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Affiliation(s)
- Chun-Hui Lee
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ching Huang
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sin-Syue Li
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ting Hsu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ping Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsai-Yun Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Liang SJ, Zheng QY, Li MS, Lv MY, Chen WT, Yang Y. Response to belimumab in thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus: a case-based review. Clin Rheumatol 2022; 41:2561-2569. [PMID: 35524885 DOI: 10.1007/s10067-022-06155-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP), a life-threatening syndrome characterized by acute microangiopathic hemolytic anemia, thrombocytopenia, and visceral ischemia, can be classified as congenital TTP (inherited due to a mutation in ADAMTS13) and acquired TTP. The acquired TTP is further classified as idiopathic and secondary TTP. Systemic lupus erythematosus (SLE) is regarded as one of the most common causes of secondary TTP (SLE-TTP). In contrast to patients with idiopathic TTP, some patients with SLE-TTP, especially those diagnosed with refractory TTP, are resistant to plasma exchange and high-dose corticosteroids and usually require second-line drugs, including newly developed biologicals. Belimumab, a B-lymphocyte stimulator-specific inhibitor, was the first approved new therapy for SLE in the past 50 years. Only two cases of SLE-TTP using belimumab have been reported; however, detailed information has not been made available. Herein, we describe a 28-year-old female patient who presented with palm petechiae, strong tawny urine, and yellow stained skin and sclera, and was diagnosed with SLE-TTP supported by high anti-ANA titers; positive anti-SSA/SM; pleural effusion; decreased platelet count, hemoglobin, and complement C3/C4 counts; increased lactate dehydrogenase level, along with increased schistocytes; and a significant deficiency of ADAMTS13 activity. Belimumab (10 mg/kg) was administered after six plasma exchanges. Good efficiency and outcomes without any adverse events, SLE, or TTP relapse were observed during 12 months of follow-up. Therefore, belimumab is a promising choice for SLE-TTP management. In addition, we provide a focused review of the existing literature on the pathogenesis, diagnosis, and therapeutic strategies for SLE-TTP.
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Affiliation(s)
- Shen-Ju Liang
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Quan-You Zheng
- Department of Nephrology and Urology, 958th Hospital, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, 400020, China
| | - Meng-Shan Li
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Ming-Ye Lv
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Wen-Ting Chen
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China
| | - Yi Yang
- Department of Rheumatology and Immunology, Daping Hospital, Army Medical University (Third Military Medical University), Chongqing, 400042, China.
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9
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Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodriguez-Salas G, Londono J. A Practical Perspective of the Hematologic Manifestations of Systemic Lupus Erythematosus. Cureus 2022; 14:e22938. [PMID: 35399432 PMCID: PMC8986464 DOI: 10.7759/cureus.22938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with an unknown etiology that can affect any organ or system of the human body. Hematological, renal, or central nervous system manifestations in these patients result in great morbidity because high doses of glucocorticoids, cytotoxic medications, or biological drugs are required to control these manifestations. It is noteworthy that hematological involvement predominates during the first years of the disease and tends to last over time, with the premise that it may be the initial manifestation of the disease. Clear examples of this are the cases of hemolytic anemia and immune thrombocytopenia that can be initially classified as idiopathic or primary to be later classified as secondary when associated with infections, medications, neoplasms, or autoimmune diseases. The spectrum of hematologic manifestations in SLE is very broad, including lymphopenia, anemia, thrombocytopenia, or pancytopenia. In some cases, lymphadenopathy and splenomegaly are also identified. The vast majority of these manifestations denote high disease activity. However, many of these alterations have a multifactorial cause that must be taken into account to adopt a more complete therapeutic approach. The objective of this review is to characterize in detail the hematological manifestations of SLE to offer clinicians a practical vision of its diagnosis and treatment.
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Jung JY, Kim JW, Suh CH, Kim HA. Successful treatment of thrombotic thrombocytopenic purpura with plasmapheresis and anti-CD20 antibodies in a patient with immune thrombocytopenia and systemic lupus erythematosus: Case report. Medicine (Baltimore) 2022; 101:e28908. [PMID: 35363211 PMCID: PMC9282078 DOI: 10.1097/md.0000000000028908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology with diverse clinical and laboratory manifestations, including thrombocytopenia. About 25% of patients with SLE may be affected by thrombocytopenia, many of whom are asymptomatic. Some patients, however, experience platelet counts that drop quite low and predispose them to bleeding. Thrombotic thrombocytopenic purpura (TTP) is defined with a classic pentad of clinical features, such as thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms and signs, renal symptoms and signs, and fever. The association of TTP and SLE has been sporadically reported in the literature. PATIENT CONCERNS AND DIAGNOSIS We describe a 16-year-old girl with SLE and immune thrombocytopenia, in whom TTP was diagnosed. INTERVENTIONS AND OUTCOMES She was treated with pulse methylprednisolone, whose platelet counts normalized after therapy with plasmapheresis and an anti-CD20 monoclonal antibody (rituximab). CONCLUSION A pediatric patient with SLE and immune thrombocytopenia in whom TTP developed was treated with plasmapheresis and rituximab therapy successfully, though the patient experienced a disease relapsed after 18 months, which was controlled by the same management.
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MESH Headings
- Adolescent
- Anemia, Hemolytic/complications
- Child
- Female
- Humans
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/therapy
- Plasmapheresis
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombotic Thrombocytopenic/complications
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/therapy
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Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Ji-Won Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
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Yang F, Tian J, Peng L, Zhang L, Liu J, Tian X, Zhang W, Li M, Zhao Y, Zhang F, Zeng X, Wang L, Leng X. Thrombocytopenia Is an Independent Risk Factor for the Prognosis of Thrombotic Microangiopathy in Chinese Patients With Systemic Lupus Erythematosus. Front Med (Lausanne) 2021; 8:772607. [PMID: 34820404 PMCID: PMC8606658 DOI: 10.3389/fmed.2021.772607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study aims to describe clinical characteristics and outcome of thrombotic microangiopathy (TMA) in Chinese patients with systemic lupus erythematosus (SLE), and investigate the risk factors. Methods: We conducted a retrospective single-center cohort and enrolled patients of TMA associated with SLE between January 2015 and December 2018. Demographic characteristics, clinical features, laboratory profiles, therapeutic strategies, and outcomes were collected. The risk factors of TMA in patients with SLE for mortality using multivariate analysis were estimated. Results: A total of 119 patients with a diagnosis of TMA were enrolled within the study period in our center, and SLE was found in 72 (60.5%) patients. The mean age was 29.2 ± 10.1 and 65 (92.3%) were women. Only 15 patients were found with definite causes, the other 57 cases remained with unclear reasons. Sixty-two patients got improved, while 10 patients died after treatment (mortality rate: 13.9%). Compared with the survival group, the deceased group had a higher prevalence of neuropsychiatric manifestations, infection with two or more sites, increased levels of C-reaction protein (CRP) and D-Dimer, and decreased platelet count. Multivariate analysis showed that the decrease of platelet count is the independent risk factor for in-hospital mortality for TMA in patients with SLE. The receiver operating characteristic (ROC) curve analysis displayed that a cutoff value of <18 × 109/L for platelet count could significantly increase the risk of death. Conclusions: Thrombotic microangiopathy often occurs in patients with active SLE with high mortality (13.9%), and thrombocytopenia, especially when the platelet count is lower than 18 × 109/L, is the risk factor for death.
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Affiliation(s)
- Fan Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Junwei Tian
- Department of Rheumatology and Nephrology, The First Hospital of Changsha, Hunan, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jia Liu
- Department of Medical Science and Technology Evaluation, Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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12
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Ibn Idris Rodwan AA, Ahmed Elmansour OK, Ahmed AFE, Elagib EM, Ahmed Eltahir NI, Hassan A, El-Sadig SM, Mohammed AGAA, Awadalla HH, Mohammed AA, Adam Essa ME. A Rare Association of Thrombotic Thrombocytopenic Purpura with Systemic Lupus Erythematosus in a Sudanese Woman: Case Report. J Blood Med 2021; 12:945-949. [PMID: 34785968 PMCID: PMC8579963 DOI: 10.2147/jbm.s334689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an uncommon life-threatening condition characterized by hemolytic disorders. The coexistence of systemic lupus erythematosus (SLE) with TTP is extremely rare, although Africans are at increased risk due to inherited risk factors. This report describes a rare clinical manifestation of TTP associated with SLE in a Sudanese patient. A 41-year-old Sudanese woman presented to the emergency department with symptoms and features that were suggestive of malaria, for which she had been treated accordingly. However, a few days later she complained of fever, and was found to have a body temperature of 39.5°C, jaundice, anemia, and thrombocytopenia. Soon after admission, she developed confusion and unrecordable blood pressure. After the patient had stabilized, clinical assessment, immune-system investigation (antinuclear antibody profile, complements, blood panel), and imaging revealed a diagnosis of TTP associated with SLE. The patient received imipenem 500 mg, five sessions of plasmapheresis (60 mL/kg), methylprednisolone 1 g pulse for 3 days, and rituximab 375 mg/week. Three weeks later, the patient was discharged after her condition had improved, and she is now on regular follow-up.
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Affiliation(s)
| | - Osama Khder Ahmed Elmansour
- Department of Rheumatology, Sudan Medical Specialization Council, Khartoum, Sudan.,Department of Rheumatology, Faculty of Medicine, Shendi University, Shendi, Sudan
| | - Amar F Eldow Ahmed
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Elnour Mohammed Elagib
- Department of Rheumatology, Sudan Medical Specialization Council, Khartoum, Sudan.,Department of Rheumatology, Omdurman Military Hospital, Khartoum, Sudan
| | - Noha Ibrahim Ahmed Eltahir
- Department of Rheumatology, Omdurman Military Hospital, Khartoum, Sudan.,Department of Medicine, Faculty of Medicine, Karary University, Khartoum, Sudan
| | - Abubaker Hassan
- Department of Clinical Medicine, Medical and Cancer Research Institute, Nyala, Sudan
| | - Sara M El-Sadig
- Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | | | - Huyam H Awadalla
- Department of Internal Medicine, Detroit Medical Centre, Detroit, MI, USA
| | | | - Mohammed Elmujtba Adam Essa
- Department of Clinical Medicine, Medical and Cancer Research Institute, Nyala, Sudan.,Faculty of Medicine, Al Fashir University, Al Fashir, Sudan
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13
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Rose J. Autoimmune Connective Tissue Diseases: Systemic Lupus Erythematosus and Rheumatoid Arthritis. Emerg Med Clin North Am 2021; 40:179-191. [PMID: 34782087 DOI: 10.1016/j.emc.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systemic lupus erythematosus and rheumatoid arthritis are just 2 of several autoimmune connective tissue diseases that are primarily chronic in nature but can present to the emergency department by virtue of an acute exacerbation of disease. Beyond an acute exacerbation of disease, their predilection for invading multiple organ systems lends itself to the potential for patients presenting to the emergency department with either a single or isolated symptom or a myriad of signs and/or symptoms indicative of a degree of disease complexity and severity that warrant timely recognition and resuscitation.
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Affiliation(s)
- Jonathan Rose
- Department of Emergency Medicine, Memorial Healthcare System, Memorial Hospital West, 703 N Flamingo Road, Pembroke Pines, FL 33028, USA.
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14
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Carvalho JF, Shoenfeld Y. Sjögren's Syndrome Associated With Thrombotic Thrombocytopenic Purpura: A Case-Based Review. Rheumatol Ther 2020; 8:621-629. [PMID: 33315186 PMCID: PMC7991010 DOI: 10.1007/s40744-020-00265-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/26/2020] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To review all published cases of the rare association between thrombotic thrombocytopenic purpura (TTP) and Sjögren's syndrome (SS). The authors report an additional case of this unique association. METHODS Systematic review of the literature and a case report. The database were articles published in PubMed/MEDLINE, Web of Science, LILACS, and SciELO, registered from 1966 to August 2020. The DESH terms were "Sjögren's syndrome" and "thrombotic thrombocytopenic purpura," without language limitation. RESULTS Most patients were female (88%), and the age varied from 30 to 75 years old. Concerning the sequence of disease appearance, SS followed by TTP was seen in seven articles, TTP and SS in three, and simultaneous appearance of both diseases in three studies. Primary SS was observed in 16 patients, and secondary SS was detected in two cases: dermatomyositis and rheumatoid arthritis. Anemia was the most common TTP manifestation, followed by thrombocytopenia, fever, consciousness alteration, renal impairment, and schistocytes' appearance on a blood smear. Treatment involved plasmapheresis, plasma exchange, rituximab, glucocorticoid, and cyclophosphamide. A good outcome was noted in most studies; few patients died. CONCLUSIONS TTP is a rare manifestation associated with SS. After the TTP diagnosis, plasmapheresis and/or plasma exchange should be immediately implemented.
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Affiliation(s)
- Jozélio F Carvalho
- Institute for Health Sciences from Federal University of Bahia, Salvador, Bahia, Brazil.
| | - Yehuda Shoenfeld
- Chaim Sheba Medical Center The Zabludowicz Center for Autoimmune Diseases, Tel Hashomer, Israel.,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Saint Petersburg, Russia
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15
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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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16
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Immune-mediated thrombotic thrombocytopenic purpura in patients with and without systemic lupus erythematosus: a retrospective study. Orphanet J Rare Dis 2020; 15:225. [PMID: 32859237 PMCID: PMC7456051 DOI: 10.1186/s13023-020-01510-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is associated with more deleterious outcomes in patients with systemic lupus erythematosus (SLE). However, ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) levels and ADAMTS13 inhibitor were not routinely assayed in most previous studies. The objective of this study is to compare the characteristics and outcomes of immune-mediated TTP (iTTP) in patients with and without SLE. Methods The medical data of 28 patients with iTTP from Peking Union Medical College Hospital were analysed. ADAMTS13 activity and ADAMTS13 inhibitor were measured in all patients. Results All 28 patients had ADAMTS13 inhibitor and severe ADAMTS13 deficiency. iTTP was considered SLE-related (SLE-TTP) in 10 patients and primary (primary iTTP) in 18 patients. Renal involvement on presentation was more severe in patients with primary iTTP as determined by higher serum creatinine (162.7 ± 110.6 vs 73.3 ± 13.4 μmol/L, p < 0.01) and more prevalent acute kidney injury (72.2% vs 10.0%, p < 0.01) than in patients with SLE-TTP. More patients with SLE-TTP were treated with steroid pulse therapy (90.0% vs 16.7%, p < 0.01) and intravenous immunoglobulin (IVIG) (50.0% vs 5.6%, p = 0.01) compared to patients with primary iTTP. After adjustments for age and treatment, including steroid pulse therapy and IVIG treatment, the likelihood of clinical remission of SLE-TTP was significantly increased compared to that of primary iTTP (HR 7.6 [1.2, 50.1], p = 0.03). Mortality was also lower among patients with SLE-TTP than among patients with primary iTTP (0 vs 38.9%, p = 0.03). Conclusions Renal involvement was less severe in patients with SLE-TTP than in patients with primary iTTP. The treatment responses and outcomes of SLE-TTP were no worse and perhaps even better than those of primary iTTP. When TTP is diagnosed in SLE patients, the ADAMTS13 level and ADAMTS13 inhibitor profile should be considered in addition to clinical features.
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17
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Ma W, Bai W, Wu X, Zhao J, Li M, Zeng X. Successful treatment of refractory thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus with combination of plasma exchange and low-dose rituximab. Lupus 2020; 29:1961-1967. [PMID: 32838618 DOI: 10.1177/0961203320953473] [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] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Thrombotic thrombocytopenia purpura (TTP) associated with systemic lupus erythematous (SLE) (i.e., SLE-TTP) is a rare life-threatening disease often requiring intensive immunosuppressive agents, in addition to high-dose corticosteroids and plasma exchange (PEX). The optimal therapy of rituximab is unclear, but 375 mg/m2 weekly for 4 weeks is the usual practice, adopted from regimens for non-Hodgkin's lymphoma. We reported two cases of refractory SLE-TTP that showed good efficacy and prognosis with combination of methylprednisolone (MP) pulse, plasma exchange and low-dose rituximab (100 mg weekly for 4 weeks) treatment. METHODS Clinical data and treatment outcomes were reviewed of two patients diagnosed with refractory SLE-TTP at Peking Union Medical College Hospital between July 2017 and July 2018. RESULTS Both patients had SLE and presented with microangiopathic anemia and thrombocytopenia. Laboratory assays revealed high anti-nuclear antibody titers, reduced complement 3 and 4 levels, proteinuria, significantly elevated lactate dehydrogenase, schistocytes on peripheral blood smear, low ADAMTS13 activity, and the presence of ADAMTS13 inhibitor. In both patients, platelet counts remained below 50 × 109/L after MP pulse and 6 PEXs, confirming the diagnosis of refractory SLE-TTP. Low-dose rituximab (100 mg weekly for 4 weeks) was administered in both cases, resulting in normalization of platelet counts and significant reductions in B-lymphocyte counts. No TTP relapse or SLE flare occurred during 24 months of follow-up. CONCLUSIONS Our cases confirmed the efficacy and good follow-up outcomes of low-dose rituximab treatment (100 mg weekly for 4 weeks) for refractory SLE-TTP.
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Affiliation(s)
- Wanlu Ma
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Bai
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xueyan Wu
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
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18
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Chen WC, Ko PS, Wang HY, Liu YC, Hsiao LT, Gau JP, Liu JH. Difference in thrombotic microangiopathy between concurrently and previously diagnosed systemic lupus erythematosus. J Chin Med Assoc 2020; 83:743-750. [PMID: 32371665 DOI: 10.1097/jcma.0000000000000344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) syndromes are potentially life-threatening complications and are defined as integrated syndromes of microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect various organs, including the hematopoietic system. SLE can complicate with TMA and can be categorized into two distinct groups by chronological association: TMA occurring as the initial presentation and leading to a diagnosis of SLE concurrently (TMA-cSLE) or TMA developing in patients previously diagnosed as having SLE (TMA-pSLE). We examined the differences in clinical characteristics, treatment responses, and clinical outcomes between these groups. METHODS We reviewed data of patients diagnosed as having TMA and SLE at Taipei Veterans General Hospital between 2002 and 2013. We included 29 patients: 8 and 21 in TMA-cSLE and TMA-pSLE groups, respectively. All underwent plasma exchange. Patients' demographic and clinical characteristics, disease activity, and treatment modality were summarized. RESULTS Overall survival (OS) from SLE or TMA diagnosis was poor for the TMA-cSLE group. Median OS from SLE diagnosis was 2.9 months in the TMA-cSLE group and 103.5 months in the TMA-pSLE group (p < 0.001). Median OS from TMA diagnosis was 2.9 months in the TMA-cSLE group and 10.7 months in the TMA-pSLE group (p = 0.58). Time to TMA remission after treatment appeared longer in the TMA-cSLE group (38.00 vs 10.76 days). Multivariate Cox analysis revealed TMA-cSLE and anti-RNP positivity were independent risk factors for mortality in SLE patients with TMA. CONCLUSION The occurrence of TMA with SLE is rare, and its vigorous course results in high mortality and morbidity rates. In patients without a history of autoimmune disease, early suspicion of TMA and working-up for SLE under this condition are vital. Early recognition of TMA-cSLE and prompt plasma exchange with upfront immunosuppressive therapies for TMA-cSLE patients or anti-RNP-positive patients may improve their prognosis.
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Affiliation(s)
- Wen-Chun Chen
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Po-Shen Ko
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hao-Yuan Wang
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Jin-Hwang Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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19
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Chen P, Ramachandran P, Josan K, Wang JC. Pancytopenia and TTP-like picture secondary to pernicious anaemia. BMJ Case Rep 2020; 13:13/7/e235288. [DOI: 10.1136/bcr-2020-235288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 21-year-old man presented to the emergency department with generalised weakness, weight loss and decreased appetite for few weeks. He had evidence of severe pancytopenia and haemolysis. His peripheral smear with many schistocytes was suspicious for thrombotic thrombocytopenic purpura (TTP). He was supported with blood transfusions and daily plasmapheresis. His platelet counts worsened despite 4 days of therapy. Bone marrow biopsy was significant for hypercellular bone marrow with megaloblastic changes. Further workup revealed normal ADAMTS13 level, low vitamin B12, positive intrinsic factor antibodies and high methylmalonic acid. Diagnosis of pernicious anaemia was established and he was started on daily treatment with intramuscular vitamin B12which subsequently improved his symptoms and haematological parameters. This report highlights the importance of checking vitamin B12level in patients presenting with pancytopenia and TTP-like picture before making a diagnosis of TTP.
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20
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Atypical hemolytic uremic syndrome and complement blockade: established and emerging uses of complement inhibition. Curr Opin Nephrol Hypertens 2020; 28:278-287. [PMID: 30865166 DOI: 10.1097/mnh.0000000000000499] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Atypical hemolytic uremic syndrome (aHUS) is a diagnosis that has captured the interest of specialists across multiple fields. The hallmark features of aHUS are microangiopathic hemolysis and thrombocytopenia, which creates a diagnostic dilemma because of the occurrence of these findings in a wide variety of clinical disorders. RECENT FINDINGS In most of the instances, aHUS is a diagnosis of exclusion after ruling out causes such as Shigella toxin, acquired or genetic a disintegrin and metalloproteinase thrombospondin motif 13 deficiency (thrombotic thrombocytopenic purpura), and vitamin B12 deficiency. In the purest sense, aHUS is a genetic condition that is activated (or unmasked) by an environmental exposure. However, it is now evident that complement activation is a feature of many diseases. Variants in complement regulatory genes predispose to microangiopathic hemolysis in many rheumatologic, oncologic, and drug-induced vascular, obstetric, peritransplant, and infectious syndromes. SUMMARY Many 'hemolysis syndromes' overlap clinically with aHUS, and we review the literature on the treatment of these conditions with complement inhibition. New reports on the treatment of C3 glomerulopathy, Shiga toxin-related classic hemolytic uremic syndrome, and medication-related thrombotic microangiopathy will be reviewed as well.
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21
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Adam Z, Sokwala A, Shah J, Ali SK. A delay in diagnosis: thrombotic thrombocytopenia purpura occurring in systemic lupus erythematous. Pan Afr Med J 2020; 34:103. [PMID: 31934246 PMCID: PMC6945373 DOI: 10.11604/pamj.2019.34.103.20524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 12/05/2022] Open
Abstract
Thrombotic thrombocytopenia purpura (TTP) in the background of systemic lupus erythematous (SLE) remains rare with an incidence of about 2%. Both conditions have overlapping features and can thus be difficult to differentiate and diagnose. A careful review of the peripheral blood smear remain essential often providing many clues. The diagnosis of TTP is a medical emergency and therapy should be instituted immediately. We present one such challenging case where a delay in diagnosis due to limited resources could have proven fatal for our patient.
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Affiliation(s)
- Zoya Adam
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
| | - Ahmed Sokwala
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
| | - Sayed Karar Ali
- Department of Internal Medicine, The Aga Khan University, Nairobi, Kenya
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22
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Furuya MY, Watanabe H, Sato S, Fujita Y, Tenmoku J, Matsuoka N, Asano T, Suzuki E, Kobayashi H, Migita K. An Autopsy Case of Mixed Connective Tissue Disease Complicated by Thrombotic Thrombocytopenic Purpura. Intern Med 2020; 59:1315-1321. [PMID: 32418955 PMCID: PMC7303452 DOI: 10.2169/internalmedicine.3939-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We herein report a patient with mixed connective tissue disease (MCTD) who had been stable for years but suddenly developed thrombotic thrombocytopenic purpura (TTP). The patient showed a clinical pentad of signs of TTP, low activity of ADAMTS13, and positivity of anti-ADAMTS13 antibodies. She did not respond to plasma exchange or steroid therapy and died five days after admission. An autopsy revealed microthrombi in the brain, heart, kidney, adrenal glands, esophageal submucosa, and bone marrow as well as diffuse alveolar hemorrhaging. Physicians should bear in mind that TTP can occur in MCTD patients regardless of disease activity.
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Affiliation(s)
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Jumpei Tenmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Eiji Suzuki
- Division of Rheumatology, Ohta-Nishinouchi Hospital, Japan
| | - Hiroko Kobayashi
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
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23
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Sharma P, Gurung A, Dahal S. Connective Tissue Disorders in Patients With Thrombotic Thrombocytopenic Purpura: A Retrospective Analysis Using a National Database. J Clin Med Res 2019; 11:509-514. [PMID: 31236170 PMCID: PMC6575126 DOI: 10.14740/jocmr3850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022] Open
Abstract
Background Prior reports have shown acquired thrombotic thrombocytopenic purpura (TTP) co-existing with connective tissue disorders (CTD). However, these are mainly limited to case reports and case-series reports, and the patient characteristics and clinical outcomes in these patients are not well known. Methods We used National Inpatient Sample and Nationwide Inpatient Sample (NIS) database for the years 2009 to 2016 to identify all adult patients with TTP and searched for either the presence or absence of any co-existing CTD. These two cohorts of TTP patients were then compared using statistical methods for baseline patient characteristics and clinical outcomes. The primary outcome of interest was the all-cause in-hospital mortality and the secondary outcomes were in-hospital length of stay, in-hospital total charge and in-hospital complications. Results Of the 14,400 cases of TTP diagnosed between 2009 and 2016, nearly 9% (n = 1,247) had one or more underlying CTD. Patients with TTP were more likely to be young, black, female, with more than one comorbidity and with private insurance if they had an underlying CTD than when they did not have any underlying CTD. There was no difference in regards to the size, location or type of the hospital, or the time taken to initiate plasmapheresis. Patients being managed for TTP had a longer mean length of hospital stay and a greater mean total inpatient stay charge if they had underlying CTD. There was however no difference in the risks of inpatient mortality, acute coronary syndrome, cardiac arrest, acute stroke, need for mechanical ventilation or hemodialysis. Conclusion TTP and CTD frequently co-existed and contributed to a longer hospital stay and a greater hospital charge.
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Affiliation(s)
- Pratibha Sharma
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Aveena Gurung
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, NY, USA
| | - Sumit Dahal
- Hospitalist Service, St. Joseph Hospital, Bangor, ME, USA
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24
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Thrombotic thrombocytopenic purpura as the first presentation in systemic lupus erythematosus. Reumatologia 2018; 56:268-270. [PMID: 30237633 PMCID: PMC6142019 DOI: 10.5114/reum.2018.77980] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/02/2018] [Indexed: 11/17/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an uncommon, life-threatening disease characterized by severe thrombocytopenia, microangiopathic haemolytic anaemia, neurologic abnormalities, renal insufficiency, and fever commonly associated with infections, malignancy, drugs, and autoimmune diseases. Coexistence of TTP with systemic lupus erythematosus (SLE) is extremely rare, and the emergence of the full manifestation of SLE starting with TTP is even rarer. Black people due to genetic risk factors are at increased risk of TTP. In the present article the authors describe the case of a Nigerian woman who developed classical features of TTP as the first manifestation of SLE. The patient's condition was stabilized after treatment with intravenous pulses of methylprednisolone and subsequently on oral prednisolone and hydroxychloroquine treatment.
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Yue C, Su J, Gao R, Wen Y, Li C, Chen G, Zhang X, Li X. Characteristics and Outcomes of Patients with Systemic Lupus Erythematosus–associated Thrombotic Microangiopathy, and Their Acquired ADAMTS13 Inhibitor Profiles. J Rheumatol 2018; 45:1549-1556. [DOI: 10.3899/jrheum.170811] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 02/01/2023]
Abstract
Objective.To investigate the characteristics and outcomes of patients with systemic lupus erythematosus (SLE)–associated thrombotic microangiopathy (TMA) based on their ADAMTS13 inhibitor profiles.Methods.The medical data of 31 SLE patients with clinically diagnosed TMA were analyzed. ADAMTS13 activity and ADAMTS13 inhibitor were measured in all patients.Results.TMA was attributable to active SLE in 19 patients. ADAMTS13 inhibitor and severe ADAMTS13 deficiency were detected in 6 of them. Patients with ADAMTS13 inhibitor (n = 6) exhibited a lower platelet count (7.3 ± 5.1 vs 25.0 ± 17.8 × 109/l, p = 0.005) and more prevalent central nervous system (CNS) involvement (100.0% vs 23.1%, p = 0.003) than patients without ADAMTS13 inhibitor (n = 13). Patients with ADAMTS13 inhibitor also had mild renal involvement characterized by a higher estimated glomerular filtration rate (112.7 ± 18.0 vs 21.6 ± 12.0, p < 0.001), lower proteinuria level [0.6 (0.2–2.5) vs 8.1 (5.2–14.0) g/d, p = 0.011], and lower mean arterial pressure (95.3 ± 13.6 vs 117.5 ± 13.1 mmHg, p = 0.008) than was observed in patients without ADAMTS13 inhibitor. All patients with ADAMTS13 inhibitor achieved complete remission within 18.6 ± 8.7 days, while 3 patients (23.1%) without ADAMTS13 inhibitor achieved complete remission during a median followup of 5.0 months, even though more patients in this group received therapeutic apheresis (100.0% vs 50.0%, p = 0.021). The chance of complete remission increased by 10.8-fold (HR 10.8, 95% CI 1.8–65.5, p < 0.001) when ADAMTS13 inhibitor was present in SLE-associated TMA.Conclusion.Acquired ADAMTS13 deficiency is associated with more severe thrombocytopenia and CNS involvement, mild renal involvement, rapid resolution, and relatively good treatment response in SLE-associated TMA.
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Sun F, Wang X, Wu W, Wang K, Chen Z, Li T, Ye S. TMA secondary to SLE: rituximab improves overall but not renal survival. Clin Rheumatol 2017; 37:213-218. [DOI: 10.1007/s10067-017-3793-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/19/2017] [Accepted: 08/14/2017] [Indexed: 12/19/2022]
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Tan Y, Luan ZQ, Hao JB, Song D, Yu F, Zhao MH. Plasma ADAMTS-13 activity in proliferative lupus nephritis: a large cohort study from China. Lupus 2017; 27:389-398. [PMID: 28786769 DOI: 10.1177/0961203317723715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The aim of this study was to investigate plasma ADAMTS-13 activity in patients with proliferative lupus nephritis and to evaluate the role of clinical, laboratory and pathological features, especially the vascular lesions in lupus nephritis. Methods Plasma samples from 163 class III and IV lupus nephritis patients confirmed by biopsy examinations and 98 normal controls were collected. ADAMTS-13 activity was evaluated by a residual collagen binding assay. IgG autoantibodies against ADAMTS-13 were detected by ELISA using recombinant ADAMTS-13 as a solid-phase ligand. Levels of vWF were measured by ELISA. Their associations with clinical, laboratory and pathological features were further assessed. Results Plasma ADAMTS-13 activity in lupus nephritis patients was significantly lower than that in normal controls (84 ± 21% vs. 90 ± 13%, p = 0.005). IgG ADAMTS-13 autoantibodies were detected in only three patients. The plasma level of vWF was significantly higher in the lupus nephritis group than in normal controls (1.00 ± 0.79 vs. 0.70 ± 0.30, p = 0.025). Plasma ADAMTS-13 activity was negatively correlated with the level of serum creatinine and proteinuria ( r = –0.354, p < 0.001; r = –0.200, p = 0.011, respectively). Patients with a higher level of ADAMTS-13 activity had significantly higher levels of factor H (401.51 ± 183.01 µg/ml vs. 239.02 ± 155.45 µg/ml, p = 0.005). Plasma ADAMTS-13 activity was negatively associated with total pathological AI scores ( r = –0.326, p < 0.001), endocapillary hypercellularity ( r = –0.419, p < 0.001), cellular crescents ( r = –0.274, p < 0.001), subendothelial hyaline deposits ( r = –0.266, p = 0.001), interstitial inflammatory cell infiltration ( r = –0.304, P < 0.001), tubular atrophy ( r = –0.199, p = 0.011), acute glomerular vascular lesions ( r = –0.344, p < 0.001) and acute renal vascular lesions ( r = –0.338, p < 0.001). No association was found between level of vWF and plasma ADAMTS-13 activity ( r = 0.033, p = 0.671). Low level of ADAMTS-13 activity was a risk factor for renal outcomes ( p = 0.039, HR = 0.047, 95% CI: 0.120–1.005). Conclusions Decreased ADAMTS-13 activity was found in patients with proliferative lupus nephritis, and plasma ADAMTS-13 activity was closely associated with renal injury indices, especially pathological vascular scores. The role of ADAMTS-13 in the disease remains to be further investigated.
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Affiliation(s)
- Y Tan
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
| | - Z Q Luan
- Department of Nephrology, First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, PR. China
| | - J B Hao
- Department of Nephrology, The First Clinical Medicine of Zhengzhou University, Zhengzhou, PR. China
| | - D Song
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
| | - F Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
- Department of Nephrology, Peking University International Hospital, Beijing, PR. China
| | - M H Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
- Peking-Tsinghua Center for Life Sciences, Beijing, PR. China
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Li Y, Feng X. Efficacy and safety of tacrolimus in systemic lupus erythematosus patients with refractory thrombocytopenia: a retrospective study. Lupus 2017; 27:60-65. [PMID: 28566017 DOI: 10.1177/0961203317711011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective We evaluated the efficacy and safety of tacrolimus in systemic lupus erythematosus patients with refractory thrombocytopenia. Methods We retrospectively reviewed the data for 20 systemic lupus erythematosus patients with refractory thrombocytopenia and treated with tacrolimus during the period January 2013 to January 2015. In addition to glucocorticoids, all patients were treated with tacrolimus, 1 mg taken twice daily. The clinical effect of tacrolimus treatment in patients was evaluated by analysis of platelet counts at baseline and after one, three and six months of tacrolimus treatment. Levels of anti-double-stranded DNA antibodies and complement C3, C4 were determined individually. Results After one month of tacrolimus treatment, three patients (15%) did not respond, three patients (15%) achieved a complete response and the other 14 patients (75%) achieved a partial response. After three months of tacrolimus treatment, the platelet counts of all patients were significantly improved. A partial response was seen in 14 patients (75%) and the complete response rate increased to 25% (five patients). After six months, all patients attained partial response or complete response without relapse, and the rate of complete response increased to 75%. Compared to pretreatment, anti-double-stranded DNA antibody levels and the disease activity index score were markedly decreased after tacrolimus treatment. The levels of serum C3 and C4 were increased significantly ( P < 0.05). Conclusions Our survey revealed that a six-month course of tacrolimus is a safe and effective treatment for systemic lupus erythematosus patients with refractory thrombocytopenia.
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Affiliation(s)
- Y Li
- Department of Physiology, Jinzhou Medical University, Jinzhou, P.R. China
| | - X Feng
- Department of Rheumatology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, P.R. China
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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Shen YM. Clinical evaluation of thrombotic microangiopathy: identification of patients with suspected atypical hemolytic uremic syndrome. Thromb J 2016; 14:19. [PMID: 27766045 PMCID: PMC5056489 DOI: 10.1186/s12959-016-0114-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare genetic disorder caused by defective complement regulation resulting in thrombotic microangiopathy (TMA). Patients can present as children or adults. The syndrome consists of hemolytic anemia with schistocytosis, thrombocytopenia, significant renal damage, and/or other organ system dysfunction(s). Patients with aHUS may succumb to the complications of the disease with the very first manifestation; surviving patients often suffer from progressive organ dysfunction with significant morbidity and mortality despite plasma infusion or plasma exchange. Eculizumab, a humanized monoclonal antibody to C5, was approved for treatment of aHUS in 2011. This is an expensive but highly effective therapy changing the lives and improving the outcome of patients with aHUS. Making timely and accurate diagnosis of aHUS can be life-saving if eculizumab treatment is begun promptly. Finding a genetic mutation in a complement regulatory protein is diagnostic with the appropriate clinical syndrome, but at least 30 % of patients do not have defined or reported mutations. Thus the diagnosis rests on the clinical acumen of the physician. However, the clinical manifestations of aHUS are shared by other etiologies of thrombotic microangiopathy. While laboratory finding of undetectable ADAMTS13 activity defines TTP, distinguishing aHUS from the other causes of TMA remains an art. In addition, aHUS can be unmasked by conditions with enhanced complement activation, such as systemic lupus erythematosus, pregnancy, malignant hypertension, and hematopoietic stem cell transplantation. Thus if TMA occurs in the setting of enhanced complement activation, one must consider aHUS as an underlying etiology, especially if treatment of the condition does not resolve the TMA.
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Affiliation(s)
- Yu-Min Shen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8852 USA
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Li QY, Yu F, Zhou FD, Zhao MH. Plasmapheresis Is Associated With Better Renal Outcomes in Lupus Nephritis Patients With Thrombotic Microangiopathy: A Case Series Study. Medicine (Baltimore) 2016; 95:e3595. [PMID: 27149490 PMCID: PMC4863807 DOI: 10.1097/md.0000000000003595] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to evaluate the efficacy of plasmapheresis in patients with lupus nephritis-combined thrombotic microangiopathy (TMA) in a Chinese cohort.Clinical and therapeutic data of patients with lupus nephritis-combined TMA were collected retrospectively. A comparison between those with and without plasmapheresis was performed.Seventy patients with renal biopsy-proven TMA in lupus nephritis were treated with conventional combined corticosteroid and immunosuppressive agents as induction therapy, 9 of the 70 patients received additional plasmapheresis. The plasmapheresis group presented with more severe SLE and renal activity indices, including a significant higher ratio of neurologic disorder (P = 0.025), lower level of platelet count (P = 0.009), higher value of serum creatinine (P = 0.038), higher percentage of anti-cardiolipin antibodies positive (P = 0.001), and higher Systemic Lupus Erythematosus Disease Activity Index scores (P = 0.012), than that of the nonplasmapheresis group. However, the plasmapheresis group had a significant higher rate of remission and a lower ratio of treatment failure than that of the nonplasmapheresis group (P = 0.03). As the baseline data were significantly different between the 2 groups, the propensity score match was further designed to avoid retrospective bias. After re-analysis, the plasmapheresis group still had a significant higher rate of remission and a lower ratio of treatment failure than that of the nonplasmapheresis group (P = 0.018). More importantly, the plasmapheresis group had significant less composite endpoints than that of the nonplasmapheresis group (P = 0.005).Our study suggested that additional plasmapheresis on conventional induction therapy may benefit patients with lupus nephritis-combined TMA, which warrants further explorations.
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Affiliation(s)
- Qiu-Yu Li
- From the Department of Medicine, Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China (Q-YL, FY, F-DZ, M-HZ); Department of Nephrology, Peking University International Hospital (FY); and Peking-Tsinghua Center for Life Sciences, Beijing, PR China (M-HZ)
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Merayo-Chalico J, Apodaca E, Barrera-Vargas A, Alcocer-Varela J, Colunga-Pedraza I, González-Patiño A, Arauz A, Abud-Mendoza C, Martínez-Martínez M, Gómez-Martín D. Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case-control study. J Neurol Neurosurg Psychiatry 2016; 87:287-94. [PMID: 25804426 DOI: 10.1136/jnnp-2014-310145] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the present study was to describe potentially unrecognised risk factors. PATIENTS AND METHODS We performed a multicentre, retrospective case-control study in Mexico between 1999 and 2014. We included a total of 168 patients who accounted for 77 episodes of PRES, as follows: SLE/PRES, 43 patients with 48 episodes; SLE without PRES, 96 patients; and PRES without SLE, 29 patients. SLE diagnosis was considered when patients fulfilled ≥4 American College of Rheumatology criteria. PRES was defined by reversible neurological manifestations and MRI changes. RESULTS Patients with SLE/PRES were younger, presented with seizures as the most common manifestation (81%) and 18% had the typical occipital MRI finding. Hypertension (OR=16.3, 95% CI 4.03 to 65.8), renal dysfunction (OR=6.65, 95% CI 1.24 to 35.6), lymphopenia (OR=5.76, 95% CI 1.36 to 24.4), Systemic Lupus Erythematosus Activity Index ≥ 6 points (OR=1.11, 95% CI 1.01 to 1.22) and younger age (OR=0.86, 95% CI 0.81 to 0.91, p<0.001) were independent risk factors for development of PRES in SLE. Furthermore, dyslipidemia also characterised the association between PRES and SLE (OR=10.6, 95% CI 1.17 to 96.4). CONCLUSIONS This is the largest reported series of patients with SLE and PRES. We were able to corroborate the known risk factors for of PRES, and found two previously undescribed factors (lymphopenia and dyslipidemia), which suggests that endothelial dysfunction is a key element in PRES pathogenesis in lupus patients.
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Affiliation(s)
- Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elia Apodaca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Iris Colunga-Pedraza
- Department of Rheumatology, Hospital Universitario Dr José E González, Monterrey, Nuevo León, Mexico
| | - Alejandra González-Patiño
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Carlos Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Marco Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Roriz M, Landais M, Desprez J, Barbet C, Azoulay E, Galicier L, Wynckel A, Baudel JL, Provôt F, Pène F, Mira JP, Presne C, Poullin P, Delmas Y, Kanouni T, Seguin A, Mousson C, Servais A, Bordessoule D, Perez P, Chauveau D, Veyradier A, Halimi JM, Hamidou M, Coppo P. Risk Factors for Autoimmune Diseases Development After Thrombotic Thrombocytopenic Purpura. Medicine (Baltimore) 2015; 94:e1598. [PMID: 26496263 PMCID: PMC4620782 DOI: 10.1097/md.0000000000001598] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Autoimmune thrombotic thrombocytopenic purpura (TTP) can be associated with other autoimmune disorders, but their prevalence following autoimmune TTP remains unknown. To assess the prevalence of autoimmune disorders associated with TTP and to determine risk factors for and the time course of the development of an autoimmune disorder after a TTP episode, we performed a cross sectional study. Two-hundred sixty-one cases of autoimmune TTP were included in the French Reference Center registry between October, 2000 and May, 2009. Clinical and laboratory data available at time of TTP diagnosis were recovered. Each center was contacted to collect the more recent data and diagnosis criteria for autoimmunity. Fifty-six patients presented an autoimmune disorder in association with TTP, 9 years before TTP (median; min: 2 yr, max: 32 yr) (26 cases), at the time of TTP diagnosis (17 cases) or during follow-up (17 cases), up to 12 years after TTP diagnosis (mean, 22 mo). The most frequent autoimmune disorder reported was systemic lupus erythematosus (SLE) (26 cases) and Sjögren syndrome (8 cases). The presence of additional autoimmune disorders had no impact on outcomes of an acute TTP or the occurrence of relapse. Two factors evaluated at TTP diagnosis were significantly associated with the development of an autoimmune disorder during follow-up: the presence of antidouble stranded (ds)DNA antibodies (hazard ratio (HR): 4.98; 95% confidence interval (CI) [1.64-15.14]) and anti-SSA antibodies (HR: 9.98; 95% CI [3.59-27.76]). A follow-up across many years is necessary after an acute TTP, especially when anti-SSA or anti-dsDNA antibodies are present on TTP diagnosis, to detect autoimmune disorders early before immunologic events spread to prevent disabling complications.
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Affiliation(s)
- Mélanie Roriz
- From the Centre hospitalier universitaire Bretonneau, Service de néphrologie, Tours (MR, CB, J-MH, FTM); Centre hospitalier universitaire Hôtel-Dieu, Service de médecine interne A, Nantes (ML, MH); Centre hospitalier de Valenciennes, Service de néphrologie, Valenciennes (JD, YD); Centre de Référence des Microangiopathies Thrombotiques, Hôpital Saint-Antoine, APHP (EA, LG, AW, J-LB, FP, FP, J-PM, CP, PP, TK, AS, DB, PP, DC, AV, J-MH, MH, PC, FTM, MH, PC); Université Paris Diderot, Sorbonne Paris Cité (EA, LG); Service de Réanimation Médicale, Hôpital Saint-Louis, AP-HP (EA); Service d'Immunologie Clinique, Hôpital Saint-Louis, AP-HP, Paris (LG); Service de Néphrologie, Hôpital Maison Blanche, Reims (AW); Sorbonne Université, UPMC Univ Paris 06 (J-LB); Service de Réanimation Médicale, CHU Saint-Antoine, AP-HP, Paris (J-LB); Service de Néphrologie, Hôpital Albert Calmette, Lille (FP); Service de Réanimation Polyvalente, Hôpital Cochin, AP-HP (FP, J-PM); Université Paris 5, Paris (FP, J-PM); Service de Néphrologie - Médecine Interne, Hôpital Sud, Amiens (CP); Service d'Hémaphérèse, Hôpital de Marseille Conception, Marseille (PP); Service de néphrologie-transplantation-dialyse, Hôpital Pellegrin, Bordeaux (YD); Unité d'Hémaphérèse thérapeutique, CHU de Montpellier (TK); Service de Réanimation Médicale, Centre Hospitalier Universitaire de Caen (AS); Service de Néphrologie, Dijon (CM); Service de Néphrologie, Hôpital Necker-Enfants Malades, AP-HP, Paris (AS); Service d'Hématologie Clinique et de Thérapie Cellulaire, CHU Dupuytren, Limoges (DB); Service de Réanimation, CHU Brabois, Nancy (PP); Service de néphrologie-immunologie clinique, hôpital Rangueil, Toulouse (DC); Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris (AV); Université Paris-Sud 11, Le Kremlin-Bicêtre (AV); Inserm U1009, Institut Gustave Roussy, Villejuif (PC); and Service d'Hématologie, Hôpital Saint-Antoine, AP-HP, Paris, France (PC)
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Changcharoen B, Bolger DT. Thrombotic thrombocytopenic purpura as an initial presentation of systemic lupus erythematosus with acquired ADAMTS 13 antibody. BMJ Case Rep 2015; 2015:bcr-2014-208477. [PMID: 25701834 DOI: 10.1136/bcr-2014-208477] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a female patient presenting with headache, fatigue, ecchymoses and recent, excessive vaginal bleeding. Prompt review of the peripheral blood smear showed evidence of microangiopathic haemolytic anaemia (MAHA) and thrombocytopenia. Thrombotic thrombocytopenic purpura (TTP) was suspected. Plasma exchange and corticosteroids were started urgently. The patient responded favourably to the treatment. Subsequently, positive serological markers returned and were compatible with systemic lupus erythematosus (SLE). A disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13 (ADAMTS 13) activity was remarkably low with a positive inhibitory ADAMTS 13 antibody. Mycophenolate and hydroxychloroquine were started along with a prolonged course and taper of corticosteroids. These medications have been maintained with an excellent response in 14 months of follow-up.
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Affiliation(s)
- Bhisit Changcharoen
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Dennis Thomas Bolger
- Hospitalist Program, The Queen's Medical Center, Honolulu, Hawaii, USA Department of Medicine, University of Hawaii, Honolulu, Hawaii, USA
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Palaniappan P, Lionel AP, Agarwal I, Mathai S, Mathew L, Agarwal S, Keni P, Khubchandani R, Kumar S. Cryosupernatant and Immunosuppression as Effective Alternative Therapies for TTP in Three Pediatric SLE Patients. Indian J Hematol Blood Transfus 2014; 30:232-6. [PMID: 25332586 DOI: 10.1007/s12288-014-0338-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/15/2014] [Indexed: 11/25/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) and systemic lupus erythematosus (SLE) very rarely present simultaneously and pose a diagnostic and therapeutic dilemma to the physician. Prompt diagnosis and management with plasma exchange and immunosuppression is life-saving. To describe the effectiveness of cryosupernatant and steroids in pediatric SLE with TTP. We describe three children aged 12-14 years with SLE who were diagnosed with TTP based on fever, CNS manifestations, ANA, anti-dsDNA, anti-sm positivity, hypocomplementemia, and microangiopathic anemia with thrombocytopenia. All three children were managed with cryosupernatant and steroids without plasmapheresis. All children improved with cryosupernatant and steroids. All attained remission within 10 days. They were doing well at last follow up without relapse or flare. Cryosupernatant and steroids may be an effective therapy for Thrombotic thrombocytopenic purpura with systemic lupus erythematosus.
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Affiliation(s)
| | | | - Indira Agarwal
- Department of Paediatrics, Christian Medical College, Vellore, 632004 India
| | - Sarah Mathai
- Department of Paediatrics, Christian Medical College, Vellore, 632004 India
| | - Leni Mathew
- Department of Paediatrics, Christian Medical College, Vellore, 632004 India
| | - Sanwar Agarwal
- Jaslok Hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, 400 026 India
| | - Purva Keni
- Jaslok Hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, 400 026 India
| | - Raju Khubchandani
- Jaslok Hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, 400 026 India
| | - Sathish Kumar
- Department of Paediatrics, Christian Medical College, Vellore, 632004 India
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Risk factors and clinical profile of thrombotic thrombocytopenic purpura in systemic lupus erythematosus patients. Is this a distinctive clinical entity in the thrombotic microangiopathy spectrum?: a case control study. Thromb Res 2014; 134:1020-7. [PMID: 25257921 DOI: 10.1016/j.thromres.2014.09.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The association of thrombotic thrombocytopenic purpura (TTP) with systemic lupus erythematosus (SLE) is rare. It is associated with high morbidity and mortality. Information about risk factors and clinical outcomes is scant. MATERIAL AND METHODS A retrospective case-control study was performed in a referral center in Mexico City between 1994 and 2013. Patients were diagnosed with TTP if they fulfilled the following criteria: microangiopathic haemolytic anaemia, thrombocytopenia, high LDH levels, normal fibrinogen and negative Coombs' test. Patients with SLE were diagnosed with ≥ 4 ACR criteria. We included three study groups: group A included patients with SLE-associated TTP (TTP/SLE; cases n = 22, TTP events n = 24); patients with non-autoimmune TTP (NA-TTP; cases n = 19, TTP events n = 22) were included in group B and patients with SLE without TTP (n = 48) in group C. RESULTS After multivariate analysis, lymphopenia < 1000/mm3 [OR 19.84, p = 0.037], high SLEDAI score three months prior to hospitalisation [OR 1.54, p = 0.028], Hg <7g/dL [OR 6.81, p = 0.026], low levels of indirect bilirubin [OR 0.51, p = 0.007], and less severe thrombocytopenia [OR 0.98, p = 0.009] were associated with TTP in SLE patients. Patients with TTP/SLE received increased cumulative steroid dose vs. NA-TTP (p = 0.006) and a higher number of immunosuppressive drugs (p = 0.015). Patients with TTP/SLE had higher survival than NA-TTP (p=0.033); however, patients hospitalised for TTP/SLE had a higher risk of death than lupus patients hospitalised for other causes CONCLUSIONS Lymphopenia is an independent risk factor for TTP/SLE. It is likely that patients with TTP/SLE present with less evident clinical features, so the level of suspicion must be higher to avoid delay in treatment.
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Fatal refractory thrombotic thrombocytopenic purpura complicating systemic lupus erythematosus. J Clin Rheumatol 2014; 19:412-4. [PMID: 24048105 DOI: 10.1097/rhu.0b013e3182a703bf] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Klonizakis P, Tselios K, Sarantopoulos A, Gougourellas I, Rouka E, Onufriadou Z, Kapali P, Kyriakou D, Boura P. ADAMTS-13 metalloprotease abnormalities in systemic lupus erythematosus: is there a correlation with disease status? Lupus 2014; 22:443-52. [PMID: 23554033 DOI: 10.1177/0961203313477898] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To clarify the role of ADAMTS-13 in the pathogenesis of thrombotic microangiopathy in systemic lupus erythematosus (SLE) we evaluated ADAMTS-13 profile (metalloprotease antigen levels, anti-ADAMTS-13 autoantibody levels, activity) in distinct patient groups according to disease activity, extent of cumulative tissue damage and history of antiphospholipid syndrome or end-organ damage. Forty-one lupus patients were analysed. ADAMTS-13 metalloprotease antigen levels and anti-ADAMTS-13 autoantibodies were evaluated by ELISA. ADAMTS-13 activity was measured by Fluorescence resonance energy transfer (FRET) technique. ADAMTS-13 metalloprotease antigen levels were significantly decreased in patients with Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) >1 (p<0.05). ADAMTS-13 metalloprotease antigen levels also exhibited a significant inverse correlation with anti-dsDNA levels (r= -0.60, p<0.05). Anti-ADAMTS-13 autoantibodies were marginally higher in patients with positive anti-dsDNA (p=0.08). Additionally, patients with positive anti-ADAMTS-13 autoantibodies exhibited the lowest activity levels (p<0.05). To our knowledge ADAMTS-13 profile in SLE has not been studied in regard to composite structured indices. The results of this study suggest that in patients with active SLE or considerable cumulative tissue damage, ADAMTS-13 levels may be decreased and anti-ADAMTS-13 autoantibodies may partially mediate this reduction. Further evaluation of ADAMTS-13 profile may explain its role in the pathogenesis of thrombotic microangiopathy in lupus patients and reveal a potential prognostic marker of microthrombotic manifestations in SLE.
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Affiliation(s)
- P Klonizakis
- Hematology Unit, Aristotle University of Thessaloniki, Greece.
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Kim D, Cho SK, Sung YK. The Present and Future of Clinical Research for Korean Lupus Patients. JOURNAL OF RHEUMATIC DISEASES 2014. [DOI: 10.4078/jrd.2014.21.2.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Dam Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
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Jiang H, An X, Li Y, Sun Y, Shen G, Tu Y, Tao J. Clinical features and prognostic factors of thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus: a literature review of 105 cases from 1999 to 2011. Clin Rheumatol 2013; 33:419-27. [PMID: 23954922 PMCID: PMC3937538 DOI: 10.1007/s10067-013-2312-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 05/29/2013] [Indexed: 11/30/2022]
Abstract
This study aims to review clinical features, treatments, and prognostic factors of thrombotic thrombocytopenic purpura (TTP) associated with systemic lupus erythematosus patients (sTTP). The case reports of sTTP published in world literature from 1999 to 2011 were collected, and 105 cases were divided into death group and survival group. The epidemiologic characteristics, clinical manifestations, laboratory examinations, treatments, and prognostic factors were analyzed. We found that coexistence of renal and neurological impairments were significantly frequent in the death group (100 %) than in the survival group (56.5 %) (P = 0.002). Type IV was predominant in 57.7 % of renal pathological damage, followed by type V (11.5 %), type II (5.8 %), and thrombotic microangiopathy (TMA) (5.8 %). TMA appeared more frequently (50 %) in the death group than in the survival group (6.25 %) (P = 0.042). End-stage renal disease occurred in nine cases with type IV in five (55.6 %), type TMA in one (11.1 %), and unspecified in three cases (33.3 %). Of 32 cases, 40.6 % showed severe ADAMTS13 deficiency and returned to normal or mildly deficient after remission. The total mortality rate of sTTP was 12.4 % and the mortality rate of patients with infection (27.3 %) was significantly higher than those without infection (8.4 %) (P = 0.028). Plasma exchange and glucocorticoids were administrated in over 80 % of cases with 65.7 % remission rate, while additional cytotoxics or rituximab was mostly used in refractory sTTP and achieved over 90 % of remission rate. Above all, coexistence of renal and neurological impairments, infection, and renal damage with type IV or TMA might denote a poor prognosis of sTTP.
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Affiliation(s)
- Honghao Jiang
- Department of Dermatology, Affiliated Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Road, Wuhan, 430030, China
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Jayabose S, Nowicki TS, Dunbar J, Levendoglu-Tugal O, Ozkaynak MF, Sandoval C. Acquired thrombotic thrombocytopenic purpura in children: a single institution experience. Indian J Pediatr 2013; 80:570-5. [PMID: 23263974 DOI: 10.1007/s12098-012-0940-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Accepted: 11/29/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the clinical features, treatment and prognosis of acquired thrombotic thrombocytopenic purpura (TTP) in children based on a single institution experience. METHODS This study is a retrospective review of all 12 children with TTP seen at New York Medical College- Westchester Medical Center during a period of 15 y from 1993 to 2008. RESULTS There were 7 females and 5 males with acquired TTP, with a median age of 13 (range, 6-17); and no cases of congenital TTP. The classic pentad of TTP (microangiopathic hemolytic anemia, thrombocytopenia, neurologic symptoms, renal dysfunction and fever) was seen in only three patients. Nine had renal involvement; eight had neurologic symptoms; and four had fever. All 12 patients had thrombocytopenia, anemia, and elevated LDH. Nine had idiopathic TTP. Three patients had one of the following underlying disorders: systemic lupus erythematosus, mixed connective tissue disorder, and aplastic anemia (post-bone marrow transplant on cyclosporine). ADAMTS13 level was decreased in 7 of 8 patients studied. Eight of 10 patients achieved remission with plasmapheresis alone. Two needed additional treatment before achieving remission. Two had one or more relapses, requiring immunosupressive treatment with vincrisine, prednisone, or rituximab. The patient with aplastic anemia died of pulmonary hypertension 5 y after bone marrow transplantation. All other 11 patients are alive and free of TTP for a median follow-up of 12 mo (range, 3-72 mo). CONCLUSIONS Acquired pediatric TTP responds well to plasmapheresis. However, many patients do require additional treatment because of refractoriness to plasmapheresis or relapse. The clinical features, response to treatment, and relapse rate of pediatric TTP appear similar to those of adult TTP.
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Affiliation(s)
- Somasundaram Jayabose
- Division of Pediatric Hematology-Oncology, Meenakshi Mission Hospital and Research Centre, Lake area, Melur Road, Madurai 625107, India.
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Bellon N, Anguel N, Vandendries C, Goujard C, Lambotte O. Auricular chondritis and thrombotic microangiopathy: an unusual combination revealing systemic lupus erythematosus. Joint Bone Spine 2013; 80:424-5. [PMID: 23332392 DOI: 10.1016/j.jbspin.2012.11.002] [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: 10/09/2012] [Accepted: 11/19/2012] [Indexed: 11/28/2022]
Abstract
Thrombotic microangiopathy is a severe disorder, which is a cause of stroke in young patients. Etiologic investigations are mandatory to diagnose underlying disease. Systemic lupus erythematosus is one of the diseases, which can be associated with thrombotic microangiopathy. Although lupus diagnosis is usually easy, relying on characteristic clinical manifestations, rare symptoms can be misinterpreted. We report here a case of polychondritis, which was the first manifestation of a lupus-associated thrombotic microangiopathy.
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Affiliation(s)
- Nathalia Bellon
- AP-HP, Department of Internal Medicine, Bicêtre University Medical Center, 78, rue du Général-Leclerc, 94275 Le-Kremlin-Bicêtre, France
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López-López L, Rivera-Rodríguez N, Vilá LM. Nitrofurantoin-induced microangiopathic haemolytic anaemia and thrombocytopaenia in a patient with systemic lupus erythematosus. BMJ Case Rep 2012; 2012:bcr-2012-006507. [PMID: 22977056 DOI: 10.1136/bcr-2012-006507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients with systemic lupus erythematosus (SLE) may develop thrombotic thrombocytopaenic purpura (TTP) or TTP-like illness manifested by microangiopathic haemolytic anaemia (MAHA) and thrombocytopaenia. The distinction between active SLE and TTP is difficult because these entities share similar clinical features. Drug-induced TTP caused by an immune-mediated reaction have been documented for several drugs. Herein, we report a middle-aged Hispanic woman with long-standing SLE, who developed a TTP-like illness characterised by MAHA and thrombocytopaenia after exposure to nitrofurantoin. The patient responded well to plasmapheresis and immunosuppressive therapy and has remained clinically stable after 18 months of follow-up. To our knowledge, this is the first case that reports the association between nitrofurantoin and a TTP-like presentation.
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Affiliation(s)
- Linnette López-López
- Department of Medicine, Division of Rheumatology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Yang Y, Zhang L, Tang Y, Zhao Y, Su B, Fu P. Systemic sclerosis with thrombotic thrombocytopenia purpura and malignant hypertension. Ren Fail 2012; 34:1170-2. [PMID: 22871138 DOI: 10.3109/0886022x.2012.712858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Thrombotic thrombocytopenia purpura (TTP) is a rare clinical syndrome characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, neurologic symptoms, acute renal impairment, and fever. It has been seldom reported in systemic sclerosis (SSc). Systemic renal crisis is an infrequent complication of SSc, and is characterized by new onset malignant hypertension, rapidly progressive oliguric renal failure, and MAHA. In this study, we present a case of SSc of 1 month duration, with TTP accompanied by new onset malignant hypertension. The patient responded to plasmapheresis but still died of septic shock.
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Affiliation(s)
- Yingying Yang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
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Radhi M, Carpenter SL. Thrombotic microangiopathies. ISRN HEMATOLOGY 2012; 2012:310596. [PMID: 22888446 PMCID: PMC3410315 DOI: 10.5402/2012/310596] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/10/2012] [Indexed: 01/13/2023]
Abstract
Thrombotic microangiopathy results from thrombotic occlusion of the microvasculature leading to fragmentation of red blood cells, profound thrombocytopenia, and a microangiopathic hemolytic anemia with elevation of lactate dehydrogenase and negative direct Coomb's test. This constellation of clinical and laboratory findings is not due to one disease entity; rather, it represents a variety of underlying diagnoses. Among the major disease entities are TTP/HUS, which can be congenital or acquired, bacterial infections, medications, vascular or endothelial pathology like Kasabach-Merritt phenomenon, and stem cell transplantation. In this paper, we offer a review of some of the major causes of thrombotic microangiopathy.
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Affiliation(s)
- Mohamed Radhi
- Pediatric Hematology/Oncology/Stem Cell Transplant, Children's Mercy Hospital, Kansas City, MO 64108, USA
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Aringer M, Burkhardt H, Burmester GR, Fischer-Betz R, Fleck M, Graninger W, Hiepe F, Jacobi AM, Kötter I, Lakomek HJ, Lorenz HM, Manger B, Schett G, Schmidt RE, Schneider M, Schulze-Koops H, Smolen JS, Specker C, Stoll T, Strangfeld A, Tony HP, Villiger PM, Voll R, Witte T, Dörner T. Current state of evidence on 'off-label' therapeutic options for systemic lupus erythematosus, including biological immunosuppressive agents, in Germany, Austria and Switzerland--a consensus report. Lupus 2011; 21:386-401. [PMID: 22072024 DOI: 10.1177/0961203311426569] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic lupus erythematosus (SLE) can be a severe and potentially life-threatening disease that often represents a therapeutic challenge because of its heterogeneous organ manifestations. Only glucocorticoids, chloroquine and hydroxychloroquine, azathioprine, cyclophosphamide and very recently belimumab have been approved for SLE therapy in Germany, Austria and Switzerland. Dependence on glucocorticoids and resistance to the approved therapeutic agents, as well as substantial toxicity, are frequent. Therefore, treatment considerations will include 'off-label' use of medication approved for other indications. In this consensus approach, an effort has been undertaken to delineate the limits of the current evidence on therapeutic options for SLE organ disease, and to agree on common practice. This has been based on the best available evidence obtained by a rigorous literature review and the authors' own experience with available drugs derived under very similar health care conditions. Preparation of this consensus document included an initial meeting to agree upon the core agenda, a systematic literature review with subsequent formulation of a consensus and determination of the evidence level followed by collecting the level of agreement from the panel members. In addition to overarching principles, the panel have focused on the treatment of major SLE organ manifestations (lupus nephritis, arthritis, lung disease, neuropsychiatric and haematological manifestations, antiphospholipid syndrome and serositis). This consensus report is intended to support clinicians involved in the care of patients with difficult courses of SLE not responding to standard therapies by providing up-to-date information on the best available evidence.
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Affiliation(s)
- M Aringer
- Rheumatology, Medicine III, University Medical Center TU Dresden, Germany.
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Thrombotic thrombocytopenic purpura associated with mixed connective tissue disease: a case report. Case Rep Med 2011; 2011:953890. [PMID: 21915182 PMCID: PMC3170900 DOI: 10.1155/2011/953890] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 07/10/2011] [Accepted: 07/13/2011] [Indexed: 11/29/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multisystemic disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia, which may be accompanied by fever, renal, or neurologic abnormalities. Cases are divided into acute idiopathic TTP and secondary TTP. Autoimmune diseases, especially systemic lupus erythematosus, in association with TTP have been described so far in many patients. In contrast, TTP occurring in a patient with mixed connected tissue disease (MCTD) is extremely rare and has only been described in nine patients. We describe the case of a 42-year-old female with MCTD who developed thrombocytopenia, microangiopathic hemolytic anemia, fever, and neurological symptoms. The patient had a good clinical evolution with infusion of high volume of fresh frozen plasma, steroid therapy, and support in an intensive care unit. Although the occurrence of TTP is rare in MCTD patients, it is important to recognize TTP as a cause of thrombocytopenia and hemolytic anemia in any patient with autoimmune diseases. Prompt institution of treatment remains the cornerstone of treatment of TTP even if plasma exchange is not available like what frequently happens in developing countries.
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Yang Z, Liang Y, Li C, Xi W, Zhong R. Associations of serum urea, creatinine and uric acid with clinical and laboratory features in patients with systemic lupus erythematosus. Rheumatol Int 2011; 32:2715-23. [PMID: 21800118 DOI: 10.1007/s00296-011-1987-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Accepted: 07/03/2011] [Indexed: 11/26/2022]
Abstract
The aim of this study is to investigate the associations of serum urea, creatinine and uric acid levels with clinical and laboratory characteristics, independent of lupus renal involvement in SLE patients. A total of 191 SLE patients were included in the present study. Some clinical and laboratory characteristics of the patients were obtained by medical record review. The results showed that serum urea, creatinine and uric acid levels seemed to be associated with several clinical and laboratory characteristics of SLE. However, multivariate logistical regression analysis indicated that increasing serum urea levels were positively associated with disease duration and thrombocytopenia, but negatively with arthritis and skin rash. Compared with quartile 1 of urea, the ORs of quartile 2, quartile 3 and quartile 4 were, respectively, 1.008 (0.997-1.015, P = 0.189), 1.010 (1.001-1.019, P = 0.038) and 1.014 (1.004-1.024, P = 0.008) with increasing disease duration; 1.912 (0.516-7.088, P = 0.332), 10.126 (2.771-36.997, P = 0.000) and 5.583 (1.285-24.266, P = 0.022) with thrombocytopenia; 0.864 (0.331-2.254, P = 0.765), 0.516 (0.18-1.475, P = 0.217) and 0.162 (0.047-0.557, P = 0.004) with arthritis; and 0.342 (0.135-0.868, P = 0.024), 0.215 (0.074-0.622, P = 0.005) and 0.332 (0.097-1.13, P = 0.078) with skin rash. Increasing serum creatinine levels were positively associated with sex, disease duration and SLEDAI, but negatively with skin rash. Compared with quartile 1 of creatinine, the ORs of quartile 2, quartile 3 and quartile 4 were, respectively, 2.993 (0.282-31.74, P = 0.363), 7.937 (0.861-73.18, P = 0.068) and 13.411 (1.32-36.246, P = 0.028) with male, 1.011 (1.002-1.02, P = 0.017), 1.002 (0.991-1.013, P = 0.684) and 1.018 (1.008-1.028, P = 0.001) with increasing disease duration; 1.112 (1.006-1.228, P = 0.038), 1.065 (0.959-1.183, P = 0.239) and 1.140 (1.022-1.272, P = 0.019) with increasing SLEDAI; and 0.303 (0.119-0.771, P = 0.012), 0.282 (0.104-0.76, P = 0.012) and 0.174 (0.052-0.584, P = 0.005) with skin rash. Increasing serum uric acid levels were only positively associated with erythrocytopenia. Compared with quartile 1 of uric acid, the ORs of quartile 2, quartile 3 and quartile 4 were, respectively, 0.910 (0.37-2.239, P = 0.837), 2.147 (0.901-5.116, P = 0.085) and 3.079 (1.211-7.828, P = 0.018) with erythrocytopenia. The present study demonstrated that, except for reflecting renal function, serum urea, creatinine and uric acid exert separate clinical significances in SLE.
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Affiliation(s)
- Zaixing Yang
- Department of Laboratory Diagnostics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China
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