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Yu J, Fu L, Jin G, Gao F, Ding L, Hong L, Lv S, Jin J, Tang L, Feng W, Zhang K, Xu C. Immune thrombocytopenia increases the risk of thrombosis: A two-sample Mendelian randomization study. Int J Cardiol 2024; 414:132417. [PMID: 39098611 DOI: 10.1016/j.ijcard.2024.132417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a prevalent autoimmune bleeding disorder, with the primary objective of treatment being the prevention of bleeding. Clinical investigations have indicated that individuals with ITP face an elevated risk of thrombosis, and the occurrence of thromboembolic events in ITP patients can be attributed to a multitude of factors. However, establishing a definitive causal relationship between ITP and thrombosis remains challenging. METHODS A two-sample Mendelian randomization (MR) study utilizing summary data from FinnGen consortium and UK Biobank was undertaken to investigate the causal association between ITP and thrombosis. The primary analysis employed the inverse-variance weighted (IVW) method, while supplementary analyses were conducted using the MR-Egger, weighted median, and MR-PRESSO approaches. RESULTS Based on IVW method, there was a statistically significant but small positive correlation between ITP and thrombosis. Specifically, ITP patients exhibited a suggestive positive correlation with myocardial infarction and deep-vein thrombosis. However, our investigation did not identify any causal relationship between ITP and cerebral infarction, arterial embolism, other arterial embolisms, pulmonary embolism, thrombophlebitis, or portal vein thrombosis. Sensitivity analyses further confirmed the accuracy and robustness of these findings. CONCLUSIONS This study presents empirical support for the causal relationship between ITP and thrombosis. It is important to note that a diminished platelet count does not serve as a preventive measure against thrombus formation. Consequently, when managing a newly diagnosed ITP patient, clinicians need to be aware that there is a slight elevation in the risk of thrombosis during treatment.
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Affiliation(s)
- Jieni Yu
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Leihua Fu
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Gan Jin
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China; Department of Vascular and Hernia Surgery, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Feidan Gao
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Lina Ding
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Li Hong
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Shanmei Lv
- Department of Laboratory, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Jing Jin
- Department of Hematology, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Liming Tang
- Department of Vascular and Hernia Surgery, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Weiying Feng
- Department of Vascular and Hernia Surgery, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China
| | - Kejie Zhang
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen City,Fujian Province, People's Republic of China
| | - Chao Xu
- Department of Vascular and Hernia Surgery, Shaoxing People's Hospital. Shaoxing City, Zhejiang Province, People's Republic of China.
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Sun T, Chen J, Xu Y, Li Y, Liu X, Li H, Fu R, Liu W, Xue F, Ju M, Dong H, Wang W, Chi Y, Yang R, Chen Y, Zhang L. Proteomics landscape and machine learning prediction of long-term response to splenectomy in primary immune thrombocytopenia. Br J Haematol 2024; 204:2418-2428. [PMID: 38513635 DOI: 10.1111/bjh.19420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
This study aimed to identify key proteomic analytes correlated with response to splenectomy in primary immune thrombocytopenia (ITP). Thirty-four patients were retrospectively collected in the training cohort and 26 were prospectively enrolled as validation cohort. Bone marrow biopsy samples of all participants were collected prior to the splenectomy. A total of 12 modules of proteins were identified by weighted gene co-expression network analysis (WGCNA) method in the developed cohort. The tan module positively correlated with megakaryocyte counts before splenectomy (r = 0.38, p = 0.027), and time to peak platelet level after splenectomy (r = 0.47, p = 0.005). The blue module significantly correlated with response to splenectomy (r = 0.37, p = 0.0031). KEGG pathways analysis found that the PI3K-Akt signalling pathway was predominantly enriched in the tan module, while ribosomal and spliceosome pathways were enriched in the blue module. Machine learning algorithm identified the optimal combination of biomarkers from the blue module in the training cohort, and importantly, cofilin-1 (CFL1) was independently confirmed in the validation cohort. The C-index of CFL1 was >0.7 in both cohorts. Our results highlight the use of bone marrow proteomics analysis for deriving key analytes that predict the response to splenectomy, warranting further exploration of plasma proteomics in this patient population.
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Affiliation(s)
- Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yuan Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yang Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Huiyuan Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Huan Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wentian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ying Chi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Shindo R, Abe R, Oku K, Tanaka T, Matsueda Y, Wada T, Arinuma Y, Tanaka S, Ikenoue T, Miyakawa Y, Yamaoka K. Involvement of the complement system in immune thrombocytopenia: review of the literature. Immunol Med 2023; 46:182-190. [PMID: 37237432 DOI: 10.1080/25785826.2023.2213976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a thrombocytopenic condition induced by autoimmune mechanisms and includes secondary ITP with underlying diseases such as connective tissue diseases (CTD). In recent years, it has been elucidated that the subsets of the ITP are associated with complement abnormalities but much remains unclear. To perform a literature review and identify the characteristics of complement abnormalities in ITP. PUBMED was used to collect the literature published up to June 2022 related to ITP and complement abnormalities. Primary and secondary ITP (CTD-related) were examined. Out of the collected articles, 17 were extracted. Eight articles were related to primary ITP (pITP) and 9 to CTD-related ITP. Analysis of the literature revealed that the ITP severity was inversely correlated with serum C3, C4 levels in both ITP subgroups. In pITP, a wide range of complement abnormalities was reported, including abnormalities of initial proteins, complement regulatory proteins, or the end products. In CTD-related ITP, reported complement abnormalities were limited to the initial proteins. Activation of the early complement system, mainly through activation of C3 and its precursor protein C4, was reported for both ITPs. On the other hand, more extensive complement activation has been reported in pITP.
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Affiliation(s)
- Risa Shindo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ryohei Abe
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomoki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yu Matsueda
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tatsuhiko Wada
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Sumiaki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
- Department of Rheumatology, Kitasato University Medical Center, Kitamoto, Japan
| | - Tatsuyoshi Ikenoue
- Data Science and AI Innovation Research Promotion Center, Shiga University, Hikone, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Miyakawa
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
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4
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Roeser A, Lazarus AH, Mahévas M. B cells and antibodies in refractory immune thrombocytopenia. Br J Haematol 2023; 203:43-53. [PMID: 37002711 DOI: 10.1111/bjh.18773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired bleeding disorder mediated by pathogenic autoantibodies secreted by plasma cells (PCs) in many patients. In refractory ITP patients, the persistence of splenic and bone marrow autoreactive long-lived PCs (LLPCs) may explain primary failure of rituximab and splenectomy respectively. The reactivation of autoreactive memory B cells generating new autoreactive PCs contributes to relapses after initial response to rituximab. Emerging strategies targeting B cells and PCs aim to prevent the settlement of splenic LLPCs with the combination of anti-BAFF and rituximab, to deplete autoreactive PCs with anti-CD38 antibodies, and to induce deeper B-cell depletion in tissues with novel anti-CD20 monoclonal antibodies and anti-CD19 therapies. Alternative strategies, focused on controlling autoantibody mediated effects, have also been developed, including SYK and BTK inhibitors, complement inhibitors, FcRn blockers and inhibitors of platelet desialylation.
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Affiliation(s)
- Anaïs Roeser
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir TeamAI2B, Paris, France
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Alan H Lazarus
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Innovation and Portfolio Management, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Matthieu Mahévas
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir TeamAI2B, Paris, France
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
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5
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Arnold DM, Clerici B, Ilicheva E, Ghanima W. Refractory immune thrombocytopenia in adults: Towards a new definition. Br J Haematol 2023; 203:23-27. [PMID: 37642211 DOI: 10.1111/bjh.19075] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune haematological disorder characterized by immune-mediated thrombocytopenia and a variable risk of bleeding. Despite the availability of multiple treatment options, some patients are considered refractory since they do not achieve a platelet count response to multiple treatments and are at risk of bleeding. The term 'refractory' has been used to identify this patient group; however, with the advent of multiple lines of treatment, its meaning has become ambiguous. To address this issue, we reviewed previous definitions of refractory ITP, solicited the views of ITP experts and collected data from registries to inform a definition. Twenty ITP experts who attended the 7th Expert Meeting of the Intercontinental Cooperative ITP Study Group in September 2022 answered a web-based survey: 95% felt that there was a need for a new definition of refractory ITP for clinical and research purposes. The use of the term refractory, accompanied by a clear indication of the type and timing of failed treatments, was supported by 85% of respondents. Preliminary data on the frequency of refractory patients from the McMaster and Norwegian ITP Registries demonstrated that the proportion of adult ITP patients who had failed first-line therapy, rituximab, thrombopoietin receptor agonists, any immune suppressant medication and splenectomy ranged from 0.4% to 3.8%. We propose a definition of refractory ITP that could be evaluated in future studies.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Bianca Clerici
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Dipartimento di Scienze della Salute, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Università degli Studi di Milano, Milan, Italy
| | | | - Waleed Ghanima
- Department of Research, Østfol Hospital, Sarpsborg, Norway
- Department of Hemato-Oncolology, Østfol Hospital, Sarpsborg, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
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6
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Sanfilippo KM, Cuker A. TPO-RAs and ITP remission: cause or coincidence? Blood 2023; 141:2790-2791. [PMID: 37289475 DOI: 10.1182/blood.2023020243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Affiliation(s)
- Kristen M Sanfilippo
- Washington University School of Medicine St. Louis
- John Cochran St. Louis Veterans Administration Medical Center
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Pulicari F, Pellegrini M, Scribante A, Kuhn E, Spadari F. Pathological Background and Clinical Procedures in Oral Surgery Haemostasis Disorders: A Narrative Review. APPLIED SCIENCES 2023; 13:2076. [DOI: 10.3390/app13042076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Haemostasis disorders are serious pathologies that could put dental and surgical procedures at risk as they are associated with postoperative bleeding, which in some circumstances could be prolonged and dangerous for the patient. In-depth knowledge of the problems associated with coagulation pathologies and the suitable specific procedures should be implemented in dental practice. A good awareness of the clinical protocols to be used in these circumstances may help reduce operator stress and increase patient compliance. Collaboration with the haematologist is always recommended to establish an adequate treatment plan, both regarding the administration of therapies that promote haemostasis and for assessing the operative risk. Hereby, we summarize the congenital and hereditary pathologies that lead to haemostasis disorders, which can be found in patients undergoing dental procedures. The purpose of this narrative review is to frame the diseases from a clinical, anamnestic, and etiopathological standpoint, as well as to evaluate an operative approach to the pathology under consideration, with particular attention to anaesthesia manoeuvres and post-surgical haemostasis, to avoid hematoma formation and uncontrolled bleeding which can lead procedure failure up and even death. Of note, it is likewise important to educate the patient about prevention, to keep the oral cavity healthy and avoid invasive procedures, limiting the number of operative sessions.
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Affiliation(s)
- Federica Pulicari
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Via Della Commenda 10, 20122 Milan, Italy
- Maxillo-Facial and Odontostomatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Matteo Pellegrini
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Via Della Commenda 10, 20122 Milan, Italy
- Maxillo-Facial and Odontostomatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Section of Dentistry, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Andrea Scribante
- Section of Dentistry, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Elisabetta Kuhn
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Via Della Commenda 10, 20122 Milan, Italy
- Pathology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Francesco Spadari
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Via Della Commenda 10, 20122 Milan, Italy
- Maxillo-Facial and Odontostomatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Platelet recovery with ibrutinib therapy in patient with treatment-refractory immune thrombocytopenia. Ann Hematol 2023; 102:237-238. [PMID: 36441261 DOI: 10.1007/s00277-022-05031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022]
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9
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Lv Y, Shi H, Liu H, Zhou L. Current therapeutic strategies and perspectives in refractory ITP: What have we learned recently? Front Immunol 2022; 13:953716. [PMID: 36003388 PMCID: PMC9393521 DOI: 10.3389/fimmu.2022.953716] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder featured by increased platelet destruction and deficient megakaryocyte maturation. First-line treatments include corticosteroids, intravenous immunoglobulin and intravenous anti-D immunoglobulin. Second-line treatments consist of rituximab, thrombopoietin receptor agonists and splenectomy. Although most patients benefit from these treatments, an individualized treatment approach is warranted due to the large heterogeneity among ITP patients. In addition, ITP patients may relapse and there remains a subset of patients who become refractory to treatments. The management of these refractory patients is still a challenge. This review aims to summarize emerging therapeutic approaches for refractory ITP in several categories according to their different targets, including macrophages, platelets/megakaryocytes, T cells, B cells, and endothelial cells. Moreover, current management strategies and combination regimens of refractory ITP are also discussed.
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Affiliation(s)
- Yue Lv
- Department of Hematology, Affiliated Hospital and Medical School of Nantong University, Nantong, China
| | - Huiping Shi
- Soochow University Medical College, Suzhou, China
| | - Hong Liu
- Department of Hematology, Affiliated Hospital and Medical School of Nantong University, Nantong, China
- *Correspondence: Lu Zhou, ; Hong Liu,
| | - Lu Zhou
- Department of Hematology, Affiliated Hospital and Medical School of Nantong University, Nantong, China
- *Correspondence: Lu Zhou, ; Hong Liu,
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10
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Lebowa W, Zdziarska J, Sacha T. Immune Thrombocytopenia: Characteristics of the Population and Treatment Methods-One-Center Experience. Hamostaseologie 2022; 43:132-141. [PMID: 35654406 DOI: 10.1055/a-1767-0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a disease with variable clinical presentation, requiring different treatment lines. AIM The study aimed to characterize a group of ITP patients in terms of clinical picture and disease treatment, as well as to present the current standard of care of ITP in Poland, in the context of local and international guidelines. MATERIALS AND METHODS The study included adult patients diagnosed with ITP, treated at the Department of Haematology of the Jagiellonian University Hospital in Krakow from January 2006 to January 2021. Patient characteristics, clinical manifestation of ITP, and treatment methods were analyzed. RESULTS A total of 245 ITP patients were included. 57.1% of them were asymptomatic at diagnosis. Most common symptoms were thrombocytopenic purpura (68.2%), followed by epistaxis (34.7%) and gum bleeds (19.2%). Life-threatening bleedings were noted in three cases (1.2%). 23.2% of patients did not require treatment. Prednisone was the most commonly used first-line therapy (75.5% of patients). Treatment with eltrombopag and romiplostim was used in 40.4 and 8.5% of patients requiring second-line therapy, respectively. 14.3% of all patients ultimately underwent splenectomy, including 51.5% of those who needed second-line treatment. The initial response rate was 74.3%; however, post-splenectomy relapses occurred in 22.9% of patients. CONCLUSIONS ITP is a disease of mild clinical course, often asymptomatic. Chronic disease often requires multiple treatment lines and balancing between bleeding risk and treatment toxicity, based on individual risk-benefit assessment. Local access restrictions to thrombopoietin receptor agonists determined the treatment strategy.
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Affiliation(s)
- Weronika Lebowa
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Joanna Zdziarska
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Sacha
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland.,Department of Haematology, Jagiellonian University Medical College, Cracow, Poland
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11
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Splenectomy of Immune Thrombocytopenic Purpura in the Era of New Medical Therapies: A Retrospective Cohort Study from a Tertiary Cancer Center in Egypt. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00316-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Effect of Thrombopoietin Receptor Agonist on Pregnant Mice. Pharmaceutics 2022; 14:pharmaceutics14030514. [PMID: 35335889 PMCID: PMC8951389 DOI: 10.3390/pharmaceutics14030514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/04/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RAs) are an effective treatment for refractory immune thrombocytopenia (ITP). However, the use of TPO-RAs is limited for ITP in pregnant women due to concerns about fetal toxicity. In this study, we examined the effects of romiplostim, one of the TPO-RAs, on pregnant mice. The mice were injected subcutaneously with romiplostim (1, 5, 10, 30, and 100 μg/kg) on gestational days (GD) 1, 8, and 15. We evaluated maternal and fetal platelet and megakaryocyte counts (MK), fetal weight at birth, placental morphology, and miscarriage rates. Romiplostim increased platelet and MK counts in pregnant mice at all doses and in fetuses at doses above 10 µg/kg. Fetal weight at birth was slightly reduced at a dose of 100 μg/kg, but there were no significant differences in placental weight, spiral artery wall thickness, placental growth factor signal changes, or the rate of resorption at that dosage. The dose of romiplostim used clinically for ITP patients (1–10 μg/kg) did not show any adverse effects on pregnant mice. Although the results of the present study are encouraging, until there are more conclusive data, the use of romiplostim should be evaluated individually in severe, life-threatening cases, and all relevant ethical aspects should be considered.
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13
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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14
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Choi PY, Merriman E, Bennett A, Enjeti AK, Tan CW, Goncalves I, Hsu D, Bird R. Consensus guidelines for the management of adult immune thrombocytopenia in Australia and New Zealand. Med J Aust 2021; 216:43-52. [PMID: 34628650 PMCID: PMC9293212 DOI: 10.5694/mja2.51284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 01/21/2023]
Abstract
Introduction The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura (ITP) underlines the need for contemporary guidelines relevant to the local treatment context. ITP is diagnosed by exclusions, with a hallmark laboratory finding of isolated thrombocytopenia. Main recommendations Bleeding, family and medication histories and a review of historical investigations are required to gauge the bleeding risk and possible hereditary syndromes. Beyond the platelet count, the decision to treat is affected by individual bleeding risk, disease stage, side effects of treatment, concomitant medications, and patient preference. Treatment is aimed at achieving a platelet count > 20 × 109/L, and avoidance of severe bleeding. Steroids are the standard first line treatment, with either 6‐week courses of tapering prednisone or repeated courses of high dose dexamethasone providing equivalent efficacy. Intravenous immunoglobulin can be used periprocedurally or as first line therapy in combination with steroids. Changes in management as a result of this statement There is no consensus on choice of second line treatments. Options with the most robust evidence include splenectomy, rituximab and thrombopoietin receptor agonists. Other therapies include azathioprine, mycophenolate mofetil, dapsone and vinca alkaloids. Given that up to one‐third of patients achieve a satisfactory haemostatic response, splenectomy should be delayed for at least 12 months if possible. In life‐threatening bleeding, we recommend platelet transfusions to achieve haemostasis, along with intravenous immunoglobulin and high dose steroids.
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Affiliation(s)
- Philip Yi Choi
- Canberra Hospital, Canberra, ACT.,Australian National University, Canberra, ACT
| | | | - Ashwini Bennett
- Monash Medical Centre, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Anoop K Enjeti
- Calvary Mater Hospital, Newcastle, NSW.,University of Newcastle, Newcastle, NSW
| | - Chee Wee Tan
- Royal Adelaide Hospital, Adelaide, SA.,SA Pathology, Adelaide, SA
| | - Isaac Goncalves
- Peter MacCallum Cancer Centre, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
| | - Danny Hsu
- South Western Sydney Local Health District, Sydney, NSW.,University of New South Wales, Sydney, NSW
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15
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Lafaurie M, Maquet J, Baricault B, Ekstrand C, Christiansen CF, Linder M, Bahmanyar S, Nørgaard M, Sailler L, Lapeyre-Mestre M, Sommet A, Moulis G. Risk factors of hospitalisation for thrombosis in adults with primary immune thrombocytopenia, including disease-specific treatments: a French nationwide cohort study. Br J Haematol 2021; 195:456-465. [PMID: 34386974 DOI: 10.1111/bjh.17709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022]
Abstract
We aimed to assess the risk factors of venous thrombosis (VT) and arterial thrombosis (AT) in adults with primary immune thrombocytopenia (ITP), particularly in relation to treatments. The population comprised all incident primary ITP adults in France between 2009 and 2017 (FAITH cohort; NCT03429660) built in the national health database. Outcomes were the first hospitalisation for VT and AT. Multivariable Cox regression models included baseline risk factors, time-varying exposure to ITP drugs, splenectomy and to cardiovascular drugs. The cohort included 10 039 patients. A higher risk of hospitalisation for VT was observed with older age, history of VT, history of cancer, splenectomy [hazard ratio (HR) 3·23, 95% confidence interval (CI) 2·26-4·61], exposure to corticosteroids (HR 3·55, 95% CI 2·74-4·58), thrombopoietin-receptor agonists (TPO-RAs; HR 2·28, 95% CI 1·59-3·26) and intravenous immunoglobulin (IVIg; HR 2·10, 95% CI 1·43-3·06). A higher risk of hospitalisation for AT was observed with older age, male sex, a history of cardiovascular disease, splenectomy (HR 1·50, 95% CI 1·12-2·03), exposure to IVIg (HR 1·85, 95% CI 1·36-2·52) and TPO-RAs (HR 1·64, 95% CI 1·26-2·13). Rituximab was not associated with an increased risk. These findings help to estimate the risk of thrombosis in adult patients with ITP and to select treatment.
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Affiliation(s)
- Margaux Lafaurie
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Julien Maquet
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | | | - Charlotta Ekstrand
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | | | - Marie Linder
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Laurent Sailler
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Agnès Sommet
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Guillaume Moulis
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
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16
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Ahmed HAW, Masoud AT, Han J, Adel Sofy A, Saeed Ahmed A, Abdesattart AT, Drokow EK, Sun K. Eltrombopag Effectiveness and Tolerability in Chronic Immune Thrombocytopenia: A Meta-Analysis. Clin Appl Thromb Hemost 2021; 27:10760296211005555. [PMID: 33874785 PMCID: PMC8060759 DOI: 10.1177/10760296211005555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 11/16/2022] Open
Abstract
Eltrombopag is an orally administered, non-peptide, thrombopoietin receptor agonist which initiates thrombopoietin signaling and stimulates the production of normally functioning platelet. We aimed to do a systematic review and meta-analysis of currently available published data to verify whether eltrombopag treatment in patients with chronic immune-mediated thrombocytopenia can prolong survival. We searched for published, randomized, controlled trials in PubMed, Cochrane and Scopus databases using the following search strategy ("Eltrombopag" OR "Benzoates" OR "Hydrazines") AND ("Idiopathic Thrombocytopenic Purpura" OR "immune thrombocytopenia" OR "Idiopathic Thrombocytopenic Purpuras" OR "Immune Thrombocytopenia" OR "Autoimmune Thrombocytopenia" OR "Werlhof"). The pooled relative risk (RR) showed that eltrombopag group has significantly higher overall platelet response than placebo group (MD = 3.42, 95% CI [2.51, 4.65], P > .0001); pooled results were homogenous (P = .27, I2 = 22%). The pooled relative risk showed that eltrombopag group has lower incidence of any bleeding than placebo group (MD = 0.65, 95% CI [0.48, 0.87], P = .003); pooled results were heterogenous (P = .001, I2 = 75%) and the detected heterogeneity was best resolved after excluding Bussel et al (P = .10). Homogeneous results were still favored eltrombopag group (MD = 0.75, 95% CI [0.60, 0.93], P = .008).
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Affiliation(s)
- Hafiz Abdul Waqas Ahmed
- Department of Hematology, Zhengzhou University People’s Hospital
& Henan Provincial People’s Hospital Henan, Zhengzhou, People’s Republic of
China
| | | | - Jia Han
- Kanazawa Medical University, Kanazawa, Japan
| | | | | | | | - Emmanuel Kwateng Drokow
- Department of Hematology, Zhengzhou University People’s Hospital
& Henan Provincial People’s Hospital Henan, Zhengzhou, People’s Republic of
China
| | - Kai Sun
- Department of Hematology, Zhengzhou University People’s Hospital
& Henan Provincial People’s Hospital Henan, Zhengzhou, People’s Republic of
China
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17
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Mahévas M, Audia S, Viallard JF. [Management of multirefractory immune thrombocytopenia]. Rev Med Interne 2020; 42:46-49. [PMID: 33334631 DOI: 10.1016/j.revmed.2020.10.378] [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: 05/24/2020] [Revised: 09/21/2020] [Accepted: 10/20/2020] [Indexed: 10/22/2022]
Abstract
Multirefractory immune thrombocytopenia (ITP) is defined by the absence of response to TPO receptor agonists, rituximab and splenectomy (or contraindicated or refused) and the need of treatment. The approach to multirefractory ITP must be systematic and firstly involves reconsidering the diagnosis. Inherited thrombocytopenia, lymphoid hemopathies and myelodysplastic syndrome are the main causes to be mentioned. Multirefractory ITP is often associated with secondary ITP with signs of clinical or biological autoimmunity, monoclonal gammopathy of undetermined significance and a poor response to corticosteroids. Therapeutic management is complex and is based on the combination of treatments. New treatments are being developed.
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Affiliation(s)
- M Mahévas
- Service de médecine interne, centre de référence des cytopénies auto-immunes de l'adulte, centre hospitalier universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, université Paris-Est-Créteil, Créteil, France.
| | - S Audia
- Service de médecine interne et immunologie clinique, médecine 1-SOC 1, hôpital François-Mitterrand, 14, rue Paul-Gaffarel, centre de référence des cytopénies auto-immunes de l'adulte, CHU de Dijon-Bourgogne, 21079 Dijon cedex, France
| | - J-F Viallard
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, université de Bordeaux, 5, avenue de Magellan, 33604 Pessac cedex, France
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18
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Thabet AF, Moeen SM. More about the combination of rituximab, cyclosporine and dexamethasone in the treatment of chronic ITP. A useful option on an environment with limited resources. Platelets 2020; 31:784-787. [PMID: 31603012 DOI: 10.1080/09537104.2019.1678121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment of chronic primary immune thrombocytopenia (ITP) is challenging especially with limited resources and therapy-related complications. This prospective interventional study assessed the efficacy and safety of triple therapy(TT4); a combination treatment of oral dexamethasone 40 mg for days1-4, oral cyclosporine A 2-3 mg/kg daily for 28 consecutive days and intravenous rituximab 100 mg for days7,14,21 and 28 among 40 patients with ITP who failed previous 2 or more treatment options. Our aim was to maintain platelet count ≥ 30 X 109/L without any obvious bleeding at any point in the study. Platelet counts were assessed weekly for a month then monthly for 2 years to evaluate the long-term response. TT4 was well tolerated and induced a good response with a significant increase in the mean platelet count after the 1st, 2nd, 3rd, and 4thweek compared to the baseline. Patients with mean platelet count ≥ 30 X 109/L at the 6th month were 75% (30/40 patients). Treatment free survivals (TFS) at 12 and 24 months were 93.3% (28/30 patients) and 80% (24/30 patients) respectively. TT4 is an effective treatment option that maintained platelet count in the desired level and induced a higher sustained response, especially in an environment with limited resources.
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Affiliation(s)
- Ahmad F Thabet
- Department of Internal Medicine, Clinical Hematology Unit, Faculty of Medicine, Assiut University , Assiut, Egypt
| | - Sawsan M Moeen
- Department of Internal Medicine, Clinical Hematology Unit, Faculty of Medicine, Assiut University , Assiut, Egypt
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19
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Moulis G, Comont T, Adoue D. New insights into the epidemiology of immune thrombocytopenia in adult patients: Impact for clinical practice. Rev Med Interne 2020; 42:11-15. [PMID: 32798089 DOI: 10.1016/j.revmed.2020.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/26/2020] [Indexed: 12/28/2022]
Abstract
New insights into immune thrombocytopenia (ITP) epidemiology in adult patients highlight three main outcomes of morbidity and mortality: bleeding, infection and thrombosis. This review depicts current evidence about incidence and risk factors of bleeding, infection and thrombosis as well as predictors of chronicity, and shows how this assessment impacts the choice of ITP second-line treatment at the individual-level basis.
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Affiliation(s)
- G Moulis
- Service de Médecine Interne, CHU de Toulouse, France; UMR 1027 INSERM, Université de Toulouse, France; CIC 1436, CHU de Toulouse, France.
| | - T Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse- Oncopôle, France
| | - D Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse- Oncopôle, France
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20
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Handtke S, Thiele T. Large and small platelets-(When) do they differ? J Thromb Haemost 2020; 18:1256-1267. [PMID: 32108994 DOI: 10.1111/jth.14788] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 02/06/2023]
Abstract
Platelets are most important in providing cellular hemostasis but also take part in inflammation and immune processes. Increased platelet size has been regarded as a feature describing a young and more reactive subpopulation until studies were published which questioned this concept. Moreover, changes of platelet size given by the mean platelet volume (MPV) were described for immune thrombocytopenia, cardiovascular disease, atherosclerosis, venous thromboembolism, chronic lung disease, sepsis, cancer-associated thrombosis, autoimmune disorders, and others. This review summarizes the literature on what is known about platelets with different size and describes controversies of studies with large and small platelets putting a focus on their thrombogenicity, age, and on the association of MPV with the mentioned diseases.
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Affiliation(s)
- Stefan Handtke
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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21
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Xu J, Wang G, Tan S, Ge Y, Liu J, Rao M, Deng Y. The clinical effect of Prednisone in combination with Mycophenolate mofetil on idiopathic thrombocytopenic purpura (ITP) and its influence on the level of peripheral blood T lymphocytes and NK lymphocytes. Saudi J Biol Sci 2020; 26:2108-2112. [PMID: 31889803 PMCID: PMC6923462 DOI: 10.1016/j.sjbs.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/29/2022] Open
Abstract
Objective To explore he curative effect and safety of Prednisone in combination with Mycophenolate in treating ITP and its influence on the level of peripheral blood T lymphocytes and NK lymphocytes. Method 93 cases of ITP patients were divided into the observation group and the control group by the Random Number Table method, 48 cases for the observation group, 45 for another. Patients in the control group orally took 0.5 mg/kg Prednisone Acetate tablets daily, two times each in the morning and evening. And the observation group, based on the treatment of the control group, orally took Mycophenolate Mofetil Dispersible tablets twice a day, 1 g each time. According to patients’ conditions, 3 to 5 courses were set for treatment with 3 weeks a course. Compared PLT amount and the changing situation of inflammatory factors, CD3+ and CD3+CD95L+ before and after the treatment, the level of CD3+Caspase-3+ and CD3+Caspase-8+, NK+, NK+ CD95L+, NK+Caspase-3+, NK+Caspase-8, the curative effect and adverse events. Result After treatment, PLT amount in both groups increased, and the increase in the observation group was much higher than that of the control group, the difference had statistical significance (P < 0.05). The time needed for PLT amount in the control group to reach the normal and peak values was longer than that of the observation group, whose PLT peak value was higher than another group. The difference had statistical significance (P < 0.05). After the treatment, the levels of TNF-α and IL-6 were lowered, and the value of the observation group was lower than that of another. The difference between and within the group has statistical significance. After the treatment, the level of CD3+, CD3+CD95L+ and CD3+Caspase-8+ is much higher and CD3+Caspase-3+ level lower than that before the treatment. The difference has statistical significance (P < 0.05). After the treatment, the level of NK+ and NK+ CD95L+ is higher and the level of NK+Caspase-8+ lower than that before the treatment. The difference has statistical significance (P < 0.05). After the treatment, the total effective rate 91.67% of the observation group is much higher than that 75.56% of another. The difference has statistical significance (P < 0.05). After the treatment, the incidence rate of adverse events in the control group is 11.11% (5/45), while 4.17% (2/48) in the observation group. The difference between groups has statistical significance (χ2 = 3.890, P < 0.05). Conclusion The curative effect of Prednisone in combination with Mycophenolate on ITP patients is better than orally taking Prednisone tablets. Moreover, when it comes to Prednisone in combination with Mycophenolate, both the PLT amount and immunocompetence are improved without much adverse reaction, and the molecules of peripheral blood T lymphocytes and NK lymphocytes can be effectively adjusted to relieve the symptoms. So the method is trustworthy to be popularized for clinical practices.
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Affiliation(s)
- Jiangwei Xu
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Gangzuo Wang
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Sihai Tan
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Yirong Ge
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Jingzhen Liu
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Mei Rao
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
| | - Yufeng Deng
- Department of Pediatrics, Department of Western Medicine, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, China
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22
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Di Pasquale I, Bertomoro A, Vianello F, Marson P, Boscaro F, Fabris F. A 29-year-old woman with persistent thrombocytopenia. Intern Emerg Med 2019; 14:1317-1320. [PMID: 30747363 DOI: 10.1007/s11739-019-02030-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/08/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Fabrizio Vianello
- Department of Medicine, Hematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Piero Marson
- Apheresis Unit, University of Padua, Padua, Italy
| | | | - Fabrizio Fabris
- Department of Medicine, University of Padua, 35128, Padua, Italy
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23
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Worrest T, Cunningham A, Dewey E, Deloughery TG, Gilbert E, Sheppard BC, Fischer LE. Immune Thrombocytopenic Purpura Splenectomy in the Context of New Medical Therapies. J Surg Res 2019; 245:643-648. [PMID: 31536907 DOI: 10.1016/j.jss.2019.06.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/04/2019] [Accepted: 06/21/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND As medical therapy improves, splenectomy has been relegated to third- or fourth-line therapy for immune thrombocytopenic purpura (ITP) in many hematologic practices. However, these medications have well-known associated morbidity and changes in treatment algorithms may affect the timing and degree of response to splenectomy as well as complications in heavily treated ITP patients. MATERIALS AND METHODS This is a retrospective study of consecutive patients who underwent ITP splenectomy from January 1994 to June 2017. Nonresponders after splenectomy and those with recurrent disease were compared to complete responders. RESULTS The cohort included 84 patients. Median number of medications received before splenectomy was 3 (1-6). 14.3% of patients had a medication-related complication, including heart failure, adrenal insufficiency, diabetes mellitus, infection, and osteoporosis. After splenectomy, 83.5% had a complete response, 7.5% partial response, and 9% no response. Complete response was associated with response to steroids before surgery (P < 0.01). Among responders, 19% had recurrent disease, which was associated with lower platelet count at diagnosis (P < 0.01). Forty-four patients (52.0%) had nonelective splenectomies for persistent bleeding or dangerously low platelets despite maximal medical therapy. Ten patients had Clavien-Dindo grade II or higher surgical complications (11.9%). Seven of these complications were related to recurrent or refractory ITP. CONCLUSIONS Many ITP patients have complications related to medication use, and 52.0% required nonelective splenectomy despite maximal medical therapy. Earlier splenectomy may avoid medication-related complications and may reduce the complications from splenectomy. Splenectomy remains an effective and safe treatment for ITP.
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Affiliation(s)
- Tarin Worrest
- Oregon Health and Science University, Portland, Oregon
| | | | | | | | - Erin Gilbert
- Oregon Health and Science University, Portland, Oregon
| | | | - Laura E Fischer
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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Le Guenno G, Guieze R, Audia S, Khellaf M, Michel M, Bonnotte B, Ruivard M, Godeau B. Characteristics, risk factors and management of venous thromboembolism in immune thrombocytopenia: a retrospective multicentre study. Intern Med J 2019; 49:1154-1162. [DOI: 10.1111/imj.14269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Guillaume Le Guenno
- Department of Internal MedicineUniversity Hospital Estaing, CHU Clermont‐Ferrand Clermont‐Ferrand France
| | - Romain Guieze
- Department of HematologyUniversity Hospital Estaing Clermont‐Ferrand France
| | - Sylvain Audia
- Department of Internal MedicineUniversity Hospital François Mitterrand Dijon France
| | - Mehdi Khellaf
- Department of Internal MedicineReference Center of Autoimmune Cytopenias, University Hospital Henri‐Mondor Créteil France
| | - Marc Michel
- Department of Internal MedicineReference Center of Autoimmune Cytopenias, University Hospital Henri‐Mondor Créteil France
| | - Bernard Bonnotte
- Department of Internal MedicineUniversity Hospital François Mitterrand Dijon France
| | - Marc Ruivard
- Department of Internal MedicineUniversity Hospital Estaing, CHU Clermont‐Ferrand Clermont‐Ferrand France
- EA 4681 PEPRADEUniversité d'Auvergne Clermont‐Ferrand France
| | - Bertrand Godeau
- Department of Internal MedicineReference Center of Autoimmune Cytopenias, University Hospital Henri‐Mondor Créteil France
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Giordano P, Lassandro G, di Meo NA, Palladino V, Lovrencic B, Spinelli M, Reale L, Jankovic M. A Narrative Approach to Describe QoL in Children With Chronic ITP. Front Pediatr 2019; 7:163. [PMID: 31134165 PMCID: PMC6513878 DOI: 10.3389/fped.2019.00163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/08/2019] [Indexed: 01/19/2023] Open
Abstract
Objective: Primary immune thrombocytopenia (ITP) is a hemorrhagic disorder. Spontaneous recovery within 12 months occurs in the majority of pediatric patients. Nevertheless, in 20-30% of children the disease is chronic. The impact extends to the patients' families, whose everyday life, in terms of interpersonal relationships and financial status, is adversely affected. This study investigated the ability of a narrative instrument to improve the quality of life of pediatric chronic ITP patients and their families and quantified the familial burden imposed by the illness. Method: A quantitative survey and a narrative plot delivered through an online platform were adopted for the analysis. Results: Pediatricians of ten Italian Hematologic Centers explained the projects to patients and their family in the outpatient clinic. 70 caregivers of children with ITP filled the ad-hoc questionnaire. Data from 53 caregivers revealed the emotional impact of pediatric chronic ITP. The narrative approach highlighted the specific resources used by patients and their families to cope with the disease and its chronicity. Discussion: Caregivers underlined the need for "humaneness" in their interactions with clinical personnel. The majority of respondents provided positive feedback regarding the narrative project, defining the experience as "liberating" and improving their quality of life.
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Affiliation(s)
- Paola Giordano
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Giuseppe Lassandro
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Antonio di Meo
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Valentina Palladino
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Barbara Lovrencic
- Italian Immune Thrombocytopenia Patients Association, Caprino Veronese, Italy
| | - Marco Spinelli
- Foundation MBBM at San Gerardo Hospital, Pediatric Clinic University Milano-Bicocca, Monza, Italy
| | | | - Momcilo Jankovic
- Foundation MBBM at San Gerardo Hospital, Pediatric Clinic University Milano-Bicocca, Monza, Italy
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Zhou H, Liu L, Shu X, Wang X, Song Y. Clinical Efficacy and Safety of High-Dose Dexamethasone Plus Low-Dose Rituximab as First-Line Therapy in Newly Diagnosed Primary Immune Thrombocytopenia. Indian J Hematol Blood Transfus 2019; 35:507-512. [PMID: 31388265 DOI: 10.1007/s12288-018-1061-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/11/2018] [Indexed: 01/10/2023] Open
Abstract
Standard-dose prednisone as first-line therapy for primary immune thrombocytopenia (ITP) can not obtain high long-term responses. Results from high-dose dexamethasone course administered in adult newly diagnosed ITP were promising. The role of standard-dose rituximab in first-line treatment of newly diagnosed ITP were also investigated. We retrospectively analyzed the efficacy and safety of high-dose dexamethasone plus low-dose (100 mg/w) rituximab for treatment of adults newly diagnosed ITP. A total of eighteen patients received dexamethasone 40 mg/day for 4 consecutive days (days + 1 to + 4), rituximab 100 mg once weekly for a total of 4 weeks (days + 7, + 14, + 21 and + 28). Non-responders accepted the repeated dexamethasone treatment every 2 weeks for a total of up to 3 treatment cycles. The overall response was 100% at 28th day. Median follow-up was 17 months (1-33 months). Six patients (33.3%) relapsed. Sustained complete response or response after 6 months and 12 months of follow-up were reached in 83.3% (15/18) and 61.5% (8/13) of patients respectively. The 12-month and 15-month cumulative relapse-free survival were 69.3% and 60.7%. Incidence of adverse effects was 11.1% (2/18). High-dose dexamethasone plus low-dose rituximab therapy had high efficacy and well tolerability as first-line treatment option in newly diagnosed ITP.
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Affiliation(s)
- Hu Zhou
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
| | - Liu Liu
- 2Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Xinhui Shu
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
| | - Xiaoran Wang
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
| | - Yongping Song
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
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Huang YT, Liu XF, Chen YF, Fu RF, Liu W, Xue F, Zhang L, Yang RC. [The incidence and risk factors for thrombosis in primary immune thrombocytopenia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:942-946. [PMID: 30486593 PMCID: PMC7342351 DOI: 10.3760/cma.j.issn.0253-2727.2018.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Indexed: 11/20/2022]
Abstract
Objective: To probe the incidence and risk factors for thrombosis in Chinese immune thrombocytopenia through a retrospective analysis of the inpatients referred to the Blood Disease Hospital, CAMS & PUMC. Methods: A retrospective survey of 3 225 patients with ITP from October 2005 to December 2017 was performed, the clinical data of the patients with thrombosis were collected to analyze the causes, diagnosis, treatment and prognosis. Results: A total of 46 patients experienced a thrombotic event with a prevalence of 1.43%(46/3 225 cases) with the median age of thrombosis as 54 years (26-83) years, the prevalence of thrombosis was 3.37% (40/1 187 cases) in>40 years old, which was significantly higher than 0.58% (6/1 030 cases) in those under 40 years old, in adults (P=0.00). There were 20 males and 26 females, there was no statistical difference in the incidence of thrombosis between males and females[1.53% (20/1 309) vs 1.36% (26/1 916), P=0.187]; The prevalence of arterial thrombosis was 1.12% (36/3 225) higher than venous thrombosis[0.22% (7/3 225), P=0.00]when 82.61%(38/46 cases) of patients with PLT<100×10(9)/L. Post-splenectomy are risk factors for thrombosis in ITP patients, P values was 0.022, There was no statistical difference in the presence or absence of thrombotic events whether received glucocorticoid or TPO/TPO-Ra treatment, the P values were 0.075 and 0.531, respectively. Conclusions: In Chinese population, ITP disease maybe with a higher risk of thrombosis, there was no positive correlation between thrombosis and platelet level; and had obvious age distribution characteristics. The history of tobacco, hypertension, diabetes and post-splenectomy are risk factors for thrombosis in ITP patients.
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Affiliation(s)
- Y T Huang
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
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Zeng DF, Chen F, Wang S, Chen SL, Xu Y, Shen MQ, Du CH, Wang C, Kong PY, Cheng TM, Su YP, Wang JP. Autoantibody against integrin α v β 3 contributes to thrombocytopenia by blocking the migration and adhesion of megakaryocytes. J Thromb Haemost 2018; 16:1843-1856. [PMID: 29953749 DOI: 10.1111/jth.14214] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Indexed: 01/04/2023]
Abstract
Essentials The pathogenesis of immune thrombocytopenia (ITP) has not been fully clarified. We analyzed the role of anti-αvβ3 autoantibody in the pathogenesis of ITP in patients. Anti-αvβ3 autoantibody impeded megakaryocyte migration and adhesion to the vascular niche. Anti-αv β3 autoantibody potentially contributes to the pathogenesis of refractory ITP. SUMMARY Background The pathogenesis of immune thrombocytopenia (ITP) has not been fully clarified. Anti-αvβ3 integrin autoantibody is detected in chronic ITP patients, but its contribution to ITP is still unclear. Objectives To clarify the potential role of anti-αvβ3 integrin autoantibody in chronic ITP and the related mechanism. Methods Relationship between levels of anti-αvβ3 autoantibody and platelets in chronic ITP patients was evaluated. The influence of anti-αvβ3 antibody on megakaryocyte (MK) survival, differentiation, migration and adhesion was assessed, and the associated signal pathways were investigated. Platelet recovery and MKs' distribution were observed in an ITP mouse model pretreated with different antibodies. Result In this study, we showed that the anti-αvβ3 autoantibody usually coexists with anti-αIIbβ3 autoantibody in chronic ITP patients, and patients with both autoantibodies have lower platelets. In in vitro studies, we showed that the anti-αvβ3 antibody had no significant effect on the survival and proliferation of MKs, whereas it decreased formations of proplatelet significantly. Anti-αvβ3 antibody impeded stromal cell derived facor-1 alpha (SDF-1α)- mediated migration and inhibited the phosphorylation of protein kinase B. Anti-αvβ3 antibody significantly inhibited MKs' adhesion to endothelial cells and Fibrogen. The phosphorylation of focal adhesion kinase and proto-oncogene tyrosine-protein kinase Src induced by adhesion was inhibited when MKs were pretreated with anti-αvβ3 antibody. In in vivo studies, we showed that injection with anti-αv antibody delayed platelet recovery in a mouse model of ITP. Conclusions These findings demonstrate that the autoantibody against integrin αv β3 may aggravate thrombocytopenia in ITP patients by impeding MK migration and adhesion to the vascular niche, which provides new insights into the pathogenesis of ITP.
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Affiliation(s)
- D F Zeng
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - F Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - S Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - S L Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Y Xu
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - M Q Shen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - C H Du
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - C Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - P Y Kong
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - T M Cheng
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Y P Su
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - J P Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, China
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Bussel J, Arnold DM, Grossbard E, Mayer J, Treliński J, Homenda W, Hellmann A, Windyga J, Sivcheva L, Khalafallah AA, Zaja F, Cooper N, Markovtsov V, Zayed H, Duliege A. Fostamatinib for the treatment of adult persistent and chronic immune thrombocytopenia: Results of two phase 3, randomized, placebo-controlled trials. Am J Hematol 2018; 93:921-930. [PMID: 29696684 PMCID: PMC6055608 DOI: 10.1002/ajh.25125] [Citation(s) in RCA: 206] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 04/17/2018] [Accepted: 04/22/2018] [Indexed: 01/19/2023]
Abstract
Spleen tyrosine kinase (Syk) signaling is central to phagocytosis-based, antibody-mediated platelet destruction in adults with immune thrombocytopenia (ITP). Fostamatinib, an oral Syk inhibitor, produced sustained on-treatment responses in a phase 2 ITP study. In two parallel, phase 3, multicenter, randomized, double-blind, placebo-controlled trials (FIT1 and FIT2), patients with persistent/chronic ITP were randomized 2:1 to fostamatinib (n = 101) or placebo (n = 49) at 100 mg BID for 24 weeks with a dose increase in nonresponders to 150 mg BID after 4 weeks. The primary endpoint was stable response (platelets ≥50 000/μL at ≥4 of 6 biweekly visits, weeks 14-24, without rescue therapy). Baseline median platelet count was 16 000/μL; median duration of ITP was 8.5 years. Stable responses occurred in 18% of patients on fostamatinib vs. 2% on placebo (P = .0003). Overall responses (defined retrospectively as ≥1 platelet count ≥50 000/μL within the first 12 weeks on treatment) occurred in 43% of patients on fostamatinib vs. 14% on placebo (P = .0006). Median time to response was 15 days (on 100 mg bid), and 83% responded within 8 weeks. The most common adverse events were diarrhea (31% on fostamatinib vs. 15% on placebo), hypertension (28% vs. 13%), nausea (19% vs. 8%), dizziness (11% vs. 8%), and ALT increase (11% vs. 0%). Most events were mild or moderate and resolved spontaneously or with medical management (antihypertensive, anti-motility agents). Fostamatinib produced clinically-meaningful responses in ITP patients including those who failed splenectomy, thrombopoietic agents, and/or rituximab. Fostamatinib is a novel ITP treatment option that targets an important mechanism of ITP pathogenesis.
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Affiliation(s)
| | - Donald M. Arnold
- McMaster University, Michael G. DeGroote School of Medicine, and Canadian Blood ServicesHamiltonOntarioCanada
| | | | - Jiří Mayer
- Fakultni nemocnice BrnoBrnoCzech Republic
| | - Jacek Treliński
- Wojewódzki Szpital Specjalistyczny im. M. Kopernika w ŁodziLodzPoland
| | - Wojciech Homenda
- Wojewódzki Szpital Specjalistyczny im. J. Korczaka i Akademia Pomorska w SłupskuSlupskPoland
| | - Andrzej Hellmann
- University Clinical Center, Medical University of GdańskGdańskPoland
| | - Jerzy Windyga
- Instytut Hematologii i TransfuzjologiiWarszawaPoland
| | - Liliya Sivcheva
- First Internal DepartmentMHAT Hristo Botev, AD, VratsaVratsaBulgaria
| | | | - Francesco Zaja
- Clinica Ematologica, DAME, University of UdineUdineItaly
| | | | | | - Hany Zayed
- Rigel PharmaceuticalsSouth San FranciscoCalifornia
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Schifferli A, Holbro A, Chitlur M, Coslovsky M, Imbach P, Donato H, Elalfy M, Graciela E, Grainger J, Holzhauer S, Riccheri C, Rodeghiero F, Ruggeri M, Tamary H, Uglova T, Wu R, Kühne T. A comparative prospective observational study of children and adults with immune thrombocytopenia: 2-year follow-up. Am J Hematol 2018. [PMID: 29516627 DOI: 10.1002/ajh.25086] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Comparative clinical studies of children and adults with immune thrombocytopenia (ITP) are poorly covered in the literature. However, the accepted classification of ITP-childhood ITP and adult ITP-results in considerable differences in treatment protocols and practice guidelines. The analysis of the Pediatric and Adult Registry on Chronic ITP (PARC-ITP) of patients at first presentation demonstrated fewer differences in clinical and laboratory findings at initial diagnosis between children and adults than expected. The present report of 2-year follow-up data supports the hypothesis that there are common aspects of childhood and adult ITP. Data of 3360 children and 420 adults were collected during the time of 2004 until 2015 at initial diagnosis. Follow-up information was available for 51% and 33% of children and 66% and 49% of adults at 12- and 24-months, respectively. Similarities were found in unexpected areas of ITP, such as the rate of late remission at 12 and 24 months, reported bleeding sites, platelet count in bleeders, and the frequency of treated patients with persistent or chronic ITP. Differences were confirmed for the overall rate of remission and treatment modalities. Unexpected differences were found in the percentage of nonbleeders, with more adults in the nonbleeder group. More studies are needed to investigate different age groups with the aim to optimize their management.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/OncologyUniversity Children's Hospital BaselBasel Switzerland
| | - Andreas Holbro
- Department of HematologyUniversity Hospital BaselBasel Switzerland
| | - Meera Chitlur
- Carmen and Ann Adams Department of Pediatrics, Division of Hematology/OncologyChildren's Hospital of Michigan, Wayne State UniversityDetroit Michigan
| | | | - Paul Imbach
- Chairperson Intercontinental Cooperative ITP Study Group (ICIS)Basel Switzerland
| | - Hugo Donato
- Hematology/Oncology, Hospital del Niño de San Justo, San JustoBuenos Aires Argentina
| | - Mohsen Elalfy
- Pediatric Hematology and OncologyPediatric Hospital Ain Shams UniversityCairo Egypt
| | - Elena Graciela
- Department of Hemalogy‐Oncology Pedro de ElizaldeChildren Hospital Buenos AiresBuenos Aires Argentina
| | - John Grainger
- Department of HaematologyRoyal Manchester Children's HospitalManchester United Kingdom
| | - Susanne Holzhauer
- Department of Pediatric Hematology and OncologyCharité Berlin Germany
| | - Cecilia Riccheri
- Servicio de Pediatria Hospital Alejandro Posadas Buenos AiresBuenos Aires Argentina
| | | | - Marco Ruggeri
- Hematology DepartmentSan Bortolo HospitalVicenza Italy
| | - Hannah Tamary
- Hematology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Sackler Faculty of MedicineTel Aviv UniversityTel Aviv Israel
| | - Tatjana Uglova
- Department of Clinical ResearchBelarusian Research Center of Pediatric Oncology, Hematology and ImmunologyMinsk Belarus
| | - Runhui Wu
- Hematology Oncology Center, Beijing Children's Hospital CapitalBeijing China
| | - Thomas Kühne
- Department of Hematology/OncologyUniversity Children's Hospital BaselBasel Switzerland
- Chairperson Intercontinental Cooperative ITP Study Group (ICIS)Basel Switzerland
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Tang Y, Xu Y, Shi Z, Ma X, Fan L, Wang K, Dang X. Multiple total hip arthroplasties in refractory immune thrombocytopenic purpura: A case report and literature review. Medicine (Baltimore) 2018; 97:e0308. [PMID: 29642159 PMCID: PMC5908576 DOI: 10.1097/md.0000000000010308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Refractory immune thrombocytopenic purpura (RITP) manifests as low platelet count, with a high risk of hemorrhage, treatment difficulty, and high mortality. Total hip arthroplasty (THA) in RITP is rarely reported. This study aimed to evaluate multiple THAs or revision total hip arthroplasties (RTHAs) in RITP. PATIENT CONCERNS The male patient with RITP was 54-year-old patient and hospitalized on September 21, 2009, with the main complaint of bilateral hip pain after traveling for 2 weeks. The patient had a history of ITP for 16-years, with no response to hormone therapy (after adequate hormone therapy, platelet count persistently remained below 30 × 10/L). Two year prior to visit, the patient underwent splenectomy, and postoperative platelet persistently fluctuated around 10 to 20 × 10/L. The patient did not undergo regular reexaminations, and declined immunosuppressants. DIAGNOSES Femoral neck fracture; Refractory immune thrombocytopenic purpura (RITP). INTERVENTIONS A RITP patient with femoral neck fracture received 2 THAs and 1 RTHA. First THA indication was significant left dislocation of Garden III type. RTHA was performed following prosthetic loosening after left total hip arthroplasty. The second THA was prompted by non-healing of the old fracture, significant pain, and a low Harris score. Platelet count remained <20 × 10/L, and conventional drugs, splenectomy, and platelet transfusion had no effects. A large gamma-globulin dose was administered preoperatively. When platelet increased to 75 × 10/L, 2 THAs and 1 RTHA were successfully completed. OUTCOMES Postsurgery, conventional management was applied; no severe complications occurred. The wound was well healed, with platelet count reduced to <15 × 10/L at hospital discharge. The patient recovered, with a Harris score >80 at 1 year postsurgery. LESSONS Extremely low platelet count is a contraindication of surgery. In this patient, preoperative platelet count was <100 × 10/L. Extended disease course and multiple operations lowered platelet count, and increased risk in surgery. However, high postoperative gamma-globulin dose impacted therapy, and all surgeries were successful, with no severe complications. The wound healed well, and the quality of life was significantly improved, demonstrating the feasibility and safety of this surgery. Multiple THA or RTHA surgeries are feasible and safe for RITP patients.
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Affiliation(s)
| | - Yan Xu
- Department of Hematopathology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xian, Shaanxi, China
| | | | - Xiaorong Ma
- Department of Hematopathology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xian, Shaanxi, China
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Splenectomy for immune thrombocytopenia: down but not out. Blood 2018; 131:1172-1182. [PMID: 29295846 DOI: 10.1182/blood-2017-09-742353] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/29/2017] [Indexed: 01/19/2023] Open
Abstract
Splenectomy is an effective therapy for steroid-refractory or dependent immune thrombocytopenia (ITP). With the advent of medical alternatives such as rituximab and thrombopoietin receptor antagonists, the use of splenectomy has declined and is generally reserved for patients that fail multiple medical therapies. Splenectomy removes the primary site of platelet clearance and autoantibody production and offers the highest rate of durable response (50% to 70%) compared with other ITP therapies. However, there are no reliable predictors of splenectomy response, and long-term risks of infection and cardiovascular complications must be considered. Because the long-term efficacy of different second-line medical therapies for ITP have not been directly compared, treatment decisions must be made without supportive evidence. Splenectomy continues to be a reasonable treatment option for many patients, including those with an active lifestyle who desire freedom from medication and monitoring, and patients with fulminant ITP that does not respond well to medical therapy. We try to avoid splenectomy within the first 12 months after ITP diagnosis for most patients to allow for spontaneous or therapy-induced remissions, particularly in older patients who have increased surgical morbidity and lower rates of response, and in young children. Treatment decisions must be individualized based on patients' comorbidities, lifestyles, and preferences. Future research should focus on comparing long-term outcomes of patients treated with different second-line therapies and on developing personalized medicine approaches to identify subsets of patients most likely to respond to splenectomy or other therapeutic approaches.
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Feng FE, Feng R, Wang M, Zhang JM, Jiang H, Jiang Q, Lu J, Liu H, Peng J, Hou M, Shen JL, Wang JW, Xu LP, Liu KY, Huang XJ, Zhang XH. Oral all-trans retinoic acid plus danazol versus danazol as second-line treatment in adults with primary immune thrombocytopenia: a multicentre, randomised, open-label, phase 2 trial. LANCET HAEMATOLOGY 2017; 4:e487-e496. [PMID: 28917657 DOI: 10.1016/s2352-3026(17)30170-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 07/31/2017] [Accepted: 08/04/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Primary immune thrombocytopenia is a severe bleeding disorder. About 50-85% of patients achieve initial remission from first-line therapies, but optimal second-line treatment remains a challenge. All-trans retinoic acid (ATRA) has an immunomodulatory effect on haemopoiesis, making it a possible treatment option. We aimed to evaluate the efficacy and safety of ATRA plus danazol versus danazol in non-splenectomised patients with corticosteroid-resistant or relapsed primary immune thrombocytopenia. METHODS We did a multicentre, randomised, open-label, phase 2 study of adult patients (≥18 years) with primary immune thrombocytopenia from five different tertiary medical centres in China. Those eligible were non-splenectomised, resistant to corticosteroid treatment or relapsed, and had a platelet count less than 30 × 109 per L. Masked statisticians used simple randomisation to assign patients (1:1) to receive oral ATRA (10 mg twice daily) plus oral danazol (200 mg twice daily) or oral danazol monotherapy (200 mg twice daily) for 16 weeks. Neither clinicians nor patients were masked to group assignments. All patients were assessed every week during the first 8 weeks of treatment, and at 2-week intervals thereafter. The primary endpoint was 12-month sustained response defined as platelet count of 30 × 109 per L or more and at least a doubling of baseline platelet count (partial response), or a platelet count of 100 × 109 per L or more (complete response) and the absence of bleeding without rescue medication at the 12-month follow-up. All randomly allocated patients, except for those who withdrew consent, were included in the modified intention-to-treat population and efficacy assessment, and all patients who received at least one dose of the study agents were included in the safety analysis. Study enrolment was stopped early because the trial results crossed the interim analysis efficacy boundary for sustained response. This trial is registered with ClinicalTrials.gov, number NCT01667263. FINDINGS From June 1, 2012, to July 1, 2016, we screened 130 patients for eligibility; 34 were excluded and 96 were randomly assigned. 93 patients were included in the modified intention-to-treat analysis: 45 in the ATRA plus danazol group and 48 in the danazol group. At the 12-month follow-up, sustained response was achieved more frequently in patients receiving ATRA plus danazol than in those receiving danazol monotherapy (28 [62%] of 45 vs 12 [25%] of 48; odds ratio 4·94, 95% CI 2·03-12·02, p=0·00037). Only two grade 3 adverse events were reported: one (2%) patient receiving ATRA plus danazol with dry skin, and one (2%) patient receiving danazol monotherapy with liver injury. There was no grade 4 or worse adverse event or treatment-related death in either group. INTERPRETATION Patients with primary immune thrombocytopenia given ATRA plus danazol had a rapid and sustained response compared with danazol monotherapy. This finding suggests that ATRA represents a promising candidate for patients with corticosteroid-resistant or relapsed primary immune thrombocytopenia. FUNDING National Natural Science Foundation of China, Beijing Natural Science Foundation, Beijing Municipal Science and Technology Commission, and the National Key Research and Development Program of China.
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Affiliation(s)
- Fei-Er Feng
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Ru Feng
- Department of Haematology, Beijing Hospital, National Centre of Gerontology, Beijing, China
| | - Min Wang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Jia-Min Zhang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Hui Liu
- Department of Haematology, Beijing Hospital, National Centre of Gerontology, Beijing, China
| | - Jun Peng
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | - Jian-Liang Shen
- Department of Haematology, PLA Navy General Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Haematology, Beijing Tongren Hospital, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Collaborative Innovation Centre of Haematology, Peking University, Beijing, China.
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Moulis G, Lapeyre-Mestre M, Adoue D, Sailler L. Épidémiologie et pharmacoépidémiologie du purpura thrombopénique immunologique. Rev Med Interne 2017; 38:444-449. [DOI: 10.1016/j.revmed.2016.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/04/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
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Wang X, Yin X, Sun W, Bai J, Shen Y, Ao Q, Gu Y, Liu Y. Intravenous infusion umbilical cord-derived mesenchymal stem cell in primary immune thrombocytopenia: A two-year follow-up. Exp Ther Med 2017; 13:2255-2258. [PMID: 28565834 PMCID: PMC5443306 DOI: 10.3892/etm.2017.4229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Four patients with chronic refractory immune thrombocytopenic purpura (ITP) received human umbilical cord-derived mesenchymal stem cells (hUC-MSCs). The hUC-MSC dose was 5×107 to 1×108. Complete remission (CR) was achieved in three patients in 12 months and one patient in 24 months. Three patients received the second hUC-MSC transplantation with the same dose. The median time between hUC-MSC transplantation and response was 12.5 days (range, 7–16). There were no severe adverse events during and post hUC-MSC transplantation. During follow-up (median, 17 months; range, 13–24) no other immunosuppressive drugs were used post-first hUC-MSCs transplantation. In conclusion, hUC-MSC transplantation is a reasonable salvage treatment in chronic refractory ITP. Prospective randomized large-scale clinical trials are needed to further elucidate the efficacy of hUC-MSCs transplantation therapy on ITP.
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Affiliation(s)
- Xiaohua Wang
- Department of Hematology, Siping Hospital of China Medical University, Siping, Jilin 136000, P.R. China.,Jilin Tuhua Bioengineering Company Ltd., Siping, Jilin 136000, P.R. China
| | - Xiaoguang Yin
- Jilin Tuhua Bioengineering Company Ltd., Siping, Jilin 136000, P.R. China
| | - Wei Sun
- Department of Hematology, Siping Hospital of China Medical University, Siping, Jilin 136000, P.R. China
| | - Jin Bai
- Department of Hematology, Siping Hospital of China Medical University, Siping, Jilin 136000, P.R. China
| | - Yawen Shen
- Department of Hematology, Siping Hospital of China Medical University, Siping, Jilin 136000, P.R. China
| | - Qiang Ao
- Department of Tissue Engineering, China Medical University, Shenyang, Liaoning 110122, P.R. China
| | - Yongquan Gu
- Department of Vascular Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, P.R. China
| | - Ying Liu
- Jilin Tuhua Bioengineering Company Ltd., Siping, Jilin 136000, P.R. China.,Key Laboratory of Tissue Engineering, Siping, Jilin 136000, P.R. China
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Thai LH, Mahévas M, Roudot-Thoraval F, Limal N, Languille L, Dumas G, Khellaf M, Bierling P, Michel M, Godeau B. Long-term complications of splenectomy in adult immune thrombocytopenia. Medicine (Baltimore) 2016; 95:e5098. [PMID: 27902585 PMCID: PMC5134764 DOI: 10.1097/md.0000000000005098] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The recent large decrease in splenectomy use for chronic immune thrombocytopenia (ITP) is partly due to still-unsolved questions about long-term safety. We performed the first single-center exposed/unexposed cohort study evaluating the long-term incidence of splenectomy complications in patients with primary ITP. Overall, 83 patients who underwent splenectomy more than 10 years ago (exposed) were matched with 83 nonsplenectomized patients (unexposed) on the date of ITP diagnosis ±5 years, age and gender. After a median follow-up of 192 months (range 0.5-528), 43 patients (52%) achieved overall response after splenectomy. Splenectomized patients experienced more venous thromboembolism (VTE) than controls (n = 13 vs n = 2, P = 0.005). On multivariate analysis, splenectomy was an independent risk factor of VTE (hazard ratio = 4.006, P = 0.032 [95% confidence interval: 1.13-14.21]). Splenectomized patients presented more severe infections on long-term follow-up: all required hospitalization, and 5/26 (19%) infections led to severe sepsis or septic shock and to death for 3 cases (none in controls). However, the incidence of malignancy was similar in both groups, as was cardiovascular risk, which appeared to be related more to ITP than splenectomy. Finally, splenectomy did not significantly decrease overall survival. Despite the risk of thrombosis and severe sepsis, splenectomy remains an effective and curative treatment for ITP.
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Affiliation(s)
- Lan-Huong Thai
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Matthieu Mahévas
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Françoise Roudot-Thoraval
- Département de Santé Publique, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Nicolas Limal
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Laetitia Languille
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Guillaume Dumas
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Mehdi Khellaf
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Philippe Bierling
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-immunes de l’adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
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Kim M, Park KM, Shin WY, Choe YM, Lee KY, Ahn SI. Platelet count evolution as a predictor of outcome after splenectomy for immune thrombocytopenic purpura. Int J Hematol 2016; 105:433-439. [PMID: 27787747 DOI: 10.1007/s12185-016-2121-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/21/2016] [Accepted: 10/23/2016] [Indexed: 12/26/2022]
Abstract
Splenectomy is the definitive second-line therapy for refractory immune thrombocytopenic purpura (ITP), and has a reported response rate of 50-80%. Medical attention should be reconsidered when there is no evidence of accessory spleen in refractory ITP patients after splenectomy. The purpose of this study was to determine whether platelet count evolution differs between patients with a successful or unsuccessful result after splenectomy for ITP. Archived records of 104 consecutive patients that underwent splenectomy for ITP were reviewed. Patients were divided into two groups (failures and successes) using a final follow-up platelet count of 100,000/μL as a cut-off. Platelet count evolutions in these two groups were compared using the Student's t test. Successes and failures were found to have significantly different platelet counts from two days postoperatively (P = 0.016). The area under the receiver operating characteristic curve was 0.630 (95% confidence interval, 0.518-0.741, P = 0.030), and when a cut-off value of 100,000/μL was used, sensitivity and specificity were 68.2 and 51.2%, respectively. To obtain positive and negative predictive values exceeding 50%, additional platelet counts were required at one week and one month after splenectomy. We propose a protocol for ITP follow-up after splenectomy.
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Affiliation(s)
- Moonhwan Kim
- Department of Surgery, Inha University School of Medicine, 27 Inhang-Ro, Jung-Gu, Incheon, 400-711, Republic of Korea
| | - Keun Myoung Park
- Department of Surgery, Inha University School of Medicine, 27 Inhang-Ro, Jung-Gu, Incheon, 400-711, Republic of Korea
| | - Woo Young Shin
- Department of Surgery, Inha University School of Medicine, 27 Inhang-Ro, Jung-Gu, Incheon, 400-711, Republic of Korea
| | - Yun-Mee Choe
- Department of Surgery, Inha University School of Medicine, 27 Inhang-Ro, Jung-Gu, Incheon, 400-711, Republic of Korea
| | - Keon-Young Lee
- Department of Surgery, Inha University School of Medicine, 27 Inhang-Ro, Jung-Gu, Incheon, 400-711, Republic of Korea.
| | - Seung-Ik Ahn
- Department of Surgery, Inha University School of Medicine, 27 Inhang-Ro, Jung-Gu, Incheon, 400-711, Republic of Korea
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Efficacy and safety of eltrombopag in treatment-refractory primary immune thrombocytopenia: a retrospective study. Blood Coagul Fibrinolysis 2016; 27:47-52. [PMID: 26258668 DOI: 10.1097/mbc.0000000000000380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Eltrombopag was used in patients with chronic primary immune thrombocytopenia (ITP) who did not tolerate or were refractory to two or more previous treatments. The primary aims of the study were to determine the efficacy and safety of long-term eltrombopag treatment. Data were extracted from medical chart records retrospectively. Platelet count of at least 50 000/μl at any time point during the treatment was defined as the 'response'. Median duration of eltrombopag treatment was 29 weeks (11-74). The number of patients who had a platelet count of at least 50 000/μl at any time point was 26 (83.9%). The response was achieved by the second week in most of the patients. Concomitant ITP medications were withdrawn in nine out of the 11 patients. Eltrombopag was discontinued in one patient due to sustained response despite discontinuation of the treatment. Age, sex, concomitant ITP treatments, and previous ITP treatment failures had no impact on the treatment response. The treatment was discontinued due to thrombosis in only four patients. Four patients experienced a minor bleeding event. Hepatotoxicity and all other adverse events were mild and manageable. Eltrombopag is effective, safe, and well tolerated in the long-term treatment of chronic ITP patients.
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Abstract
OBJECTIVES Classically, immune thrombocytopenia (ITP) was thought to be caused by the destruction and insufficient production of platelets, as mediated by autoantibodies. More recently other immune mechanisms that contribute to the disease have been discovered. This review attempts to address the main unresolved questions in ITP. METHODS We review the most current knowledge of the pathophysiology of ITP. Immunological effects of available therapies are also described. DISCUSSION The trigger may be a loss of tolerance due to molecular mimicry with cross-reaction of antibodies arising from infectious agents or drugs, genetic factors, and/or platelet Toll receptors. This loss of tolerance activates autoreactive effector B and T lymphocytes, which in turn initiates platelet destruction, mediated by cytotoxic T lymphocytes and the release of pro-inflammatory cytokines (IL-2/IL-17) by T helper (Th) cells (Th1/Th17). Th2 (anti-inflammatory) and regulatory B (Breg) and Treg cells are also inhibited (with decrease in IL-10/TGF-β), which leads to the disease becoming chronic. Some isotypes of autoantibodies may increase the bleeding risk. Corticosteroids, rituximab, and thrombopoietin receptor agonists (A-TPOs) all increase levels of Tregs and TGF-β. The A-TPOs also increase Breg levels, which could explain why complete remission has been seen in some cases. CONCLUSION A better understanding of the immunomodulatory effects of each ITP therapy is needed to best manage the disease.
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Affiliation(s)
- María Perera
- a Haematology Service , University Hospital Doctor Negrín , Las Palmas de Gran Canaria, Spain
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Characteristics, outcome, and response to therapy of multirefractory chronic immune thrombocytopenia. Blood 2016; 128:1625-30. [DOI: 10.1182/blood-2016-03-704734] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/31/2016] [Indexed: 12/13/2022] Open
Abstract
Key Points
The baseline characteristics of multirefractory ITP differed from “typical” ITP, outcome was severe, and was associated with high morbidity and mortality. Combining immunosuppressant therapy with a thrombopoietin-receptor agonist may be a relevant option for these patients.
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How I treat refractory immune thrombocytopenia. Blood 2016; 128:1547-54. [DOI: 10.1182/blood-2016-03-603365] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/04/2016] [Indexed: 01/19/2023] Open
Abstract
Abstract
This article summarizes our approach to the management of children and adults with primary immune thrombocytopenia (ITP) who do not respond to, cannot tolerate, or are unwilling to undergo splenectomy. We begin with a critical reassessment of the diagnosis and a deliberate attempt to exclude nonautoimmune causes of thrombocytopenia and secondary ITP. For patients in whom the diagnosis is affirmed, we consider observation without treatment. Observation is appropriate for most asymptomatic patients with a platelet count of 20 to 30 × 109/L or higher. We use a tiered approach to treat patients who require therapy to increase the platelet count. Tier 1 options (rituximab, thrombopoietin receptor agonists, low-dose corticosteroids) have a relatively favorable therapeutic index. We exhaust all Tier 1 options before proceeding to Tier 2, which comprises a host of immunosuppressive agents with relatively lower response rates and/or greater toxicity. We often prescribe Tier 2 drugs not alone but in combination with a Tier 1 or a second Tier 2 drug with a different mechanism of action. We reserve Tier 3 strategies, which are of uncertain benefit and/or high toxicity with little supporting evidence, for the rare patient with serious bleeding who does not respond to Tier 1 and Tier 2 therapies.
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Wang Y, Ni H. Fibronectin maintains the balance between hemostasis and thrombosis. Cell Mol Life Sci 2016; 73:3265-77. [PMID: 27098513 PMCID: PMC11108312 DOI: 10.1007/s00018-016-2225-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 03/27/2016] [Accepted: 04/12/2016] [Indexed: 11/29/2022]
Abstract
Fibronectin is a dimeric protein widely distributed in solid tissues and blood. This major extracellular matrix protein is indispensable for embryogenesis and plays crucial roles in many physiological and pathological processes. Fibronectin pre-mRNA undergoes alternative splicing to generate over 20 splicing variants, which are categorized as either plasma fibronectin (pFn) or cellular fibronectin (cFn). All fibronectin variants contain integrin binding motifs, as well as N-terminus collagen and fibrin binding motifs. With motifs that can be recognized by platelet integrins and coagulation factors, fibronectin, especially pFn, has long been suspected to be involved in hemostasis and thrombosis, but the exact function of fibronectin in these processes is controversial. The advances made using intravital microscopy models and fibronectin deficient and mutant mice have greatly facilitated the direct investigation of fibronectin function in vivo. Recent studies revealed that pFn is a vital hemostatic factor that is especially crucial for hemostasis in both genetic and anticoagulant-induced deficiencies of fibrin formation. pFn may also be an important self-limiting regulator to prevent hemorrhage as well as excessive thrombus formation and vessel occlusion. In addition to pFn, cFn is found to be prothrombotic and may contribute to thrombotic complications in various diseases. Further investigations of the role of pFn and cFn in thrombotic and hemorrhagic diseases may provide insights into development of novel therapeutic strategies (e.g., pFn transfusion) for the maintenance of the fine balance between hemostasis and thrombosis.
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Affiliation(s)
- Yiming Wang
- Room 420, LKSKI-Keenan Research Centre for Biomedical Science, Department of Laboratory Medicine, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1W8, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Canadian Blood Services, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
| | - Heyu Ni
- Room 420, LKSKI-Keenan Research Centre for Biomedical Science, Department of Laboratory Medicine, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1W8, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Canadian Blood Services, Toronto, ON, Canada.
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada.
- Department of Physiology, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Dai L, Zhang R, Wang Z, He Y, Bai X, Zhu M, Yu Z, Ruan CG. Efficacy of immunomodulatory therapy with all- trans retinoid acid in adult patients with chronic immune thrombocytopenia. Thromb Res 2016; 140:73-80. [DOI: 10.1016/j.thromres.2016.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/22/2016] [Accepted: 02/12/2016] [Indexed: 02/03/2023]
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Tsukune Y, Komatsu N. Management of Adult Chronic Immune Thrombocytopenia in Japan: Patient and Hematologist Perspectives from a Multi-center Cross-sectional Questionnaire Survey. Intern Med 2016; 55:2379-85. [PMID: 27580537 DOI: 10.2169/internalmedicine.55.6407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The objective of this study was to explore the perspective of hematologists and their patients regarding the management of adult chronic immune thrombocytopenia (ITP). Methods This was a multi-center, questionnaire-based, cross-sectional study conducted between 2012 and 2013 throughout Japan. Patients Hematologists, members of the Japanese Society of Hematology in 171 institutions, and their patients were invited to participate in this study. The hematologists were mainly asked about their treatment strategies, while patients were asked about their opinion of the applied treatments, treatment effect, impact on their quality of life (QOL), and treatment satisfaction. Results Questionnaires from 204 hematologists and 213 patients were collected. One hundred sixty hematologists (78.4%) started treatment based on the patient's platelet count. Corticosteroids were considered to be the most effective treatment (44.1%). Forty-six percent of hematologists responded that treatment would be started after the platelet count fell below 20×10(9)/L with bleeding symptoms, compared to 62.9% for patients with no bleeding symptoms. A platelet count of 50×10(9)/L or lower was acceptable for 94.0% of hematologists and 66.8% of patients. Fatigue was most frequently experienced by patients (44.6%). Patients also experienced psychological symptoms (feeling of anxiety or depressive mood: 29.1%, labyrinthitis: 23.5%). While 70.6% of hematologists assumed that the patient QOL was impaired to a moderate to substantial degree, the QOL was impaired in 34.3% of patients. Conclusion A substantial gap which exists between hematologists and their patients highlights a need for better understanding of potential conflicts for establishing effective strategies for ITP management.
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Affiliation(s)
- Yutaka Tsukune
- Department of Hematology, Juntendo University School of Medicine, Japan
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Rodeghiero F. Is ITP a thrombophilic disorder? Am J Hematol 2016; 91:39-45. [PMID: 26547507 DOI: 10.1002/ajh.24234] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/03/2015] [Indexed: 01/09/2023]
Abstract
Immune thrombocytopenia (ITP) represents the epitome of acquired bleeding diseases for the hematologist. Stemming from the interest for the safety of thrombopoietin-receptor agonists (TPO-ra) romiplostim and eltrombopag, recent data have investigated if thrombotic risk is also increased in this disorder. In patients not treated with TPO-ra, a slightly higher risk of venous thrombosis (VTE) is consistently found in ITP, but not to a rate demanding special attention in the generality of cases. No significant increase of arterial thrombosis (AT) is apparent. However, age, splenectomy, and personal risk factors may put some ITP patient to a particularly higher risk of venous and arterial thrombosis (three to four times higher than the average subject). Patients exposed to TPO-ra present indirect evidence of a much higher risk of both AT and VTE. Unfortunately, no matched control population is available and the prospective and registrative nature of these studies may have emphasized the incidence of thrombosis, which was recorded as adverse event. The clinician should be able to individualize the best treatment for the patient, taking also into account the thrombotic risk, limiting active treatment of ITP to those patients really at risk of bleeding.
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Abstract
Primary immune thrombocytopenia is an autoimmune disorder of unknown cause affecting both children and adults. The low peripheral blood platelet count is caused by premature platelet destruction by self-reacting antibodies in addition to an impairment of platelet production. The disease is heterogeneous in its pathophysiology, clinical features and responses to treatment. To date, most of the treatments used have been immune-modulating drugs and these contribute to increased morbidity and mortality in patients. A new class of drugs, the thrombopoietin receptor agonists, has been developed for use in ITP. These have gone through randomised controlled trials in large numbers of patients with ITP. These drugs have high efficacy and are well tolerated. In addition, around 30% of patients receiving these drugs are able to stop them and maintain a safe or normal platelet count. Older treatments such as splenectomy are being used less than before, largely because of the introduction of the thrombopoietin receptor agonists. Currently there are trials underway evaluating novel therapies for ITP that will become available over the next few years once the trials are complete.
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Affiliation(s)
- Drew Provan
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Whitechapel, London, UK.
| | - Adrian C Newland
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Whitechapel, London, UK
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48
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Vaughn JE, Anwer F, Deeg HJ. Treatment of refractory ITP and Evans syndrome by haematopoietic cell transplantation: is it indicated, and for whom? Vox Sang 2015; 110:5-11. [PMID: 26178735 DOI: 10.1111/vox.12314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/13/2022]
Abstract
Several lines of therapy have been established for patients with immune thrombocytopenia (ITP) and Evans syndrome. However, these therapies generally require prolonged administration, lead to profound immunosuppression and increased infectious risk, and are often poorly tolerated. While most patients with these disorders will respond to first-line steroid therapy, others will prove refractory or intolerant to multiple treatments. In these patients (and possibly even selected patients who are not considered refractory), autologous or allogeneic haematopoietic stem cell transplantation (HCT) may provide definitive therapy. We review the literature on the treatment of ITP and Evans syndrome with HCT and discuss its use in the management of these disorders. We also pose, for the purpose of discussion, research questions that will be important to address if HCT is to be considered a viable option for more patients with these diseases.
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Affiliation(s)
- J E Vaughn
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - F Anwer
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - H J Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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Severe Refractory Immune Thrombocytopenia Successfully Treated with High-Dose Pulse Cyclophosphamide and Eltrombopag. Case Rep Hematol 2015; 2015:583451. [PMID: 26180646 PMCID: PMC4477130 DOI: 10.1155/2015/583451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/03/2015] [Indexed: 12/29/2022] Open
Abstract
Severe refractory ITP is clinically challenging and a variety of single or combination chemotherapies have been tried with limited outcome. We report a case of ITP that was unresponsive to multiple agents including high-dose steroid, IVIG, Rho(D) immune globulin, rituximab, cyclosporine, azathioprine, vincristine, mycophenolate mofetil, romiplostim, and eltrombopag; however, it achieved complete remission with combination treatment of cyclophosphamide and eltrombopag.
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Gerfaud-valentin M, Mahévas M, Terriou L, Lambotte O, Cheze S, Cliquennois M, Viallard J, Le Guenno G, Hot A, Durieu I, Michel M, Godeau B. Caractéristiques et modalités évolutives du purpura thrombopénique idiopathique multiréfractaire en 2014 : analyse de 26 observations. Rev Med Interne 2014. [DOI: 10.1016/j.revmed.2014.10.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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