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Losa-Rodríguez R, Pérez Martínez C, Rodríguez Pérez G, de la Fuente Graciani I, Gómez García LM. Clínica neurológica fluctuante: ¿Llamo al neurólogo o al hematólogo? ADVANCES IN LABORATORY MEDICINE 2021; 2:129-136. [PMID: 37359202 PMCID: PMC10197384 DOI: 10.1515/almed-2020-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/30/2020] [Indexed: 06/28/2023]
Abstract
Objetivos Resaltar el papel del laboratorio clínico y la pronta comunicación con el servicio de Hematología en el diagnóstico y la rapidez en la instauración del tratamiento de una patología hematológica tan urgente como la Púrpura Trombótica Trombocitopénica (PTT). Caso clínico Varón de edad avanzada derivado a Urgencias hospitalarias por su médico de Atención Primaria por trastorno de emisión del lenguaje, asimetría facial y disminución de fuerza en extremidad superior, por lo que se activa el código ictus. Sin embargo, los hallazgos de laboratorio (anemia y trombocitopenia, creatinina, bilirrubina total y LDH elevadas, test de Coombs directo negativo) y presencia de esquistocitos en el frotis de sangre periférica, acaban derivando en un diagnóstico completamente diferente: microangiopatía trombótica tipo PTT. Conclusiones La primera orientación diagnóstica de ictus hemisférico izquierdo fue rechazada ante los signos de anemia hemolítica no autoinmune, trombocitopenia sin causa aparente y presencia de esquistocitos. No debemos olvidar que esta patología puede cursar con afectación multiorgánica y características clínicas muy variables. Aunque su diagnóstico definitivo se basa en la determinación de actividad de ADAMTS-13, debido a la elevada mortalidad es necesario instaurar tratamiento de forma inmediata tras su sospecha.
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Affiliation(s)
- Rita Losa-Rodríguez
- Servicio de Análisis Clínicos, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Carmen Pérez Martínez
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - Gabriel Rodríguez Pérez
- Servicio de Análisis Clínicos, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | | | - Lara M. Gómez García
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario de Valladolid, Valladolid, España
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Losa-Rodríguez R, Pérez Martínez C, Rodríguez Pérez G, de la Fuente Graciani I, Gómez García LM. Fluctuating neurological symptoms: should I call the neurologist or the hematologist? ADVANCES IN LABORATORY MEDICINE 2021; 2:129-136. [PMID: 37359200 PMCID: PMC10197350 DOI: 10.1515/almed-2020-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/30/2020] [Indexed: 06/28/2023]
Abstract
Objectives The objective of this study was to highlight the role of the clinical laboratory and the relevance of reporting the case immediately to the unit of hematology for the diagnosis and early administration of treatment in the presence of such an urgent hematologic disease as thrombotic thrombocytopenic purpura (TTP). Case presentation An elderly patient was referred to the emergency department of our hospital by his general practitioner for speech difficulty, facial asymmetry and weakness in the upper limb. Stroke code was activated. However, laboratory findings (anemia, thrombocytopenia, elevated creatinine, total bilirubin and LDH, negative direct Coombs test) and presence of schistocytes in the peripheral blood smear test were consistent with a completely different diagnosis: TTP thrombotic microangiopathy. Conclusions The first diagnostic approach of left hemispheric stroke was not confirmed in the laboratory, with findings of nonautoimmune hemolytic anemia, thrombocytopenia without apparent cause and presence of schistocytes. We should not forget that the clinical manifestations of this condition are widely variable and may include multiorganic dysfunction. Although confirmation of diagnosis is based on ADAMTS-13, its associated high mortalitiy requires immediate treatment on mere suspicion.
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Affiliation(s)
- Rita Losa-Rodríguez
- Service of Laboratory Analysis, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Carmen Pérez Martínez
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Gabriel Rodríguez Pérez
- Service of Laboratory Analysis, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Lara M. Gómez García
- Servicio de Hematología y Hemoterapia, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Characterization and treatment of congenital thrombotic thrombocytopenic purpura. Blood 2019; 133:1644-1651. [PMID: 30770395 DOI: 10.1182/blood-2018-11-884700] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/06/2019] [Indexed: 12/15/2022] Open
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is an ultra-rare thrombomicroangiopathy caused by an inherited deficiency of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). There are limited data on genotype-phenotype correlation; there is no consensus on treatment. We reviewed the largest cohort of cTTP cases, diagnosed in the United Kingdom, over the past 15 years. Seventy-three cases of cTTP were diagnosed, confirmed by genetic analysis. Ninety-three percent were alive at the time of review. Thirty-six percent had homozygous mutations; 64% had compound heterozygous mutations. Two presentation peaks were seen: childhood (median diagnosis age, 3.5 years) and adulthood, typically related to pregnancy (median diagnosis age, 31 years). Genetic mutations differed by age of onset with prespacer mutations more likely to be associated with childhood onset (P = .0011). Sixty-nine percent of adult presentations were associated with pregnancy. Fresh-frozen plasma (FFP) and intermediate purity factor VIII concentrate were used as treatment. Eighty-eight percent of patients with normal blood counts, but with headaches, lethargy, or abdominal pain, reported symptom resolution with prophylactic therapy. The most common currently used regimen of 3-weekly FFP proved insufficient for 70% of patients and weekly or fortnightly infusions were required. Stroke incidence was significantly reduced in patients receiving prophylactic therapy (2% vs 17%; P = .04). Long-term, there is a risk of end-organ damage, seen in 75% of patients with late diagnosis of cTTP. In conclusion, prespacer mutations are associated with earlier development of cTTP symptoms. Prophylactic ADAMTS13 replacement decreases the risk of end-organ damage such as ischemic stroke and resolved previously unrecognized symptoms in patients with nonovert disease.
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Iqbal S, Zaidi SZA, Motabi IH, Alshehry NF, AlGhamdi MS, Tailor IK. Thrombotic thrombocytopenic purpura - analysis of clinical features, laboratory characteristics and therapeutic outcome of 24 patients treated at a Tertiary Care Center in Saudi Arabia. Pak J Med Sci 2016; 32:1494-1499. [PMID: 28083052 PMCID: PMC5216308 DOI: 10.12669/pjms.326.11274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease. The primary aim was overall response rate (ORR) assessment in the treated patients Methods: This retrospective study included 24 patients treated during 2006-2015. TTP patients with microangiopathic hemolysis (MAHA) and thrombocytopenia were included. We analyzed clinical features, laboratory characteristics and treatment outcomes of 24 TTP patients treated at our tertiary care center (KFMC). Results: Twenty-four TTP patients (18 females; 6 males) had a mean age of 33.5±13.9 years; 22(91%) had neurologic features, 7(29%) fever, 10(42%) renal impairment; 4(20.83%) cardiac manifestations; 22(91.7%) had triad with additional neurologic abnormalities; only 2(8.2%) had pentad of TTP. Majority (54.16%) had idiopathic TTP. All patients received therapeutic plasma exchange (TPE); 23(95.8%) received adjunctive corticosteroids and 13(54.2%) received rituximab either due to refractoriness to TPE on ~day7, or earlier. Twenty-one out of 24 (87.5%) achieved complete remission (CR) without any subsequent relapse. At 22 months (median, range 1-113), 20 patients (83.3%) are alive at the time of report. Three patients died during acute episode because of sever disease or delayed treatment and one died in CR. Conclusion: TPE, steroids and or rituximab was very effective in preventing high risk of mortality and achieving durable CR in 87.5% of patients. More awareness is needed for early diagnosis and early referral to centers with appropriate tertiary care facilities..
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Affiliation(s)
- Shahid Iqbal
- Shahid Iqbal MBBS, FCPS, MRCP (UK), Department of Adult Hematology / BMT, CCC, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Syed Z A Zaidi
- Syed Z. A. Zaidi, MBBS, FRCP, FCPS, FRCPath, FACP, Department of Adult Hematology / BMT, CCC, King Fahad Medical City, Riyadh, Saudi Arabia, Faculty of Medicine, King Saud Bin AbdulAziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Ibraheem H Motabi
- Ibraheem H Motabi, MRCP, MD, Department of Adult Hematology / BMT, CCC, King Fahad Medical City, Riyadh, Saudi Arabia, Faculty of Medicine, King Saud Bin AbdulAziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Nawal Faiez Alshehry
- Nawal Faiez Alshehry, MD, SBIM, SBAH, Department of Adult Hematology / BMT, CCC, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mubarak S AlGhamdi
- Mubarak S. AlGhamdi, MD, Department of Adult Hematology / BMT, CCC, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imran Khan Tailor
- Imran Khan Tailor, MBBS, MD, MRCP, FRCPath, Department of Adult Hematology / BMT, CCC, King Fahad Medical City, Riyadh, Saudi Arabia
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Bansal R, Baer MR, Zimrin AB, Law JY. Isolated thrombocytopenia and liver function abnormalities characterizing an atypical presentation of thrombotic thrombocytopenic purpura. Ann Hematol 2016; 95:2079-2080. [PMID: 27542956 DOI: 10.1007/s00277-016-2797-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 08/09/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Rajat Bansal
- Department of Internal Medicine, University of Maryland Medical Center, 22 S. Greene St. N3E09, Baltimore, MD, 21201, USA.
| | - Maria R Baer
- Division of Hematology-Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Ann B Zimrin
- Division of Hematology-Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Jennie Y Law
- Division of Hematology-Oncology, Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
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Mai Falk J, Scharrer I. Idiopathic thrombotic thrombocytopenic purpura: strongest risk factor for relapse from remission is having had a relapse. Transfusion 2016; 56:2819-2823. [PMID: 27514869 DOI: 10.1111/trf.13751] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 05/17/2016] [Accepted: 06/20/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare, episodic clinical syndrome involving the production of thrombi in the microvasculature accompanied by thrombocytopenia and symptoms of organ ischemia. Idiopathic TTP develops when a patient produces antibodies that react with the protease ADAMTS13. The course after an episode is unpredictable; patients may relapse frequently or never. There is no laboratory value that can reliably predict potential relapse. STUDY DESIGN AND METHODS To assess diagnostic and predictive values for risk of relapse, plasma samples from 27 patients with idiopathic TTP in remission were analyzed for anti-ADAMTS13 immunoglobulin (Ig)G, ADAMTS13 activity, and ADAMTS13 inhibitor titer. Patients were recruited at the Department of Hematology at the University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany. RESULTS Anti-ADAMTS13 IgG was detected in 12 patients (44%); their median level of ADAMTS13 activity was nondetectable. Patients with anti-ADAMTS13 IgG had a median number of three previous relapses, whereas the 15 patients without presence of IgG (56%) had a median number of one previous relapse (p < 0.001; Mann-Whitney U test). The concentration of free anti-ADAMTS13 IgG and the levels measuring inhibitory activity (Bethesda unit) were positively correlated. CONCLUSION A subgroup of TTP patients in remission with anti-ADAMTS13 IgG and nondetectable ADAMTS13 activity showed an increased risk for relapsing disease as demonstrated by their number of past relapses. The positive correlation we observed between anti-ADAMTS13 IgG and inhibitor levels supports the theory of ADAMTS13 inhibition as the crucial mechanism causing severe deficiency in ADAMTS13 activity in TTP.
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Affiliation(s)
- Jennifer Mai Falk
- Department of Hematology at the University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Inge Scharrer
- Department of Hematology at the University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
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Atypical presentations of thrombotic thrombocytopenic purpura in middle-aged women with recurrent cerebral macrovascular thrombosis: a case report. Ann Hematol 2015; 94:1597-8. [PMID: 26051903 DOI: 10.1007/s00277-015-2415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/30/2015] [Indexed: 10/23/2022]
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Wieland I, Kentouche K, Jentzsch M, Lothschütz D, Graf N, Sykora KW. Long-term remission of recurrent thrombotic thrombocytopenic purpura (TTP) after Rituximab in children and young adults. Pediatr Blood Cancer 2015; 62:823-9. [PMID: 25623397 DOI: 10.1002/pbc.25398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/18/2014] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Acquired thrombotic-thrombocytopenic purpura (TTP) is an autoimmune disorder characterized by autoantibodies directed against the von Willebrand metalloprotease. Depletion of B-cells can prevent synthesis of this antibody and presumably induce remission of the disease. In adults, Rituximab (RTX) was effective in relapsed or refractory acute idiopathic TTP. PROCEDURE We report the long-term follow-up of five children and two adolescents (age at diagnosis 6-19 years, median 15 years) who were treated with RTX for recurrent or refractory TTP. Some of the patients suffered from recurrent refractory TTP with long histories of previous unsuccessful treatments. One had TTP associated with pancreatitis. RESULTS Three patients have been in complete remission after one treatment course with RTX. Four relapsed after 1 to 5 years, respectively, and responded to additional courses of RTX. One of them is in long-term remission after a third course of RTX and splenectomy. Compared to literature reports with a median follow up of 1.4 years (3-46 month), follow-up of our patients after treatment with RTX was very long (2-12.7 years, median 7.7 years). RTX therapy could induce long-term remissions in children with refractory recurrent TTP. Median duration of remission was longer and relapses per patient-years less frequent in patients receiving RTX compared to patients not receiving it. Remissions were achieved in children within one week, much faster than in adults. CONCLUSION Because of the rapid induction of remissions, RTX may be suitable for first-line therapy in pediatric acquired antibody-mediated TTP.
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Affiliation(s)
- Ivonne Wieland
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
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Mariani M, Cairo A, Palla R, Lotta LA, Consonni D, Rovati A, Trisolini S, Peyvandi F. B and T lymphocytes in acquired Thrombotic Thrombocytopenic Purpura during disease remission. Thromb Res 2011; 128:590-2. [DOI: 10.1016/j.thromres.2011.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Revised: 06/29/2011] [Accepted: 07/20/2011] [Indexed: 12/21/2022]
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Barcellini W, Zanella A. Rituximab therapy for autoimmune haematological diseases. Eur J Intern Med 2011; 22:220-9. [PMID: 21570637 DOI: 10.1016/j.ejim.2010.12.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 12/21/2010] [Accepted: 12/22/2010] [Indexed: 01/19/2023]
Abstract
Autoimmune haematological diseases are characterized by the production of antibodies against blood proteins or cells, and comprise primary immune thrombocytopenia, autoimmune haemolytic anaemia, acquired haemophilia, and thrombotic thrombocytopenic purpura. Current treatments for these disorders include corticosteroids, cytotoxic drugs and splenectomy, which may be associated with significant systemic toxicity and/or morbility. B cells play a key role in both the development and perpetuation of autoimmunity, since they produce autoantibodies but also function as antigen-presenting cells, and release immunomodulatory cytokines. Rituximab, an anti-CD20 monoclonal antibody that specifically depletes B cells, may be an effective treatment strategy for patients with autoimmune disorders. This article reviews data of the literature, showing that patients with autoimmune haematological diseases can respond to rituximab irrespective of age and number or type of prior treatments. These data suggest that rituximab provides an effective and well-tolerated treatment option for these conditions.
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Affiliation(s)
- Wilma Barcellini
- U.O. Ematologia 2, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Han Y, Xiao J, Falls E, Zheng XL. A shear-based assay for assessing plasma ADAMTS13 activity and inhibitors in patients with thrombotic thrombocytopenic purpura. Transfusion 2011; 51:1580-91. [PMID: 21251003 DOI: 10.1111/j.1537-2995.2010.03020.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Severe deficiency of plasma ADAMTS13 activity is a frequent finding in patients with hereditary and acquired thrombotic thrombocytopenic purpura (TTP). To date, plasma ADAMTS13 activity is determined by cleavage of either predenatured von Willebrand factor (VWF) or small peptides derived from the VWF-A2 domain. The physiologic relevance of the assay results is uncertain. STUDY DESIGN AND METHODS We sought to develop a novel shear-based assay to assess plasma ADAMTS13 activity and inhibitors. We also compared this assay with a fluorogenic peptide assay. RESULTS We found that an incubation of purified plasma VWF with 0.5 to 1.0 µL of citrated plasma under constant vortexing at 2500 rpm for 60 minutes in the presence of 5 mmol/L CaCl(2) and 1.7 µmol/L ZnCl(2) and low concentration of NaCl resulted in the maximal cleavage of VWF. The cleavage product could be separated by a 2.5% agarose gel and detected by Western blotting. The assay revealed that plasma and recombinant ADAMTS13 are highly sensitive to inhibition by zinc and chloride ions. Under the optimal conditions, the shear-based assay appeared to be more sensitive than the guanidine-denaturization assay for determining plasma ADAMTS13 activity. CONCLUSIONS Our fluid shear-based assay may be useful for investigating basic biologic function and regulation of ADAMTS13 metalloprotease. It may also be applicable for assessing plasma ADAMTS13 activity and inhibitors in TTP patients.
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Affiliation(s)
- Yue Han
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA
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Rubia JDL, Moscardó F, Gómez MJ, Guardia R, Rodríguez P, Sebrango A, Zamora C, Debén G, Goterris R, López R, Peña F, Pujol M, Vidaller A, Río-Garma JD, Sanz MA. Efficacy and safety of rituximab in adult patients with idiopathic relapsing or refractory thrombotic thrombocytopenic purpura: results of a Spanish multicenter study. Transfus Apher Sci 2010; 43:299-303. [PMID: 20934383 DOI: 10.1016/j.transci.2010.09.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Between 30% and 60% of patients with thrombotic thrombocytopenic purpura (TTP) relapse and mortality remains at 15-20%. Limited clinical data suggest that the administration of anti-CD20 antibody (rituximab) may be useful in preventing acute refractory and chronic relapsing TTP. DESIGN AND METHODS We studied the clinical response to rituximab in 24 adult patients (median age 42 years, range 24-72 years) from 15 Spanish centers with an acute refractory (14 patients) or acute relapsing (10 patients) episode of idiopathic TTP. On admission, every patient received daily plasma exchange (PE). Rituximab was administered at a dose of 375 mg/m(2) weekly for a median of 13 days (range 0-57 days) after starting PE for a median of 4 doses (range 1-8 doses). RESULTS No severe acute or delayed toxicity was observed in the patients treated with rituximab. Three (12.5%) patients died because of TTP-related causes. The remaining 21 (87.5%) patients achieved complete remission in a median of 21 days (range 2-35 days) after initiating rituximab. After a median follow-up of 30 months (range 7.5-74 months), 18 patients are in remission and 3 patients have relapsed at 7, 29, and 29 months. CONCLUSIONS Rituximab appears to be a safe, effective therapy and has a high response rate for the treatment of acute refractory or relapsing idiopathic TTP in adult patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Miguel A Sanz
- Hospital La Fe, Universidad Católica de Valencia, Spain
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Long-term follow-up of idiopathic thrombotic thrombocytopenic purpura treated with rituximab. Ann Hematol 2010; 89:1029-33. [PMID: 20422413 DOI: 10.1007/s00277-010-0968-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 04/13/2010] [Indexed: 12/30/2022]
Abstract
Rituximab may be used to treat patients with thrombotic thrombocytopenic purpura (TTP) refractory to plasma exchange or recurrent disease. While initial response rates are reported to be high, long-term follow-up data of patients treated with rituximab are not available to date, however important to estimate the safety and benefit of this treatment. Twelve patients with non-familial idiopathic TTP refractory to plasma exchange or with recurrent disease treated with rituximab between 2000 and 2008 were reexamined. The median follow-up was 49.6 months, ranging from 11 to 97 months. All patients achieved initial complete remission after application of rituximab. During follow-up, nine patients remained disease-free and three patients suffered from recurrent disease. All patients with recurrent disease responded to subsequent rituximab therapy. No long-term side effects were noted during the follow-up period. In conclusion, rituximab represents an effective second-line treatment option in relapsing or refractory TTP. Still, patients need to be closely monitored for relapses with extended follow-up.
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John BM, Singh D, Ravichander B, Madan R, Raghu Raman TS. Upshaw-Schulman Syndrome. Med J Armed Forces India 2010; 66:188-9. [PMID: 27375335 DOI: 10.1016/s0377-1237(10)80149-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 02/22/2010] [Indexed: 11/30/2022] Open
Affiliation(s)
- B M John
- Reader (Dept of Paediatrics), AFMC, Pune-40
| | - D Singh
- Senior Advisor (Paediatrics & Neonatology), Command Hospital (SC), Pune-40
| | - B Ravichander
- Professor & HOD (Paediatrics), MVJ Medical College, Bangalore
| | - R Madan
- Classified Specialist (Pathology), Army Hospital (R&R), New Delhi
| | - T S Raghu Raman
- Medical Superintendent, Kasturba Hospital, Manipal-576104, Karnataka
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Saltzman DJ, Chang JC, Jimenez JC, Carson JG, Abolhoda A, Newman RS, Milliken JC. Postoperative Thrombotic Thrombocytopenic Purpura After Open Heart Operations. Ann Thorac Surg 2010; 89:119-23. [DOI: 10.1016/j.athoracsur.2009.09.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Revised: 09/09/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
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Bouw MC, Dors N, van Ommen H, Ramakers-van Woerden NL. Thrombotic thrombocytopenic purpura in childhood. Pediatr Blood Cancer 2009; 53:537-42. [PMID: 19544391 DOI: 10.1002/pbc.22094] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disease, especially in childhood, and has a high mortality rate in the absence of appropriate treatment. It is characterised by microangiopathic haemolytic anaemia and consumptive thrombocytopenia. TTP may be difficult to distinguish from haemolytic uraemic syndrome (HUS) because of similar clinical manifestations and laboratory findings. In the past, TTP and HUS have often been considered to represent variable expressions of a single entity. Our increased understanding of the pathogenesis of TTP has in turn resulted in significant improvements in its treatment and outcomes. Several immunomodulating agents are currently being used with variable outcomes.
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Affiliation(s)
- Maria C Bouw
- Department of Paediatrics, Meander Medical Centre, Amersfoort, The Netherlands
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Platelet adhesive dynamics. Part II: high shear-induced transient aggregation via GPIbalpha-vWF-GPIbalpha bridging. Biophys J 2008; 95:2556-74. [PMID: 18515386 DOI: 10.1529/biophysj.107.128520] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
A three-dimensional multiscale computational model, platelet adhesive dynamics (PAD), is developed and applied in Part I and Part II articles to characterize and quantify key biophysical aspects of GPIbalpha-von-Willebrand-factor (vWF)-mediated interplatelet binding at high shear rates, a necessary and enabling step that initiates shear-induced platelet aggregation. In this article, an adhesive dynamics model of the transient aggregation of two unactivated platelets via GPIbalpha-vWF-GPIbalpha bridging is developed and integrated with the three-dimensional hydrodynamic flow model discussed in Part I. Platelet binding efficiencies predicted by PAD are in good agreement with platelet aggregation behavior observed experimentally, as documented in the literature. Deviations from average vWF ligand size or healthy GPIbalpha-vWF-A1 binding kinetics are observed in simulations to have significant effects on the dynamics of transient platelet aggregation, i.e., the efficiency of platelet aggregation and characteristics of bond failure, in ways that typify diseased conditions. The GPIbalpha-vWF-A1 bond formation rate is predicted to have piecewise linear dependence on the prevailing fluid shear rate, with a sharp transition in fluid shear dependency at 7200 s(-1). Interplatelet bond force-loading is found to be complex and highly nonlinear. These results demonstrate PAD as a powerful predictive modeling tool for elucidating platelet adhesive phenomena under flow.
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Yuen LK, Lai WM, Tong PC, Poon WT, Tse KC, Chiu MC. Recurrent Thrombotic Thrombocytopenic Purpura in a Young Boy With Systemic Lupus Erythematosus. J Clin Rheumatol 2007; 13:224-8. [PMID: 17762461 DOI: 10.1097/rhu.0b013e318133a476] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially fatal disease in childhood. The association of microangiopathic hemolytic anemia, schistocytes, and thrombocytopenia without fever, neurologic, and renal involvement is sufficient to suspect TTP at an early stage for prompt plasma infusion or exchange therapy. TTP has been increasingly described especially in association with systemic lupus erythematosus (SLE). We report the youngest Chinese boy who presented his SLE with TTP and subsequently experienced 9 relapses of TTP in a 2-year period. SLE disease activity index was low during his TTP relapses and therefore alertness of TTP relapse is required even in a relatively inactive period of SLE. TTP should be recognized even without renal or neurologic features and can respond to plasma therapy.
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Affiliation(s)
- Lai-kei Yuen
- Department of Pediatrics and Adolescent Medicine, Princess Margaret Hospital, Kowloon, Hong Kong.
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21
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Fan X, Venegas R, Fey R, van der Heyde H, Bernard MA, Lazarides E, Woods CM. An in vivo approach to structure activity relationship analysis of peptide ligands. Pharm Res 2007; 24:868-79. [PMID: 17377744 DOI: 10.1007/s11095-007-9238-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Accepted: 01/05/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE The goals in this study were several-fold. First, to optimize the in vivo phage display methodology by incorporating phage pharmacokinetic properties, to isolate peptides that target the brain microvasculature, and then to build focused libraries to obtain structure activity relationship information in vivo to identify the optimal targeting motif. MATERIALS AND METHODS The blood pharmacokinetics of filamentous and T7 phage were evaluated to choose the optimal platform. A randomized peptide library with a motif CX(10)C was constructed in T7 phage and used for in vivo panning. Focused peptide libraries around each structural element of the brain-specific peptide were constructed to perform kinetic structure activity relationship (kSAR) analysis in vivo. To determine potential function, sepsis was induced in mice by LPS administration and four hours later the effect of GST-peptide on adhesion of rhodamine-labelled lymphocytes or CFDA-labelled platelets to pial microvasculature was observed by intravital microscopy. RESULTS The blood phamacokinetics of T7 was rapid (half-life of 12 min) which aids the clearance of non-specific phage. In vivo panning in brain enriched for isolates expressing the motif CAGALCY. Kinetic analysis of focused libraries built around each structural element of the peptide provided for rapid pharmacophore mapping. The computer modeling data suggested the peptide showed similarities to peptide mimetics of adhesion molecule ligands. GST-CAGALCY but not GST control protein was able to inhibit the rolling and adhesion of labeled platelets to inflamed pial vasculature. GST-CAGALCY had no effect on lymphocyte adhesion. CONCLUSIONS Incorporating normal blood phamacokinetics of T7 phage into in vivo phage display improves the ability to recover targeting peptide motifs and allows effective lead optimization by kSAR. This approach led to the isolation of a brain-specific peptide, CAGALCY, which appears to function as an effective antagonist of platelet adhesion to activated pial microvasculature.
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Affiliation(s)
- Xiaomin Fan
- AvantGen, Inc., 9924 Mesa Rim Rd, San Diego, California 92121, USA
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22
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Tuncer HH, Oster RA, Huang ST, Marques MB. Predictors of response and relapse in a cohort of adults with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: a single-institution experience. Transfusion 2007; 47:107-14. [PMID: 17207238 DOI: 10.1111/j.1537-2995.2007.01071.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a diagnosis of exclusion when a patient presents with the sine qua non findings of thrombocytopenia and microangiopathic hemolytic anemia without an identifiable cause. Although most patients respond to therapeutic plasma exchange (TPE), a significant number of patients relapse. The aim was to determine if clinical, laboratory, and/or treatment features could predict response and/or relapse. STUDY DESIGN AND METHODS This study was a retrospective review of adults with TTP-HUS treated with TPE at our institution from January 1996 to February 2004. RESULTS The study population consisted of 90 patients (69% female) with mean age of 45 years and mostly obese (65%). The majority of cases were considered idiopathic. Ten patients died (11%) from the disease before achieving a response, whereas 79 percent were considered responders. Obesity and severe anemia at presentation were predictors of response to TPE (p = 0.0126 and p = 0.0071, respectively). Among the responders, 28 percent relapsed in a median of 14 months. Male sex, severe thrombocytopenia (mean +/- SD, 13 x 10(9) +/- 8 x 10(9)/L), and higher lactate dehydrogenase pre-/posttreatment ratio were associated with relapse (p values of 0.0141, 0.0199, and 0.0407, respectively). ADAMTS-13 values were not obtained on enough number of patients to provide important data. CONCLUSION Although patient and laboratory characteristics associated with response and relapse were identified, there was significant overlap between patient groups. Thus, our findings offer preliminary evidence and do not yet justify short- or long-term changes in the management of patients with TTP-HUS.
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Affiliation(s)
- Hande H Tuncer
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Cataland SR, Jin M, Smith E, Stanek M, Wu HM. Full evaluation of an acquired case of thrombotic thrombocytopenic purpura following the surgical resection of glioblastoma multiforme. J Thromb Haemost 2006; 4:2733-7. [PMID: 16972936 DOI: 10.1111/j.1538-7836.2006.02217.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Curtillet C, Poullin P, Doré E, Fossat C, Lefevre P, Michel G. Purpura thrombotique thrombocytopénique acquis auto-immun chez l'enfant : à propos d'1 cas. Arch Pediatr 2006; 13:1521-4. [PMID: 17010579 DOI: 10.1016/j.arcped.2006.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 08/09/2006] [Indexed: 10/24/2022]
Abstract
UNLABELLED Thrombotic thrombocytopenic purpura (TTP), when accompanied by regenerative anaemia with schizocytosis, thrombopenia and neurological manifestations, is a disease whose main characteristic is the absence of the von Willebrand factor (vWF) cleaving protease. The two types of TTP are distinguishable by the presence or absence of antiprotease inhibitors, which are, respectively, either acquired or constitutional. The acquired autoimmune form is most frequently observed in adults. OBSERVATION An adolescent with a previous history of moderate, isolated thrombopenia first showed symptoms of TTP at the age of 14. Positive antiprotease inhibitors in combination with a degeneration of protease activity confirmed the diagnosis of acquired autoimmune TTP. A treatment consisting of daily plasma exchange led to rapid improvement; however, a failed attempt to space out plasma exchanges necessitated the introduction of 4 weekly injections of Rituximab beginning on day 40, which was successful. Indeed, since the second injection of Rituximab on day 51, the number of platelets stabilized at a normal level, thereby allowing for the complete cessation of plasma exchange. At this writing - day 89 - the patient remains in persistent remission. CONCLUSION Given the different therapeutic and prognostic implications of the 2 types of TTP in child patients, it is mandatory to end at an accurate biological diagnosis: whereas the constitutional form is effectively treated with plasma injections, the acquired form, while initially requiring plasma exchange, often necessitates the use of immunosuppressors during acute or relapse phase. The present study concerns a paediatric case of acquired TTP treated successfully with Rituximab during an acute dependant phase.
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MESH Headings
- Adolescent
- Age Factors
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Humans
- Immunologic Factors/administration & dosage
- Immunologic Factors/therapeutic use
- Male
- Plasma Exchange
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/drug therapy
- Purpura, Thrombotic Thrombocytopenic/therapy
- Remission Induction
- Rituximab
- Time Factors
- Treatment Outcome
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Affiliation(s)
- C Curtillet
- Service Hématologie Pédiatrique du Professeur-Michel, Hôpital Timone-Enfants Marseille, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
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25
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Dwyre DM, Bell AM, Siechen K, Sethi S, Raife TJ. Disseminated histoplasmosis presenting as thrombotic microangiopathy. Transfusion 2006; 46:1221-5. [PMID: 16836570 DOI: 10.1111/j.1537-2995.2006.00873.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Thrombotic microangiopathies (TMA) are systemic vasoocclusive disorders associated with significant morbidity and mortality. Rapid and reliable diagnosis of TMA is critical. The diagnosis is complicated by a lack of objective and sensitive laboratory testing as well as multiple concurrent diseases, including infectious processes. CASE STUDY We report two cases of disseminated histoplasmosis associated with TMA manifestations in renal transplant recipients, including one patient with histologically documented renal microthrombi; both patients were referred for plasma exchange. After the diagnosis of histoplasmosis, the treatment plan was changed to antifungal medications, reduced immuno-suppression, and supportive care, with progressive resolution of TMA manifestations. CONCLUSION TMA occurs in transplant populations in association with infections, medications, and other factors. Appropriate management includes recognition and treatment of possible etiological factors. Disseminated histoplasmosis should be considered in transplant patients presenting with TMA.
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Affiliation(s)
- Denis M Dwyre
- Department of Pathology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA
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Iosifidis MI, Ntavlis M, Giannoulis I, Malioufas L, Ioannou A, Giantsis G. Acute thrombotic thrombocytopenic purpura following orthopedic surgery: a case report. Arch Orthop Trauma Surg 2006; 126:335-8. [PMID: 16525809 DOI: 10.1007/s00402-005-0014-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Indexed: 10/24/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) or Moschowitz's syndrome is characterized by release of unusually large von Willebrand factor (ULvWF) multimers and a deficiency of vWF metalloprotease. It is a very rare condition, but it causes serious problems. The etiology is still unknown, although surgical stress has been associated with TTP, probably by releasing massive amounts of ULvWF. TTP is an acute, recurrent disease of the circulatory system, consisting of thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological signs, and renal dysfunction. It has the strong possibility of being fatal and thus should be treated immediately, mostly by plasmapheresis. We report a case of TTP following a high tibial valgus osteotomy. An association between TTP and orthopedic surgery--as far as we know--has only once been reported in the literature. We suggest that orthopedic surgeons should be aware of this because, although very rare, postsurgical TTP could be a life-threatening postoperative complication, which needs prompt diagnosis and treatment.
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Affiliation(s)
- Michael I Iosifidis
- Orthopaedic Department, Naoussa General Hospital Naoussa, 21 Filiaton-Ikarou Str, 55438 Thessaloniki, Greece.
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27
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Shelat SG, Ai J, Zheng XL. Molecular biology of ADAMTS13 and diagnostic utility of ADAMTS13 proteolytic activity and inhibitor assays. Semin Thromb Hemost 2006; 31:659-72. [PMID: 16388417 PMCID: PMC2577222 DOI: 10.1055/s-2005-925472] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
ADAMTS13, a reprolysin-like metalloprotease, limits platelet-rich thrombus formation in the small arteries by cleaving von Willebrand factor (vWF) at the Tyr1605-Met1606 peptide bond. Deficiency of plasma ADAMTS13 activity, due to either an inherited or an acquired etiology, may lead to a potentially lethal syndrome, thrombotic thrombocytopenic purpura (TTP). Molecular cloning and characterization of the ADAMTS13 gene have provided further insight into the structure-function relationships, biosynthesis, and regulation of the ADAMTS13 protease, in addition to understanding the pathogenesis of TTP and perhaps other thrombotic disorders. ADAMTS13 consists of a short propeptide, a typical reprolysin-like metalloprotease domain, followed by a disintegrin-like domain, first thrombospondin type 1 (TSP1) repeat, Cys-rich domain, and spacer domain. The carboxyl terminus of ADAMTS13 has seven more TSP1 repeats and two CUB domains. ADAMTS13 is synthesized mainly in hepatic stellate cells, but also in vascular endothelial cells. Recognition and cleavage of vWF require the proximal carboxyl terminal domains, but not the middle and distal carboxyl terminal domains. Cleavage of vWF appears to be modulated by shear force, binding to platelet or platelet glycoprotein-1balpha, heparin, inflammatory cytokine (interleukin-6), and chloride ion. At the site of thrombus formation, the ADAMTS13 may be inactivated by thrombin, plasmin, and factor Xa. Having a sensitive and specific assay for ADAMTS13 activity is not only critical to understand the basic biology of ADAMTS13 protease, but also to facilitate a more timely and accurate clinical diagnosis of TTP, and to initiate potentially life-saving plasma exchange therapy. Although many assays have been developed and tested for clinical applications, the fluorescent resonance energy transfer-vWF73 assay appears to be the simplest and most promising assay to date.
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Affiliation(s)
- Suresh G. Shelat
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia
- The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Jihui Ai
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia
- Assistant Professor, Philadelphia, Pennsylvania
- The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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28
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Vural F, Donmez A, Cagirgan S, Tombuloglu M. Local experience with thrombotic thrombocytopenic purpura from the western part of Turkey. Transfus Apher Sci 2006; 34:163-9. [PMID: 16504585 DOI: 10.1016/j.transci.2005.09.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 09/30/2005] [Indexed: 01/30/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a fatal disorder if left untreated. Therapeutic plasma exchange (PE) has resulted in excellent remission and survival rates in these patients but there is a need for alternative immuno-modulatory treatments in unresponsive patients. We present a descriptive, retrospective study of 25 (14 female, 11 male) adult patients admitted to our hematology unit with TTP. The patients' median age was 32 years. The patients were treated with immediate PE and a standard dose of corticosteroid therapy. Twenty percent of the patients obtained a complete response after the addition of Intravenous immuno-globulin (IVIg). Improvement of clinical status, platelet counts and serum LDH levels were seen after a median 13, 14 and 3.5 PE sessions, respectively. The mortality rate was 12%. One patient has a chronic relapsing form of TTP and two patients have relapsed. All the other patients are still in complete remission after a median of 7 years of follow-up. Although PE therapy is life-saving and the application of early corticosteroid treatment could obtain early and durable responses, addition of other immuno-modulatory treatments are needed in unresponsive patients. The use of IVIg could result in a dramatic response.
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Affiliation(s)
- Filiz Vural
- Department of Hematology, Medical Faculty, Ege University, 35100 Bornova, Izmir, Turkey.
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29
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Jin M, Cataland S, Bissell M, Wu HM. A rapid test for the diagnosis of thrombotic thrombocytopenic purpura using surface enhanced laser desorption/ionization time-of-flight (SELDI-TOF)-mass spectrometry. J Thromb Haemost 2006; 4:333-8. [PMID: 16420561 DOI: 10.1111/j.1538-7836.2006.01758.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP), a life-threatening thrombotic microangiopathy, requires immediate diagnosis and plasma exchange therapy. Development of TTP is related to functional deficiency of ADAMTS-13 protease that leads to the accumulation of ultra large von Willebrand factor (VWF) and subsequent platelet thrombosis. Currently no clinical test is available for the rapid detection of ADAMTS-13 activity. OBJECTIVES The goal is to devise a novel method to rapidly detect functional activity of ADAMTS-13 and improve clinical outcome. METHODS AND RESULTS A recombinant VWF substrate containing the ADAMTS-13 cleavage site and a 6X Histidine tag was cleaved by ADAMTS-13 in a dose-dependent manner, generating approximately 7739 Da peptide containing a 6X Histidine tag. This cleaved peptide, bound to an IMAC/Nickel ProteinChip, was quantified using Surface Enhanced Laser Desorption/Ionization Time-of-flight Mass Spectrometry (SELDI-TOF-MS). The assay is capable of quantifying ADAMTS-13 activity as low as 2.5% in plasma within 4 h. When the cleaved peptide was quantified as a ratio of an internal control peptide, the test displayed good reproducibility, with an average inter-assay coefficient of variation (CV) of < 33%. Further validation revealed a mean ADAMTS-13 activity of 92.5% +/- 16.6% in 39 healthy donors. Sixteen patients with idiopathic TTP displayed mean ADAMTS-13 activity of 1.73% +/- 3.62%. Further utility of this novel method includes determining the inhibitory titer of ADAMTS-13 antibody in cases of acquired TTP. CONCLUSIONS We have devised a novel SELDI-TOF-MS assay that offers a rapid, cost-effective, and functionally relevant test for timely diagnosis and management of TTP.
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Affiliation(s)
- M Jin
- Department of Pathology, Ohio State University College of Medicine and Public Health, Columbus, OH 43210, USA
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30
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Affiliation(s)
- A Veyradier
- Inserm Unité 143, Le Kremlin-Bicêtre and Service d'Hématologie Biologique, Hôpital Antoine-Béclère, Clamart, France
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31
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Soejima K, Nakagaki T. Interplay between ADAMTS13 and von Willebrand factor in inherited and acquired thrombotic microangiopathies. Semin Hematol 2005; 42:56-62. [PMID: 15662617 DOI: 10.1053/j.seminhematol.2004.09.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The presence of unusually large multimers of von Willebrand factor (VWF) is thought to be a major pathogenic factor for thrombotic thrombocytopenic purpura (TTP). ADAMTS13 is a protease that regulates the multimeric size and function of VWF by cleaving VWF. Hence, congenital or acquired deficiency of ADAMTS13 causes life-threatening illness of TTP. Mutations in the ADAMTS13 gene cause inherited TTP, and the development of autoantibodies that inhibit ADAMTS13 activity frequently are associated with acquired TTP. ADAMTS13 consists of 1,427 amino acid residues and is composed of multiple structural and functional domains, containing a signal peptide, a propeptide, a reprolysin-like metalloprotease domain, a disintegrin-like domain, a thrombospondin type-1 (Tsp1) motif, a cysteine-rich domain, a spacer domain, seven additional Tsp1 repeats, and two CUB domains. In particular, the cysteine-rich/spacer domains are essential for VWF cleavage and are the principal epitopes recognized by autoantibodies in patients with acquired TTP. Therefore, it is likely that these domains are involved in the recognition and binding of ADAMTS13 to VWF. ADAMTS13 circulates in the blood in an active state, and efficiently cleaves unfold form of VWF induced under shear stress caused by blood flow, preventing the accumulation of pathogenic unusually large VWF multimers (ULVWF). Thus, ADAMTS13 helps maintain vascular homeostasis by preventing the excess thrombus formation.
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Affiliation(s)
- Kenji Soejima
- First Research Department, The Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan.
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32
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Sugimoto T, Saigo K, Shin T, Kaneda Y, Manabe N, Narita H, Wakuya J, Imoto S, Murayama T, Matsumoto M, Fujimura Y, Nishimura R, Koizumi T, Kumagai S. Von Willebrand factor-cleaving protease activity remains at the intermediate level in thrombotic thrombocytopenic purpura. Acta Haematol 2005; 113:198-203. [PMID: 15870491 DOI: 10.1159/000084451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2004] [Accepted: 10/28/2004] [Indexed: 11/19/2022]
Abstract
A 59-year-old woman, diagnosed with chronic myelogenous leukemia (chronic phase) and treated with interferon-alpha for 13 years, developed renal failure. Renal biopsy showed thrombotic thrombocytopenic purpura, but intensive therapy including plasma exchange and steroid administration was not effective. The activity of von Willebrand factor-cleaving protease was detectable at the intermediate level (15-46%) during the clinical course, suggesting that this case was not compatible with the previously reported pattern of idiopathic or drug-induced thrombotic thrombocytopenic purpura, but with the pattern associated with malignant disease or immunological disorders. Further studies to determine the effects of interferon-alpha on endothelial cells in chronic myelogenous leukemia patients are needed.
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MESH Headings
- ADAM Proteins
- ADAMTS13 Protein
- Disease Progression
- Female
- Humans
- Interferon-alpha/administration & dosage
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/enzymology
- Metalloendopeptidases/blood
- Middle Aged
- Plasma Exchange
- Purpura, Thrombotic Thrombocytopenic/enzymology
- Purpura, Thrombotic Thrombocytopenic/etiology
- Purpura, Thrombotic Thrombocytopenic/therapy
- Renal Insufficiency/etiology
- Renal Insufficiency/metabolism
- Steroids/therapeutic use
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Affiliation(s)
- Takeshi Sugimoto
- Hematology Oncology Division, Department of Medicine, Hyogo Medical Center for Adults, Akashi, Japan
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van Runnard Heimel PJ, Franx A, Schobben AFAM, Huisjes AJM, Derks JB, Bruinse HW. Corticosteroids, pregnancy, and HELLP syndrome: a review. Obstet Gynecol Surv 2005; 60:57-70; quiz 73-4. [PMID: 15618920 DOI: 10.1097/01.ogx.0000150346.42901.07] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Corticosteroids are potent antiinflammatory and immunosuppressive drugs, which are used in the treatment of a wide range of medical disorders. During pregnancy, several corticosteroids are administered for maternal as well as fetal reasons. Prednisone and prednisolone show limited transplacental passage and are thus used for treatment of maternal disease. Dexamethasone and betamethasone, drugs that can easily cross the placenta, are more suitable for fetal indications. During the last decade, administration of corticosteroids was introduced in the treatment of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome), a severe form of preeclampsia unique to human pregnancy. Several randomized, controlled trials as well as other prospective and retrospective studies have been performed to investigate this beneficial effect of corticosteroids on biochemical measures and clinical signs. This review discusses the characteristics of corticosteroids in humans and details the use of corticosteroids during pregnancy. A review of literature on the effect of corticosteroids on HELLP syndrome is given and possible mechanisms of action are discussed.
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Affiliation(s)
- P J van Runnard Heimel
- Department of Perinatology and Gynecology, University Medical Center, Utrecht, The Netherlands.
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34
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Wyrick-Glatzel J. Thrombotic Thrombocytopenic Purpura and ADAMTS-13: New Insights into Pathogenesis, Diagnosis, and Therapy. Lab Med 2004. [DOI: 10.1309/77krkljw0ea75t2r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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35
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Kremer Hovinga JA, Studt JD, Alberio L, Lämmle B. von Willebrand factor-cleaving protease (ADAMTS-13) activity determination in the diagnosis of thrombotic microangiopathies: the Swiss experience. Semin Hematol 2004; 41:75-82. [PMID: 14727262 DOI: 10.1053/j.seminhematol.2003.10.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Severe deficiency of von Willebrand factor (VWF)-cleaving protease (ADAMTS-13) activity (<5% of normal) is a specific finding for acute idiopathic thrombotic thrombocytopenic purpura (TTP), a disorder that presents as thrombocytopenia, microangiopathic hemolytic anemia, and often organ dysfunction such as neurological disturbances or renal failure, and fever. Between January 2001 and July 2003, ADAMTS-13 activity was determined in plasma samples of 396 consecutive patients referred to our laboratory for diagnostic purposes. Plasma samples with ADAMTS-13 activity less than 5% were in addition tested for the presence of inhibitory antibodies. Patients were assigned to 10 predefined clinical categories according to information provided by the referring clinician: thrombotic microangiopathy (TMA) not further specified; neoplasia- or chemotherapy-associated TMA; TMA following hematopoietic stem cell transplantation; TMA with additional/alternative disorder; idiopathic TTP; hemolytic-uremic syndrome (HUS) not specified; HUS with diarrhea prodrome (D+HUS); atypical HUS; other hematological disorder; and no clinical information available. Severe ADAMTS-13 deficiency was found in 69 (17%) patients, including 42 with acquired idiopathic TTP, either at initial presentation or at relapse, 14 with confirmed or suspected hereditary TTP, 10 with TMA not further specified, two with neoplasia- or chemotherapy-associated TMA, and one in continued clinical remission 3.4 years after splenectomy for plasma-refractory TTP. Forty-three (62%) patients with ADAMTS-13 activity less than 5% displayed inhibitory antibodies. Severe ADAMTS-13 deficiency was found in 60% of patients diagnosed with acute idiopathic TTP, but in none of 130 patients diagnosed with HUS or in any of the 14 patients with hematopoietic stem cell transplantation-associated TMA. Thus, plasma ADAMTS-13 activity less than 5% does not identify all patients clinically diagnosed with TTP, and severe ADAMTS-13 deficiency is not invariably associated with clinical manifestations of microvascular platelet clumping.
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Abstract
In patients with thrombotic thrombocytopenic purpura (TTP), unusually large multimers of von Willebrand factor (VWF) circulate in the plasma. This is caused by a functional deficiency of VWF-cleaving protease, ADAMTS-13. Although TTP usually occurs as an acquired form due to autoantibodies against ADAMTS-13, the condition may be inherited in an autosomal recessive fashion. Thus far, genomic DNA from 23 patients with hereditary TTP and their families has been analyzed and 33 causative mutations identified in the ADAMTS13 gene: 19 missense, five nonsense, five frameshift, and four splice mutations. Common missense polymorphisms have been also found, one of which significantly reduces ADAMTS-13 activity. No cases have been found without mutations in the ADAMTS13 gene, suggesting that genetic defects in ADAMTS13 are the dominant cause of hereditary TTP. Further analysis may reveal the genetic background associated with acquired TTP and other thrombotic diseases.
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Affiliation(s)
- Koichi Kokame
- National Cardiovascular Center Research Institute, Suita, Osaka, Japan
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Coca C, Noel E, Maloisel F, Blicklé JF, Andrès E. Un diagnostic pas aussi mécanique qu'il y paraît…. Rev Med Interne 2004; 25 Suppl 2:S239-41. [PMID: 15460462 DOI: 10.1016/s0248-8663(04)80015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- C Coca
- Service de médecine interne, diabète et maladies métaboliques, clinique médicale B, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
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Sadler JE, Moake JL, Miyata T, George JN. Recent advances in thrombotic thrombocytopenic purpura. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2004; 2004:407-423. [PMID: 15561695 DOI: 10.1182/asheducation-2004.1.407] [Citation(s) in RCA: 197] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia and thrombocytopenia, accompanied by microvascular thrombosis that causes variable degrees of tissue ischemia and infarction. Intravascular coagulation is not a prominent feature of the disorder. Plasma exchange can induce remissions in approximately 80% of patients with idiopathic TTP, but patients have a much worse prognosis when thrombotic microangiopathy is associated with cancer, certain drugs, infections, or tissue transplantation. Recently, acquired autoimmune deficiency of a plasma metalloprotease named ADAMTS13 was shown to cause many cases of idiopathic TTP. This review describes our current understanding of how to use this knowledge clinically. In Section I, Dr. Joel Moake describes the presentation of thrombotic microangiopathy, emphasizing the pathophysiology of idiopathic TTP. Platelets adhere to ultra-large (or "unusually large") von Willebrand factor (ULVWF) multimers that are immobilized in exposed subendothelial connective tissue and secreted into the circulation in long "strings" from stimulated endothelial cells. ADAMTS13 cleaves ULVWF multimers within growing platelet aggregates under flowing conditions, and this normally limits platelet thrombus formation. If ADAMTS13 is absent, either congenitally or due to acquired autoantibodies, platelet-rich microvascular thrombosis proceeds unchecked and TTP ensues. Plasma exchange is effective therapy for idiopathic TTP, probably because it replenishes the deficient ADAMTS13 and removes some of the pathogenic autoantibodies and endothelial-stimulating cytokines. Some patients have a type of thrombotic microangiopathy after transplantation/chemotherapy but do not have severe ADAMTS13 deficiency. The pathogenesis of their disease must differ but remains poorly understood. In Section II, Dr. Toshiyuki Miyata describes recent advances in assay methods that should facilitate routine laboratory testing of ADAMTS13 for patients with thrombotic microangiopathy. ADAMTS13 cleaves a single Tyr-Met bond in domain A2 of the VWF subunit. ADAMTS13 assays based on the cleavage of plasma VWF multimers have been used extensively but require considerable time and expertise to perform. A recombinant substrate containing 73 amino acid residues of VWF domain A2 has been devised that allows short incubation times and rapid product detection by gel electrophoresis or immunoassay. These results should encourage the development of even simpler assays that can be performed in most clinical laboratories. In Section III, Dr. James George provides an update on the long-term prospective study of thrombotic microangiopathy in the Oklahoma TTP-HUS Registry. At presentation, the clinical distinction between idiopathic TTP, various forms of secondary thrombotic microangiopathy, and even Shiga toxin-associated hemolytic uremic syndrome (HUS) can be problematic because the symptoms and laboratory findings often overlap. Consequently, plasma exchange usually is administered to any patient with thrombotic microangiopathy if there is doubt about the cause. The role of ADAMTS13 testing in choosing therapy remains uncertain, but the results do appear to have prognostic significance. Severe ADAMTS13 deficiency is specific for idiopathic TTP and identifies a subgroup with a high likelihood of response to plasma exchange, and high-titer ADAMTS13 inhibitors correlate strongly with a high risk of relapsing disease. Patients with normal ADAMTS13 activity have a much worse prognosis, although many factors probably contribute to this difference. Longitudinal study of these patients will continue to clarify the relationship of ADAMTS13 deficiency to the clinical course of thrombotic microangiopathy.
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Jackson SP, Schoenwaelder SM. Antiplatelet therapy: in search of the 'magic bullet'. Nat Rev Drug Discov 2003; 2:775-89. [PMID: 14526381 DOI: 10.1038/nrd1198] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The central importance of platelets in the development of arterial thrombosis and cardiovascular disease is well established. No other single cell type is responsible for as much morbidity and mortality as the platelet and, as a consequence, it represents a major target for therapeutic intervention. The growing awareness of the importance of platelets is reflected in the increasing number of patients receiving antiplatelet therapy, a trend that is likely to continue in the future. There are, however, significant drawbacks with existing therapies, including issues related to limited efficacy and safety. The discovery of a 'magic bullet' that selectively targets pathological thrombus formation without undermining haemostasis remains elusive, although recent progress in unravelling the molecular events regulating thrombosis has provided promising new avenues to solve this long-standing problem.
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Affiliation(s)
- Shaun P Jackson
- The Australian Centre for Blood Diseases, Department of Medicine, Monash University, Arnold Street, Box Hill Hospital, Box Hill, Victoria 3128, Australia.
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Kokame K, Matsumoto M, Fujimura Y, Miyata T. VWF73, a region from D1596 to R1668 of von Willebrand factor, provides a minimal substrate for ADAMTS-13. Blood 2003; 103:607-12. [PMID: 14512308 DOI: 10.1182/blood-2003-08-2861] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
ADAMTS-13 was recently identified as a new hemostatic factor, von Willebrand factor (VWF)-cleaving protease. Either congenital or acquired defects of the enzymatic activity lead to thrombotic thrombocytopenic purpura (TTP). ADAMTS-13 specifically cleaves a peptidyl bond between Y1605 and M1606 in the A2 domain of VWF. Here, we determined the minimal region recognized as a specific substrate by ADAMTS-13. A series of partial deletions in the A2 domain flanked with N- and C-terminal tags were expressed in Escherichia coli and affinity-purified. These purified proteins were incubated with human plasma, subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and analyzed by Western blot. Judging from mobility shifts, all constructs except one were cleaved at the expected site. Data suggested that a minimal region as a functional substrate consisted of 73 amino acid residues from D1596 to R1668 of VWF, designated VWF73, and that further deletion of the E1660-R1668 region led to the loss of cleavage by ADAMTS-13. VWF73 was not cleaved by plasma from patients with congenital or acquired TTP, but cleaved by plasma from patients with hemolytic uremic syndrome, suggesting that VWF73 is a specific substrate forADAMTS-13. Thus, VWF73 will be a useful seed to develop a new rapid assay to determine ADAMTS-13 activity.
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Affiliation(s)
- Koichi Kokame
- National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan.
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Pimanda JE, Chesterman CN, Hogg PJ. A perspective on the measurement of ADAMTS13 in thrombotic thrombocytopaenic purpura. Eur J Haematol 2003; 70:257-62. [PMID: 12656756 DOI: 10.1034/j.1600-0609.2003.00057.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The recent discovery of the von Willebrand Factor (vWF) cleaving protease (ADAMTS13) and the association of its deficiency with thrombotic thrombocytopaenic purpura (TTP) has generated both enormous interest and considerable confusion. Ultra large von Willebrand Factor (UL vWF) multimers are present in the plasmas of patients with chronic relapsing TTP in remission but disappear during an attack. This observation led to the recognition that UL vWF multimers precipitate the thrombotic occlusion of arterioles, a feature that characterizes TTP. Multiple mutations in ADAMTS13 are associated with congenital TTP and neutralizing autoantibodies have been demonstrated in the acquired TTP syndrome. Although a number of functional assays for this enzyme have been described, the more rigorously evaluated assays are difficult to perform outside a research laboratory. There is also an enduring uncertainty about the specificity of ADAMTS13 deficiency for the diagnosis of acquired TTP and a perception that the result does not alter patient management. The cloning of the ADAMTS13 gene has also raised the prospect of recombinant enzyme therapy for the treatment of TTP, and this has heightened the need for a simple assay. In this review, we evaluate the value of measuring this enzyme in the management of TTP.
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Affiliation(s)
- John E Pimanda
- The University of New South Wales and The Department of Haematology, The Prince of Wales Hospital, Sydney, Australia.
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