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Liu W, Zhu X, Xiao Y. Neurological involvement in hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Ann Hematol 2024; 103:3303-3313. [PMID: 38763940 PMCID: PMC11358180 DOI: 10.1007/s00277-024-05798-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/08/2024] [Indexed: 05/21/2024]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a well-recognized serious complication of hematopoietic stem cell transplantation (HSCT). The understanding of TA-TMA pathophysiology has expanded in recent years. Dysregulation of the complement system is thought to cause endothelial injury and, consequently, microvascular thrombosis and tissue damage. TA-TMA can affect multiple organs, and each organ exhibits specific features of injury. Central nervous system (CNS) manifestations of TA-TMA include posterior reversible encephalopathy syndrome, seizures, and encephalopathy. The development of neurological dysfunction is associated with a significantly lower overall survival in patients with TA-TMA. However, there are currently no established histopathological or radiological criteria for the diagnosis of CNS TMA. Patients who receive total body irradiation (TBI), calcineurin inhibitors (CNI), and severe acute and chronic graft-versus-host disease (GVHD) are at a high risk of experiencing neurological complications related to TA-TMA and should be considered for directed TA-TMA therapy. However, the incidence and clinical manifestations of TA-TMA neurotoxicity remain unclear. Studies specifically examining the involvement of CNS in TMA syndromes are limited. In this review, we discuss clinical manifestations and imaging abnormalities in patients with nervous system involvement in TA-TMA. We summarize the mechanisms underlying TA-TMA and its neurological complications, including endothelial injury, evidence of complement activation, and treatment options for TA-TMA.
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Affiliation(s)
- Wanying Liu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Yi Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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2
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Zhou X, Ye Y, Jin A, Pan Z, Xu Z, Ding S, Yan J, Cheng Y, Huang Y, Cao K, Xie W, Zhang J, Xu L, Zhou W, Huang L. Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study. BMC Nurs 2024; 23:535. [PMID: 39113009 PMCID: PMC11304727 DOI: 10.1186/s12912-024-02093-7] [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: 12/19/2023] [Accepted: 06/13/2024] [Indexed: 08/11/2024] Open
Abstract
OBJECTIVE The early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project. METHODS This study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement. RESULTS A total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001). CONCLUSION The evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.
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Affiliation(s)
- Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhengwen Pan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhe Xu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Shuyi Ding
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jiali Yan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yin Cheng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yixuan Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Kai Cao
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Wei Xie
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jianli Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Liwei Xu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Weiwei Zhou
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Lihua Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China.
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3
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Ito S, Saito A, Sakurai A, Watanabe K, Karakawa S, Miyamura T, Yokosuka T, Ueki H, Goto H, Yagasaki H, Kinoshita M, Ozeki M, Yokoyama N, Teranishi H. Eculizumab treatment in paediatric patients diagnosed with aHUS after haematopoietic stem cell transplantation: a HSCT-TMA case series from Japanese aHUS post-marketing surveillance. Bone Marrow Transplant 2024; 59:315-324. [PMID: 38102212 PMCID: PMC10920193 DOI: 10.1038/s41409-023-02161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/26/2023] [Accepted: 11/22/2023] [Indexed: 12/17/2023]
Abstract
Haematopoietic stem-cell transplantation (HSCT)-associated thrombotic microangiopathy (HSCT-TMA) is a serious complication with high mortality. Accumulating evidence suggests that complement dysregulation is potentially involved in the development of HSCT-TMA. We retrospectively analysed the clinical characteristics and outcomes of thirteen paediatric patients who were diagnosed with atypical haemolytic uremic syndrome and treated with eculizumab to manage HSCT-TMA during post-marketing surveillance in Japan. The median time from HSCT to TMA was 31 days (Interquartile range, IQR;21-58) and the median doses of eculizumab was three (IQR;2-5). Seven patients (54%) were alive at the last follow-up while six died due to complications related to HSCT. Six of seven survivors initiated eculizumab after insufficient response to plasma therapy. Following eculizumab treatment, median platelet counts and LDH levels in all survivors significantly improved and renal function improved in 4/7 patients. All survivors possessed potential risk factors of complement overactivation. During the follow-up period after eculizumab discontinuation (median;111.5 days, IQR;95-555), no TMA recurrence was observed. In this analysis, eculizumab showed benefit in over half of this paediatric patient population. Ongoing clinical studies are expected to optimize the treatment regimen of terminal complement pathway inhibitor, and it may become a therapeutic option for paediatric HSCT-TMA in the future.
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Affiliation(s)
- Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Atsuro Saito
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, 1-6-7 Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Ayako Sakurai
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Iida-cho, Narita, Chiba, 286-8523, Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Shuhei Karakawa
- Department of Pediatrics, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-15 Yamadaoka Suita-shi, Osaka, 565-0871, Japan
| | - Tomoko Yokosuka
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Hideaki Ueki
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Iida-cho, Narita, Chiba, 286-8523, Japan
| | - Hiroaki Goto
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Hiroshi Yagasaki
- Pediatrics, Nihon University Itabashi hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173- 8610, Japan
| | - Mariko Kinoshita
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Norifumi Yokoyama
- Department of Pediatrics, Gifu Municipal Hospital, 7-1 Kashima-cho, Gifu, Gifu, 500-8513, Japan
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Azimi S, Hajifathali A, Parkhideh S, Salamzadeh J, Rahmati-Kamel B, Dastan F, Mehdizadeh M, Abiyarghamsari M, Tavakoli-Ardakani M. Efficacy and Safety of a DOAC Compared to Unfractionated Heparin and A Low Molecular Weight Heparin in the Prevention of Thromboembolism in Hematopoietic Stem Cell Transplant Recipients. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2024; 23:e143213. [PMID: 39005732 PMCID: PMC11246640 DOI: 10.5812/ijpr-143213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/19/2023] [Accepted: 12/26/2023] [Indexed: 07/16/2024]
Abstract
Background Hematopoietic stem cell transplantation (HSCT) patients are at risk of thromboembolic events, making thromboprophylaxis crucial. Objectives This study aimed to compare apixaban, a direct factor Xa inhibitor (DOAC), with dalteparin and unfractionated heparin for thromboprophylaxis in HSCT recipients. The safety outcome included the assessment of hemorrhagic events. Methods In this open-label randomized clinical trial, 182 HSCT recipients were divided into three groups: Apixaban (n = 61, 2.5 mg two times a day), dalteparin (n = 59, 5000 IU daily), and unfractionated heparin (n = 62, 5000 IU twice daily). These anticoagulant regimens were administered after central vein catheterization and during hospitalization. The primary clinical outcome was the risk of thrombosis, and the secondary outcome was the rate of bleeding. Relevant laboratory results were analyzed using appropriate statistical tests. Results Among the 61 patients in the apixaban group, six experienced thrombosis (9.83%), with four (6.65%) of them on anticoagulants. In the dalteparin group, three patients (5%) developed thrombosis, two of whom (3.38%) were on anticoagulants. In the heparin group, all four thrombosis cases (6.4%) occurred in patients on anticoagulants (P = 0.543 overall and P = 0.776 in anticoagulant users). Only two cases of bleeding were reported (1.09% overall), one in the dalteparin group (1.69%) and the other in the apixaban group (1.63%). Conclusions Apixaban, dalteparin, and heparin demonstrated similar effectiveness in preventing thromboembolism in HSCT recipients. Furthermore, the comparison of bleeding rates across the study groups did not reveal significant differences. Larger studies with higher event rates may yield more precise conclusions.
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Affiliation(s)
- Saeed Azimi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Hajifathali
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayeh Parkhideh
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jamshid Salamzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Farzaneh Dastan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mahshid Mehdizadeh
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdiye Abiyarghamsari
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Internal Medicines, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maria Tavakoli-Ardakani
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pharmaceutical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Aklilu AM, Shirali AC. Chemotherapy-Associated Thrombotic Microangiopathy. KIDNEY360 2023; 4:409-422. [PMID: 36706238 PMCID: PMC10103319 DOI: 10.34067/kid.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023]
Abstract
Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as antiangiogenesis agents and proteasome inhibitors have been implicated in oncotherapy-associated TMA. Among TMA subtypes, drug-induced TMA is less well-understood. Treatment generally involves withdrawal of the offending agent and supportive care targeting blood pressure and proteinuria reduction. Immunosuppression and therapeutic plasma exchange have not shown clear benefit. The terminal complement inhibitor, eculizumab, has shown promising results in some cases of chemotherapy-associated TMA including in re-exposure. However, the data are limited, and unlike in primary atypical hemolytic uremic syndrome, the role of complement in the pathogenesis of drug-induced TMA is unclear. Larger multicenter studies and unified definitions are needed to elucidate the extent of the problem and potential treatment strategies.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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6
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Leimi L, Jahnukainen K, Olkinuora H, Meri S, Vettenranta K. Early vascular toxicity after pediatric allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2022; 57:705-711. [PMID: 35177827 PMCID: PMC9090633 DOI: 10.1038/s41409-022-01607-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/08/2022]
Abstract
Treatment-related mortality and morbidity remain a challenge in hematopoietic stem cell transplantation (HSCT). In this retrospective, single-center study, we analyzed endothelial damage as a potential, common denominator and mechanism for the adverse effects. We evaluated the prevalence of key vascular complications and graft-versus-host disease among 122 pediatric patients with an allogeneic HSCT between 2001 and 2013. The spectrum and frequency of acute adverse events emerging ≤100 days post transplant were graded according to the CTCAE 4.03 and analyzed. We identified a total of 19/122 (15.6%) patients with vascular complications, fulfilling the criteria of capillary leak syndrome, veno-occlusive disease/sinusoidal obstruction syndrome or thrombotic microangiopathy. The patients had a poorer overall survival (77% versus 26%, p < 0.001). Nearly one half (56/122, 45.9%) had at least one, severe (grade 3 or 4) adverse event. Patients with vascular complications had more often edema/effusions (p = 0.023), thrombocytopenia (p = 0.001), gastrointestinal bleeding (p < 0.001), acute kidney injury (p < 0.001), ascites (p < 0.001) or bilirubin increase (p = 0.027). These endotheliopathy-related adverse events appeared early post HSCT, varied in their clinical phenotype and predicted a poor outcome. An unrelated donor but not previous exposure to leukemia or irradiation-based conditioning was identified as a risk factor for vascular complications and endotheliopathy.
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Affiliation(s)
- Lilli Leimi
- University of Helsinki, Helsinki University Hospital, Children's Hospital, and Pediatric Research Center, Helsinki, Finland.
| | - Kirsi Jahnukainen
- University of Helsinki, Helsinki University Hospital, Children's Hospital, and Pediatric Research Center, Helsinki, Finland
- NORDFERTIL Research Lab Stockholm, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Helena Olkinuora
- University of Helsinki, Helsinki University Hospital, Children's Hospital, and Pediatric Research Center, Helsinki, Finland
| | - Seppo Meri
- Department of Bacteriology and Immunology and Translational Immunology Research Program, University of Helsinki, and Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Kim Vettenranta
- University of Helsinki, Helsinki University Hospital, Children's Hospital, and Pediatric Research Center, Helsinki, Finland
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7
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Acute graft-versus-host disease increase risk and accuracy in prediction model of transplantation-associated thrombotic microangiopathy in patients with myelodysplastic syndrome. Ann Hematol 2022; 101:1295-1309. [PMID: 35357522 DOI: 10.1007/s00277-022-04820-z] [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: 05/12/2021] [Accepted: 03/23/2022] [Indexed: 11/01/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation is the only curative therapy for patients with myelodysplastic syndrome. Transplantation-associated thrombotic microangiopathy (TA-TMA) remains a cause of death after transplantation. This study assessed the risk factors of TA-TMA and established a prediction model for this complication. We launched a real-world study from 303 MDS patients after allo-HSCT from Dec 1, 2007, to Jun 1, 2018. Logistic regression was used to analyze risk factors and to establish a nomogram. The accuracy of the model was assessed by C-index and calibration curve. TA-TMA class was associated with an over twofold increase in the risk of death (HR 2.66, 95% CI 1.39-5.09, p = 0.003). Stage III or IV acute graft-versus-host disease (aGVHD) (OR: 6.17, 95% CI: 2.19-17.18, p < 0.001) and occurrence time of aGVHD were the risk factors for TA-TMA. Next, we put these two variants and the other three variants into the prediction model via multivariate Lasso regression. In order to quantify the contribution of each factor, a nomogram was generated and displayed (C index of 0.783). TA-TMA predicts worsened outcomes of overall survival. A cross-validated multivariate score including aGVHD occurrence showed excellent concordance and efficacy of predicting TA-TMA in HSCT patients.
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8
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Cugno M, Berra S, Depetri F, Tedeschi S, Griffini S, Grovetti E, Caccia S, Cresseri D, Messa P, Testa S, Giglio F, Peyvandi F, Ardissino G. IgM Autoantibodies to Complement Factor H in Atypical Hemolytic Uremic Syndrome. J Am Soc Nephrol 2021; 32:1227-1235. [PMID: 33712527 PMCID: PMC8259677 DOI: 10.1681/asn.2020081224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/18/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS), a severe thrombotic microangiopathy, is often related to complement dysregulation, but the pathomechanisms remain unknown in at least 30% of patients. Researchers have described autoantibodies to complement factor H of the IgG class in 10% of patients with aHUS but have not reported anti-factor H autoantibodies of the IgM class. METHODS In 186 patients with thrombotic microangiopathy clinically presented as aHUS, we searched for anti-factor H autoantibodies of the IgM class and those of the IgG and IgA classes. We used immunochromatography to purify anti-factor H IgM autoantibodies and immunoenzymatic methods and a competition assay with mapping mAbs to characterize interaction with the target protein. RESULTS We detected anti-factor H autoantibodies of the IgM class in seven of 186 (3.8%) patients with thrombotic microangiopathy presented as aHUS. No association was observed between anti-factor H IgM and homozygous deletions involving CFHR3-CFHR1. A significantly higher proportion of patients with bone marrow transplant-related thrombotic microangiopathy had anti-factor H IgM autoantibodies versus other patients with aHUS: three of 20 (15%) versus four of 166 (2.4%), respectively. The identified IgM autoantibodies recognize the SCR domain 19 of factor H molecule in all patients and interact with the factor H molecule, inhibiting its binding to C3b. CONCLUSIONS Detectable autoantibodies to factor H of the IgM class may be present in patients with aHUS, and their frequency is six-fold higher in thrombotic microangiopathy forms associated with bone marrow transplant. The autoantibody interaction with factor H's active site may support an autoimmune mechanism in some cases previously considered to be of unknown origin.
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Affiliation(s)
- Massimo Cugno
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Berra
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Federica Depetri
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvana Tedeschi
- Laboratorio di Genetica Medica, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Samantha Griffini
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Grovetti
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Sonia Caccia
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Donata Cresseri
- Unità Operativa di Nefrologia, Dialisi e Trapianto Renale, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Piergiorgio Messa
- Unità Operativa di Nefrologia, Dialisi e Trapianto Renale, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Sara Testa
- Center for Hemolytic Uremic Syndrome Prevention, Control and Management, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico S. Raffaele Scientific Institution, Milan, Italy
| | - Flora Peyvandi
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Ardissino
- Center for Hemolytic Uremic Syndrome Prevention, Control and Management, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
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9
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Páramo JA. [Microvascular thrombosis and clinical implications]. Med Clin (Barc) 2021; 156:609-614. [PMID: 33875227 DOI: 10.1016/j.medcli.2020.12.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 01/10/2023]
Abstract
Thrombosis is often present in the microcirculation in a variety of significant human diseases, such as disseminated intravascular coagulation, thrombotic microangiopathy, sickle cell disease, and others. Microvascular thrombosis has also recently been demonstrated in patients with COVID-19 and has been proposed to mediate the pathogenesis of organ injury in the lung and other organs. In many of these conditions, microvascular thrombosis is accompanied by inflammation, an association referred to as thromboinflammation or immunothrombosis. A greater understanding of the links between inflammation and thrombosis in the microcirculation will provide new therapeutic options for human diseases accompanied by microvascular thrombosis.
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Affiliation(s)
- José A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, IdiSNA, CIBERCV, Pamplona, Navarra, España.
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10
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Valério P, Barreto JP, Ferreira H, Chuva T, Paiva A, Costa JM. Thrombotic microangiopathy in oncology - a review. Transl Oncol 2021; 14:101081. [PMID: 33862523 PMCID: PMC8065296 DOI: 10.1016/j.tranon.2021.101081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Thrombotic microangiopathy is a syndrome triggered by a wide spectrum of situations, some of which are specific to the Oncology setting. It is characterized by a Coombs-negative microangiopathic haemolytic anemia, thrombocytopenia and organ injury, with characteristic pathological features, resulting from platelet microvascular occlusion. TMA is rare and its cancer-related subset even more so. TMA triggered by drugs is the most common within this group, including classic chemotherapy and the latest targeted therapies. The neoplastic disease itself and hematopoietic stem-cell transplantation could also be potential triggers. Evidence-based medical guidance in the management of cancer-related TMA is scarce and the previous knowledge about primary TMA is valuable to understand the disease mechanisms and the potential treatments. Given the wide spectrum of potential causes for TMA in cancer patients, the aim of this review is to gather the vast information available. For each entity, pathophysiology, clinical features, therapeutic approaches and prognosis will be covered.
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Affiliation(s)
- Patrícia Valério
- Nephrology Department, Setúbal Hospital Center, Portugal Rua Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal.
| | - João Pedro Barreto
- Laboratory Diagnosis Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Hugo Ferreira
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Teresa Chuva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Ana Paiva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - José Maximino Costa
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
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11
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[Chinese consensus on the diagnosis and management of transplant-associated thrombotic microangiopathy (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:177-184. [PMID: 33910301 PMCID: PMC8081937 DOI: 10.3760/cma.j.issn.0253-2727.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Indexed: 01/04/2023]
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12
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Gomez-Ganda L, Benitez-Carabante MI, Fernandez-Polo A, Muñoz-Lopez M, Renedo-Miro B, Ariceta G, Diaz De Heredia C. Use of Eculizumab in Pediatric Patients With Transplant Associated Thrombotic Microangiopathy. Front Pediatr 2021; 9:761726. [PMID: 34858907 PMCID: PMC8632356 DOI: 10.3389/fped.2021.761726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/06/2021] [Indexed: 01/27/2023] Open
Abstract
Background: Transplant-associated thrombotic microangiopathy (TA-TMA) is a serious complication of hematopoietic stem cell transplantation (HSCT) associated with high morbidity and mortality. High-risk TA-TMA (hrTA-TMA) is characterized by multifactorial endothelial damage caused by environmental stressors, dysregulation of the complement system, and genetic predisposition. Complement inhibitors have significantly decreased mortality and are the current treatment of choice. In this article, we describe our experience with the use of eculizumab in pediatric patients diagnosed with hrT-TMA after HSCT. Method: Retrospective study of pediatric patients with hrTA-TMA treated with eculizumab between January 2016 and December 2020. Results: Four pediatric patients aged 1, 12, 14, and 17 years at the time of HSCT were diagnosed with hrTA-TMA and treated with eculizumab during the study. At diagnosis, they all had renal impairment with proteinuria, and hypertension under treatment with at least two antihypertensive drugs. The patient who presented multisystemic involvement died instead of treatment. The three patients with exclusive renal involvement achieved TA-TMA resolution after treatment with eculizumab for 65, 52, and 40.6 weeks and were able to stop treatment. The two patients with follow-up data one year after eculizumab withdrawal sustained a favorable response. Eculizumab was well tolerated, and with adequate vaccination and antibiotic prophylaxis, did not increase the risk of infection. Conclusions: Eculizumab appears to be both safe and effective for the treatment of hrTA-TMA in patients with renal impairment. Early diagnosis and initiation of treatment may improve response. Eculizumab withdrawal can be contemplated in patients who achieve laboratory and clinical resolution of TA-TMA.
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Affiliation(s)
- Laura Gomez-Ganda
- Pharmacy Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Isabel Benitez-Carabante
- Pediatric Oncology and Hematology Service, Hematopoietic Stem Cell Transplantation Section, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Marina Muñoz-Lopez
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Berta Renedo-Miro
- Pharmacy Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Gema Ariceta
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cristina Diaz De Heredia
- Pediatric Oncology and Hematology Service, Hematopoietic Stem Cell Transplantation Section, Vall d'Hebron University Hospital, Barcelona, Spain
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13
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Malyszko J, Basak G, Batko K, Capasso G, Capasso A, Drozd-Sokolowska J, Krzanowska K, Kulicki P, Matuszkiewicz-Rowinska J, Soler MJ, Sprangers B, Malyszko J. Haematological disorders following kidney transplantation. Nephrol Dial Transplant 2020; 37:409-420. [PMID: 33150431 DOI: 10.1093/ndt/gfaa219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Indexed: 01/19/2023] Open
Abstract
Transplantation offers cure for some haematological cancers, end-stage organ failure, but at the cost of long-term complications. Renal transplantation is the best-known kidney replacement therapy and it can prolong end-stage renal disease patient lives for decades. However, patients after renal transplantation are at a higher risk of developing different complications connected not only with surgical procedure but also with immunosuppressive treatment, chronic kidney disease progression and rejection processes. Various blood disorders can develop in post-transplant patients ranging from relatively benign anaemia through cytopenias to therapy-related myelodysplasia and acute myeloid leukaemia (AML) and post-transplant lymphoproliferative disorders followed by a rare and fatal condition of thrombotic microangiopathy and haemophagocytic syndrome. So far literature mainly focused on the post-transplant lymphoproliferative disease. In this review, a variety of haematological problems after transplantation ranging from rare disorders such as myelodysplasia and AML to relatively common conditions such as anaemia and iron deficiency are presented with up-to-date diagnosis and management.
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Affiliation(s)
| | - Grzegorz Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Batko
- Department of Nephrology, Collegium Medicum, Jagiellonian University, Cracow, Poland
| | - Giavambatista Capasso
- Department of Translational Medical Sciences, University Luigi Vanvitelli, Naples, Italy
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, The University of Texas, Austin, TX, USA
| | - Joanna Drozd-Sokolowska
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Krzanowska
- Department of Nephrology, Collegium Medicum, Jagiellonian University, Cracow, Poland
| | - Pawel Kulicki
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Maria Jose Soler
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ben Sprangers
- Department of Microbiology, Immunology, and Transplantation, Laboratory of Molecular Immunology, Rega Institute, Katholieke Universiteit Leuven, Belgium.,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Jacek Malyszko
- 1st Department of Nephrology and Transplantology, Medical University of Bialystok, Bialystok, Poland
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Bray MA, Sartain SE, Gollamudi J, Rumbaut RE. Microvascular thrombosis: experimental and clinical implications. Transl Res 2020; 225:105-130. [PMID: 32454092 PMCID: PMC7245314 DOI: 10.1016/j.trsl.2020.05.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 02/07/2023]
Abstract
A significant amount of clinical and research interest in thrombosis is focused on large vessels (eg, stroke, myocardial infarction, deep venous thrombosis, etc.); however, thrombosis is often present in the microcirculation in a variety of significant human diseases, such as disseminated intravascular coagulation, thrombotic microangiopathy, sickle cell disease, and others. Further, microvascular thrombosis has recently been demonstrated in patients with COVID-19, and has been proposed to mediate the pathogenesis of organ injury in this disease. In many of these conditions, microvascular thrombosis is accompanied by inflammation, an association referred to as thromboinflammation. In this review, we discuss endogenous regulatory mechanisms that prevent thrombosis in the microcirculation, experimental approaches to induce microvascular thrombi, and clinical conditions associated with microvascular thrombosis. A greater understanding of the links between inflammation and thrombosis in the microcirculation is anticipated to provide optimal therapeutic targets for patients with diseases accompanied by microvascular thrombosis.
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Key Words
- adamts13, a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13
- ap, alternate pathway
- apc, activated protein c
- aps, antiphospholipid syndrome
- caps, catastrophic aps
- asfa, american society for apheresis
- atp, adenosine triphosphate
- cfh, complement factor h
- con a, concavalin a
- cox, cyclooxygenase
- damp, damage-associated molecular pattern
- dic, disseminated intravascular coagulation
- gbm, glomerular basement membrane
- hellp, hemolysis, elevated liver enzymes, low platelets
- hitt, heparin-induced thrombocytopenia and thrombosis
- hlh, hemophagocytic lymphohistiocytosis
- hus, hemolytic-uremic syndrome
- isth, international society for thrombosis and haemostasis
- ivig, intravenous immunoglobulin
- ldh, lactate nos, nitric oxide synthase
- net, neutrophil extracellular trap
- pai-1, plasminogen activator inhibitor 1
- pf4, platelet factor 4
- prr, pattern recognition receptor
- rbc, red blood cell
- scd, sickle cell disease
- sle, systemic lupus erythematosus
- tlr, toll-like receptor
- tf, tissue factor
- tfpi, tissue factor pathway inhibitor
- tma, thrombotic microangiopathy
- tnf-α, tumor necrosis factor-α
- tpe, therapeutic plasma exchange
- ulc, ultra large heparin-pf4 complexes
- ulvwf, ultra-large von willebrand factor
- vwf, von willebrand factor
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Affiliation(s)
- Monica A Bray
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Sarah E Sartain
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Jahnavi Gollamudi
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas
| | - Rolando E Rumbaut
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey VA Medical Center, Houston, Texas; Baylor College of Medicine, Houston, Texas.
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15
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Fornwalt RA, Brigham EP, Scott Stephens R. Critical Care of Hematopoietic Stem Cell Transplant Patients. Crit Care Clin 2020; 37:29-46. [PMID: 33190774 DOI: 10.1016/j.ccc.2020.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Life-threatening complications are frequent after hematopoietic stem cell transplant (HSCT), and optimum critical care is essential to ensuring good outcomes. The immunologic consequences of HSCT result in a markedly different host response to critical illness. Infection is the most common cause of critical illness but noninfectious complications are frequent. Respiratory failure or sepsis are the typical presentations but the sequelae of HSCT can affect nearly any organ system. Pattern recognition can facilitate anticipation and early intervention in post-HSCT critical illness. HSCT critical care is a multidisciplinary endeavor. Continued investigation and focus on process improvement will continue to improve outcomes.
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Affiliation(s)
- Rachael A Fornwalt
- Oncology Intensive Care Unit, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Harry and Jeanette Weinberg Building, Pod 5C, 401 North Broadway, Baltimore, MD 21231, USA
| | - Emily P Brigham
- Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - R Scott Stephens
- Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Oncology, Johns Hopkins University, 1800 Orleans Street, Suite 9121 Zayed Tower, Baltimore, MD 21287, USA.
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16
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Hildebrandt GC, Chao N. Endothelial cell function and endothelial-related disorders following haematopoietic cell transplantation. Br J Haematol 2020; 190:508-519. [PMID: 32319084 PMCID: PMC7496350 DOI: 10.1111/bjh.16621] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022]
Abstract
Use of haematopoietic cell transplantation (HCT) in the treatment of haematologic and neoplastic diseases may lead to life-threatening complications that cause substantial morbidity and mortality if untreated. In addition to patient- and disease-related factors, toxicity associated with HCT puts patients at risk for complications that share a similar pathophysiology involving endothelial cells (ECs). Normally, the endothelium plays a role in maintaining homeostasis, including regulation of coagulation, vascular tone, permeability and inflammatory processes. When activated, ECs acquire cellular features that may lead to phenotypic changes that induce procoagulant, pro-inflammatory and pro-apoptotic mediators leading to EC dysfunction and damage. Elevated levels of coagulation factors, cytokines and adhesion molecules are indicative of endothelial dysfunction, and endothelial damage may lead to clinical signs and symptoms of pathological post-HCT conditions, including veno-occlusive disease/sinusoidal obstruction syndrome, graft-versus-host disease, transplant-associated thrombotic microangiopathy and idiopathic pneumonia syndrome/diffuse alveolar haemorrhage. The endothelium represents a rational target for preventing and treating HCT complications arising from EC dysfunction and damage. Additionally, markers of endothelial damage may be useful in improving diagnosis of HCT-related complications and monitoring treatment effect. Continued research to effectively manage EC activation, injury and dysfunction may be important in improving patient outcomes after HCT.
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Affiliation(s)
| | - Nelson Chao
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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17
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Hyzy RC, McSparron J. ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7121823 DOI: 10.1007/978-3-030-26710-0_80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hematopoietic stem cell transplant (HSCT) is an essential treatment modality for many malignant and non-malignant hematologic diseases. Advances in HSCT techniques have dramatically decreased peri-transplant morbidity and mortality, but it remains a high-risk procedure, and a significant number of patients will require critical care during the transplant process. Complications of HSCT are both infectious and non-infectious, and the intensivist must be familiar with common infections, the management of neutropenic sepsis and septic shock, the management of respiratory failure in the immunocompromised host, and a plethora of HSCT-specific complications. Survival from critical illness after HSCT is improving, but the mortality rate remains unacceptably high. Continued research and optimization of critical care provision in this population should continue to improve outcomes.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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18
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Complement-mediated thrombotic microangiopathy as a link between endothelial damage and steroid-refractory GVHD. Blood Adv 2019; 2:2619-2628. [PMID: 30327370 DOI: 10.1182/bloodadvances.2018020321] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/07/2018] [Indexed: 12/19/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA), a complication of hematopoietic cell transplant (HCT), is associated with significant morbidity and mortality. The pathophysiology and overlap of TA-TMA with other posttransplant complications such as graft-versus-host disease (GVHD) is poorly understood. We retrospectively identified cases of TA-TMA among patients with grade 3/4 gastrointestinal (GI) GVHD, reviewed intestinal biopsy specimens, and performed correlative testing of biomarkers associated with TA-TMA. TA-TMA was more common in patients with steroid-refractory GVHD compared with steroid-responsive GVHD (79.3% vs 42.1%; P = .001). Among patients surviving 100 days post-HCT, 1-year survival from day 100 was significantly better for patients who had not developed TA-TMA in the first 100 days (69.5% vs 36.7%; P < .001). Only 1 of 7 proposed TA-TMA histology criteria (mucosal hemorrhage) differed significantly based on GVHD steroid response. In multivariable modeling, steroid-refractory GVHD was a risk factor for development of TA-TMA (hazard ratio, 3.09; 95% confidence interval, 1.68-5.67; P < .001). There were no differences in complement activation at GVHD onset; however, 2 to 6 weeks later, patients with TA-TMA had higher levels of BBPlus and C5b-9, markers of alternative and terminal pathway activation (BBPlus: median, 600 vs 209.3 ng/mL; P = .0045) (C5b-9: median, 425.9 vs 258.4 ng/mL; P = .029). TA-TMA is associated with poor overall survival (OS) following HCT and may be detected early by histologic findings and may be differentiated from GVHD by measurement of alternative and terminal complement pathway activation. It is unknown whether treatment of TA-TMA will improve survival in steroid-refractory GVHD.
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19
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Wanchoo R, Bayer RL, Bassil C, Jhaveri KD. Emerging Concepts in Hematopoietic Stem Cell Transplantation-Associated Renal Thrombotic Microangiopathy and Prospects for New Treatments. Am J Kidney Dis 2018; 72:857-865. [PMID: 30146419 DOI: 10.1053/j.ajkd.2018.06.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 06/06/2018] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy associated with hematopoietic stem cell transplantation (HSCT-TMA) is a well-recognized complication of HSCT that has a high risk for death. Even in patients who survive, HSCT-TMA is associated with long-term morbidity and chronic organ injury. HSCT-TMA is a multisystem disease that often affects the kidneys. Renal manifestations of HSCT-TMA include reduced glomerular filtration rate, proteinuria, and hypertension. Understanding of the pathophysiology of HSCT-TMA has expanded in the last decade. Endothelial injury plays a major role. Recent studies also suggest involvement of complement activation. HSCT-TMA has also been considered by some to be an endothelial variant of graft-versus-host disease. Understanding the pathophysiology of HSCT-TMA and its association with activation of the complement system may aid in developing novel therapeutic options. In this review, we summarize current knowledge focusing on epidemiology and prognosis, evidence of complement activation, and endothelial injury; the possible link to graft-versus-host disease; and treatment options for HSCT-TMA.
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Affiliation(s)
- Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Ruthee L Bayer
- Division of Hematology and Oncology and the Northwell Cancer Institute, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Claude Bassil
- Division of Nephrology and Hypertension, University of South Florida, Tampa, FL; Renal Service, H. Lee Moffitt Center, Tampa, FL
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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20
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Rudoni J, Jan A, Hosing C, Aung F, Yeh J. Eculizumab for transplant-associated thrombotic microangiopathy in adult allogeneic stem cell transplant recipients. Eur J Haematol 2018; 101:389-398. [PMID: 29920784 DOI: 10.1111/ejh.13127] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate response rates and survival in adults with transplant-associated thrombotic microangiopathy (TA-TMA) after allogeneic hematopoietic stem cell transplantation (HSCT) who were treated with eculizumab (ECU). METHODS Patients were identified retrospectively and data collected through HSCT and pharmacy databases. RESULTS Ten patients with TA-TMA after allogeneic HSCT were treated with ECU between 2013 and 2016. TA-TMA was diagnosed at a median of 93 days post-HSCT. Organ-specific injury was documented in all ten patients at time of TA-TMA diagnosis, the most common being renal dysfunction (90%). Acute GVHD (70%) and active infection (80%) were common at time of diagnosis. The median time to ECU initiation from TA-TMA diagnosis was 4 days. Seven patients received ECU as first-line therapy in combination with other treatment modalities, while three patients were treated with ECU as second-line therapy. ECU was well tolerated with the exception of one case of severe skin rash leading to discontinuation. ECU achieved an overall hematologic response rate of 70% and an overall survival rate of 60%. One patient achieved a complete response with corresponding organ recovery. CONCLUSION Early initiation of ECU may not alter the disease process enough to restore organ function, but it may prolong survival.
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Affiliation(s)
- Joslyn Rudoni
- Department of Pharmacy, Cleveland Clinic Health System, Cleveland, Ohio
| | - Anna Jan
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Division of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fleur Aung
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Yeh
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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21
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Winthrop KL, Mariette X, Silva JT, Benamu E, Calabrese LH, Dumusc A, Smolen JS, Aguado JM, Fernández-Ruiz M. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors). Clin Microbiol Infect 2018; 24 Suppl 2:S21-S40. [PMID: 29447987 DOI: 10.1016/j.cmi.2018.02.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection. IMPLICATIONS Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.
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Affiliation(s)
- K L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA.
| | - X Mariette
- Department of Rheumatology, Hôpitaux Universitaire Paris-Sud, Université Paris-Sud, INSERM U1184, Paris, France
| | - J T Silva
- Department of Infectious Diseases, University Hospital of Badajoz, Fundación para La Formación e Investigación de Los Profesionales de La Salud (FundeSalud), Badajoz, Spain
| | - E Benamu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - L H Calabrese
- Department of Rheumatic and Immunological Diseases, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH, USA
| | - A Dumusc
- Department of Rheumatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - J S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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22
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Weitz IC. Thrombotic microangiopathy in cancer. Thromb Res 2018; 164 Suppl 1:S103-S105. [PMID: 29703465 DOI: 10.1016/j.thromres.2018.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/08/2018] [Indexed: 12/28/2022]
Abstract
Thrombotic microangiopathy (TMA) is clinical syndrome based on the presence of thrombocytopenia (platelet count <150 K or a reduction of the platelet count by >30% from baseline) accompanied by fragmentation hemolysis (MAHA) and evidence of organ damage. It can be seen in a variety of disorders including thrombotic thrombocytopenic purpura (TTP), atypical hemolytic uremic syndrome (aHUS), shigatoxin related hemolytic uremic syndrome (STEC-HUS). Cancer itself has long been associated with both macro and microvascular thrombosis. In addition, treatment with chemotherapy as well as hematopoetic stem cell transplantation (HCST) has been associated with atypical hemolytic uremic (aHUS) like syndrome. In this review, I will discuss the pathophysiology of TMA in cancer, chemotherapy associated HUS, and HSCT, well as new therapeutic interventions.
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Affiliation(s)
- Ilene Ceil Weitz
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California-Keck School of Medicine, Los Angeles, CA, USA.
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23
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Infections associated with the use of eculizumab: recommendations for prevention and prophylaxis. Curr Opin Infect Dis 2018; 29:319-29. [PMID: 27257797 DOI: 10.1097/qco.0000000000000279] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Eculizumab inhibits complement effector functions and has significantly impacted the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. However, the risks of potentially life-threatening infections, notably with Neisseria spp. in addition to its cost, are major challenges in clinical practice. In this review, we characterize and summarize the infectious complications reported with the use of eculizumab in the context of its typical and expanding indications. RECENT FINDINGS Use of eculizumab is rapidly extending to the fields of transplantation and neurology. Eculizumab has been primarily associated with an increased risk of meningococcal infections. Immunization against its commonest serotypes (ABCWY) is now possible with the advent of the meningococcal B vaccine. A combined ABCWY vaccine is underway. Preventive strategies against breakthrough Neisseria infections should also include chemoprophylaxis. Less is known about the association of eculizumab with other infections as recently reported. Surrogate markers of complement blockade, notably CH50, and eculizumab efficacy may help in the risk assessment of infection. SUMMARY Eculizumab has opened new horizons in the treatment of complement-mediated disorders. Prophylactic and immunization strategies against the risk of Nesseria spp. infections are sound and feasible. The use of eculizumab is expanding beyond complement-mediated diseases to transplantation and neurological disorders. Further research is needed to better define and stratify the risk of infection and prevention strategies in patients with the latter indications.
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24
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Zhang XH, Liu X, Wang QM, He Y, Zhu XL, Zhang JM, Han W, Chen H, Chen YH, Wang FR, Wang JZ, Zhang YY, Mo XD, Chen Y, Wang Y, Fu HX, Chang YJ, Xu LP, Liu KY, Huang XJ. Thrombotic microangiopathy with concomitant GI aGVHD after allogeneic hematopoietic stem cell transplantation: Risk factors and outcome. Eur J Haematol 2017; 100:171-181. [PMID: 29114931 DOI: 10.1111/ejh.12996] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To explore the possible risk factors for the occurrence and mortality of thrombotic microangiopathy (TMA) with concomitant acute graft-vs-host disease (aGVHD) and to investigate outcomes and treatments of this disorder after allo-HSCT. METHODS Fifty cases diagnosed with TMA with concomitant aGVHD and 150 controls were identified from a cohort composed of 3992 patients who underwent allo-HSCT from 2008 to 2016. RESULTS Grade III-IV aGVHD (P = .000), acute kidney injury (AKI) (P = .033), and hypertension (P = .028) were significant independent risk factors associated with the occurrence of TMA with concomitant aGVHD. A haptoglobin level below normal (P = .013), a maximum volume of diarrhea >2500 mL/d (P = .015), and bloody diarrhea (P = .049) were significant markers for death in both univariate and multivariate analyses. Patients diagnosed with TMA with concomitant aGVHD had a lower overall survival (OS), a higher non-relapse mortality (NRM), but a lower risk of relapse. CONCLUSIONS Thrombotic microangiopathy with concomitant aGVHD is a significant complication after allo-HSCT, with a worse outcome, including significantly lower OS and higher NRM. There are specific risk factors associated with occurrence and mortality of this complication.
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Affiliation(s)
- Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Qian-Ming Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yun He
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jia-Min Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
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25
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Chaudhary RK, Dhakal P, Aryal A, Bhatt VR. Central nervous system complications after allogeneic hematopoietic stem cell transplantation. Future Oncol 2017; 13:2297-2312. [PMID: 28984145 DOI: 10.2217/fon-2017-0274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Allogenic hematopoietic stem cell transplant (alloSCT) is a potentially curative modality of treatment for patients with hematological malignancies. However, CNS complications following transplant pose a risk to survival of the patients. Early recognition and management of these complications are crucial to reduce morbidity and mortality of patients following transplant. Early CNS complications associated with alloSCT are infection, cerebrovascular events, chemotherapy and radiation-induced toxicities while late complications include post-transplant lymphoproliferative disorder, CNS relapse of underlying malignancy and viral and fungal infections. Development of graft-versus-host disease can further increase the risk of CNS complications and outcomes after alloSCT. Strategies aimed to reduce the risk of CNS complications and early management may ameliorate the morbidity and mortality in transplant recipients.
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Affiliation(s)
- Ranjit Kumar Chaudhary
- Department of Radiodiagnosis & Imaging, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Prajwal Dhakal
- Department of Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Aashrayata Aryal
- Department of Neurology, University of Nebraska Medical Center; Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center; Omaha, NE 68198, USA
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26
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Khosla J, Yeh AC, Spitzer TR, Dey BR. Hematopoietic stem cell transplant-associated thrombotic microangiopathy: current paradigm and novel therapies. Bone Marrow Transplant 2017; 53:129-137. [DOI: 10.1038/bmt.2017.207] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/20/2017] [Accepted: 07/28/2017] [Indexed: 02/08/2023]
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27
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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28
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Zeisbrich M, Becker N, Benner A, Radujkovic A, Schmitt K, Beimler J, Ho AD, Zeier M, Dreger P, Luft T. Transplant-associated thrombotic microangiopathy is an endothelial complication associated with refractoriness of acute GvHD. Bone Marrow Transplant 2017. [PMID: 28650448 DOI: 10.1038/bmt.2017.119] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There is increasing evidence that endothelial dysfunction is involved in refractoriness of acute GvHD (aGvHD). Here we investigated the hypothesis that another endothelial complication, transplant-associated thrombotic microangiopathy (TMA), contributes to the pathogenesis of aGvHD refractoriness. TMA was retrospectively assessed in 771 patients after allogeneic stem cell transplantation (alloSCT). Incidences of TMA and refractory aGvHD were correlated with biomarkers of endothelial damage obtained before alloSCT for patients receiving or not receiving statin-based endothelial prophylaxis (SEP). Diagnostic criteria for TMA and refractory aGvHD were met by 41 (5.3%) and 76 (10%) patients, respectively. TMA was overrepresented in patients with refractory aGvHD (45.0 vs 2.3% in all other patients, P<0.001). TMA independently increased mortality. Elevated pretransplant suppressor of tumorigenicity-2 and nitrates along with high-risk variants of the thrombomodulin gene were associated with increased risk of TMA. In contrast, SEP abolished the unfavorable outcome predicted by pretransplant biomarkers on TMA risk. Patients on SEP had a significantly lower risk of TMA (P=0.001) and refractory aGvHD (P=0.055) in a multivariate multistate model. Our data provide evidence that TMA contributes to the pathogenesis of aGvHD refractoriness. Patients with an increased TMA risk can be identified pretransplant and may benefit from pharmacological endothelium protection.
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Affiliation(s)
- M Zeisbrich
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - N Becker
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - A Benner
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - A Radujkovic
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - K Schmitt
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - J Beimler
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - A D Ho
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - M Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - P Dreger
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - T Luft
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
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29
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Use of defibrotide to treat transplant-associated thrombotic microangiopathy: a retrospective study of the Paediatric Diseases and Inborn Errors Working Parties of the European Society of Blood and Marrow Transplantation. Bone Marrow Transplant 2017; 52:762-764. [PMID: 28092354 DOI: 10.1038/bmt.2016.351] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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30
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[Transfer of allogeneic stem cell transplant recipients to the intensive care unit: Guidelines from the Francophone society of marrow transplantation and cellular therapy (SFGM-TC)]. Bull Cancer 2016; 103:S220-S228. [PMID: 27816169 DOI: 10.1016/j.bulcan.2016.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 09/01/2016] [Indexed: 12/31/2022]
Abstract
Transferring a patient undergoing an allogeneic stem cell transplantation to the intensive care unit (ICU) is always a challenging situation on a medical and psychological point of view for the patient and his relatives as well as for the medical staff. Despite the progress in hematology and intensive care during the last decade, the prognosis of these patients admitted to the ICU remains poor and mortality is around 50 %. The harmonization working party of the SFGM-TC assembled hematologists and intensive care specialist in order to improve conditions and modalities of the transfer of a patient after allogeneic stem cell transplantation to the ICU. We propose a structured medical form comprising all essential information necessary for optimal medical care on ICU.
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31
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An overview of hematopoietic stem cell transplantation related thrombotic complications. Crit Rev Oncol Hematol 2016; 107:149-155. [DOI: 10.1016/j.critrevonc.2016.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/19/2016] [Accepted: 09/21/2016] [Indexed: 02/07/2023] Open
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32
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Is complement blockade an acceptable therapeutic strategy for hematopoietic cell transplant-associated thrombotic microangiopathy? Bone Marrow Transplant 2016; 52:352-356. [PMID: 27775697 DOI: 10.1038/bmt.2016.253] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/07/2016] [Accepted: 08/16/2016] [Indexed: 12/13/2022]
Abstract
Diagnosis and management of hematopoietic cell transplant-associated thrombotic microangiopathy (TA-TMA) are very complex and controversial, given multiple ongoing issues and comorbidities in sick transplant recipients. Complement activation via classic and alternative pathways is emerging as a potential pathogenetic mechanism in the development of TA-TMA. Complement-centric diagnostic strategy using functional and genetic tests may possibly support diagnosis, enhance molecular understanding and direct drug development. Complement blockade using eculizumab has shown some promising rates of hematologic responses, however, survival may still be poor. Early discontinuation of calcineurin inhibitor where feasible, use of eculizumab, aggressive infection prophylaxis, close monitoring and early treatment of potential complications including GvHD and organ failure may improve outcomes. A number of complement inhibitors are in the development and may change treatment paradigm. Future studies are important to better understand TA-TMA as a disease process and may aim to confirm the role of complement activation in TA-TMA, enhance diagnostic strategy, determine therapeutic approaches and strategies to reduce the risk of other complications particularly infection and GvHD.
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33
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Jodele S, Dandoy CE, Myers KC, El-Bietar J, Nelson A, Wallace G, Laskin BL. New approaches in the diagnosis, pathophysiology, and treatment of pediatric hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Transfus Apher Sci 2016; 54:181-90. [PMID: 27156964 DOI: 10.1016/j.transci.2016.04.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is an understudied complication of HSCT that significantly affects transplant-related morbidity and mortality. Over the past several decades, the cause of TA-TMA has remained unknown, limiting treatment options to non-specific therapies adapted from other diseases. Recent prospective studies dedicated to the study of TA-TMA have provided new insights into the pathogenesis of, and genetic susceptibility to TA-TMA, raising awareness of this important transplant complication and allowing for the identification of potentially novel therapeutic targets. Specifically, many patients with TA-TMA develop multi-organ tissue injury through endothelial damage mediated by the activation of the complement pathway, leading to rational therapeutic strategies including complement blockade. This new knowledge has the potential to favorably influence clinical practice and change the standard of care for how patients with TA-TMA are managed. In this review, we summarize novel approaches to the recognition and management of TA-TMA, using case examples to illustrate key clinical points that hopefully lead to improved short and long-term outcomes for these complex HSCT patients, who remain at significant risk for treatment-related morbidity and mortality.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Javier El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adam Nelson
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gregory Wallace
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin L Laskin
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA
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34
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Fishing for complements. Blood 2016; 127:957-8. [PMID: 26917734 DOI: 10.1182/blood-2015-12-685131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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