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Hoffmann J, Schliesser G, Neubauer A. Abatacept as salvage therapy for life-threatening refractory autoimmune hemolytic anemia: a case report. Hematology 2023; 28:2208010. [PMID: 37133319 DOI: 10.1080/16078454.2023.2208010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) can be life-threatening, if hemoglobin (Hb) levels continue to decline after established treatments with glucocorticoids, rituximab, intravenous immunoglobulins, and plasmapheresis. Impaired regulatory T cells (Treg) are proposed to alleviate AIHA development through decreased binding of CTLA-4 to antigen-presenting cells. Abatacept is a fusion protein with a CTLA-4 domain and is approved for use in rheumatoid arthritis. It mimics the immunosuppressive CTLA-4 effect of Treg. Thus, application of abatacept in refractory AIHA might be reasonable. A 54-year-old woman with known AIHA was admitted to our clinic due to therapy-refractory hemoglobin decrease to 4.0 g/dl. Previously, multiple courses of glucocorticoids, rituximab, azathioprine, mycophenolate mofetil, cyclophosphamide, bortezomib, and a splenectomy failed to stop or stabilize hemoglobin levels and hemolysis. A new immunosuppressive therapy with cyclosporine was initiated and erythropoiesis was stimulated with darbepoetin alfa. Again, therapy failed even though we tried to support immunosuppressive therapy by reducing the amount of pathogenic antibody through plasmapheresis. We stopped the treatment with cyclosporine and applied abatacept instead. After seven days hemoglobin stabilized at 4.3 g/dl and no further red blood cells transfusions were necessary. About one month later hemolysis aggravated again and azathioprine was added to the ongoing abatacept treatment. Finally, the combination of abatacept and azathioprine led to a long-lasting increase of the Hb level above 11 g/dl six months later. Abatacept can be applied to overcome therapy refractory autoimmune hemolytic anemia but should be combined with an additional immunosuppressive medication such as azathioprine.
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Affiliation(s)
- Joerg Hoffmann
- Department of Hematology, Oncology and Immunology, Philipps University Marburg, University Hospital Giessen and Marburg, Marburg, Germany
| | | | - Andreas Neubauer
- Department of Hematology, Oncology and Immunology, Philipps University Marburg, University Hospital Giessen and Marburg, Marburg, Germany
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2
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Argüello Marina M, López Rubio M, Castilla García L. [Autoimmune haemolytic anaemia]. Med Clin (Barc) 2023; 160:30-38. [PMID: 36334945 DOI: 10.1016/j.medcli.2022.07.021] [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: 03/14/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/29/2022]
Abstract
Autoimmune haemolytic anaemias (AIHA) are acquired haematological disorders caused by increased peripheral erythrocyte destruction mediated by autoantibodies against erythrocyte antigens. They classified according to aetiology into primary and secondary, and according to the type of antibody and reaction temperature into AIHA due to warm antibodies (w-AIHA) and AIHA due to cold antibodies (c-AIHA). The mainstay of management in w-AIHA remains glucocorticoid therapy, and the early addition of rituximab has shown good results in recent studies. Primary c-AIHA is mainly treated with rituximab, alone or in combination with chemotherapy. New drugs such as Syk inhibitors, anti-FcRn Ig and complement inhibitors are in advanced development and will expand the therapeutic arsenal, especially in refractory or relapsed cases.
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Affiliation(s)
- María Argüello Marina
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Montserrat López Rubio
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - Lucía Castilla García
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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3
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Kapur R. The potential of metabolomics as a predictive guide for clinical management in autoimmunity against red blood cells. Br J Haematol 2023; 201:13-14. [PMID: 36597858 DOI: 10.1111/bjh.18633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023]
Abstract
Autoimmune-responses leading to increased destruction of red blood cells occur in autoimmune haemolytic anaemia (AIHA). The pathophysiology of AIHA is multifactorial and not fully understood, and clinically it remains challenging to manage relapsed and treatment-refractory cases. Rabelo and colleagues conduct metabolomic profiling in plasma of 26 patients with primary warm AIHA, with consideration of haemolytic activity and relapse occurrence. They identify distinct metabolites to be increased in primary warm AIHA patients, thereby providing an encouraging basis for further validation and exploration of metabolomic profiling as a predictive tool for the management of AIHA. Commentary on: Rabelo et al. Metabolomic profile in patients with primary warm autoimmune haemolytic anaemia. Br J Haematol 2022 (Online ahead of print). doi: 10.1111/bjh.18584.
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Affiliation(s)
- Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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4
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Gordon MJ, Ferrajoli A. Unusual complications in the management of chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S26-S34. [PMID: 35491515 DOI: 10.1002/ajh.26585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common, indolent disease that typically presents with a proliferation of mature, immunologically dysfunctional CD5+ B-cells which preferentially occupy the bone marrow, peripheral blood and lymphoid organs. Immune dysfunction leads to an increase in autoimmune diseases which occur in approximately 10% of patients with CLL. Autoimmune cytopenias are the most common, but other organs may be affected as well. The treatment of these conditions typically depends on the extent of CLL and severity of symptoms, but generally consists of CLL-directed therapies, immunosuppression or both. CLL may also infiltrate extranodal sites in the body. Symptomatic extranodal CLL or extranodal disease which threatens normal organ function is an indication for initiation of CLL-directed therapy. The following review summarizes autoimmune and extranodal complications that can occur in patients with CLL and our suggested approach to their treatment.
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Affiliation(s)
- Max J Gordon
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
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5
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Anemia, Hemolytic, Autoimmune/therapy
- Blood Transfusion
- Complement Inactivating Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/pathology
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Immunologic Factors/therapeutic use
- Rituximab/therapeutic use
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Affiliation(s)
- Sigbjørn Berentsen
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
| | - Wilma Barcellini
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
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Jain NA, Zhao S, Wei L, Rogers KA, Otterson GA, Wang TF, Owen DH. Association Between RBC Antigen Allo-Antibodies and Immune-Related Adverse Events During Immune Checkpoint Inhibitor Treatment for Advanced Cancers. Cancer Manag Res 2020; 12:11743-11749. [PMID: 33235503 PMCID: PMC7680604 DOI: 10.2147/cmar.s264166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Immune checkpoint inhibitors (ICI) have become a primary treatment modality for patients with a variety of malignancies. Given their increasing use, it is essential to be familiar with their immune-related adverse events (irAEs). Here we report a severe case of autoimmune hemolytic anemia (AIHA) associated with cold agglutinin precipitated by pembrolizumab, and a retrospective study of patients treated with ICI utilizing an institutional database where we analyzed the patterns of anti-RBC testing and their ability to predict irAE. Methods Patients treated with at least one dose of ICI (PD-1, PD-L1, CTLA-4 inhibitors) for advanced cancer between November 2012 and September 2017 at our institution were included. Electronic Medical Records were reviewed to abstract data. Medians and 95% CIs were estimated using Kaplan–Meier method and differences compared using the Log Rank test. Fisher’s exact test and Chi square test were used to analyze clinical associations. Results We identified 1065 patients who received at least one dose of ICI: 180/1065 (17%) underwent direct antiglobulin test (DAT) or allo-antibody (alloAb) testing at any time; 127/1065 (12%) had either DAT or alloAb testing pre-ICI; 129 had either DAT or alloAb testing after ICI initiation; and 76 had either DAT or alloAb testing at both time points. There was a significant association between positive alloAb pre-ICI and the development of irAE while on ICI (p = 0.04). Conclusion Given the increasing use of ICI, oncologists should be aware of potential irAEs with ICI. We found an association between the presence of an alloAb pre-ICI and the development of irAE, indicating that this previous non-self antigen response may predict immune adverse events. A larger prospective study is needed for systematic evaluation of the association between alloAb testing and irAE, and whether routine testing may inform clinical decision-making for patients.
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Affiliation(s)
- Natasha A Jain
- Division of Medical Oncology, The Ohio State University, Columbus, OH, USA.,Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Songzhu Zhao
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Lai Wei
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Kerry A Rogers
- Division of Medical Oncology, The Ohio State University, Columbus, OH, USA.,Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Gregory A Otterson
- Division of Medical Oncology, The Ohio State University, Columbus, OH, USA
| | - Tzu-Fei Wang
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Dwight H Owen
- Division of Medical Oncology, The Ohio State University, Columbus, OH, USA
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Fattizzo B, Barcellini W. Autoimmune Cytopenias in Chronic Lymphocytic Leukemia: Focus on Molecular Aspects. Front Oncol 2020; 9:1435. [PMID: 31998632 PMCID: PMC6967408 DOI: 10.3389/fonc.2019.01435] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/02/2019] [Indexed: 01/12/2023] Open
Abstract
Autoimmune cytopenias, particularly autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP), complicate up to 25% of chronic lymphocytic leukemia (CLL) cases. Their occurrence correlates with a more aggressive disease with unmutated VHIG status and unfavorable cytogenetics (17p and 11q deletions). CLL lymphocytes are thought to be responsible of a number of pathogenic mechanisms, including aberrant antigen presentation and cytokine production. Moreover, pathogenic B-cell lymphocytes may induce T-cell subsets imbalance that favors the emergence of autoreactive B-cells producing anti-red blood cells and anti-platelets autoantibodies. In the last 15 years, molecular insights into the pathogenesis of both primary and secondary AIHA/ITP has shown that autoreactive B-cells often display stereotyped B-cell receptor and that the autoantibodies themselves have restricted phenotypes. Moreover, a skewed T-cell repertoire and clonal T cells (mainly CD8+) may be present. In addition, an imbalance of T regulatory-/T helper 17-cells ratio has been involved in AIHA and ITP development, and correlates with various cytokine genes polymorphisms. Finally, altered miRNA and lnRNA profiles have been found in autoimmune cytopenias and seem to correlate with disease phase. Genomic studies are limited in these forms, except for recurrent mutations of KMT2D and CARD11 in cold agglutinin disease, which is considered a clonal B-cell lymphoproliferative disorder resulting in AIHA. In this manuscript, we review the most recent literature on AIHA and ITP secondary to CLL, focusing on available molecular evidences of pathogenic, clinical, and prognostic relevance.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Hall LS, Lennon CS, Hall AM, Urbaniak SJ, Vickers MA, Barker RN. Combination peptide immunotherapy suppresses antibody and helper T-cell responses to the major human platelet autoantigen glycoprotein IIb/IIIa in HLA-transgenic mice. Haematologica 2019; 104:1074-1082. [PMID: 30514805 PMCID: PMC6518892 DOI: 10.3324/haematol.2017.179424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/29/2018] [Indexed: 12/19/2022] Open
Abstract
Platelet destruction in immune thrombocytopenia is caused by autoreactive antibody and T-cell responses, most commonly directed against platelet glycoprotein IIb/IIIa. Loss of self-tolerance in the disease is also associated with deficient activity of regulatory T cells. Having previously mapped seven major epitopes on platelet glycoprotein IIIa that are recognized by helper T cells from patients with immune thrombocytopenia, the aim was to test whether peptide therapy with any of these sequences, alone or in combination, could inhibit responses to the antigen in humanized mice expressing HLA-DR15. None of the individual peptides, delivered by a putative tolerogenic regimen, consistently suppressed the antibody response to subsequent immunization with human platelet glycoprotein IIb/IIIa. However, the combination of glycoprotein IIIa peptides aa6-20 and aa711-725, which contain the predominant helper epitopes in patients and elicited the strongest trends to suppress when used individually, did abrogate this response. The peptide combination also blunted, but did not reverse, the ongoing antibody response when given after immunization. Suppression of antibody was associated with reduced splenocyte T-cell responsiveness to the antigen, and with the induction of a regulatory T-cell population that is more responsive to the peptides than to purified platelet glycoprotein IIb/IIIa. Overall, these data demonstrate that combinations of peptides containing helper epitopes, such as platelet glycoprotein IIIa aa6-20 and aa711-725, can promote in vivo suppression of responses to the major antigen implicated in immune thrombocytopenia. The approach offers a promising therapeutic option to boost T-cell regulation, which should be taken forward to clinical trials.
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Affiliation(s)
- Lindsay S Hall
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
- Scottish National Blood Transfusion Service, Foresterhill Road, Aberdeen, UK
| | - Charlotte S Lennon
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
| | - Andrew M Hall
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
| | - Stanislaw J Urbaniak
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
- Scottish National Blood Transfusion Service, Foresterhill Road, Aberdeen, UK
| | - Mark A Vickers
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
- Scottish National Blood Transfusion Service, Foresterhill Road, Aberdeen, UK
| | - Robert N Barker
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
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9
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Barcellini W, Fattizzo B, Zaninoni A. Current and emerging treatment options for autoimmune hemolytic anemia. Expert Rev Clin Immunol 2018; 14:857-872. [PMID: 30204521 DOI: 10.1080/1744666x.2018.1521722] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is a heterogeneous disease mainly due to autoantibody-mediated destruction of erythrocytes but also involves complement activation, dysregulation of cellular and innate immunity, and defective bone marrow compensatory response. Several drugs targeting these mechanisms are under development in addition to standard therapies. Areas covered: The following targeted therapies are illustrated: drugs acting on CD20 (rituximab, alone or in association with bendamustine and fludarabine) and CD52 (alemtuzumab), B cell receptor and proteasome inhibitors (ibrutinib, bortezomib), complement inhibitors (eculizumab, BIVV009, APL-2), and other drugs targeting T lymphocytes (subcutaneous IL-2, belimumab, and mTOR inhibitors), IgG driven extravascular hemolysis (fostamatinib), and bone marrow activity (luspatercept). Expert opinion: Although AIHA is considered benign and often easy to treat, chronic/refractory cases represent a challenge even for experts in the field. Bone marrow biopsy is fundamental to assess one of the main mechanisms contributing to AIHA severity, i.e. inadequate compensation, along with lymphoid infiltrate, the presence of fibrosis or dyserythropoiesis. The latter may give hints for targeted therapies (either B or T cell directed) and for new immunomodulatory drugs. Future studies on the genomic landscape in AIHA will further help in designing the best choice, sequence and/or combination of targeted therapies.
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Affiliation(s)
- Wilma Barcellini
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
| | - Bruno Fattizzo
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
| | - Anna Zaninoni
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
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Hess J, Su L, Nizzi F, Beebe K, Magee K, Salzberg D, Stahlecker J, Miller HK, Adams RH, Ngwube A. Successful treatment of severe refractory autoimmune hemolytic anemia after hematopoietic stem cell transplant with abatacept. Transfusion 2018; 58:2122-2127. [DOI: 10.1111/trf.14907] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/21/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Jennifer Hess
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Leon Su
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Frank Nizzi
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Kristen Beebe
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Kyrie Magee
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Dana Salzberg
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Jennifer Stahlecker
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Holly K. Miller
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
| | - Roberta H. Adams
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders; Phoenix Children's Hospital; Phoenix Arizona
- Mayo Clinic; Scottsdale Arizona
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11
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Berentsen S. Complement Activation and Inhibition in Autoimmune Hemolytic Anemia: Focus on Cold Agglutinin Disease. Semin Hematol 2018; 55:141-149. [PMID: 30032751 DOI: 10.1053/j.seminhematol.2018.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 12/25/2022]
Abstract
The classical complement pathway and, to some extent, the terminal pathway, are involved in the immune pathogenesis of autoimmune hemolytic anemia (AIHA). In primary cold agglutinin disease (CAD), secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria, the hemolytic process is entirely complement dependent. Complement activation also plays an important pathogenetic role in some warm-antibody AIHAs, especially when immunoglobulin M is involved. This review describes the complement-mediated hemolysis in AIHA with a major focus on CAD, in which activation of the classical pathway is essential and particularly relevant for complement-directed therapy. Several complement inhibitors are candidate therapeutic agents in CAD and other AIHAs, and some of these drugs seem very promising. The relevant in vitro findings, early clinical data and future perspectives are reviewed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna HF, Haugesund, Norway.
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12
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Hull CM, Peakman M, Tree TIM. Regulatory T cell dysfunction in type 1 diabetes: what's broken and how can we fix it? Diabetologia 2017; 60:1839-1850. [PMID: 28770318 PMCID: PMC6448885 DOI: 10.1007/s00125-017-4377-1] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/17/2017] [Indexed: 01/07/2023]
Abstract
Type 1 diabetes is an autoimmune disease characterised by the destruction of insulin producing beta cells in the pancreas. Whilst it remains unclear what the original triggering factors for this destruction are, observations from the natural history of human type 1 diabetes, including incidence rates in twins, suggest that the disease results from a combination of genetic and environmental factors. Whilst many different immune cells have been implicated, including members of the innate and adaptive immune systems, a view has emerged over the past 10 years that beta cell damage is mediated by the combined actions of CD4+ and CD8+ T cells with specificity for islet autoantigens. In health, these potentially pathogenic T cells are held in check by multiple regulatory mechanisms, known collectively as 'immunological tolerance'. This raises the question as to whether type 1 diabetes develops, at least in part, as a result of a defect in one or more of these control mechanisms. Immunological tolerance includes both central mechanisms (purging of the T cell repertoire of high-affinity autoreactive T cells in the thymus) and peripheral mechanisms, a major component of which is the action of a specialised subpopulation of T cells, known as regulatory T cells (Tregs). In this review, we highlight the evidence suggesting that a reduction in the functional capacity of different Treg populations contributes to disease development in type 1 diabetes. We also address current controversies regarding the putative causes of this defect and discuss strategies to correct it as a means to reduce or prevent islet destruction in a clinical setting.
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Affiliation(s)
- Caroline M Hull
- Programme of Infection and Immunity, Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, Borough Wing, Guy's Hospital, London, SE1 9RT, UK.
| | - Mark Peakman
- Programme of Infection and Immunity, Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, Borough Wing, Guy's Hospital, London, SE1 9RT, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Timothy I M Tree
- Programme of Infection and Immunity, Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, Borough Wing, Guy's Hospital, London, SE1 9RT, UK.
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
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13
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Khan U, Ali F, Khurram MS, Zaka A, Hadid T. Immunotherapy-associated autoimmune hemolytic anemia. J Immunother Cancer 2017; 5:15. [PMID: 28239468 PMCID: PMC5319184 DOI: 10.1186/s40425-017-0214-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 01/23/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Immunotherapy has been widely used in the treatment of several solid and hematologic malignancies. Checkpoint inhibitors have been the forefront of cancer immunotherapy in recent years. Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death 1 (PD-1) pathway are the prototypic checkpoint targets for immunotherapy. When combined, CTLA-4 and PD-1 checkpoint inhibitors work synergistically, but with increased probability of toxicity. The following case represents an unusual adverse effect of combined treatment with ipilimumab and nivolumab used for treatment of metastatic melanoma. CASE PRESENTATION A 43-year-old woman with metastatic melanoma presented with severe generalized weakness and fatigue. She has received two cycles of ipilimumab and nivolumab, last administered 3 weeks prior to her presentation. Initial investigations revealed severe anemia with appropriate reticulocytosis, severely elevated lactate dehydrogenase, undetectable haptoglobin level and positive direct coombs test. Patient was diagnosed with severe autoimmune hemolytic anemia secondary to ipilimumab and nivolumab. She was successfully treated with high dose steroids and rituximab. CONCLUSIONS In our case, we present a rare but serious adverse effect of immunotherapy. We illustrate the clinical presentation and management of immunotherapy associated autoimmune hemolytic anemia. Immunotherapy has revolutionized the treatment of many malignant conditions; therefore, it is imperative for health care professionals caring for cancer patient to be familiar with the adverse effects of immunotherapy, which allow for early recognition and management of these potentially lethal side effects.
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Affiliation(s)
- Uqba Khan
- Graduate Medical Education, St. John Hospital and Medical Center, Detroit, MI USA.,Van Elslander Cancer Center, 19229 Mack Ave, Suite 23, Grosse Pointe Woods, MI 48236 USA
| | - Farman Ali
- Graduate Medical Education, St. John Hospital and Medical Center, Detroit, MI USA
| | | | - Awais Zaka
- Department of Internal Medicine, Henry Ford Macomb Hospital, Clinton Township, MI USA
| | - Tarik Hadid
- Van Elslander Cancer Center, 19229 Mack Ave, Suite 23, Grosse Pointe Woods, MI 48236 USA
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14
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Swann JW, Woods K, Wu Y, Glanemann B, Garden OA. Characterisation of the Immunophenotype of Dogs with Primary Immune-Mediated Haemolytic Anaemia. PLoS One 2016; 11:e0168296. [PMID: 27942026 PMCID: PMC5152924 DOI: 10.1371/journal.pone.0168296] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/28/2016] [Indexed: 01/03/2023] Open
Abstract
Background Immune-mediated haemolytic anaemia (IMHA) is reported to be the most common autoimmune disease of dogs, resulting in significant morbidity and mortality in affected animals. Haemolysis is caused by the action of autoantibodies, but the immunological changes that result in their production have not been elucidated. Aims To investigate the frequency of regulatory T cells (Tregs) and other lymphocyte subsets and to measure serum concentrations of cytokines and peripheral blood mononuclear cell expression of cytokine genes in dogs with IMHA, healthy dogs and dogs with inflammatory diseases. Animals 19 dogs with primary IMHA, 22 dogs with inflammatory diseases and 32 healthy control dogs. Methods Residual EDTA-anti-coagulated blood samples were stained with fluorophore-conjugated monoclonal antibodies and analysed by flow cytometry to identify Tregs and other lymphocyte subsets. Total RNA was also extracted from peripheral blood mononuclear cells to investigate cytokine gene expression, and concentrations of serum cytokines (interleukins 2, 6 10, CXCL-8 and tumour necrosis factor α) were measured using enhanced chemiluminescent assays. Principal component analysis was used to investigate latent variables that might explain variability in the entire dataset. Results There was no difference in the frequency or absolute numbers of Tregs among groups, nor in the proportions of other lymphocyte subsets. The concentrations of pro-inflammatory cytokines were greater in dogs with IMHA compared to healthy controls, but the concentration of IL-10 and the expression of cytokine genes did not differ between groups. Principal component analysis identified four components that explained the majority of the variability in the dataset, which seemed to correspond to different aspects of the immune response. Conclusions The immunophenotype of dogs with IMHA differed from that of dogs with inflammatory diseases and from healthy control dogs; some of these changes could suggest abnormalities in peripheral tolerance that permit development of autoimmune disease. The frequency of Tregs did not differ between groups, suggesting that deficiency in the number of these cells is not responsible for development of IMHA.
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Affiliation(s)
- James W. Swann
- Department of Clinical Science and Services, Royal Veterinary College, Hawskhead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
- Immune Regulation Laboratory, Royal Veterinary College, London, United Kingdom
| | - Kelly Woods
- Immune Regulation Laboratory, Royal Veterinary College, London, United Kingdom
| | - Ying Wu
- Immune Regulation Laboratory, Royal Veterinary College, London, United Kingdom
| | - Barbara Glanemann
- Department of Clinical Science and Services, Royal Veterinary College, Hawskhead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
| | - Oliver A. Garden
- Department of Clinical Science and Services, Royal Veterinary College, Hawskhead Lane, North Mymms, Hatfield, Hertfordshire, United Kingdom
- Immune Regulation Laboratory, Royal Veterinary College, London, United Kingdom
- * E-mail:
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Smirnova SJ, Sidorova JV, Tsvetaeva NV, Nikulina OF, Biderman BV, Nikulina EE, Kulikov SM, Sudarikov AB. Expansion of CD8+ cells in autoimmune hemolytic anemia. Autoimmunity 2016; 49:147-54. [DOI: 10.3109/08916934.2016.1138219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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16
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Swann JW, Garden OA. Novel immunotherapies for immune-mediated haemolytic anaemia in dogs and people. Vet J 2016; 207:13-9. [DOI: 10.1016/j.tvjl.2015.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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17
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Barcellini W. New Insights in the Pathogenesis of Autoimmune Hemolytic Anemia. Transfus Med Hemother 2015; 42:287-93. [PMID: 26696796 PMCID: PMC4678320 DOI: 10.1159/000439002] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/28/2015] [Indexed: 12/18/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is caused by the increased destruction of red blood cells (RBCs) by anti-RBC autoantibodies with or without complement activation. RBC destruction may occur both by a direct lysis through the sequential activation of the final components of the complement cascade (membrane attack complex), or by antibody-dependent cell-mediated cytotoxicity (ADCC). The pathogenic role of autoantibodies depends on their class (the most frequent are IgG and IgM), subclass, thermal amplitude (warm and cold forms),as well as affinity and efficiency in activating complement. Several cytokines and cytotoxic mechanisms (CD8+ T and natural killer cells) are further involved in RBC destruction. Moreover, activated macrophages carrying Fc receptors may recognize and phagocyte erythrocytes opsonized by autoantibodies and complement. Direct complement-mediated lysis takes place mainly in the circulations and liver, whereas ADCC, cytotoxicity, and phagocytosis occur preferentially in the spleen and lymphoid organs. The degree of intravascular hemolysis is 10-fold greater than extravascular one. Finally, the efficacy of the erythroblastic compensatory response can greatly influence the clinical picture of AIHA. The interplay and relative burden of all these pathogenic mechanisms give reason for the great clinical heterogeneity of AIHAs, from fully compensated to rapidly evolving fatal cases.
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Affiliation(s)
- Wilma Barcellini
- U.O. Oncoematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Berentsen S. Role of Complement in Autoimmune Hemolytic Anemia. Transfus Med Hemother 2015; 42:303-10. [PMID: 26696798 PMCID: PMC4678321 DOI: 10.1159/000438964] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/26/2015] [Indexed: 11/25/2022] Open
Abstract
The classification of autoimmune hemolytic anemias and the complement system are reviewed. In autoimmune hemolytic anemia of the warm antibody type, complement-mediated cell lysis is clinically relevant in a proportion of the patients but is hardly essential for hemolysis in most patients. Cold antibody-mediated autoimmune hemolytic anemias (primary cold agglutinin disease, secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria) are entirely complement-mediated disorders. In cold agglutinin disease, efficient therapies have been developed in order to target the pathogenic B-cell clone, but complement modulation remains promising in some clinical situations. No established therapy exists for secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria, and the possibility of therapeutic complement inhibition is interesting. Currently, complement modulation is not clinically documented in any autoimmune hemolytic anemia. The most relevant candidate drugs and possible target levels of action are discussed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Development, Haugesund Hospital, Helse Fonna HF, Haugesund, Norway
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19
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Hamilton AJ, Webb LH, Williams JK, D'Souza RJ, Ngu LSP, Moore J. Autoimmune haemolytic anaemia associated with Epstein Barr virus infection as a severe late complication after kidney transplantation and successful treatment with rituximab: case report. BMC Nephrol 2015; 16:108. [PMID: 26187383 PMCID: PMC4506635 DOI: 10.1186/s12882-015-0096-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/25/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Autoimmune haemolytic anaemia (AIHA) is a rare complication following kidney transplantation and usually occurs early in its course. It is characterised by autoantibodies or alloantibodies directed against red blood cells (RBCs). CASE PRESENTATION We describe a 44 year old woman who presented 5 years after kidney transplantation with profound transfusion dependent warm AIHA. Investigations confirmed an IgG autoantibody against RBCs and high titre Epstein-Barr virus (EBV) viraemia. The patient was at higher risk for EBV disease being seronegative at the time of transplantation but had detectable EBV capsid IgG antibody at the time of presentation. The haemolysis was refractory to high dose steroid and intravenous immunoglobulin. There was a rapid and complete resolution of both the anaemia and the viraemia following rituximab therapy, with no adverse events. Twenty-six units of blood were required during the course of treatment. CONCLUSIONS To our knowledge this is the first reported case of EBV associated AIHA in a renal transplant recipient. It highlights a rare pathology associated with post-transplant EBV infection, of broad interest to transplant physicians, haematologists, and microbiologists, and the effective novel use of monoclonal anti-CD20 therapy.
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Affiliation(s)
- Alexander J Hamilton
- Department of Nephrology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK. .,Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
| | - Lynsey H Webb
- Department of Nephrology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Jennifer K Williams
- Department of Nephrology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Richard J D'Souza
- Department of Nephrology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Loretta S P Ngu
- Department of Haematology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Jason Moore
- Department of Nephrology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
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20
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Mahévas M, Michel M, Vingert B, Moroch J, Boutboul D, Audia S, Cagnard N, Ripa J, Menard C, Tarte K, Mégret J, Le Gallou S, Patin P, Thai L, Galicier L, Bonnotte B, Godeau B, Noizat-Pirenne F, Weill JC, Reynaud CA. Emergence of long-lived autoreactive plasma cells in the spleen of primary warm auto-immune hemolytic anemia patients treated with rituximab. J Autoimmun 2015; 62:22-30. [PMID: 26112660 DOI: 10.1016/j.jaut.2015.05.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/12/2015] [Accepted: 05/18/2015] [Indexed: 01/31/2023]
Abstract
Primary warm autoimmune hemolytic anemia (wAIHA) is a rare autoimmune disease in which red blood cells are eliminated by IgG autoantibodies. We analyzed the antibody-secreting cells in the spleen and the peripheral blood of wAIHA patients in various contexts of treatment. Plasmablasts were observed in peripheral blood of newly diagnosed wAIHA patients and, accordingly, active germinal center reactions were present in the spleen of patients receiving short-term corticosteroid therapy. Long-term corticosteroid regimens markedly reduced this response while splenic plasma cells were able to persist, a fraction of them secreting anti-red blood cell IgG in vitro. In wAIHA patients treated by rituximab and who underwent splenectomy because of treatment failure, plasma cells were still present in the spleen, some of them being autoreactive. By using a set of diagnostic genes that allowed us to assess the plasma cell maturation stage, we observed that these cells displayed a long-lived program, differing from the one of plasma cells from healthy donors or from wAIHA patients with various immunosuppressant treatments, and more similar to the one of normal long-lived bone-marrow plasma cells. Interestingly, an increased level of B-cell activating factor (BAFF) was observed in the supernatant of spleen cell cultures from such rituximab-treated wAIHA patients. These results suggest, in line with our previous report on primary immune thrombocytopenia, that the B-cell depletion induced by rituximab promoted a suitable environment for the maturation and survival of auto-immune long-lived plasma cells in the spleen.
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Affiliation(s)
- Matthieu Mahévas
- Institut Necker-Enfants Malades, INSERM U1151-CNRS UMR 8253, Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine-Site Broussais, Paris, France; Service de Médecine Interne, Centre de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France; Etablissement Français du Sang, Ile de France, Institut Mondor Recherche Biomédicale, Inserm U955, équipe 2, Université Paris-Est Créteil, Créteil, France.
| | - Marc Michel
- Service de Médecine Interne, Centre de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France; Etablissement Français du Sang, Ile de France, Institut Mondor Recherche Biomédicale, Inserm U955, équipe 2, Université Paris-Est Créteil, Créteil, France
| | - Benoit Vingert
- Etablissement Français du Sang, Ile de France, Institut Mondor Recherche Biomédicale, Inserm U955, équipe 2, Université Paris-Est Créteil, Créteil, France
| | - Julien Moroch
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - David Boutboul
- Service d'Immunologie Clinique, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Sylvain Audia
- Service de Médecine Interne et d'immunologie Clinique, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Nicolas Cagnard
- Plateforme Bio-informatique, Université Paris Descartes-Structure Fédérative de Recherche Necker, INSERM US24/CNRS UMS 3633, Paris, France
| | - Julie Ripa
- Etablissement Français du Sang, Ile de France, Institut Mondor Recherche Biomédicale, Inserm U955, équipe 2, Université Paris-Est Créteil, Créteil, France
| | - Cédric Menard
- INSERM U917, Université de Rennes 1, Hôpital Universitaire de Rennes, Rennes, France
| | - Karin Tarte
- INSERM U917, Université de Rennes 1, Hôpital Universitaire de Rennes, Rennes, France
| | - Jérôme Mégret
- Plateforme de cytométrie en flux, Structure Fédérative de Recherche Necker, INSERM US24/CNRS UMS 3633, Paris, France
| | - Simon Le Gallou
- Institut Necker-Enfants Malades, INSERM U1151-CNRS UMR 8253, Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine-Site Broussais, Paris, France
| | - Pauline Patin
- Institut Necker-Enfants Malades, INSERM U1151-CNRS UMR 8253, Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine-Site Broussais, Paris, France
| | - Lan Thai
- Institut Necker-Enfants Malades, INSERM U1151-CNRS UMR 8253, Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine-Site Broussais, Paris, France
| | - Lionel Galicier
- Service d'Immunologie Clinique, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | - Bernard Bonnotte
- Service de Médecine Interne et d'immunologie Clinique, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - France Noizat-Pirenne
- Etablissement Français du Sang, Ile de France, Institut Mondor Recherche Biomédicale, Inserm U955, équipe 2, Université Paris-Est Créteil, Créteil, France
| | - Jean-Claude Weill
- Institut Necker-Enfants Malades, INSERM U1151-CNRS UMR 8253, Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine-Site Broussais, Paris, France
| | - Claude-Agnès Reynaud
- Institut Necker-Enfants Malades, INSERM U1151-CNRS UMR 8253, Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine-Site Broussais, Paris, France
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Wu B, Wang W, Zhan Y, Li F, Zou S, Sun L, Cheng Y. CXCL13, CCL4, and sTNFR as circulating inflammatory cytokine markers in primary and SLE-related autoimmune hemolytic anemia. J Transl Med 2015; 13:112. [PMID: 25889297 PMCID: PMC4419446 DOI: 10.1186/s12967-015-0474-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/23/2015] [Indexed: 01/10/2023] Open
Abstract
Background A considerable proportion of autoimmune hemolytic anemia (AIHA) are secondary to underlying autoimmune disorders, especially syetemic lupus erythematosus (SLE), and the clinical and laboratory index for early discrimination between primary and SLE-related AIHA has yet to be defined. In the present study, we proposed novel cytokine patterns in the pathogenesis of AIHA as well as parameters for the timely identification of SLE-related patients. Methods AIHA patients confirmed by immunohematology techniques from September 2010 to December 2012 in our facility were consecutively included and categorized into primary (n = 19) and SLE-related (n = 18) groups. Plasma cytokine profiles were measured in a single procedure by Quantibody Human Inflammatory Array 1 (RayBiotech, Norcross, GA). Results SLE-related AIHA patients demonstrated younger age (39 ± 20 vs.57 ± 16 years, p = 0.004), poorer reticulocyte compensation (6.8 ± 7.1 vs.12.2 ± 8.6%, p = 0.045), lower levels of lactate dehydrogenase [361 (265-498) vs. 622 (387-1154) U/L, p = 0.004], and higher occurrence of anticardiolipin antibody [9/18 (50%) vs. 2/19 (10.9%), p = 0.009]. MCP-1/CCL2, MIP-1β/CCL4, BLC/CXCL13, IL-8/CXCL8, sTNFRI, and sTNFRII were significantly up-regulated in both groups, while sTNFRII was remarkably higher in SLE-related patients. Among both groups, hemoglobin level was negatively correlated with CXCL13 (r = -0.332, p = 0.044), while reticulocyte count was positively correlated with CCL4 (r = 0.456, p = 0.005). Conclusion CXCL13 and CCL4 could act as circulating biomarkers in AIHA, and indicated disease severity and erythroid compensation, respectively. Higher plasma sTNFRII might favor the diagnosis of SLE-related instead of primary AIHA.
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Affiliation(s)
- Boting Wu
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China. .,Department of Transfusion, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
| | - Weiguang Wang
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
| | - Feng Li
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
| | - Shanhua Zou
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
| | - Lihua Sun
- Department of Hematology, Zhongshan Hospital Qingpu Branch, Fudan Universiy, Shanghai, 201700, China.
| | - Yunfeng Cheng
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China. .,Biomedical Research Center, Zhongshan Hospital Fudan Universiy, Shanghai, 200032, China. .,Department of Hematology, Zhongshan Hospital Qingpu Branch, Fudan Universiy, Shanghai, 201700, China.
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22
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Nyilas R, Székely B, Váróczy L, Simon Z, Árokszállási A, Illés Á, Gergely L. Autoimmune haemolytic anaemia: a review and report of four cases. Orv Hetil 2015; 156:449-56. [DOI: 10.1556/oh.2015.30105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Treatment of autoimmune haemolytic anaemia is still a challenge to clinicians. Even today it may be lethal. Half of the cases are secondary due to an underlying disease, and the others are primary or idiopathic cases. According to the specificity and type of autoantibodies there are warm and cold type forms of autoimmune haemolytic anaemia. The hallmark of the diagnosis is to detect the presence of haemolysis by clinical and laboratory signs and detect the underlying autoantibodies. Treatment of autoimmune haemolytic anaemia is still a challenge to clinicians. We still loose patients due to excessive haemolysis or severe infections caused by immunosuppression. First line treatment is corticosteroids. Other immunosuppressive agents like: cyclophosphamide, azathioprine, cyclosporine or the off label rituximab can be used in case of corticosteroid refractoriness. Splenectomy is a considerable option in selective cases. The authors discuss treatment options and highlight difficulties by presenting 4 cases. Orv. Hetil., 2015, 156(11), 449–456.
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Affiliation(s)
- Renáta Nyilas
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Borbála Székely
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - László Váróczy
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Zsófia Simon
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Anita Árokszállási
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Árpád Illés
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
| | - Lajos Gergely
- Debreceni Egyetem, Klinikai Központ, Általános Orvostudományi Kar Belgyógyászati Intézet, Hematológiai Tanszék Debrecen Nagyerdei krt. 98. 4032
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Red blood cell destruction in autoimmune hemolytic anemia: role of complement and potential new targets for therapy. BIOMED RESEARCH INTERNATIONAL 2015; 2015:363278. [PMID: 25705656 PMCID: PMC4326213 DOI: 10.1155/2015/363278] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 11/06/2014] [Accepted: 11/10/2014] [Indexed: 01/13/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a collective term for several diseases characterized by autoantibody-initiated destruction of red blood cells (RBCs). Exact subclassification is essential. We provide a review of the respective types of AIHA with emphasis on mechanisms of RBC destruction, focusing in particular on complement involvement. Complement activation plays a definitive but limited role in warm-antibody AIHA (w-AIHA), whereas primary cold agglutinin disease (CAD), secondary cold agglutinin syndrome (CAS), and paroxysmal cold hemoglobinuria (PCH) are entirely complement-dependent disorders. The details of complement involvement differ among these subtypes. The theoretical background for therapeutic complement inhibition in selected patients is very strong in CAD, CAS, and PCH but more limited in w-AIHA. The optimal target complement component for inhibition is assumed to be important and highly dependent on the type of AIHA. Complement modulation is currently not an evidence-based therapy modality in any AIHA, but a number of experimental and preclinical studies are in progress and a few clinical observations have been reported. Clinical studies of new complement inhibitors are probably not far ahead.
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24
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Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol 2014; 89:1055-62. [PMID: 24912821 DOI: 10.1002/ajh.23785] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is frequently complicated by secondary autoimmune cytopenias (AIC) represented by autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), pure red cell aplasia, and autoimmune granulocytopenia. The distinction of immune cytopenias from cytopenias due to bone marrow infiltration, usually associated with a worse outcome and often requiring a different treatment, is mandatory. AIHA and ITP are more frequently found in patients with unfavorable biological risk factors for CLL. AIC secondary to CLL respond less favorably to standard treatments than their primary forms, and treating the underlying CLL with chemotherapy or monoclonal antibodies may ultimately be necessary.
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Affiliation(s)
- Carlo Visco
- Department of Cell Therapy and Hematology; Ospedale San Bortolo Vicenza
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
| | - Francesco Maura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Antonino Neri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Agostino Cortelezzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
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Abstract
Type 1 diabetes mellitus (T1DM) is the result of autoimmune destruction of pancreatic β cells in genetically predisposed individuals with impaired immune regulation. The insufficiency in the modulation of immune attacks on the β cells might be partly due to genetic causes; indeed, several of the genetic variants that predispose individuals to T1DM have functional features of impaired immune regulation. Whilst defects in immune regulation in patients with T1DM have been identified, many patients seem to have immune regulatory capacities that are indistinguishable from those of healthy individuals. Insight into the regulation of islet autoimmunity might enable us to restore immune imbalances with therapeutic interventions. In this Review, we discuss the current knowledge on immune regulation and dysfunction in humans that is the basis of tissue-specific immune regulation as an alternative to generalized immune suppression.
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Affiliation(s)
- Bart O Roep
- Leiden University Medical Center, Department of Immunohaematology & Blood Transfusion, P. O. Box 9600, NL-2300 RC Leiden, Netherlands
| | - Timothy I M Tree
- Department of Immunobiology, King's College London, School of Medicine, London SE1 9RT, UK
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26
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Bass GF, Tuscano ET, Tuscano JM. Diagnosis and classification of autoimmune hemolytic anemia. Autoimmun Rev 2014; 13:560-4. [DOI: 10.1016/j.autrev.2013.11.010] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 12/27/2022]
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Hall LS, Hall AM, Pickford W, Vickers MA, Urbaniak SJ, Barker RN. Combination peptide immunotherapy suppresses antibody and helper T-cell responses to the RhD protein in HLA-transgenic mice. Haematologica 2014; 99:588-96. [PMID: 24441145 DOI: 10.3324/haematol.2012.082081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The offspring from pregnancies of women who have developed anti-D blood group antibodies are at risk of hemolytic disease of the newborn. We have previously mapped four peptides containing immunodominant T-helper cell epitopes from the RhD protein and the purpose of the work was to develop these into a product for suppression of established anti-D responses. A panel of each of the four immunodominant RhD peptides was synthesized with modifications to improve manufacturability and solubility, and screened for retention of recognition by human T-helper cells. A selected version of each sequence was combined in a mixture (RhDPmix), which was tested for suppressive ability in a humanized murine model of established immune responses to RhD protein. After HLA-DR15 transgenic mice had been immunized with RhD protein, a single dose of RhDPmix, given either intranasally (P=0.008, Mann-Whitney rank sum test) or subcutaneously (P=0.043), rapidly and significantly suppressed the ongoing antibody response. This was accompanied by reduced T-helper cell responsiveness, although this change was less marked for subcutaneous RhDPmix delivery, and by the recruitment of cells with a regulatory T-cell phenotype. The results support human trials of RhDPmix peptide immunotherapy in women with established antibody responses to the RhD blood group.
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28
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Kaneko S, Sato M, Sasaki G, Eguchi H, Oishi T, Kamesaki T, Kawaguchi H. Case of cytomegalovirus-associated direct anti-globulin test-negative autoimmune hemolytic anemia. Pediatr Int 2013; 55:785-8. [PMID: 24330288 DOI: 10.1111/ped.12128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 12/15/2012] [Accepted: 04/11/2013] [Indexed: 11/29/2022]
Abstract
A 1-year-old boy developed autoimmune hemolytic anemia after a negative direct anti-globulin test. The concentration of erythrocyte membrane-associated immunoglobulin G, determined using an immunoradiometric assay, correlated with disease activity. He was positive for cytomegalovirus (CMV) both serologically and by quantitative real-time polymerase chain reaction, indicating that his autoimmune hemolytic anemia was directly caused by CMV infection. Since anti-CMV immunoglobulin G was not absorbed by the patient's erythrocytes, cross-reaction between erythrocyte antigens and CMV was not likely a causative factor for hemolysis.
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Affiliation(s)
- Saeko Kaneko
- Department of Pediatrics, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
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Immunotherapy treatments of warm autoimmune hemolytic anemia. Clin Dev Immunol 2013; 2013:561852. [PMID: 24106518 PMCID: PMC3784078 DOI: 10.1155/2013/561852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 07/31/2013] [Accepted: 08/13/2013] [Indexed: 12/31/2022]
Abstract
Warm autoimmune hemolytic anemia (WAIHA) is one of four clinical types of autoimmune hemolytic anemia (AIHA), with the characteristics of autoantibodies maximally active at body temperature. It produces a variable anemia—sometimes mild and sometimes severe. With respect to the absence or presence of an underlying condition, WAIHA is either idiopathic (primary) or secondary, which determines the treatment strategies in practice. Conventional treatments include immune suppression with corticosteroids and, in some cases, splenectomy. In recent years, the number of clinical studies with monoclonal antibodies and immunosuppressants in the treatment of WAIHA increased as the knowledge of autoimmunity mechanisms extended. This thread of developing new tools of treating WAIHA is well exemplified with the success in using anti-CD20 monoclonal antibody, Rituximab. Following this success, other treatment methods based on the immune mechanisms of WAIHA have emerged. We reviewed these newly developed immunotherapy treatments here in order to provide the clinicians with more options in selecting the best therapy for patients with WAIHA, hoping to stimulate researchers to find more novel immunotherapy strategies.
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Nakasone H, Kako S, Endo H, Ito A, Sato M, Terasako K, Okuda S, Tanaka Y, Yamazaki R, Oshima K, Tanihara A, Kida M, Higuchi T, Izutsu K, Nishida J, Urabe A, Usuki K, Kanda Y. Diabetes mellitus is associated with high early-mortality and poor prognosis in patients with autoimmune hemolytic anemia. Hematology 2013; 14:361-5. [DOI: 10.1179/102453309x12473408860262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Hideki Nakasone
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan; Division of Hematology, Kanto Medical Center NTT EC, Tokyo, Japan
| | - Shinichi Kako
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Endo
- Division of HematologyKanto Medical Center NTT EC, Tokyo, Japan
| | - Ayumu Ito
- Division of HematologyKanto Medical Center NTT EC, Tokyo, Japan
| | - Miki Sato
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kiriko Terasako
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shinya Okuda
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yukie Tanaka
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Rie Yamazaki
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kumi Oshima
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Aki Tanihara
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Michiko Kida
- Division of HematologyKanto Medical Center NTT EC, Tokyo, Japan
| | - Takakazu Higuchi
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koji Izutsu
- Division of HematologyKanto Medical Center NTT EC, Tokyo, Japan
| | - Junji Nishida
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akio Urabe
- Center of Preventive MedicineKanto Medical Center NTT EC, Tokyo, Japan
| | - Kensuke Usuki
- Division of HematologyKanto Medical Center NTT EC, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of HematologySaitama Medical Center, Jichi Medical University, Saitama, Japan
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STAT3 mutations unify the pathogenesis of chronic lymphoproliferative disorders of NK cells and T-cell large granular lymphocyte leukemia. Blood 2012; 120:3048-57. [PMID: 22859607 DOI: 10.1182/blood-2012-06-435297] [Citation(s) in RCA: 312] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic lymphoproliferative disorders of natural killer cells (CLPD-NKs) and T-cell large granular lymphocytic leukemias (T-LGLs) are clonal lymphoproliferations arising from either natural killer cells or cytotoxic T lymphocytes (CTLs). We have investigated for distribution and functional significance of mutations in 50 CLPD-NKs and 120 T-LGL patients by direct sequencing, allele-specific PCR, and microarray analysis. STAT3 gene mutations are present in both T and NK diseases: approximately one-third of patients with each type of disorder convey these mutations. Mutations were found in exons 21 and 20, encoding the Src homology 2 domain. Patients with mutations are characterized by symptomatic disease (75%), history of multiple treatments, and a specific pattern of STAT3 activation and gene deregulation, including increased expression of genes activated by STAT3. Many of these features are also found in patients with wild-type STAT3, indicating that other mechanisms of STAT3 activation can be operative in these chronic lymphoproliferative disorders. Treatment with STAT3 inhibitors, both in wild-type and mutant cases, resulted in accelerated apoptosis. STAT3 mutations are frequent in large granular lymphocytes suggesting a similar molecular dysregulation in malignant chronic expansions of NK and CTL origin. STAT3 mutations may distinguish truly malignant lymphoproliferations involving T and NK cells from reactive expansions.
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Berentsen S. Flere sykdommer med samme kliniske presentasjon. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:968. [DOI: 10.4045/tidsskr.12.0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Oprea MM, Ivanescu AM, Colita A, Coles E, Momanu RC, Berbec N, Lupu AR. Etiopathogenesis and prognostic implications of autoimmune hemolytic anemia association with chronic lymphocytic leukemia B. J Med Life 2012; 5:44-47. [PMID: 31803285 PMCID: PMC6880212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Biological complexity of mechanisms of autoimmune hemolytic anemia (AHAI) in chronic lymphocytic leukemia B (CLL) and the relation cause / effect between these two diseases has been extensively researched, but currently is still far from being completely understood. It is known that the immune system has an important role in the pathogenesis of autoimmune diseases but also in the chronic lymphoproliferative malignancies. In this process of autoimmunity associated with immunodeficiency, the CLL neoplastic cells, the non-malignant B cells, T cells, and the cellular microenvironment cells are also involved. CLL pathological lymphocytes change peripheral immune tolerance acting as an antigen presenting cells and / or cells expressing inhibitory cytokines. The two subpopulations of T cells also have an important place: self-reactive T helper cells (TH) and regulatory T cells (Treg). The Fas / Fas ligand - cell death mechanism has a significant role both in maintaining cellular homeostasis, malignant hematopoietic cell expansion and the development of autoimmune disorders, including AIHA. The article reviews the etiopathogenesis of the autoimmune mechanism of AIHA in CLL, and its impact on the prognosis and long - term survival of patients with chronic lymphocytic leukemia B.
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Affiliation(s)
- MM Oprea
- Hematology Department, Coltea Clinical Hospital, Bucharest
| | - AM Ivanescu
- Hematology Department, Coltea Clinical Hospital, Bucharest
| | - A Colita
- Hematology Department, Coltea Clinical Hospital, Bucharest,“Carol Davila” University of Medicine and Pharmacy, Bucharest
| | - E Coles
- “Carol Davila” University of Medicine and Pharmacy, Bucharest
| | | | - N Berbec
- Hematology Department, Coltea Clinical Hospital, Bucharest,“Carol Davila” University of Medicine and Pharmacy, Bucharest
| | - AR Lupu
- Hematology Department, Coltea Clinical Hospital, Bucharest,“Carol Davila” University of Medicine and Pharmacy, Bucharest
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Sève P, Philippe P, Dufour JF, Broussolle C, Michel M. Autoimmune hemolytic anemia: classification and therapeutic approaches. Expert Rev Hematol 2011; 1:189-204. [PMID: 21082924 DOI: 10.1586/17474086.1.2.189] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon cause of anemia. Classifications of AIHA include warm AIHA, cold AIHA (including mainly chronic cold agglutinin disease and paroxysmal cold hemoglobinuria), mixed-type AIHA and drug-induced AIHA. AIHA may also be further subdivided on the basis of etiology. Management of AIHA is based mainly on empirical data and on small, retrospective, uncontrolled studies. The therapeutic options for treating AIHA are increasing with monoclonal antibodies and, potentially, complement inhibitory drugs. Based on data available in the literature and our experience, we propose algorithms for the treatment of warm AIHA and cold agglutinin disease in adults. Therapeutic trials are needed in order to better stratify treatment, taking into account the promising efficacy of rituximab.
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Affiliation(s)
- Pascal Sève
- Department of Internal Medicine, Hôtel Dieu, 1 place de l'Hôpital, Lyon Cedex 02, France.
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Dromey JA, Lee BH, Yu H, Young HE, Thearle DJ, Jensen KP, Mannering SI, Harrison LC. Generation and expansion of regulatory human CD4(+) T-cell clones specific for pancreatic islet autoantigens. J Autoimmun 2010; 36:47-55. [PMID: 21050716 DOI: 10.1016/j.jaut.2010.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 10/06/2010] [Accepted: 10/11/2010] [Indexed: 10/18/2022]
Abstract
Autoantigen-specific regulatory T cells (Treg) are a potential cell therapy for human autoimmune disease, provided they could be generated in adequate numbers and with stable function. To this end, we determined the feasibility of cloning and expanding human CD4(+) Treg specific for the type 1 diabetes autoantigens, GAD65 and proinsulin. Blood CD4(+) cells stimulated to divide in response to GAD65 (in three healthy individuals) or proinsulin (in one type 1 diabetic) were flow sorted into single cells and cultured on feeder cells in the presence of anti-CD3 monoclonal antibody, IL-2 and IL-4. Clones were expanded over 4-6 weeks and screened for autoantigen-dependent suppression of tetanus toxoid-specific T-cell proliferation. Suppression by Treg clones was then confirmed against autoantigen-specific non-Treg clones. Of a total of 447 clones generated, 98 (21.9%) had autoantigen-dependent suppressor function. Treg clones were anergic but proliferated to autoantigen after addition of IL-2 or in co-culture with stimulated bulk T cells, without loss of suppressor function. Treg clones were stored over liquid N(2), thawed and further expanded over 12 days, whereupon they exhibited decreased suppressor function. Expansion of Treg clones overall was in the order 10⁷-10⁸-fold. Treg clones were not distinguished by markers of conventional CD4(+)CD25(+) Treg and suppressed independently of cell-cell contact but not via known soluble suppressor factors. This study demonstrates that autoantigen-specific CD4(+) Treg clones with potential application as a cell therapy for autoimmune disease can be generated and expanded from human blood.
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Affiliation(s)
- James A Dromey
- The Walter & Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3050 Victoria, Australia
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Barros MM, Blajchman MA, Bordin JO. Warm Autoimmune Hemolytic Anemia: Recent Progress in Understanding the Immunobiology and the Treatment. Transfus Med Rev 2010; 24:195-210. [DOI: 10.1016/j.tmrv.2010.03.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Abstract
Patients with B-chronic lymphocytic leukaemia /small lymphocytic lymphoma (CLL) have a 5-10% risk of developing autoimmune complications, which primarily cause cytopaenia. These autoimmune cytopaenias can occur at any stage of CLL and do not have independent prognostic significance. The most common autoimmune complication is autoimmune haemolytic anaemia with a lower frequency of immune thrombocytopaenia and pure red blood cell aplasia and only rarely, autoimmune granulocytopaenia (AIG). Autoimmune cytopaenia should always be considered in the differential diagnosis of cytopaenia in patients with CLL. Patients with CLL can also have more than one form of autoimmune cytopaenia, which can occur together with bone-marrow failure. Treatment is usually effective but rarely curative for autoimmune cytopaenia complicating CLL. Optimal therapy will depend on a timely and accurate diagnosis of autoimmune cytopaenia and should be individualised according to the severity of the cytopaenia and the presence or absence of concomitant progressive CLL requiring therapy.
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Affiliation(s)
- Clive S Zent
- Division of Hematology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Yoshida H, Ishida H, Yoshihara T, Oyamada T, Kuwana M, Imamura T, Morimoto A. Complications of Evans' syndrome in an infant with hereditary spherocytosis: a case report. J Hematol Oncol 2009; 2:40. [PMID: 19740448 PMCID: PMC2753340 DOI: 10.1186/1756-8722-2-40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 09/10/2009] [Indexed: 11/10/2022] Open
Abstract
Hereditary spherocytosis (HS) is a genetic disorder of the red blood cell membrane clinically characterized by anemia, jaundice and splenomegaly. Evans' syndrome is a clinical syndrome characterized by autoimmune hemolytic anemia (AIHA) accompanied by immune thrombocytopenic purpura (ITP). It results from a malfunction of the immune system that produces multiple autoantibodies targeting at least red blood cells and platelets. HS and Evans' syndrome have different mechanisms of pathophysiology one another. We reported the quite rare case of an infant who had these diseases concurrently. Possible explanations of the unexpected complication are discussed.
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Affiliation(s)
- Hideki Yoshida
- Department of Pediatrics, Matsushita Memorial Hospital, Moriguchi, Japan.
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Serafini G, Andreani M, Testi M, Battarra M, Bontadini A, Biral E, Fleischhauer K, Marktel S, Lucarelli G, Roncarolo MG, Bacchetta R. Type 1 regulatory T cells are associated with persistent split erythroid/lymphoid chimerism after allogeneic hematopoietic stem cell transplantation for thalassemia. Haematologica 2009; 94:1415-26. [PMID: 19608686 DOI: 10.3324/haematol.2008.003129] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Thalassemia major can be cured with allogeneic hematopoietic stem cell transplantation. Persistent mixed chimerism develops in around 10% of transplanted thalassemic patients, but the biological mechanisms underlying this phenomenon are poorly understood. DESIGN AND METHODS The presence of interleukin-10-producing T cells in the peripheral blood of eight patients with persistent mixed chimerism and five with full donor chimerism was investigated. A detailed characterization was then performed, by T-cell cloning, of the effector and regulatory T-cell repertoire of one patient with persistent mixed chimerism, who developed stable split erythroid/lymphoid chimerism after a hematopoietic stem cell transplant from an HLA-matched unrelated donor. RESULTS Higher levels of interleukin-10 were produced by peripheral blood mononuclear cells from patients with persistent mixed chimerism than by the same cells from patients with complete donor chimerism or normal donors. T-cell clones of both host and donor origin could be isolated from the peripheral blood of one, selected patient with persistent mixed chimerism. Together with effector T-cell clones reactive against host or donor alloantigens, regulatory T-cell clones with a cytokine secretion profile typical of type 1 regulatory cells were identified at high frequencies. Type 1 regulatory cell clones, of both donor and host origin, were able to inhibit the function of effector T cells of either donor or host origin in vitro. CONCLUSIONS Overall these results suggest that interleukin-10 and type 1 regulatory cells are associated with persistent mixed chimerism and may play an important role in sustaining long-term tolerance in vivo. These data provide new insights into the mechanisms of peripheral tolerance in chimeric patients and support the use of cellular therapy with regulatory T cells following hematopoietic stem cell transplantation.
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Affiliation(s)
- Giorgia Serafini
- Mediterranean Institute of Hematology, IME Foundation, Policlinico di Tor Vergata, Rome, Italy
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Berentsen S, Sundic T, Hervig T, Tjønnfjord G. Autoimmun hemolytisk anemi. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2226-31. [DOI: 10.4045/tidsskr.09.0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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41
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EpCAM-specific Vaccine Response by Modified Antigen and Chimeric Costimulatory Molecule in Cynomolgus Monkeys. J Immunother 2008; 31:644-55. [DOI: 10.1097/cji.0b013e3181826d89] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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