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Pokhriyal SC, Sule-Saa S, Alemonai JA, Al-Ghuraibawi MMH, Pierre L, Parkash S, Panigrahi K. A Rare Case of Atypical Hemolytic Uremic Syndrome (HUS) in an Adult Male: A Catastrophic Presentation. Cureus 2024; 16:e62590. [PMID: 39027763 PMCID: PMC11256214 DOI: 10.7759/cureus.62590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Atypical hemolytic uremic syndrome (HUS) is extremely rare in adults. HUS is characterized by hallmark features of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury. Atypical HUS (aHUS) is caused by uncontrolled complement activation. The complement activation can be triggered by infections such as Streptococcus pneumoniae or influenza, pregnancy, malignancy, cytotoxic drugs, organ transplants, or autoimmune diseases. Genetic mutations and autoantibodies have been found to play a crucial role in the pathogenesis of dysregulated complement activity. The majority of cases of atypical HUS due to invasive S. pneumoniae infection are more commonly seen in children. We present a case of S. pneumoniae HUS (Sp-HUS) presenting with multiorgan failure, disseminated intravascular coagulation (DIC), and limb ischemia in an adult. This case highlights the importance of considering S. pneumoniae HUS (Sp-HUS) in the differential diagnosis of thrombotic microangiopathies (TMA) in adults.
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Affiliation(s)
- Sindhu C Pokhriyal
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Samuel Sule-Saa
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Jemima A Alemonai
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | | | - Luckencia Pierre
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Sunil Parkash
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Kalpana Panigrahi
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
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2
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Castelli M, Micò MC, Grassi A, Algarotti A, Lussana F, Finazzi MC, Rambaldi B, Pavoni C, Rizzuto G, Tebaldi P, Vendemini F, Verna M, Bonanomi S, Biondi A, Balduzzi A, Rambaldi A, Gotti G. Safety and efficacy of narsoplimab in pediatric and adult patients with transplant-associated thrombotic microangiopathy: a real-world experience. Bone Marrow Transplant 2024:10.1038/s41409-024-02305-3. [PMID: 38773280 DOI: 10.1038/s41409-024-02305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication following hematopoietic stem cell transplantation (HSCT). No approved treatments are currently available. This study presents real-world data obtained with narsoplimab, a human immunoglobulin G4 monoclonal antibody that inhibits MASP-2, the effector enzyme of the lectin pathway of the complement system. Between January 2018 and August 2023, 20 (13 adult and 7 pediatric) patients diagnosed with TA-TMA received narsoplimab under an ongoing compassionate use program. The diagnosis was based on internationally defined criteria for pediatric and adult patients. Fifteen patients fulfilled the criteria recently established by an international consensus on TA-TMA. Nineteen patients exhibited high-risk characteristics. Thirteen patients (65%) responded to narsoplimab, achieving transfusion independence and significant clinical improvement. The one-hundred-day Overall Survival (OS) post-TA-TMA diagnosis was 70%, and 100% for responders. Narsoplimab proved to be effective and safe in the treatment of high-risk TA-TMA, with no increased infectious complications or other safety signals of concern across all age groups. The high response rates and the encouraging survival outcomes underscore the potential of narsoplimab as a valuable therapeutic option, particularly for high-risk cases.
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Affiliation(s)
- Marta Castelli
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Caterina Micò
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Grassi
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Alessandra Algarotti
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Lussana
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Chiara Finazzi
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Benedetta Rambaldi
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Pavoni
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Giuliana Rizzuto
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Paola Tebaldi
- Department of Pathology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Marta Verna
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
| | - Sonia Bonanomi
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
| | - Andrea Biondi
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Adriana Balduzzi
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy.
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy.
| | - Giacomo Gotti
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [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] [Indexed: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Schoettler ML, French K, Harris A, Bryson E, Deeb L, Hudson Z, Obordo J, Chandrakasan S, Parikh S, Watkins B, Stenger E, Qayed M, Chonat S, Westbrook A, Switchenko J, Williams KM. D-dimer and sinusoidal obstructive syndrome-novel poor prognostic features of thrombotic microangiopathy in children after hematopoietic cellular therapy in a single institution prospective cohort study. Am J Hematol 2024; 99:370-379. [PMID: 38164997 DOI: 10.1002/ajh.27186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a common, severe complication of allogeneic hematopoietic cellular therapy (HCT). Even when treated in many studies, morbidity and mortality rates are high. This prospective single-institution cohort study serially enrolled all allogeneic HCT recipients from August 2019-August 2022. Patients were universally screened for TA-TMA and intermediate and high-risk patients were immediately treated with eculizumab. Sub-distribution cox-proportional hazards models were used to identify sub-distribution hazard ratios (sHR) for multi-organ dysfunction (MOD) and non-relapse-related mortality (NRM). Of 136 patients, 36 (26%) were diagnosed with TA-TMA and 21/36 (58%) developed MOD, significantly more than those without TA-TMA, (p < .0001). Of those with TA-TMA, 18 (50%) had high-risk TA-TMA (HR-TA-TMA), 11 (31%) had intermediate-risk TA-TMA (IR-TA-TMA), and 8 (22%) had standard risk (SR-TA-TMA). Twenty-six were treated with eculizumab (1/8 SR, 7/11 IR, and 18/18 HR). Elevated D-dimer predicted the development of MOD (sHR 7.6, 95% confidence interval [CI] 1.8-32.3). Children with concurrent sinusoidal obstructive syndrome (SOS) and TA-TMA had an excess risk of MOD of 34% and data supported a biologic interaction. The adjusted NRM risk was significantly higher in the TA-TMA patients (sHR 10.54, 95% CI 3.8-29.2, p < .0001), despite prompt treatment with eculizumab. Significant RF for NRM in TA-TMA patients included SOS (HR 2.89, 95% 1.07-7.80) and elevated D-dimer (HR 3.82, 95% CI 1.14-12.84). An unrelated donor source and random urine protein to creatine ratio ≥2 mg/mg were significantly associated with no response to eculizumab (odds ratio 15, 95% CI 2.0-113.6 and OR 6.5, 95% CI 1.1-38.6 respectively). TA-TMA was independently associated with NRM despite early diagnosis and treatment with eculizumab in this large pediatric transplant cohort. Prognostic implications of D-dimer in TA-TMA merit further investigation as this is a readily accessible biomarker. Concurrent SOS is an exclusion criterion of many ongoing clinical trials, but these data highlight these patients could benefit from novel therapeutic approaches. Multi-institutional clinical trials are needed to understand the impact of TA-TMA-targeted therapies.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Kaley French
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Anora Harris
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Elyse Bryson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Laura Deeb
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Zuri Hudson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Jeremy Obordo
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Adrianna Westbrook
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | | | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
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Xu C, Wong V, Kurniawan A, Wilson S, Gopal B, Lawton PD. Eculizumab was safe and effective in the management of transplant-associated thrombotic microangiopathy in a heart transplant recipient with concurrent COVID-19 infection. Intern Med J 2023; 53:1506-1508. [PMID: 37599228 DOI: 10.1111/imj.16178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/27/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Chi Xu
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Renal Services, Western Health, Melbourne, Victoria, Australia
| | - Vincent Wong
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Renal Services, Western Health, Melbourne, Victoria, Australia
| | | | - Scott Wilson
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Basu Gopal
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Paul D Lawton
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
- Menzies School of Health Research, Darwin, Northwest Territories, Australia
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Gudsoorkar P, Abudayyeh A, Tchakarov A, Hanna R. Onconephrology and Thrombotic Microangiopathy: Looking Beyond the Horizon. Semin Nephrol 2023; 42:151345. [PMID: 37196461 DOI: 10.1016/j.semnephrol.2023.151345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Thrombotic microangiopathies (TMAs) represent a complex interaction of endothelial and podocyte biology, nephron physiology, complement genetics, and oncologic therapies with host immunology. The complexity of various factors, such as molecular causes, genetic expressions, and immune system mimicking, along with incomplete penetrance, make it difficult to find a straightforward solution. As a result, there may be variations in diagnosis, study, and treatment approaches, and achieving a consensus can be challenging. Here, we review the molecular biology, pharmacology, immunology, molecular genetics, and pathology of the various TMA syndromes in the setting of cancer. Controversies in etiology, nomenclature, and points requiring further clinical, translational, and bench research are discussed. Complement-mediated TMAs, chemotherapy drug-mediated TMAs, TMAs in monoclonal gammopathy, and other TMAs central to onconephrology practice are reviewed in detail. In addition, established and emerging therapies within the US Food and Drug Administration pipeline subsequently are discussed. Finally, a comprehensive review of critical areas of onconephrology clinical practice is presented as practical value to the clinical practitioner and seeds of investigation to be sown among the community of atypical hemolytic uremic syndrome researchers.
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Affiliation(s)
- Prakash Gudsoorkar
- Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, OH
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Amanda Tchakarov
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine Medical Center, Orange, CA.
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Mahmoudjafari Z, Alencar MC, Alexander MD, Johnson DJ, Yeh J, Evans MD. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy and the role of advanced practice providers and pharmacists. Bone Marrow Transplant 2023:10.1038/s41409-023-01951-3. [PMID: 37059738 DOI: 10.1038/s41409-023-01951-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a severe and potentially life-threatening complication. HSCT-TMA is often underdiagnosed due to multifactorial pathophysiology and a historic lack of standard diagnostic criteria. Identification of the multi-hit hypothesis and the key role of the complement system, particularly the lectin pathway of complement, has led to development of treatments targeting the underlying pathogenesis of HSCT-TMA. Additional research is ongoing to investigate the efficacy and safety of these targeted therapies in patients with HSCT-TMA. Advanced practice providers (APPs; nurse practitioners and physician assistants) and pharmacists are critical members of the multidisciplinary HSCT team and ensure management of patients throughout the continuum of care. Additionally, pharmacists and APPs can improve patient care through medication management of complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives to improve outcomes. Understanding the presentation, prognosis, pathophysiology, and treatment options for HSCT-TMA can improve each of these efforts. Collaborative practice model for monitoring and care of HSCT-TMA. Advanced practice providers and pharmacists contribute to many aspects of patient care in transplant centers, including medication management for complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives. HSCT-TMA is a severe and potentially life-threatening complication that is often underdiagnosed. The collaboration of a multidisciplinary team of advanced practice providers, pharmacists, and physicians can optimize recognition, diagnosis, management, and monitoring of patients with HSCT-TMA, thereby improving outcomes for these patients.
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Affiliation(s)
- Zahra Mahmoudjafari
- Department of Pharmacy, University of Kansas Cancer Center, Kansas City, KS, USA.
| | - Maritza C Alencar
- Oncology Service Line, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Darren J Johnson
- Pediatric Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jason Yeh
- Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | - Misty D Evans
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- Sarah Cannon Pediatric Hematology/Oncology & Cellular Therapy at TriStar Centennial, Nashville, TN, USA
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Use of eculizumab in children with allogeneic haematopoietic stem cell transplantation associated thrombotic microangiopathy - a multicentre retrospective PDWP and IEWP EBMT study. Bone Marrow Transplant 2023; 58:129-141. [PMID: 36333550 DOI: 10.1038/s41409-022-01852-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 09/24/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Terminal complement blockade by humanised monoclonal antibody eculizumab has been used to treat transplantation-associated thrombotic microangiopathy (TA-TMA) in recent years. This retrospective international study conducted by the Paediatric Diseases (PDWP) and Inborn Error Working Party (IEWP) of the European Society for Blood and Marrow Transplantation (EBMT) describes outcome and response of 82 paediatric patients from 29 centres who developed TA-TMA and were treated with eculizumab between January 2014 and May 2019. The median time from hematopoietic stem cell transplantation (HSCT) to TA-TMA manifestation was 92 days (range: 7-606) and from TA-TMA diagnosis to the start of eculizumab treatment 6 days (range: 0-135). Most patients received eculizumab weekly (72%, n = 55) with a standard weight (kg)-based dose (78%, n = 64). Six months from beginning of eculizumab therapy, the cumulative incidence of TA-TMA resolution was 36.6% (95% CI: 26.2-47) and the overall survival (OS) was 47.1% (95% CI: 35.9-57.5). All 43 patients with unresolved TA-TMA died. The cause of death was HSCT-related in 41 patients. This study also documents poor outcome of patients without aGvHD and their frequent concomitant viral infections. Considering recent publications, intensified eculizumab dosing and complement monitoring could potentially improve upon outcomes observed in this study.
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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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Abudayyeh A, Wanchoo R. Kidney Disease Following Hematopoietic Stem Cell Transplantation. Adv Chronic Kidney Dis 2022; 29:103-115.e1. [PMID: 35817518 DOI: 10.1053/j.ackd.2021.11.003] [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: 06/24/2021] [Revised: 10/07/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022]
Abstract
Hematopoietic stem cell transplantation (SCT) provides a curative option for the treatment of several malignancies. Its growing use is associated with an increased burden of kidney disease. Acute kidney injury is usually seen within the first 100 days of transplantation and has an incidence ranging between 12 and 73%, with the highest rate in myeloablative allogeneic SCT. A large subset of patients after SCT develop chronic kidney disease. They can be broadly classified into thrombotic microangiopathy, nephrotic syndrome, and calcineurin toxicity. Dialysis requirement after SCT is associated with mortality exceeding 80%. Given the higher morbidity and mortality related to development kidney disease, nephrologists need to be aware of the various causes and best treatment options.
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Affiliation(s)
- Ala Abudayyeh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY.
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Shimizu S, Morohashi T, Kanezawa K, Yagasaki H, Takahashi S, Morioka I. Case Report: Successful Treatment With Anti-C5 Monoclonal Antibody in a Japanese Adolescent Who Developed Thrombotic Microangiopathy After Autologous Bone Marrow Transplantation for Malignant Lymphoma. Front Pediatr 2022; 10:908183. [PMID: 35859949 PMCID: PMC9289264 DOI: 10.3389/fped.2022.908183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is a serious complication of bone marrow transplantation (BMT). Recently, abnormalities in the complement system have been identified in the pathogenesis of TA-TMA, and there are series of reports stating that anti-C5 monoclonal antibody (eculizumab) is effective in patients with high levels of the membrane attack complex (C5b-9). CASE PRESENTATION A 12-year-old boy underwent autologous BMT after receiving high-dose chemotherapy for malignant lymphoma. The patient was engrafted on day 19 after transplantation; however, hemolytic anemia and non-immune thrombocytopenia persisted, and haptoglobin decreased on day 46. Moreover, on day 83, the patient developed pulmonary hemorrhage, hypertension, severe proteinuria, hematuria, and acute kidney injury (AKI). Pulmonary bleeding stopped with daily platelet transfusion and hemostatic agents, but reappeared on day 100. Based on the presence of destruction of red blood cells, elevated lactate dehydrogenase levels, negative direct and indirect Coombs tests, normal ADAMTS13 levels, hemolytic anemia, non-immune thrombocytopenia, and AKI, the patient was diagnosed with systemic TA-TMA and we initiated plasma exchange (PE) and continuous hemodialysis for AKI. High C5b-9 levels were identified at the start of the series of PE, therefore we decided to administer eculizumab. After three courses of eculizumab, no pulmonary hemorrhage was observed, and anemia, thrombocytopenia, renal dysfunction, hematuria, and proteinuria all tended to improve. Three years after transplantation, the patient is alive and does not require eculizumab. DISCUSSION Eculizumab is a humanized monoclonal antibody that binds complement protein C5, preventing cleavage C5 and the formation of C5b-9. In this case, TA-TMA could not be controlled with PE alone. We therefore decided to use eculizumab relatively early based on the high C5b-9 level and could resolve the momentum of TA-TMA. CONCLUSION In previous reports, TA-TMA typically occurred in early post-allogeneic BMT of patients with lymphoma or in post-autologous BMT of patients with neuroblastoma and was treated with eculizumab. We here reported that eculizumab could be successful treatment for TA-TMA in post-autologous BMT of patient with lymphoma.
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Affiliation(s)
- Shoichi Shimizu
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Tamaki Morohashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Koji Kanezawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagasaki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | | | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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12
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Sharif MO, Leavis HL, van Paassen P, van Rhenen A, Timmermans SAMEG, Ton E, Laar JMV, Spierings J. Severe thrombotic microangiopathy after autologous stem cell transplantation in systemic sclerosis: a case report. Rheumatology (Oxford) 2021; 60:e326-e328. [PMID: 33711097 DOI: 10.1093/rheumatology/keab239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 01/13/2023] Open
Affiliation(s)
- Maryam O Sharif
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht
| | - Helen L Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht Universitair Medisch Centrum, Maastricht
| | - Anna van Rhenen
- Department of Haematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht Universitair Medisch Centrum, Maastricht
| | - Evelien Ton
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht
| | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht
| | - Julia Spierings
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht
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13
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Gabr JB, Bilal H, Mirchia K, Perl A. The Use of Eculizumab in Tacrolimus-Induced Thrombotic Microangiopathy. J Investig Med High Impact Case Rep 2021; 8:2324709620947266. [PMID: 32757799 PMCID: PMC7412890 DOI: 10.1177/2324709620947266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Drug-induced thrombotic microangiopathy (DITMA) is a secondary cause of thrombotic microangiopathy and a potentially fatal inflammatory disease. DITMA has been attributed to a variety of drugs, particularly chemotherapeutic and immunosuppressive agents. Prompt diagnosis is critical for survival and treatment necessitates withdrawal of the offending drug; however, many cases require further treatment including plasmapheresis, immunosuppression, and anticoagulation. In this article, we report a cutaneous biopsy-proven case of tacrolimus-induced DITMA, which was successfully treated with eculizumab after failing the conventional standard of care.
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Affiliation(s)
| | - Hiba Bilal
- SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Andras Perl
- SUNY Upstate Medical University, Syracuse, NY, USA
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14
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Risk factors for transplant-associated thrombotic microangiopathy and mortality in a pediatric cohort. Blood Adv 2021; 4:2536-2547. [PMID: 32516415 DOI: 10.1182/bloodadvances.2019001242] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/28/2020] [Indexed: 11/20/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a well-recognized complication of hematopoietic cell transplantation (HCT). Diagnosis is challenging and in the absence of a tissue biopsy, TA-TMA is provisionally diagnosed by meeting clinical criteria. In this study, we describe the prevalence, outcomes, and risk factors for meeting 2 different diagnostic criteria for TA-TMA and for increased transplant-related mortality (TRM). In this retrospective study of 307 pediatric HCT patients, records were reviewed for the first 100 days after HCT. Patients who were diagnosed with TA-TMA by a provider during this time were included. In addition, the Cho et al criteria (2010) and Jodele et al (2014) TA-TMA criteria were applied retrospectively. Eight patients (2.6%) were diagnosed with TA-TMA by their provider. However, on retrospective review, 20% and 36% met the Cho and Jodele criteria for TA-TMA, respectively. Overall survival was significantly worse (P < .0001) and TRM was significantly higher in patients who met criteria for TA-TMA (MC-TA-TMA) (P < .0001). After controlling for comorbid conditions, MC-TA-TMA (hazard ratio [HR], 10.9; P = .0001) and grade 3/4 acute graft-versus-host-disease (aGVHD) (HR 3.5; P = .01) remained independently associated with increased TRM. Among allogeneic HCT recipients, features associated with an increased risk for MC-TA-TMA included ≥2 HCT, concurrent grade 3/4 aGVHD and concurrent infections. Among patients who MC-TA-TMA, LDH ≥2 times the upper limit of normal (P = .001), the need for ≥2 antihypertensive medications (P < .0001), and acute kidney injury (P = .003) were associated with significantly increased TRM.
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15
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Awidi M, Jain M, Baur R. Transplant-associated Thrombotic Microangiopathy Treated with Eculizumab and Romiplostim. Eur J Case Rep Intern Med 2021; 8:002294. [PMID: 33768076 DOI: 10.12890/2021_002294] [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: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 11/05/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) can occur after solid organ transplantation. It results in thrombocytopenia, haemolytic anaemia and microvascular occlusion. TA-TMA is not fully understood and treatment has not been clearly established. However, there is increasing evidence to suggest an immune-complement mediated component to its development. Eculizumab is a monoclonal antibody that inhibits the cleavage of C5 into pro-inflammatory, prothrombotic terminal complement elements and has been utilized in the treatment of atypical haemolytic uremic syndrome. We report a case of TA-TMA successfully treated with eculizumab and romiplostim. This case adds to the evidence that TA-TMA is triggered by complement dysregulation and suggests possible interventions for refractory cases. LEARNING POINTS Transplant-associated thrombotic microangiopathy (TA-TMA) may occur in solid organ transplant patients.Eculizumab may be used for the treatment of TA-TMA.
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Affiliation(s)
- Muhammad Awidi
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Meenu Jain
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Russell Baur
- Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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16
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Zhang R, Zhou M, Qi J, Miao W, Zhang Z, Wu D, Han Y. Efficacy and Safety of Eculizumab in the Treatment of Transplant-Associated Thrombotic Microangiopathy: A Systematic Review and Meta-Analysis. Front Immunol 2021; 11:564647. [PMID: 33552043 PMCID: PMC7856300 DOI: 10.3389/fimmu.2020.564647] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a dangerous and life-threatening complication in patients undergoing hematopoietic stem cell transplantation (HSCT). Eculizumab has been used in the treatment of TA-TMA, and several studies have confirmed the benefit of Eculizumab in patients with TA-TMA. However, the results remain controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of Eculizumab for TA-TMA. Materials and Methods We searched PubMed and Embase for studies on the efficacy and safety of Eculizumab in TA-TMA patients. Efficacy outcomes consisted of overall response rate (ORR), complete response rate (CRR), and survival rate at the last follow-up (SR). Safety outcomes were adverse events (AEs), including infection, sepsis, impaired liver function, infusion reactions, and death. Results A total of 116 patients from six studies were subjected to meta-analysis. The pooled estimates of ORR, CRR, and SR for TA-TMA patients were 71% (95% CI: 58-82%), 32% (95% CI: 11-56%), and 52% (95% CI: 40-65%), respectively. Only one patient presented with a severe rash, and infection was the most common AEs. The main causes of death were infection and GvHD. Conclusion Current evidence suggests that Eculizumab improves SR and ORR in patients with TA-TMA and that Eculizumab is well tolerated. However, the number of studies is limited, and the findings are based mainly on data from observational studies. Higher quality randomized controlled trials and more extensive prospective cohort studies are needed.
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Affiliation(s)
- Rui Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Meng Zhou
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Jiaqian Qi
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Wenjing Miao
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Ziyan Zhang
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Yue Han
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,National Clinical Research Center for Hematologic Diseases, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
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17
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Complement blockade for TA-TMA: lessons learned from a large pediatric cohort treated with eculizumab. Blood 2020; 135:1049-1057. [PMID: 31932840 DOI: 10.1182/blood.2019004218] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/04/2020] [Indexed: 01/03/2023] Open
Abstract
Overactivated complement is a high-risk feature in hematopoietic stem cell transplant (HSCT) recipients with transplant-associated thrombotic microangiopathy (TA-TMA), and untreated patients have dismal outcomes. We present our experience with 64 pediatric HSCT recipients who had high-risk TA-TMA (hrTA-TMA) and multiorgan injury treated with the complement blocker eculizumab. We demonstrate significant improvement to 66% in 1-year post-HSCT survival in treated patients from our previously reported untreated cohort with same hrTA-TMA features that had 1-year post-HSCT survival of 16.7%. Responding patients benefited from a brief but intensive course of eculizumab using pharmacokinetic/pharmacodynamic-guided dosing, requiring a median of 11 doses of eculizumab (interquartile range [IQR] 7-20). Treatment was discontinued because TA-TMA resolved at a median of 66 days (IQR 41-110). Subjects with higher complement activation measured by elevated blood sC5b-9 at the start of treatment were less likely to respond (odds ratio, 0.15; P = .0014) and required more doses of eculizumab (r = 0.43; P = .0004). Patients with intestinal bleeding had the fastest eculizumab clearance, required the highest number of eculizumab doses (20 vs 9; P = .0015), and had lower 1-year survival (44% vs 78%; P = .01). Over 70% of survivors had proteinuria on long-term follow-up. The best glomerular filtration rate (GFR) recovery in survivors was a median 20% lower (IQR, 7.3%-40.3%) than their pre-HSCT GFR. In summary, complement blockade with eculizumab is an effective therapeutic strategy for hrTA-TMA, but some patients with severe disease lacked a complete response, prompting us to propose early intervention and search for additional targetable endothelial injury pathways.
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18
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Jarmoliński T, Rosa M, Puziewicz-Zmonarska A, Kałwak K. Short Course of Eculizumab May Be Effective in Dialysis-Dependent Transplantation-Associated Thrombotic Microangiopathy After Hematopoietic Stem Cell Transplantation: A Case Report. Transplant Proc 2020; 52:2544-2547. [PMID: 32917392 DOI: 10.1016/j.transproceed.2020.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (alloHSCT) could induce several complications. The most frequent viral infections and graft-vs-host disease (GvHD) sometimes lead to thrombotic microangiopathy (TMA). It is associated with significant morbidity and mortality with the risk of death reaching 90%. Effective prevention and treatment are not available to date. Recent attempts at using antibody against C5 have been made. CASE REPORT A 19-year-old girl with acute myeloid leukemia twice underwent alloHSCTs from her 10/10 HLA-matched sister. After the second HSCT severe acute steroid-resistant grade 4 GvHD occurred. Despite treatment with high doses of steroids, mycophenolate mofetil, biological therapy, and extracorporeal photopheresis, the patient developed TMA with acute kidney injury and the need for renal replacement therapy. The concentration of complement component 3 and activity of ADAMTS 13 were normal, and infection with Escherichia coli (E. coli) 0157H7 was excluded. Due to failure of all ordered therapies and severity of the condition, an attempt was taken to use eculizumab. Two 900-mg doses of eculizumab (Soliris) were administered at an interval of 2 weeks, which resulted in the improvement of renal function and amelioration of hemolysis and thrombocytopenia. Dialysis therapy was finished after 5 weeks, and then a third dose of the drug was administered. Eighteen months later, the patient is alive and well, with limited chronic GvHD. eGFR remains stable at 40 to 46 mL/min/1.73 m2, and mild hypertension requires treatment with angiotensin converting enzyme inhibitors and furosemide. CONCLUSION Even a short course of eculizumab can be sufficient in controlling the TMA after HSCT, provided that the TMA-triggering factors are well controlled.
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Affiliation(s)
- Tomasz Jarmoliński
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland; Department of Pediatrics and Pediatric Neurology, District Hospital, Gorzów Wielkopolski, Poland
| | - Monika Rosa
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Krzysztof Kałwak
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland.
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19
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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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20
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García-Martín E, Manrique-Rodríguez S, Martínez Fernández-Llamazares C, Goicoechea-Diezhondino M, Álvarez-Blanco O, García-Morín M, Sanjurjo-Sáez M. Variability in management and outcomes of therapy with eculizumab in atypical hemolytic uremic syndrome. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1703108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Estela García-Martín
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Silvia Manrique-Rodríguez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | - Marian Goicoechea-Diezhondino
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Olalla Álvarez-Blanco
- Pediatric Nephrology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Marina García-Morín
- Pediatric Oncohematology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - María Sanjurjo-Sáez
- Director of Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
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21
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Treatment Options in Patients Suffering from Hemolytic-Uremic Syndrome: the Serbian Military Medical Academy Experience. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hemolytic-Uremic Syndrome (HUS) is a clinical syndrome with a triad of non-immune Microangiopathic Hemolytic Anemia (MAHA), thrombocytopenia and renal failure. Together with the Thrombotic Thrombocytopenic Purpura (TTP), it belongs to a group of diseases characterized as the Thrombotic Microangiopathy (TMA), which represents a microvascular occlusive disorder with the formation of a predominantly thrombocytic thrombus in the renal and/or systemic circulation. In the period starting from 2001 to 2017, 14 patients with a HUS were diagnosed at the Clinic for Nephrology (unfortunately ADAMTS 13 could not have been done due to technical reasons). In a retrospective clinical laboratory analysis and monitoring, we obtained the following results. Out of 14 patients, 10 were female (or 71.43%) and 4 were male (28.57%), the youngest patient was aged 17 and the oldest one 78, the average age of our patients was 55.33 years, the annual number of patients with the diagnosis of HUS was 0.93 patients per year, or 0.00116 in relation to the total number of patients treated. After monitoring the patients individually for the period ranging from 1 to 14 years, a stable remission was achieved in 5 patients, while a chronic renal insufficiency occurred in 3 patients. In two of our patients, a percutaneous kidney biopsy was performed with pathohistological findings described in references. Having done this retrospective analysis, we can conclude that the survival and complications of this rare, but serious disease correspond to the available world data.
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22
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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: 36] [Impact Index Per Article: 7.2] [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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23
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Zhou H, Hara H, Cooper DK. The complex functioning of the complement system in xenotransplantation. Xenotransplantation 2019; 26:e12517. [PMID: 31033064 PMCID: PMC6717021 DOI: 10.1111/xen.12517] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 03/15/2019] [Accepted: 03/22/2019] [Indexed: 12/25/2022]
Abstract
The role of complement in xenotransplantation is well-known and is a topic that has been reviewed previously. However, our understanding of the immense complexity of its interaction with other constituents of the innate immune response and of the coagulation, adaptive immune, and inflammatory responses to a xenograft is steadily increasing. In addition, the complement system plays a function in metabolism and homeostasis. New reviews at intervals are therefore clearly warranted. The pathways of complement activation, the function of the complement system, and the interaction between complement and coagulation, inflammation, and the adaptive immune system in relation to xenotransplantation are reviewed. Through several different mechanisms, complement activation is a major factor in contributing to xenograft failure. In the organ-source pig, the detrimental influence of the complement system is seen during organ harvest and preservation, for example, in ischemia-reperfusion injury. In the recipient, the effect of complement can be seen through its interaction with the immune, coagulation, and inflammatory responses. Genetic-engineering and other therapeutic methods by which the xenograft can be protected from the effects of complement activation are discussed. The review provides an updated source of reference to this increasingly complex subject.
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Affiliation(s)
- Hongmin Zhou
- Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K.C. Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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24
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Schoettler M, Duncan C, Lehmann L. Severe, persistent neurotoxicity after transplant-associated thrombotic microangiopathy in a pediatric patient despite treatment with eculizumab. Pediatr Transplant 2019; 23:e13381. [PMID: 30828947 PMCID: PMC6650335 DOI: 10.1111/petr.13381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/11/2018] [Accepted: 01/04/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND TA-TMA is a described complication of aHCT in children with neuroblastoma. Outcomes are poor with mortality rates approaching 60%. Described late effects in survivors include chronic kidney disease and persistent pulmonary hypertension. CASE We report a case of a 2-year-old with neuroblastoma who developed severe TA-TMA 35 days after high dose chemotherapy and autologous stem cell rescue. He presented with respiratory failure, pericardial and pleural effusions, hemolysis, hypertension, and mild altered mental status. He was mechanically ventilated for 3 weeks and after sedation was lifted, he was minimally responsive. He was treated with eculizumab with resolution of hemolysis, kidney injury and polyserositis. Initially he was more responsive; however, after almost a year of intensive therapy he remained nonverbal and had persistent irritability and behavioral changes. He had an extensive negative evaluation. On day +345, he presented with severe, refractory epilepsy. Three years after TA-TMA, he continues to have severe neurologic disabilities. CONCLUSIONS To our knowledge, persistent neurologic toxicity has not been reported in TA-TMA. However, deficits and seizures are reported in other TMAs, particularly in children with atypical HUS who present with significant neurologic changes at diagnosis. Our patient's persistent neurologic disability despite eculizumab response in all other involved organs may reflect irreversible damage. This case describes a new long-term sequela of TA-TMA and highlights the need for further studies to understand both acute and long-term neurologic complications of this disease.
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Affiliation(s)
- Michelle Schoettler
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
| | - Christine Duncan
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
| | - Leslie Lehmann
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
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25
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A Heterozygous CFHR3-CFHR1 Gene Deletion in a Pediatric Patient With Transplant-associated Thrombotic Microangiopathy Who was Treated With Eculizumab. J Pediatr Hematol Oncol 2018; 40:e544-e546. [PMID: 28991129 DOI: 10.1097/mph.0000000000000986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Complement system dysregulation, such as complement Factor H (CFH) autoantibodies and deletions in CFH-related (CFHR) genes 3 and 1, might cause transplant-associated thrombotic microangiopathy (TA-TMA). The use of eculizumab, a terminal complement inhibitor, could be a targeted therapy for TA-TMA. We report a 1-year-old girl who developed TA-TMA, just after autologous peripheral blood stem cell transplantation in neuroblastoma therapy. Eculizumab improved TA-TMA. Investigation for the complement alternative pathway showed a heterozygous CFHR3-CFHR1 gene deletion, which is involved in complement activation. The patient might develop TA-TMA as a result of complement regulatory gene mutation.
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26
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Kaplan SL. Meningococcal Serogroup B Vaccine Immunogenicity in High-Risk Groups: What Are the Implications? Pediatrics 2018; 142:peds.2018-0554. [PMID: 30068712 DOI: 10.1542/peds.2018-0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sheldon L Kaplan
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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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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Gavriilaki E, Sakellari I, Batsis I, Mallouri D, Bousiou Z, Vardi A, Yannaki E, Constantinou V, Tsompanakou A, Vadikoliou C, Kaloyannidis P, Bamihas G, Anagnostopoulos A. Transplant-associated thrombotic microangiopathy: Incidence, prognostic factors, morbidity, and mortality in allogeneic hematopoietic cell transplantation. Clin Transplant 2018; 32:e13371. [DOI: 10.1111/ctr.13371] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/20/2018] [Accepted: 07/29/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Eleni Gavriilaki
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Ioanna Sakellari
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Ioannis Batsis
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Despina Mallouri
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Zoi Bousiou
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Anna Vardi
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | - Evangelia Yannaki
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | | | - Aliki Tsompanakou
- Hematology Department - BMT Unit; G. Papanicolaou Hospital; Thessaloniki Greece
| | | | | | - Gerasimos Bamihas
- Nephrology Department; G. Papanicolaou Hospital; Thessaloniki Greece
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29
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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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30
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Vakiti A, Singh D, Pilla R, Alhaj-Moustafa M, Fitzpatrick KW. Bevacizumab-induced atypical hemolytic uremic syndrome and treatment with eculizumab. J Oncol Pharm Pract 2018; 25:1011-1015. [PMID: 29768958 DOI: 10.1177/1078155218774895] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Bevacizumab (Avastin) is a recombinant humanized monoclonal antibody used for the management of various solid malignancies including colorectal, lung, brain, renal, and ovarian cancers as well as age-related macular degeneration of the eye. It is a vascular endothelial growth factor inhibitor which exhibits its action by blocking the growth of blood vessels in cancerous tissue. Common side effects include hypertension, fatigue, headaches, and increased risk of infections. Atypical hemolytic uremic syndrome is a serious side effect associated with bevacizumab due to its anti-angiogenic effect. It encompasses the clinical triad of thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure, without any association with Shiga toxins. Eculizumab is a terminal complement inhibitor used in the treatment of atypical hemolytic uremic syndrome. Herein, we present three cases of bevacizumab-induced atypical hemolytic syndrome treated successfully with eculizumab.
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Affiliation(s)
- Anusha Vakiti
- 1 Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Daulath Singh
- 2 Department of Hematology and Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Ravi Pilla
- 1 Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Muhamad Alhaj-Moustafa
- 1 Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kelly W Fitzpatrick
- 3 Division of Hematology and Oncology, Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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Jodele S. Complement in Pathophysiology and Treatment of Transplant-Associated Thrombotic Microangiopathies. Semin Hematol 2018; 55:159-166. [PMID: 30032753 DOI: 10.1053/j.seminhematol.2018.04.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 02/27/2018] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a form of microangiopathy specifically occurring in the context of hematopoietic stem cell transplantation. Similarly, to other microangiopathies, TA-TMA is characterized by hemolytic anemia, thrombocytopenia, and organ failure due to endothelial injury. Although its clinical association with medications (eg, calcineurin inhibitors), immune reactions (eg, graft vs host disease) or infectious complications is well established, the pathophysiology remains largely unknown. Recent data have highlighted the role of complement in the pathophysiology of TA-TMA, which are frequently associated with a functional impairment (either inherited or acquired) of the endogenous regulation of the complement classic and alternative pathway. This manuscript will review the data supporting the involvement of complement in the pathophysiology of TA-TMA, as well as the clinical data supporting the use of anticomplement agents in this rare condition.
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Affiliation(s)
- Sonata Jodele
- Department of Hematology, Oncology and Blood & Marrow Transplantation, USC Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
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32
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Horváth O, Kállay K, Csuka D, Mező B, Sinkovits G, Kassa C, Stréhn A, Csordás K, Sinkó J, Prohászka Z, Kriván G. Early Increase in Complement Terminal Pathway Activation Marker sC5b-9 Is Predictive for the Development of Thrombotic Microangiopathy after Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:989-996. [PMID: 29339271 DOI: 10.1016/j.bbmt.2018.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/08/2018] [Indexed: 12/17/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is a multifactorial complication, and its prediction is largely unresolved. Our aim was to analyze changes of complement profile after HSCT to identify potential markers of TA-TMA development. Thirty-three consecutive pediatric patients (9.6 ± 4.4 years old) who underwent allogeneic HSCT due to malignant (n = 17) or nonmalignant (n = 16) indications were included in this study. Graft-versus-host disease (GVHD) was diagnosed using Glucksberg criteria, viral reactivation was monitored, 5 different TA-TMA diagnostic criteria were applied, and all important clinical and laboratory parameters of TA-TMA activity were registered. Complement pathway activities, components and terminal pathway activation marker (sC5b-9) levels were systematically measured before transplantation and on days 28, 56, and 100 after HSCT. During the first 100 days after HSCT, 1 of 33 patients died (day 50, multiple organ failure), whereas 10 subjects met the criteria for TA-TMA, typically on day 61 (range, 16 to 98 days). TA-TMA was preceded by acute GVHD in 3 of 10 patients, by viral reactivation in 2 of 10, or by both in 4 of 10 cases. Baseline sC5b-9 levels did not differ in patients without (200 [interquartile range, 144 to 266] ng/mL), or with (208 [interquartile range, 166 to 271] ng/mL) subsequent TA-TMA; however, on day 28 significant differences were observed (201 [interquartile range, 185 to 290] ng/mL versus 411 [interquartile range, 337 to 471] ng/mL; P = .004). Importantly, all 10 patients with TMA showed increase in sC5b-9 level from baseline level to day 28, whereas in patients without TMA the same tendency was observed for only 9 of 23 patients (P = .031). No additional complement parameters were closely associated with the development of TA-TMA. Development of TA-TMA occurred in 30% of our patients, typically after GVHD and/or viral reactivation. However, early raise of sC5b-9 activation marker was predictive for later development of TA-TMA, and should therefore be considered as an alarming sign necessitating a careful monitoring of all TA-TMA activity markers. Further studies enrolling a higher number of patients are necessary to determine if terminal pathway activation is an independent predictor of TA-TMA.
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Affiliation(s)
- Orsolya Horváth
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary; Doctoral School of Medicine, Semmelweis University, Budapest, Hungary.
| | - Krisztián Kállay
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - Dorottya Csuka
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Blanka Mező
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - György Sinkovits
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Csaba Kassa
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - Anita Stréhn
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - Katalin Csordás
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
| | - János Sinkó
- Department of Hematology and Stem Cell Transplantation, United St. István and St. László Hospital, Budapest, Hungary
| | - Zoltán Prohászka
- Research Laboratory, IIIrd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Gergely Kriván
- Department of Pediatric Hematology and Stem Cell Transplantation, United St.István and St. László Hospital, Budapest, Hungary
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33
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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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34
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Epperla N, Hemauer K, Hamadani M, Friedman KD, Kreuziger LB. Impact of treatment and outcomes for patients with posttransplant drug-associated thrombotic microangiopathy. Transfusion 2017; 57:2775-2781. [PMID: 28836275 DOI: 10.1111/trf.14263] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/17/2017] [Accepted: 06/17/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drug-induced transplant-associated thrombotic microangiopathy (DTA-TMA) is a rare but serious complication that can occur after hematopoietic cell transplantation (HCT) or solid organ transplantation (SOT) without guidelines for optimal management of this condition. STUDY DESIGN AND METHODS Given the ambiguity surrounding the treatment for DTA-TMA, we conducted a retrospective review to evaluate the impact of different treatment strategies in DTA-TMA patients. Our primary endpoint was to determine the overall response rate (ORR) for DTA-TMA based on the type of treatment modality chosen while secondary endpoints included the time to response, relapse rates, and overall survival for DTA-TMA cases. RESULTS There were a total of 14 DTA-TMA patients of whom nine were post-HCT and five were post-SOT. Most of the DTA-TMA cases were due to tacrolimus (n = 11) with a minority related to sirolimus (n = 3). A total of nine of 14 patients demonstrated response and five had no response to therapy. The ORR among the DTA-TMA patients after HCT and SOT who received plasma exchange (PLEX) were 25 and 100%, respectively. The ORRs among the patients (includes HCT and SOT) who received rituximab (n = 3) and eculizumab (n = 5) were 67 and 60%, respectively. There were two relapses noted in our study and both were in the HCT group. CONCLUSION While discontinuation of the offending agent may be sufficient for treatment of DTA-TMA after HCT, PLEX may be a reasonable option for DTA-TMA after SOT. Although the results are encouraging with rituximab and eculizumab in the treatment of DTA-TMA, larger prospective studies are needed to validate our findings.
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Affiliation(s)
| | | | | | - Kenneth D Friedman
- Division of Hematology and Oncology.,BloodCenter of Wisconsin, Milwaukee, Wisconsin
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35
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Parolin M, Vidal E. Complications of therapeutic apheresis in pediatric kidney transplantation. Transfus Apher Sci 2017; 56:510-514. [PMID: 28760487 DOI: 10.1016/j.transci.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In the setting of kidney transplantation, therapeutic apheresis (TA) is employed both for pre-intervention procedures and during the post-transplant period. In pediatric nephrology units, TA is usually performed as a therapeutic plasma exchange (TPE) with dialysis equipment, and using non-plasma replacement fluids. In children undergoing kidney transplantation, complications of TPE are mainly related to its depletive properties combined with the iatrogenic immunodeficiency status of the patient. Moreover, the use of small central venous catheters and the equipment standardized for adults can increase the risk of adverse events. Focusing on these preconditions, TA in kidney-transplanted children should be performed in specialized centers with specific protocols and a trained staff.
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Affiliation(s)
- Mattia Parolin
- Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University-Hospital of Padova, Padova, Italy
| | - Enrico Vidal
- Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University-Hospital of Padova, Padova, Italy.
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36
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None of the above: thrombotic microangiopathy beyond TTP and HUS. Blood 2017; 129:2857-2863. [PMID: 28416509 DOI: 10.1182/blood-2016-11-743104] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/21/2017] [Indexed: 12/13/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are appropriately at the top of a clinician's differential when a patient presents with a clinical picture consistent with an acute thrombotic microangiopathy (TMA). However, there are several additional diagnoses that should be considered in patients presenting with an acute TMA, especially in patients with nondeficient ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity (>10%). An increased awareness of drug-induced TMA is also essential because the key to their diagnosis more often is an appropriately detailed medical history to inquire about potential exposures. Widespread inflammation and endothelial damage are central in the pathogenesis of the TMA, with the treatment directed at the underlying disease if possible. TMA presentations in the critically ill, drug-induced TMA, cancer-associated TMA, and hematopoietic transplant-associated TMA (TA-TMA) and their specific treatment, where applicable, will be discussed in this manuscript. A complete assessment of all the potential etiologies for the TMA findings including acquired TTP will allow for a more accurate diagnosis and prevent prolonged or inappropriate treatment with plasma exchange therapy when it is less likely to be successful.
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Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy characterized by intravascular hemolysis, thrombocytopenia, and acute kidney failure. HUS is usually categorized as typical, caused by Shiga toxin-producing Escherichia coli (STEC) infection, as atypical HUS (aHUS), usually caused by uncontrolled complement activation, or as secondary HUS with a coexisting disease. In recent years, a general understanding of the pathogenetic mechanisms driving HUS has increased. Typical HUS (ie, STEC-HUS) follows a gastrointestinal infection with STEC, whereas aHUS is associated primarily with mutations or autoantibodies leading to dysregulated complement activation. Among the 30% to 50% of patients with HUS who have no detectable complement defect, some have either impaired diacylglycerol kinase ε (DGKε) activity, cobalamin C deficiency, or plasminogen deficiency. Some have secondary HUS with a coexisting disease or trigger such as autoimmunity, transplantation, cancer, infection, certain cytotoxic drugs, or pregnancy. The common pathogenetic features in STEC-HUS, aHUS, and secondary HUS are simultaneous damage to endothelial cells, intravascular hemolysis, and activation of platelets leading to a procoagulative state, formation of microthrombi, and tissue damage. In this review, the differences and similarities in the pathogenesis of STEC-HUS, aHUS, and secondary HUS are discussed. Common for the pathogenesis seems to be the vicious cycle of complement activation, endothelial cell damage, platelet activation, and thrombosis. This process can be stopped by therapeutic complement inhibition in most patients with aHUS, but usually not those with a DGKε mutation, and some patients with STEC-HUS or secondary HUS. Therefore, understanding the pathogenesis of the different forms of HUS may prove helpful in clinical practice.
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Ikeda T, Okumi M, Unagami K, Kanzawa T, Sawada A, Kawanishi K, Omoto K, Ishida H, Tanabe K. Two cases of kidney transplantation-associated thrombotic microangiopathy successfully treated with eculizumab. Nephrology (Carlton) 2017; 21 Suppl 1:35-40. [PMID: 26970541 DOI: 10.1111/nep.12768] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is relatively rare and requires immediate intervention to avoid irreversible organ damage or death; however, consensus regarding the treatment approach is lacking. Atypical haemolytic uraemic syndrome (aHUS) is a rare disease caused by dysregulation of the alternative complement pathway resulting in TMA. aHUS is histologically similar to TA-TMA; approximately 60% of TA-TMA patients have complement dysregulation. Eculizumab, a humanized anti-C5 monoclonal antibody, inhibits terminal membrane-attack complex formation and TMA progression. Eculizumab has been successfully used to treat aHUS post-transplant. We present two cases of kidney TA-TMA due to unknown causes, suspected antibody-mediated rejection, or calcineurin inhibitor (CNI)-related toxicity that developed on day 1 or 2 post-kidney transplantation. Low platelet count and haemoglobin level with red cell fragments were detected. Despite steroid pulse, plasma exchange (PE), and intravenous immunoglobulin therapy, TA-TMA did not improve; therefore, eculizumab was administered despite no genetic testing. Laboratory data, including renal function, improved immediately. TA-TMA treatment primarily involves PE initiation or CNI discontinuation; eculizumab can be used to safely treat TA-TMA and then be ceased in the short term. Therefore, eculizumab administration might be beneficial for kidney TA-TMA as early as the diagnosis of refractory to PE.
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Affiliation(s)
- Takashi Ikeda
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Internal Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Anri Sawada
- Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kunio Kawanishi
- Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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39
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Zwang NA, Ho B, Kanwar YS, Lewis B, Cusick M, Friedewald JJ, Gallon L. A case of atypical hemolytic uremic syndrome in a second renal transplant. J Nephrol 2017; 31:165-172. [PMID: 28224376 DOI: 10.1007/s40620-016-0373-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/22/2016] [Indexed: 01/29/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) has gained increased visibility over several years as an important cause of renal failure. Unfortunately, diagnosis is often difficult because individual courses can be highly variable depending the causative genetic mutations. Here we present the case of a patient with a failed renal allograft and acute failure of a second allograft who was ultimately diagnosed with aHUS. Interestingly, he developed early de novo donor specific antibodies (DSA) after the second renal transplant in context of likely recurrent aHUS. Terminal complement inhibition with eculizumab resulted in prompt improvement of renal allograft function.
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Affiliation(s)
- Nicholas A Zwang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA. .,McGaw Medical Center of Northwestern University, Chicago, USA. .,Northwestern Memorial Hospital/Arkes Family Pavilion Suite 1900, 676N. St. Clair, Chicago, IL, 60611, USA.
| | - Bing Ho
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Yashpal S Kanwar
- Department of Pathology, Northwestern Memorial Hospital, Chicago, USA
| | | | - Matthew Cusick
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - John J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA.,McGaw Medical Center of Northwestern University, Chicago, USA.,Department of Pathology, Northwestern Memorial Hospital, Chicago, USA.,Machaon Diagnostics, Oakland, CA, USA.,Northwestern Memorial Hospital/Arkes Family Pavilion Suite 1900, 676N. St. Clair, Chicago, IL, 60611, USA
| | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA
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40
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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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41
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Rosenthal J. Hematopoietic cell transplantation-associated thrombotic microangiopathy: a review of pathophysiology, diagnosis, and treatment. J Blood Med 2016; 7:181-6. [PMID: 27621680 PMCID: PMC5015877 DOI: 10.2147/jbm.s102235] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a multifactorial disorder caused by systemic vascular endothelial injury that can be triggered by several mechanisms during the transplant process. Thrombotic microangiopathy may affect multiple systems and occurs in ~30% of patients undergoing hematopoietic stem cell transplantation. A subgroup of patients with thrombotic microangiopathy develop TA-TMA, and the other may develop other thrombotic microangiopathic disorders such as thrombotic thrombocytopenic purpura, a condition with similar finding but different pathophysiology involving ADAMTS-13. The mortality rates in patients who develop severe TA-TMA are in excess of 80%. Recent investigations show that complement system activation in patients with TA-TMA is a very poor prognostic sign and implicates complement dysregulation as a key pathway in the pathogenesis of TA-TMA and its disease phenotype. The original diagnostic criteria for TA-TMA included hematologic and renal injury markers, which are limited in their ability to detect only advanced disease, and therefore may result in delayed TA-TMA diagnosis in transplant patients. A recent set of diagnostic criteria added markers of complement activation, proteinuria, and hypertension, with predicted improved detection of early TA-TMA. Supportive care that includes elimination of potentially toxic agents such as calcineurin inhibitors and sirolimus, adequate antimicrobial treatment, and maintaining adequate renal functions using renal replacement therapy may be sufficient for treatment of mild-to-moderate TA-TMA. Plasma exchange, which is a potentially curative therapy in thrombotic thrombocytopenic purpura, has no proven efficacy in TA-TMA. Blocking the complement system with eculizumab is currently the most effective treatment to circumvent the poor outcome in patients with severe TA-TMA.
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Affiliation(s)
- Joseph Rosenthal
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA, USA
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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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