1
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Semple JW, Schifferli A, Cooper N, Saad H, Mytych DT, Chea LS, Newland A. Immune thrombocytopenia: Pathophysiology and impacts of Romiplostim treatment. Blood Rev 2024:101222. [PMID: 38942688 DOI: 10.1016/j.blre.2024.101222] [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: 04/21/2024] [Revised: 06/04/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disease caused by immune-mediated platelet destruction and decreased platelet production. ITP is characterized by an isolated thrombocytopenia (<100 × 109/L) and increased risk of bleeding. The disease has a complex pathophysiology wherein immune tolerance breakdown leads to platelet and megakaryocyte destruction. Therapeutics such as corticosteroids, intravenous immunoglobulins (IVIg), rituximab, and thrombopoietin receptor agonists (TPO-RAs) aim to increase platelet counts to prevent hemorrhage and increase quality of life. TPO-RAs act via stimulation of TPO receptors on megakaryocytes to directly stimulate platelet production. Romiplostim is a TPO-RA that has become a mainstay in the treatment of ITP. Treatment significantly increases megakaryocyte maturation and growth leading to improved platelet production and it has recently been shown to have additional immunomodulatory effects in treated patients. This review will highlight the complex pathophysiology of ITP and discuss the usage of Romiplostim in ITP and its ability to potentially immunomodulate autoimmunity.
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Affiliation(s)
- John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden, Clinical Immunology and Transfusion Medicine, Office of Medical Services, Region Skåne, Lund, Sweden; Departments of Pharmacology, Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, USA.
| | - Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | | | | | | | | | - Adrian Newland
- Barts and The London School of Medicine and Dentistry, London, UK.
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2
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Chen Y, Xu Y, Chi Y, Sun T, Gao Y, Dou X, Han Z, Xue F, Li H, Liu W, Liu X, Dong H, Fu R, Ju M, Dai X, Wang W, Ma Y, Song Z, Gu J, Gong W, Yang R, Zhang L. Efficacy and safety of human umbilical cord-derived mesenchymal stem cells in the treatment of refractory immune thrombocytopenia: a prospective, single arm, phase I trial. Signal Transduct Target Ther 2024; 9:102. [PMID: 38653983 PMCID: PMC11039759 DOI: 10.1038/s41392-024-01793-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/18/2024] [Accepted: 03/02/2024] [Indexed: 04/25/2024] Open
Abstract
Patients with refractory immune thrombocytopenia (ITP) frequently encounter substantial bleeding risks and demonstrate limited responsiveness to existing therapies. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) present a promising alternative, capitalizing on their low immunogenicity and potent immunomodulatory effects for treating diverse autoimmune disorders. This prospective phase I trial enrolled eighteen eligible patients to explore the safety and efficacy of UC-MSCs in treating refractory ITP. The research design included administering UC-MSCs at escalating doses of 0.5 × 106 cells/kg, 1.0 × 106 cells/kg, and 2.0 × 106 cells/kg weekly for four consecutive weeks across three cohorts during the dose-escalation phase, followed by a dose of 2.0 × 106 cells/kg weekly for the dose-expansion phase. Adverse events, platelet counts, and changes in peripheral blood immunity were monitored and recorded throughout the administration and follow-up period. Ultimately, 12 (with an addition of three patients in the 2.0 × 106 cells/kg group due to dose-limiting toxicity) and six patients were enrolled in the dose-escalation and dose-expansion phase, respectively. Thirteen patients (13/18, 72.2%) experienced one or more treatment emergent adverse events. Serious adverse events occurred in four patients (4/18, 22.2%), including gastrointestinal hemorrhage (2/4), profuse menstruation (1/4), and acute myocardial infarction (1/4). The response rates were 41.7% in the dose-escalation phase (5/12, two received 1.0 × 106 cells/kg per week, and three received 2.0 × 106 cells/kg per week) and 50.0% (3/6) in the dose-expansion phase. The overall response rate was 44.4% (8/18) among all enrolled patients. To sum up, UC-MSCs are effective and well tolerated in treating refractory ITP (ClinicalTrials.gov ID: NCT04014166).
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Affiliation(s)
- Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yanmei Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ying Chi
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yuchen Gao
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xueqing Dou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Zhibo Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- National Engineering Research Centre of Cell Products, Tianjin Key Laboratory of Engineering Technologies for Cell Pharmaceutical, AmCellGene Engineering Co., Ltd, Tianjin, 300457, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Huiyuan Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Huan Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Wentian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yueshen Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Zhen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Jundong Gu
- National Engineering Research Centre of Cell Products, Tianjin Key Laboratory of Engineering Technologies for Cell Pharmaceutical, AmCellGene Engineering Co., Ltd, Tianjin, 300457, China
| | - Wei Gong
- National Engineering Research Centre of Cell Products, Tianjin Key Laboratory of Engineering Technologies for Cell Pharmaceutical, AmCellGene Engineering Co., Ltd, Tianjin, 300457, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
- Tianjin Institutes of Health Science, Tianjin, 301600, China.
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China.
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3
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [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: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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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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Xiang Y, Liu L, Hou Y, Du S, Xu S, Zhou H, Shao L, Li G, Yu T, Liu Q, Xue M, Yang J, Peng J, Hou M, Shi Y. The mTORC1 pathway participate in hyper-function of B cells in immune thrombocytopenia. Ann Hematol 2023; 102:2317-2327. [PMID: 37421506 DOI: 10.1007/s00277-023-05348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
B cell hyper-function plays an important role in the pathogenesis of immune thrombocytopenia (ITP), but the molecular mechanisms underlying such changes remain unclear. We sought to identify regulators of B cell dysfunction in ITP patients through transcriptome sequencing and the use of inhibitors. B cells were isolated from PBMC of 25 ITP patients for B cell function test and transcriptome sequencing. For the potential regulatory factors identified by transcriptome sequencing, the corresponding protein inhibitors were used to explore the regulatory effect of the regulatory factors on B cell dysfunction in vitro. In this study, increased antibody production, enhanced terminal differentiation and highly expressed costimulatory molecules CD80 and CD86 were found in B cells of patients with ITP. In addition, RNA sequencing revealed highly activated mTOR pathway in these pathogenic B cells, indicating that the mTOR pathway may be involved in B cell hyper-function. Furthermore, mTOR inhibitors rapamycin or Torin1 effectively blocked the activation of mTORC1 in B cells, resulting in reduce antibody secretion, impaired differentiation of B cells into plasmablasts and downregulation of costimulatory molecules. Interestingly, as an unspecific inhibitor of mTORC2 besides mTORC1, Torin1 did not show a stronger capacity to modulate B cell function than rapamycin, suggesting that the regulation of B cells by Torin1 may depend on blockade of mTORC1 rather than mTORC2 pathway. These results indicated that the activation of mTORC1 pathway is involved in B cell dysfunction in patients with ITP, and inhibition of mTORC1 pathway might be a potential therapeutic approach for ITP.
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Affiliation(s)
- Yujiao Xiang
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Lu Liu
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
- Department of Hematology, Qilu Hospital (Qingdao) of Shandong University, Qingdao, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Jinan, China
- Department of Hematology, Qilu Hospital (Qingdao) of Shandong University, Qingdao, China
| | - Shenghong Du
- Department of Hematology, Taian Central Hospital, Taian, China
| | - Shuqian Xu
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Hai Zhou
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Linlin Shao
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Guosheng Li
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Tianshu Yu
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Qiang Liu
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Meijuan Xue
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Junhui Yang
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center in Hematological Diseases, Jinan, China
- Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital of Shandong University, Jinan, China
| | - Yan Shi
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China.
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Xiao Z, Murakhovskaya I. Rituximab resistance in ITP and beyond. Front Immunol 2023; 14:1215216. [PMID: 37575230 PMCID: PMC10422042 DOI: 10.3389/fimmu.2023.1215216] [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: 05/01/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
The pathophysiology of immune thrombocytopenia (ITP) is complex and encompasses innate and adaptive immune responses, as well as megakaryocyte dysfunction. Rituximab is administered in relapsed cases and has the added benefit of inducing treatment-free remission in over 50% of patients. Nevertheless, the responses to this therapy are not long-lasting, and resistance development is frequent. B cells, T cells, and plasma cells play a role in developing resistance. To overcome this resistance, targeting these pathways through splenectomy and novel therapies that target FcγR pathway, FcRn, complement, B cells, plasma cells, and T cells can be useful. This review will summarize the pathogenetic mechanisms implicated in rituximab resistance and examine the potential therapeutic interventions to overcome it. This review will explore the efficacy of established therapies, as well as novel therapeutic approaches and agents currently in development.
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Affiliation(s)
| | - Irina Murakhovskaya
- Division of Hematology, Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY, United States
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Zhang GC, Wu YJ, Liu FQ, Chen Q, Sun XY, Qu QY, Fu HX, Huang XJ, Zhang XH. β2-adrenergic receptor agonist corrects immune thrombocytopenia by reestablishing the homeostasis of T cell differentiation. J Thromb Haemost 2023; 21:1920-1933. [PMID: 36972787 DOI: 10.1016/j.jtha.2023.02.030] [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: 11/01/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The sympathetic nerve is known to regulate immune responses in autoimmunity. Aberrant T cell immunity plays a vital role in immune thrombocytopenia (ITP) pathogenesis. The spleen is the primary site of platelet destruction. However, little is known whether and how splenic sympathetic innervation and neuroimmune modulation contribute to ITP pathogenesis. OBJECTIVES To determine the sympathetic distribution in the spleen of ITP mice and the association between splenic sympathetic nerves and T cell immunity in ITP development, and to evaluate the treatment potential of β2-adrenergic receptor (β2-AR) in ITP. METHODS Chemical sympathectomy was performed in an ITP mouse model with 6-hydroxydopamine and treated with β2-AR agonists to evaluate the effects of sympathetic denervation and activation. RESULTS Decreased sympathetic innervation in the spleen of ITP mice was observed. Significantly increased percentages of Th1 and Tc1 cells and reduced percentages of regulatory T cells (Tregs) were also observed in ITP mice with chemical sympathectomy (ITP-syx mice) relative to mice without sympathectomy (controls). Expression of genes associated with Th1, including IFN-γ and IRF8, was significantly upregulated, whereas genes associated with Tregs, including Foxp3 and CTLA4, were significantly downregulated in ITP-syx mice compared with controls. Furthermore, β2-AR restored the percentage of Tregs and increased platelet counts at days 7 and 14 in ITP mice. CONCLUSION Our findings indicate that decreased sympathetic distribution contributes to ITP pathogenesis by disturbing the homeostasis of T cells and that β2-AR agonists have potential as a novel treatment for ITP.
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Affiliation(s)
- Gao-Chao Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ye-Jun Wu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feng-Qi Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qi Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xue-Yan Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qing-Yuan Qu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China.
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8
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Sun M, Wang X, Zhang N, Wang L, Wang X, Fan W, Li Q, Liu Y, Song M, Guo X. Imbalance of follicular regulatory T (Tfr) cells/follicular helper T (Tfh) cells in adult patients with primary immune thrombocytopenia. Exp Biol Med (Maywood) 2023; 248:959-965. [PMID: 37208911 PMCID: PMC10525409 DOI: 10.1177/15353702231168142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/13/2023] [Indexed: 05/21/2023] Open
Abstract
This study is to investigate the role of follicular regulatory T (Tfr) cells/follicular helper T (Tfh) cells imbalance in adult patients with primary immune thrombocytopenia (ITP). Totally, 40 cases of primary ITP patients and 30 healthy controls were enrolled. Blood samples were collected from ITP patients (pre- and post-therapy) and controls. Flow cytometry was used to detect the proportion of Tfr and Tfh cells in peripheral blood. Real-time quantitative polymerase chain reaction (PCR) was performed to detect the mRNA expression levels of FOXP3, BCL-6, and BLIMP-1. Enzyme-linked immunosorbent assay (ELISA) was conducted to detect interleukin (IL)-10 and IL-21 levels. Spearman's correlation was used for correlation analysis. Compared with control, Tfr cell proportion, FOXP3 mRNA, and IL-10 were significantly decreased in the pre-therapy ITP group, but were significantly increased post-therapy. Tfh cell proportion, BCL-6 mRNA, and IL-21 were increased, while BLIMP-1 mRNA was decreased, in the pre-therapy ITP group than the control group. These effects were reversed in the post-therapy ITP group. Moreover, the Tfr/Tfh ratio was decreased in the pre-therapy ITP group than control group, whereas was increased in the post-therapy ITP group than the pre-therapy ITP group. Furthermore, Tfr cell proportion, FOXP3 mRNA, IL-10, and Tfr/Tfh ratio were positively correlated with the platelet count (PLT) in the ITP pre-therapy group. In addition, Tfh cell proportion, BCL-6 mRNA, and IL-21 were negatively correlated with the PLT, while BLIMP-1 mRNA was positively correlated with the PLT. Conclusively, Tfr cell proportion in peripheral blood is decreased and Tfh cell proportion is increased, leading to unbalanced Tfr/Tfh ratio in ITP patients pre-therapy. The imbalance of Tfr/Tfh is recovered post-therapy, suggesting that the Tfr and Tfh cells may be involved in ITP pathogenesis. The abnormal expression of FOXP3, BCL-6, and BLIMP-1 mRNA and the changes in IL-10 and IL-21 levels may be related to the imbalance of Tfr/Tfh.
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Affiliation(s)
- Mingling Sun
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Xiujuan Wang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Ning Zhang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Lei Wang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Xinyou Wang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Wenxia Fan
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Qinzhi Li
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Ying Liu
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Mengting Song
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Xinhong Guo
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
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9
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Anagnostou T, Yang ZZ, Jalali S, Kim HJ, Larson DP, Tang X, Yu Y, Pritchett JC, Bisneto JV, Price-Troska TL, Mondello P, Novak AJ, Ansell SM. Characterization of immune exhaustion and suppression in the tumor microenvironment of splenic marginal zone lymphoma. Leukemia 2023:10.1038/s41375-023-01911-2. [PMID: 37117318 DOI: 10.1038/s41375-023-01911-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/13/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
The role of the tumor microenvironment (TME) and intratumoral T cells in splenic marginal zone lymphoma (sMZL) is largely unknown. In the present study, we evaluated 36 sMZL spleen specimens by single cell analysis to gain a better understanding of the TME in sMZL. Using mass cytometry (CyTOF), we observed that the TME in sMZL is distinct from that of control non-malignant reactive spleen (rSP). We found that the number of TFH cells varied greatly in sMZL, ICOS+ TFH cells were more abundant in sMZL than rSP, and TFH cells positively correlated with increased numbers of memory B cells. Treg cell analysis revealed that TIGIT+ Treg cells are enriched in sMZL and correlate with suppression of TH17 and TH22 cells. Intratumoral CD8+ T cells were comprised of subsets of short-lived, exhausted and late-stage differentiated cells, thereby functionally impaired. We observed that T-cell exhaustion was present in sMZL and TIM-3 expression on PD-1low cells identified cells with severe immune dysfunction. Gene expression profiling by CITE-seq analysis validated this finding. Taken together, our data suggest that the TME as a whole, and T-cell population specifically, are heterogenous in sMZL and immune exhaustion is one of the major factors impairing T-cell function.
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Affiliation(s)
- Theodora Anagnostou
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zhi-Zhang Yang
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Shahrzad Jalali
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hyo Jin Kim
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Xinyi Tang
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yue Yu
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Joshua C Pritchett
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Patrizia Mondello
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anne J Novak
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen M Ansell
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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10
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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11
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Si X, Gu T, Liu L, Huang Y, Han Y, Qian P, Huang H. Hematologic cytopenia post CAR T cell therapy: Etiology, potential mechanisms and perspective. Cancer Lett 2022; 550:215920. [PMID: 36122628 DOI: 10.1016/j.canlet.2022.215920] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022]
Abstract
Chimeric Antigen-Receptor (CAR) T-cell therapies have shown dramatic efficacy in treating relapsed and refractory cancers, especially B cell malignancies. However, these innovative therapies cause adverse toxicities that limit the broad application in clinical settings. Hematologic cytopenias, one frequently reported adverse event following CAR T cell treatment, are manifested as a disorder of hematopoiesis with decreased number of mature blood cells and subdivided into anemia, thrombocytopenia, leukopenia, and neutropenia, which increase the risk of infections, fatigue, bleeding, fever, and even fatality. Herein, we initially summarized the symptoms, etiology, risk factors and management of cytopenias. Further, we elaborated the cellular and molecular mechanisms underlying the initiation and progression of cytopenias following CAR T cell therapy based on previous studies about acquired cytopenias. Overall, this review will facilitate our understanding of the etiology of cytopenias and shed lights into developing new therapies against CAR T cell-induced cytopenias.
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Affiliation(s)
- Xiaohui Si
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Tianning Gu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lianxuan Liu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yue Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yingli Han
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Pengxu Qian
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
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12
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Systemic lupus erythematosus-complicating immune thrombocytopenia: From pathogenesis to treatment. J Autoimmun 2022; 132:102887. [PMID: 36030136 DOI: 10.1016/j.jaut.2022.102887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
Immune thrombocytopenia (ITP) is a common hematological manifestation of systemic lupus erythematosus (SLE). The heterogeneity of its clinical characteristics and therapeutic responses reflects a complex pathogenesis. A better understanding of its pathophysiological mechanisms and employing an optimal treatment regimen is therefore important to improve the response rate and prognosis, and avoid unwanted outcomes. Besides glucocorticoids, traditional immunosuppressants (i.e. cyclosporine, mycophenolate mofetil) and intravenous immunoglobulins, new therapies are emerging and promising for the treatment of intractable SLE-ITP, such as thrombopoietin receptor agonists (TPO-RAs), platelet desialylation inhibitors(i.e. oseltamivir), B-cell targeting therapy(i.e. rituximab, belimumab), neonatal Fc receptor(FcRn) inhibitor, spleen tyrosine kinase(Syk) inhibitor and Bruton tyrosine kinase(BTK) inhibitor et al., although more rigorous randomized controlled trials are needed to substantiate their efficacy. In this review, we update our current knowledge on the pathogenesis and treatment of SLE-ITP.
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13
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Canales-Herrerias P, Crickx E, Broketa M, Sokal A, Chenon G, Azzaoui I, Vandenberghe A, Perima A, Iannascoli B, Richard-Le Goff O, Castrillon C, Mottet G, Sterlin D, Robbins A, Michel M, England P, Millot GA, Eyer K, Baudry J, Mahevas M, Bruhns P. High-affinity autoreactive plasma cells disseminate through multiple organs in patients with immune thrombocytopenic purpura. J Clin Invest 2022; 132:153580. [PMID: 35503254 PMCID: PMC9197514 DOI: 10.1172/jci153580] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
The major therapeutic goal for immune thrombocytopenic purpura (ITP) is to restore normal platelet counts using drugs to promote platelet production or by interfering with mechanisms responsible for platelet destruction. Eighty percent of patients with ITP possess anti–integrin αIIbβ3 IgG autoantibodies that cause platelet opsonization and phagocytosis. The spleen is considered the primary site of autoantibody production by autoreactive B cells and platelet destruction. The immediate failure in approximately 50% of patients to recover a normal platelet count after anti-CD20 rituximab-mediated B cell depletion and splenectomy suggests that autoreactive, rituximab-resistant, IgG-secreting B cells (IgG-SCs) reside in other anatomical compartments. We analyzed more than 3,300 single IgG-SCs from spleen, bone marrow, and/or blood of 27 patients with ITP, revealing high interindividual variability in affinity for αIIbβ3, with variations over 3 logs. IgG-SC dissemination and range of affinities were, however, similar for each patient. Longitudinal analysis of autoreactive IgG-SCs upon treatment with the anti-CD38 mAb daratumumab demonstrated variable outcomes, from complete remission to failure with persistence of high-affinity anti–αIIbβ3 IgG-SCs in the bone marrow. This study demonstrates the existence and dissemination of high-affinity autoreactive plasma cells in multiple anatomical compartments of patients with ITP that may cause the failure of current therapies.
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Affiliation(s)
| | - Etienne Crickx
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
| | - Matteo Broketa
- Department of Immunology, Institut Pasteur, Paris, France
| | - Aurélien Sokal
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
| | - Guilhem Chenon
- Laboratoire Colloïdes et Matériaux Divisés (LCMD), ESPCI, Paris, France
| | - Imane Azzaoui
- Service de Médecine Interne, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Paris, France
| | - Alexis Vandenberghe
- Service de Médecine Interne, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Paris, France
| | - Angga Perima
- Department of Immunology, Institut Pasteur, Paris, France
| | | | | | | | | | | | - Ailsa Robbins
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunolo, Robert Debré Hospital, Reims University Hospitals, Reims, France
| | - Marc Michel
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Créteil, France
| | - Patrick England
- Plateforme de Biophysique Moléculaire, Institut Pasteur, Paris, France
| | - Gael A Millot
- Hub Bioinformatique et Biostatistique, Institut Pasteur, Paris, France
| | - Klaus Eyer
- Laboratory for Functional Immune Repertoire Analysis, ETH Zurich, Zurich, Switzerland
| | - Jean Baudry
- Laboratoire Colloïdes et Matériaux Divisés (LCMD), ESPCI, Paris, France
| | - Matthieu Mahevas
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
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14
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Tărniceriu CC, Hurjui LL, Florea ID, Hurjui I, Gradinaru I, Tanase DM, Delianu C, Haisan A, Lozneanu L. Immune Thrombocytopenic Purpura as a Hemorrhagic Versus Thrombotic Disease: An Updated Insight into Pathophysiological Mechanisms. Medicina (B Aires) 2022; 58:medicina58020211. [PMID: 35208534 PMCID: PMC8875804 DOI: 10.3390/medicina58020211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/25/2022] [Accepted: 01/29/2022] [Indexed: 11/16/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is a blood disorder characterized by a low platelet count of (less than 100 × 109/L). ITP is an organ-specific autoimmune disease in which the platelets and their precursors become targets of a dysfunctional immune system. This interaction leads to a decrease in platelet number and, subsequently, to a bleeding disorder that can become clinically significant with hemorrhages in skin, on the mucous membrane, or even intracranial hemorrhagic events. If ITP was initially considered a hemorrhagic disease, more recent studies suggest that ITP has an increased risk of thrombosis. In this review, we provide current insights into the primary ITP physiopathology and their consequences, with special consideration on hemorrhagic and thrombotic events. The autoimmune response in ITP involves both the innate and adaptive immune systems, comprising both humoral and cell-mediated immune responses. Thrombosis in ITP is related to the pathophysiology of the disease (young hyperactive platelets, platelets microparticles, rebalanced hemostasis, complement activation, endothelial activation, antiphospholipid antibodies, and inhibition of natural anticoagulants), ITP treatment, and other comorbidities that altogether contribute to the occurrence of thrombosis. Physicians need to be vigilant in the early diagnosis of thrombotic events and then institute proper treatment (antiaggregant, anticoagulant) along with ITP-targeted therapy. In this review, we provide current insights into the primary ITP physiopathology and their consequences, with special consideration on hemorrhagic and thrombotic events. The accumulated evidence has identified multiple pathophysiological mechanisms with specific genetic predispositions, particularly associated with environmental conditions.
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Affiliation(s)
- Claudia Cristina Tărniceriu
- Department of Morpho-Functional Sciences I, Discipline of Anatomy, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
- Hematology Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Loredana Liliana Hurjui
- Department of Morpho-Functional Sciences II, Discipline of Physiology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
- Central Clinical Laboratory-Hematology Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania;
- Correspondence: authors: (L.L.H.); (I.D.F.)
| | - Irina Daniela Florea
- Department of Morpho-Functional Sciences I, Discipline of Imunology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania
- Correspondence: authors: (L.L.H.); (I.D.F.)
| | - Ion Hurjui
- Department of Morpho-Functional Sciences II, Discipline of Biophysics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Irina Gradinaru
- Department of Implantology Removable Dentures Technology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
| | - Daniela Maria Tanase
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania;
| | - Carmen Delianu
- Central Clinical Laboratory-Hematology Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania;
- Department of Biochemistry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Anca Haisan
- Surgery Department, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
- Emergency Department, “Sf. Spiridon” Emergency County Hospital, 700111 Iasi, Romania
| | - Ludmila Lozneanu
- Department of Morpho-Functional Sciences I, Discipline of Histology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
- Department of Pathology, “Sf. Spiridon” Emergency County Hospital, 700111 Iasi, Romania
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15
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[Prospects of individualized diagnosis and treatment of primary immune thrombocytopenia in the era of new drugs]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:965-968. [PMID: 35045664 PMCID: PMC8763589 DOI: 10.3760/cma.j.issn.0253-2727.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Jafarzadeh A, Marzban H, Nemati M, Jafarzadeh S, Mahjoubin-Tehran M, Hamblin MR, Mirzaei H, Mirzaei HR. Dysregulated expression of miRNAs in immune thrombocytopenia. Epigenomics 2021; 13:1315-1325. [PMID: 34498489 DOI: 10.2217/epi-2021-0092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In recent years the critical role of miRNAs has been established in many diseases, including autoimmune disorders. Immune thrombocytopenia purpura (ITP) is a predominant autoimmune disease, in which aberrant expression of miRNAs has been observed, suggesting that miRNAs are involved in its development. miRNAs could induce an imbalance in the T helper (Th)1/Th2 cell and Th17/Treg cell-related responses. Moreover, they could also cause alterations in Th9 and Th22 cell responses, and activate Tfh (T follicular helper) cell-dependent auto-reactive B cells, thus influencing megakaryogenesis. Herein, we summarize the role of immune-related miRNAs in ITP pathogenesis, and look forward to clinical applications.
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Affiliation(s)
- Abdollah Jafarzadeh
- Department of Immunology, School of Medicine, Kerman University of Medical Sciences, 76169-13555, Kerman, Iran.,Department of Immunology, School of Medicine, Rafsanjan University of Medical Sciences, 7718175911, Rafsanjan, Iran
| | - Havva Marzban
- Department of Pathology & Experimental Animals, Razi Vaccine & Serum Research Institute, Agricultural Research, Education & Extension Organization (AREEO), 31975/148 Karaj, Iran
| | - Maryam Nemati
- Immunology of Infectious Diseases Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, 77181/75911, Rafsanjan, Iran.,Department of Hematology & Laboratory Sciences, School of Para-Medicine, Kerman University of Medical Sciences, 76169-13555, Kerman, Iran
| | - Sara Jafarzadeh
- Student Research Committee, School of Medicine, Kerman University of Medical Sciences, 76169-13555, Kerman, Iran
| | - Maryam Mahjoubin-Tehran
- Department of Medical Biotechnology, Faculty of Medicine, Mashhad University of Medical Sciences, 13131- 99137, Mashhad, Iran
| | - Michael R Hamblin
- Laser Research Centre, Faculty of Health Science, University of Johannesburg, 2028 Doornfontein, South Africa
| | - Hamed Mirzaei
- Research Center for Biochemistry & Nutrition in Metabolic Diseases, Institute for Basic Sciences, Kashan University of Medical Sciences, 87159-88141, Kashan, Iran.,Student Research Committee, Kashan University of Medical Sciences, 87159-88141, Kashan, Iran
| | - Hamid Reza Mirzaei
- Department of Medical Immunology, School of Medicine, Tehran University of Medical Sciences, 1417613151, Tehran, Iran
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17
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Bradbury CA, Pell J, Hill Q, Bagot C, Cooper N, Ingram J, Breheny K, Kandiyali R, Rayment R, Evans G, Talks K, Thomas I, Greenwood R. Mycophenolate Mofetil for First-Line Treatment of Immune Thrombocytopenia. N Engl J Med 2021; 385:885-895. [PMID: 34469646 DOI: 10.1056/nejmoa2100596] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Immune thrombocytopenia is a rare autoimmune disorder with associated bleeding risk and fatigue. Recommended first-line treatment for immune thrombocytopenia is high-dose glucocorticoids, but side effects, variable responses, and high relapse rates are serious drawbacks. METHODS In this multicenter, open-label, randomized, controlled trial conducted in the United Kingdom, we assigned adult patients with immune thrombocytopenia, in a 1:1 ratio, to first-line treatment with a glucocorticoid only (standard care) or combined glucocorticoid and mycophenolate mofetil. The primary efficacy outcome was treatment failure, defined as a platelet count of less than 30×109 per liter and initiation of a second-line treatment, assessed in a time-to-event analysis. Secondary outcomes were response rates, side effects, occurrence of bleeding, patient-reported quality-of-life measures, and serious adverse events. RESULTS A total of 120 patients with immune thrombocytopenia underwent randomization (52.4% male; mean age, 54 years [range 17 to 87]; mean platelet level, 7×109 per liter) and were followed for up to 2 years after beginning trial treatment. The mycophenolate mofetil group had fewer treatment failures than the glucocorticoid-only group (22% [13 of 59 patients] vs. 44% [27 of 61 patients]; hazard ratio, 0.41; range, 0.21 to 0.80; P = 0.008) and greater response (91.5% of patients having platelet counts greater than 100×109 per liter vs. 63.9%; P<0.001). We found no evidence of a difference between the groups in the occurrence of bleeding, rescue treatments, or treatment side effects, including infection. However, patients in the mycophenolate mofetil group reported worse quality-of-life outcomes regarding physical function and fatigue than those in the glucocorticoid-only group. CONCLUSIONS The addition of mycophenolate mofetil to a glucocorticoid for first-line treatment of immune thrombocytopenia resulted in greater response and a lower risk of refractory or relapsed immune thrombocytopenia, but with somewhat decreased quality of life. (Funded by the U.K. National Institute for Health Research; FLIGHT ClinicalTrials.gov number, NCT03156452; EudraCT number, 2017-001171-23.).
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Affiliation(s)
- Charlotte A Bradbury
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Julie Pell
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Quentin Hill
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Catherine Bagot
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Nichola Cooper
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Jenny Ingram
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Katie Breheny
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rebecca Kandiyali
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rachel Rayment
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Gillian Evans
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Kate Talks
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Ian Thomas
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rosemary Greenwood
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
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18
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Mahévas M, Azzaoui I, Crickx E, Canoui-Poitrine F, Gobert D, Languille L, Limal N, Guillaud C, Croisille L, Jeljeli M, Batteux F, Baloul S, Fain O, Pirenne F, Weill JC, Reynaud CA, Godeau B, Michel M. Efficacy, safety and immunological profile of combining rituximab with belimumab for adults with persistent or chronic immune thrombocytopenia: results from a prospective phase 2b trial. Haematologica 2021; 106:2449-2457. [PMID: 32817288 PMCID: PMC8409028 DOI: 10.3324/haematol.2020.259481] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 12/24/2022] Open
Abstract
B-cell activating factor may be involved in the failure of B-cell depleting therapy with rituximab in immune thrombocytopenia (ITP) by promoting the emergence of splenic long-lived plasma cells. From results obtained in mouse models, we hypothesized that combining rituximab with sequential injections of belimumab could increase the rate of response at one year in patients with persistent or chronic ITP by preventing the emergence of these long-lived plasma cells. The study was a single-center, single arm, prospective phase 2b trial (RITUX-PLUS, NCT03154385) investigating the safety and efficacy of rituximab given at a fixed dose of 1,000 mg, two weeks apart, combined with five infusions of belimumab, 10 mg/kg at week 0 (W0)+2 days, W2+2 days, W4, W8 and W12 for adults with primary persistent or chronic ITP. The primary endpoint was the total number of patients achieving an overall response (complete response + response) at W52 according to a standard definition. In total, 15 non-splenectomized adults, nine (60%) with persistent IPT and six (40%) with chronic ITP, were included. No severe adverse event, infection, or severe hypogammaglobulinemia was observed. Thirteen patients achieved an initial overall response. At W52, 12 (80%) patients achieved an overall response, including ten (66.7%) with complete response. When compared with a cohort of patients receiving rituximab alone, the kinetics of B-cell repopulation appeared similar, but the number of circulating T follicular helper cells was significantly decreased with belimumab combination therapy. Combining rituximab and belimumab seems a promising strategy in ITP, with high efficacy and acceptable safety.
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Affiliation(s)
- Matthieu Mahévas
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | | | - Etienne Crickx
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Florence Canoui-Poitrine
- University Paris-Est, Paris Est Creteil University, CEpiA, Henri-Mondor Hospital, Creteil, France
| | | | - Laetitia Languille
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Nicolas Limal
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Constance Guillaud
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Laure Croisille
- Service d'immunologie plaquettaire, Hopital Henri Mondor, Creteil, France
| | - Mohamed Jeljeli
- Service d'Immunologie biologique, Hopital Cochin, Institut Cochin, Paris, France
| | - Fréderic Batteux
- Service d'Immunologie biologique, Hopital Cochin, Institut Cochin, Paris, France
| | - Samia Baloul
- University Paris-Est, Paris Est Creteil University, CEpiA, Henri-Mondor Hospital, Creteil, France
| | - Olivier Fain
- Sorbonne Université, Service de Medecine Interne, Hopital Saint-Antoine, Paris, France
| | | | - Jean-Claude Weill
- Institut Necker Enfants Malades, Université Paris Descartes, Paris, France
| | | | - Bertrand Godeau
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Marc Michel
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
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19
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Hewavisenti RV, Ferguson AL, Gasparini G, Ohashi T, Braun A, Watkins TS, Miles JJ, Elliott M, Sierro F, Feng CG, Britton WJ, Gebhardt T, Tangye S, Palendira U. Tissue-resident regulatory T cells accumulate at human barrier lymphoid organs. Immunol Cell Biol 2021; 99:894-906. [PMID: 34080230 DOI: 10.1111/imcb.12481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/19/2021] [Accepted: 05/31/2021] [Indexed: 12/17/2022]
Abstract
Regulatory T cells (Tregs) play a critical role in immune regulation and peripheral tolerance. While different types of Tregs have been identified in both mice and humans, much of our understanding about how these cells maintain immune homeostasis is derived from animal models. In this study, we examined two distinct human lymphoid organs to understand how repeated exposure to infections at the mucosal surface influences the phenotype and tissue localization of Tregs. We show that while Tregs in both tonsils and spleen express a tissue-resident phenotype, they accumulate in greater numbers in tonsils. Tonsillar-resident Tregs exhibit a highly suppressive phenotype with significantly increased expression of CD39, ICOS and CTLA-4 compared with their counterparts in circulation or in the spleen. Functionally, resident Tregs are able effectively to suppress T cell proliferation. We further demonstrate that tonsillar-resident Tregs share key features of T follicular helper cells. Spatial analysis reveals that the vast majority of resident Tregs are localized at the border of the T-zone and B cell follicle, as well as within the lymphocyte pockets enriched with resident memory T cells. Together our findings suggest that resident Tregs are strategically co-localized to maintain immune homeostasis at sites of recurrent inflammation.
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Affiliation(s)
- Rehana V Hewavisenti
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Angela L Ferguson
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Georgia Gasparini
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Tomoki Ohashi
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Asolina Braun
- Department of Immunology and Microbiology, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Thomas S Watkins
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
| | - John J Miles
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia
| | - Michael Elliott
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Chris O'Brien Lifehouse Cancer Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Frederic Sierro
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Australian Nuclear Science and Technology Organisation, Sydney, NSW, Australia
| | - Carl G Feng
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Warwick J Britton
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Thomas Gebhardt
- Department of Immunology and Microbiology, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Stuart Tangye
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, UNSW Sydney, Darlinghurst, NSW, Australia
| | - Umaimainthan Palendira
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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20
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Increasing numbers of CD19 + CD24 highCD38 high regulatory B cells and pre-germinal center B cells reflect activated autoimmunity and predict future treatment response in patients with untreated immune thrombocytopenia. Int J Hematol 2021; 114:580-590. [PMID: 34309815 DOI: 10.1007/s12185-021-03192-w] [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: 04/23/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/07/2023]
Abstract
The pathophysiology of immune thrombocytopenia (ITP) is poorly understood, particularly aspects regarding abnormal homeostasis and dysregulation of B cells. In this study, we analyzed peripheral lymphocyte subsets in patients with untreated ITP and healthy controls, and examined correlations between cell percentages/counts and titers of serum cytokines and antibodies. We also compared ITP patients who later required second-line therapies and those who did not. The percentages of CD19 + CD24highCD38high regulatory B cells, pre-germinal center (GC) B cells, and plasmablast-like B cells were significantly higher in ITP patients than in healthy controls. Absolute counts of regulatory B cells and pre-GC B cells were significantly higher in those who needed second-line therapies. In addition, serum B cell-activating factor belonging to the tumor necrosis factor family (BAFF) levels and platelet-associated immune globulin G antibody titers correlated positively with regulatory B cell, pre-GC B cell, and auto-reactive B cell counts. Serum interferon-α (IFN-α) levels were elevated in four ITP patients with high auto-reactive B cell counts. These results indicate that increases in regulatory B cells and pre-GC B cells may reflect activated autoimmunity induced by BAFF and/or IFN-α. Consequently, evaluation of B cell subsets in untreated ITP patients may predict treatment response.
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21
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Crickx E, Chappert P, Sokal A, Weller S, Azzaoui I, Vandenberghe A, Bonnard G, Rossi G, Fadeev T, Storck S, Fadlallah J, Meignin V, Rivière E, Audia S, Godeau B, Michel M, Weill JC, Reynaud CA, Mahévas M. Rituximab-resistant splenic memory B cells and newly engaged naive B cells fuel relapses in patients with immune thrombocytopenia. Sci Transl Med 2021; 13:13/589/eabc3961. [PMID: 33853929 DOI: 10.1126/scitranslmed.abc3961] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/29/2020] [Accepted: 03/22/2021] [Indexed: 01/19/2023]
Abstract
Rituximab (RTX), an antibody targeting CD20, is widely used as a first-line therapeutic strategy in B cell-mediated autoimmune diseases. However, a large proportion of patients either do not respond to the treatment or relapse during B cell reconstitution. Here, we characterize the cellular basis responsible for disease relapse in secondary lymphoid organs in humans, taking advantage of the opportunity offered by therapeutic splenectomy in patients with relapsing immune thrombocytopenia. By analyzing the B and plasma cell immunoglobulin gene repertoire at bulk and antigen-specific single-cell level, we demonstrate that relapses are associated with two responses coexisting in germinal centers and involving preexisting mutated memory B cells that survived RTX treatment and naive B cells generated upon reconstitution of the B cell compartment. To identify distinctive characteristics of the memory B cells that escaped RTX-mediated depletion, we analyzed RTX refractory patients who did not respond to treatment at the time of B cell depletion. We identified, by single-cell RNA sequencing (scRNA-seq) analysis, a population of quiescent splenic memory B cells that present a unique, yet reversible, RTX-shaped phenotype characterized by down-modulation of B cell-specific factors and expression of prosurvival genes. Our results clearly demonstrate that these RTX-resistant autoreactive memory B cells reactivate as RTX is cleared and give rise to plasma cells and further germinal center reactions. Their continued surface expression of CD19 makes them efficient targets for current anti-CD19 therapies. This study thus identifies a pathogenic contributor to autoimmune diseases that can be targeted by available therapeutic agents.
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Affiliation(s)
- Etienne Crickx
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France.,Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Pascal Chappert
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France.,Inovarion, 75005 Paris, France
| | - Aurélien Sokal
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Sandra Weller
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Imane Azzaoui
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Alexis Vandenberghe
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Guillaume Bonnard
- INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
| | - Geoffrey Rossi
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Tatiana Fadeev
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Sébastien Storck
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Jehane Fadlallah
- Service d'immunologie clinique, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, 75010 Paris, France
| | - Véronique Meignin
- Service d'anatomopathologie, Hôpital Saint-Louis (AP-HP), 75010 Paris, France
| | - Etienne Rivière
- Service de médecine interne, Hôpital Haut-Lévêque, 33604 Pessac, France
| | - Sylvain Audia
- Service de médecine interne, Hôpital du Bocage, 21000 Dijon, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France
| | - Jean-Claude Weill
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Claude-Agnès Reynaud
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France
| | - Matthieu Mahévas
- Institut Necker-Enfants Malades, INSERM U1151/CNRS UMS8253, Université Paris Descartes, Sorbonne Paris Cité, 75993 Paris Cedex 14, France. .,Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, 94000 Créteil, France.,INSERM U955, Université Paris Est Créteil (UPEC), 94000 Créteil, France
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22
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Razanamahery J, Humbert S, Emile JF, Cohen-Aubart F, Fontan J, Maksud P, Audia S, Haroche J. Immune Thrombocytopenia Revealing Enriched IgG-4 Peri-Renal Rosai-Dorfman Disease Successfully Treated with Rituximab: A Case Report and Literature Review. Front Med (Lausanne) 2021; 8:678456. [PMID: 34222286 PMCID: PMC8244783 DOI: 10.3389/fmed.2021.678456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/13/2021] [Indexed: 12/03/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune-mediated condition characterized by isolated thrombocytopenia (<100 G/L) after exclusion of other causes. Mostly primary, it is associated with hematological malignancy, autoimmune disorders, or infection in 20% of patients. It is exceptionally described in patients with histiocytosis, mostly in children (seven patients in literature). We report a case of a 69-year-old man with ITP leading to the diagnosis of histiocytosis. At ITP's diagnosis, the patient had elevated gamma-globulins leading to computed tomography showing bilateral peri-renal infiltration. The biopsy showed enriched IgG-4 peri-renal Rosai Dorfman disease with MAP2K1 mutation, although peri-renal infiltration is highly suggestive of Erdheim-Chester disease. This overlapping association was described in men with mutation in MAP2K1 gene. Macrophages are implicated in the pathophysiology of ITP in multiple ways, notably by the phagocytosis of opsonized platelets and their function of antigen-presenting cells able to stimulate autoreactive T cells. Histiocytic cells derivate from monocyte-macrophage lineage. Activation of macrophages in active histiocytosis is responsible for consequential platelet destruction in ITP associated histiocytosis. Finally, this case highlights a rare presentation of ITP revealing histiocytosis, both being efficiently treated with rituximab.
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Affiliation(s)
- Jerome Razanamahery
- Internal Medicine Department and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - Sebastien Humbert
- Internal Medicine Department, Besancon University Hospital, Besançon, France
| | - Jean-Francois Emile
- Department of Pathology, Ambroise-Paré Hospital, Assistance-Publique Hopitaux de Paris, Paris, France
| | - Fleur Cohen-Aubart
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Internal Medicine Department 2, National Reference Center for Histiocytosis, Paris, France
| | - Jean Fontan
- Department of Haematology, Besancon University Hospital, Besançon, France
| | - Philippe Maksud
- Department of Nuclear Medicine, Pitié-Salpêtrière Hospital, Paris, France
| | - Sylvain Audia
- Internal Medicine Department and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - Julien Haroche
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Internal Medicine Department 2, National Reference Center for Histiocytosis, Paris, France
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23
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Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. Hemasphere 2021; 5:e574. [PMID: 34095758 PMCID: PMC8171374 DOI: 10.1097/hs9.0000000000000574] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to both a peripheral destruction of platelets and an inappropriate bone marrow production. Although the primary triggering factors of ITP remain unknown, a loss of immune tolerance-mostly represented by a regulatory T-cell defect-allows T follicular helper cells to stimulate autoreactive splenic B cells that differentiate into antiplatelet antibody-producing plasma cells. Glycoprotein IIb/IIIa is the main target of antiplatelet antibodies leading to platelet phagocytosis by splenic macrophages, through interactions with Fc gamma receptors (FcγRs) and complement receptors. This allows macrophages to activate autoreactive T cells by their antigen-presenting functions. Moreover, the activation of the classical complement pathway participates to platelet opsonization and also to their destruction by complement-dependent cytotoxicity. Platelet destruction is also mediated by a FcγR-independent pathway, involving platelet desialylation that favors their binding to the Ashwell-Morell receptor and their clearance in the liver. Cytotoxic T cells also contribute to ITP pathogenesis by mediating cytotoxicity against megakaryocytes and peripheral platelets. The deficient megakaryopoiesis resulting from both the humoral and the cytotoxic immune responses is sustained by inappropriate levels of thrombopoietin, the major growth factor of megakaryocytes. The better understanding of ITP pathogenesis has provided important therapeutic advances. B cell-targeting therapies and thrombopoietin-receptor agonists (TPO-RAs) have been used for years. New emerging therapeutic strategies that inhibit FcγR signaling, the neonatal Fc receptor or the classical complement pathway, will deeply modify the management of ITP in the near future.
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24
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Emerging Therapies in Immune Thrombocytopenia. J Clin Med 2021; 10:jcm10051004. [PMID: 33801294 PMCID: PMC7958340 DOI: 10.3390/jcm10051004] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder caused by peripheral platelet destruction and inappropriate bone marrow production. The management of ITP is based on the utilization of steroids, intravenous immunoglobulins, rituximab, thrombopoietin receptor agonists (TPO-RAs), immunosuppressants and splenectomy. Recent advances in the understanding of its pathogenesis have opened new fields of therapeutic interventions. The phagocytosis of platelets by splenic macrophages could be inhibited by spleen tyrosine kinase (Syk) or Bruton tyrosine kinase (BTK) inhibitors. The clearance of antiplatelet antibodies could be accelerated by blocking the neonatal Fc receptor (FcRn), while new strategies targeting B cells and/or plasma cells could improve the reduction of pathogenic autoantibodies. The inhibition of the classical complement pathway that participates in platelet destruction also represents a new target. Platelet desialylation has emerged as a new mechanism of platelet destruction in ITP, and the inhibition of neuraminidase could dampen this phenomenon. T cells that support the autoimmune B cell response also represent an interesting target. Beyond the inhibition of the autoimmune response, new TPO-RAs that stimulate platelet production have been developed. The upcoming challenges will be the determination of predictive factors of response to treatments at a patient scale to optimize their management.
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25
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Pizzi M, Friziero A, Vianello F, Binotto G, Da Dalt G, Zoletto S, Carraro E, Fassan M, Sbaraglia M, Sperti C, Baldan N, D'Amore F, Bertozzi I, Righi S, Pierobon ES, Moletta L, Capovilla G, Grego A, Sabattini E, Fabris F, Merigliano S, Dei Tos AP. Histology of the spleen in immune thrombocytopenia: clinical-pathological characterization and prognostic implications. Eur J Haematol 2020; 106:281-289. [PMID: 33190299 DOI: 10.1111/ejh.13547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Immune thrombocytopenia (ITP) is an acquired disorder, characterized by immune-mediated platelet destruction. The spleen plays a key pathogenic role in ITP and splenectomy is a valuable second-line therapy for this disease. Little is known on ITP spleen histology and response to splenectomy is unpredictable. This study aims to characterize ITP spleen histology and assess possible predictors of splenectomy outcome. METHODS A series of 23 ITP spleens were retrospectively assessed for the following histological parameters: density of lymphoid follicles (LFs), marginal zones (MZs), T helper and cytotoxic T cells; presence of reactive germinal centers (GCs); width of perivascular T cell sheaths; and red pulp features. Clinical and histological data were matched with postsplenectomy platelet counts to assess their prognostic relevance. RESULTS Three histological patterns were documented: a hyperplastic white pulp pattern, a non-activated white pulp pattern (lacking GCs), and a white pulp-depleted pattern. Poor surgical responses were associated with presplenectomy high-dose steroid administration, autoimmune comorbidities and low T follicular helper cell density. The combination of such parameters stratified patients into different splenectomy response groups. The removal of accessory spleens was also associated with better outcome. CONCLUSION ITP spleens are histologically heterogeneous and clinical-pathological parameters may help predict the splenectomy outcome.
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Affiliation(s)
- Marco Pizzi
- Surgical Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Alberto Friziero
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Fabrizio Vianello
- Hematology and Clinical Immunology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Gianni Binotto
- Hematology and Clinical Immunology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Gianfranco Da Dalt
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Simone Zoletto
- Surgical Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Elisa Carraro
- Oncohematology Unit, Department of Women and Children's Health, University of Padova, Padova, Italy
| | - Matteo Fassan
- Surgical Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Marta Sbaraglia
- Surgical Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Cosimo Sperti
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Nicola Baldan
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Fabio D'Amore
- Hematology and Clinical Immunology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Irene Bertozzi
- 1st Medical Clinic, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Simona Righi
- Haematopathology Unit, Sant'Orsola Hospital, Bologna, Italy
| | - Elisa Sefora Pierobon
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Lucia Moletta
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Giovanni Capovilla
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Andrea Grego
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | | | - Fabrizio Fabris
- 1st Medical Clinic, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Stefano Merigliano
- 3rd Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Angelo Paolo Dei Tos
- Surgical Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
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26
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Wang X, Lu J, Wei G, Tong H, Zhou J, Ding Y, Zhang S, Xu X, Lai R, Luo Q, Ju W, Yan Z, Zeng L, Xu K, Qiao J. Tacrolimus ameliorates thrombocytopenia in an ITP mouse model. Ann Hematol 2020; 99:2315-2322. [PMID: 32728937 DOI: 10.1007/s00277-020-04203-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/27/2020] [Indexed: 02/06/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by lower platelet count resulting from immune cells-mediated platelet clearance. Tacrolimus is an immunosuppressive agent which selectively inhibits T cell activation. Whether tacrolimus plays a role in ITP remains unclear. This study aimed to investigate the effect of tacrolimus on ITP in mice. An ITP mouse model was established by injection of rat anti-mouse integrin GPIIb/CD41 immunoglobulin and treated with tacrolimus followed by isolation of peripheral blood mononuclear cells and plasma. The mRNA expression of T-bet, GATA3, and Foxp3 was measured by RT-PCR, and level of IFN-γ, IL-12p70, IL-4, IL-13, and TGF-β in plasma was measured by ELISA. Tacrolimus inhibited antiplatelet antibody-mediated platelet clearance in ITP mouse model. Meanwhile, tacrolimus-treated ITP mice displayed a significant decrease in the mRNA expression of T-bet and plasma level of IFN-γ and IL-12p70 compared with ITP mice but without differences when compared with normal mice. Furthermore, the expression of GATA3, Foxp3, and plasma level of IL-4 and TGF-β were upregulated in tacrolimus-treated ITP mice without significant differences to normal mice (except TGF-β). Tacrolimus prevents antiplatelet antibody-mediated thrombocytopenia in ITP mice possibly through regulating T cell differentiations, suggesting it might be a novel approach for preventing ITP.
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MESH Headings
- Animals
- Blood Platelets/immunology
- Cytokines/biosynthesis
- Cytokines/genetics
- Disease Models, Animal
- Gene Expression Regulation/drug effects
- Humans
- Immunosuppressive Agents/therapeutic use
- Isoantibodies/blood
- Mice
- Mice, Inbred C57BL
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/genetics
- Purpura, Thrombocytopenic, Idiopathic/metabolism
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- Specific Pathogen-Free Organisms
- T-Lymphocyte Subsets/drug effects
- T-Lymphocyte Subsets/immunology
- Tacrolimus/therapeutic use
- Transcription Factors/biosynthesis
- Transcription Factors/genetics
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Affiliation(s)
- Xiamin Wang
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Jun Lu
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Guangyu Wei
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Huan Tong
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Jingxin Zhou
- Department of Hematology, The First People's Hospital of Suqian City, Suqian, 223899, China
| | - Yangyang Ding
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Sixuan Zhang
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Xiaoqi Xu
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Ran Lai
- Department of Pharmacy, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Qi Luo
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Wen Ju
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China
| | - Zhiling Yan
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China
| | - Lingyu Zeng
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China.
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China.
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China.
| | - Kailin Xu
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China.
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China.
| | - Jianlin Qiao
- Blood Diseases Institute, Xuzhou Medical University, 84 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China.
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Rd, Quanshan District, Xuzhou, 221002, Jiangsu, China.
- Key Laboratory of Bone Marrow Stem Cell, Xuzhou, 221002, Jiangsu Province, China.
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27
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Audia S, Mahevas M, Bonnotte B. [Immune thrombocytopenia: From pathogenesis to treatment]. Rev Med Interne 2020; 42:16-24. [PMID: 32741715 DOI: 10.1016/j.revmed.2020.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/29/2020] [Accepted: 06/20/2020] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to an immune peripheral destruction of platelets and an inappropriate platelet production. The pathogenesis of ITP is now better understood: it involves a humoral immune response which dependents on the stimulation of B cells by specific T cells called T follicular helper cells, leading to their differentiation into plasma cells that produce antiplatelet antibodies thus promoting the phagocytosis of platelets mainly by splenic macrophages. The deciphering of ITP pathogenesis has led to a better understanding of the inefficiency of treatments such as rituximab, although it has not provided yet the determination of biological predictive factor of response to treatments. Moreover, new therapeutic perspectives have been opened in the last few years with the development of molecules targeting Fcγ receptor signalling such as Syk inhibitor, or molecules increasing the clearance of pathogenic autoantibodies such as inhibitors of the neonatal Fc receptor (FcRn).
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Affiliation(s)
- S Audia
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France.
| | - M Mahevas
- 1 Service de Médecine Interne, Centre National 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; IMRB - U955 - Equipe n°2 "Transfusion et maladies du globule rouge" EFS Île-de-France, Hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, France
| | - B Bonnotte
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France
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28
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Boccia R, Cooper N, Ghanima W, Boxer MA, Hill QA, Sholzberg M, Tarantino MD, Todd LK, Tong S, Bussel JB. Fostamatinib is an effective second-line therapy in patients with immune thrombocytopenia. Br J Haematol 2020; 190:933-938. [PMID: 33439486 PMCID: PMC7540289 DOI: 10.1111/bjh.16959] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/02/2020] [Indexed: 12/25/2022]
Abstract
Fostamatinib demonstrated efficacy in phase 3 trials of adults with immune thrombocytopenia (ITP). Post hoc analysis compared patients who received fostamatinib as second‐line therapy (after steroids ± immunoglobulins) versus third‐or‐later‐line therapy (after ≥2 prior lines of therapy including a second‐line agent). Platelet responses ≥50 000/µl were observed in 25/32 (78%) second‐line and 54/113 (48%) third‐or‐later‐line patients. Bleeding events were less frequent in second‐line (28%) versus third‐or‐later‐line (45%) patients. Responses once achieved tended to be durable in both groups. The safety profile was similar in both groups. In this post hoc analysis, fostamatinib was more effective as second‐line than third‐or‐later‐line therapy for ITP.
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Affiliation(s)
- Ralph Boccia
- Centre for Cancer and Blood Disorders, Bethesda, MD, USA
| | - Nichola Cooper
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Waleed Ghanima
- Department of Research, Østfold Hospital Trust, Sarpsborg, Norway.,Department of Hematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Quentin A Hill
- Department of Haematology, St. James University Hospital, Leeds, UK
| | | | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
| | - Leslie K Todd
- Rigel Pharmaceuticals, Inc, South San Francisco, CA, USA
| | - Sandra Tong
- Rigel Pharmaceuticals, Inc, South San Francisco, CA, USA
| | - James B Bussel
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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29
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Cellular immune dysregulation in the pathogenesis of immune thrombocytopenia. Blood Coagul Fibrinolysis 2020; 31:113-120. [PMID: 31977328 DOI: 10.1097/mbc.0000000000000891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
: Immune thrombocytopenia (ITP) is an acquired autoimmune hemorrhagic disease characterized by immune-mediated increased platelet destruction and decreased platelet production, resulting from immune intolerance to autoantigen. The pathogenesis of ITP remains unclear, although dysfunction of T and B lymphocytes has been shown to be involved in the pathogenesis of ITP. More recently, it is found that dendritic cells, natural killer, and myeloid-derived suppressor cells also play an important role in ITP. Elucidating its pathogenesis is expected to provide novel channels for the targeted therapy of ITP. This article will review the role of different immune cells in ITP.
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30
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Kasahara TDM, Bento CADM, Gupta S. Phenotypic and Functional Analysis of T Follicular Cells in Common Variable Immunodeficiency. Int Arch Allergy Immunol 2020; 181:635-647. [PMID: 32492690 DOI: 10.1159/000507995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/17/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION One of the most frequent abnormalities of B cells in common variable immunodeficiency (CVID) is reduced number of class-switched memory B cells, suggesting an impaired germinal center response. Therefore, due to its pivotal role in regulating the development of humoral immunity, the objective of this study was to evaluate the role of circulating T follicular helper (cTFH) and circulating T follicular regulatory (cTFR) cells in the pathogenesis of CVID. METHODS cTFH and cTFR cells from CVID patients and healthy subjects were phenotypically characterized by flow cytometry. cTFH and memory B cells from CVID patients and healthy subjects were isolated and cocultured. RESULTS Our results showed a reduced proportion of cTFH17 cells in patients with CVID and an increased ratio of cTFH/cTFR cells in CVID patients with autoimmune diseases. Furthermore, the proportion of IL-21-producing cTFH cells was directly related to the proportion of CD27+ IgD- B cells. Interestingly, coculture assay showed that CVID-derived cTFH cells are able to help memory B cells from healthy controls to produce immunoglobulins. CONCLUSIONS The proportions of cTFH17 and cTFR cells are altered in CVID patients; however, the cTFH function in assisting B cells to produce antibodies in vitro is preserved.
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Affiliation(s)
- Taissa de Matos Kasahara
- Department of Microbiology, Immunology and Parasitology, State University of Rio de Janeiro, Rio de Janeiro, Brazil, .,Division of Basic and Clinical Immunology, Department of Medicine, University of California, Irvine, Irvine, California, USA,
| | - Cleonice Alves de Melo Bento
- Department of Microbiology, Immunology and Parasitology, State University of Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sudhir Gupta
- Division of Basic and Clinical Immunology, Department of Medicine, University of California, Irvine, Irvine, California, USA
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31
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CD4 + T cell phenotypes in the pathogenesis of immune thrombocytopenia. Cell Immunol 2020; 351:104096. [PMID: 32199587 DOI: 10.1016/j.cellimm.2020.104096] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/14/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by low platelet counts due to enhanced platelet clearance and compromised production. Traditionally, ITP was regarded a B cell mediated disorder as anti-platelet antibodies are detected in most patients. The very nature of self-antigens, evident processes of isotype switching and the affinity maturation of anti-platelet antibodies indicate that B cells in order to mount anti-platelet immune response require assistance of auto-reactive CD4+ T cells. For a long time, ITP pathogenesis has been exclusively reviewed through the prism of the disturbed balance between Th1 and Th2 subsets of CD4+ T cells, however, more recently new subsets of these cells have been described including Th17, Th9, Th22, T follicular helper and regulatory T cells. In this paper, we review the current understanding of the role and immunological mechanisms by which CD4+ T cells contribute to the pathogenesis of ITP.
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Hicks SM, Coupland LA, Jahangiri A, Choi PY, Gardiner EE. Novel scientific approaches and future research directions in understanding ITP. Platelets 2020; 31:315-321. [PMID: 32054377 DOI: 10.1080/09537104.2020.1727871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diagnosis of immune thrombocytopenia (ITP) and prediction of response to therapy remain significant and constant challenges in hematology. In patients who present with ITP, the platelet count is frequently used as a surrogate marker for disease severity, and so often determines the need for therapy. Although there is a clear link between thrombocytopenia and hemostasis, a direct correlation between the extent of thrombocytopenia and bleeding symptoms, especially at lower platelet counts is lacking. Thus, bleeding in ITP is heterogeneous, unpredictable, and nearly always based on a multitude of risk factors, beyond the platelet count. The development of an evidence-based, validated risk stratification model for ITP treatment is a major goal in the ITP community and this review discusses new laboratory approaches to evaluate the various pathobiologies of ITP that may inform such a model.
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Affiliation(s)
- Sarah M Hicks
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| | - Lucy A Coupland
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia
| | - Anila Jahangiri
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| | - Philip Y Choi
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia.,Haematology Department, The Canberra Hospital, Canberra, Australia
| | - Elizabeth E Gardiner
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia
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The Role of T Follicular Helper Cells and T Follicular Regulatory Cells in the Pathogenesis of Autoimmune Hemolytic Anemia. Sci Rep 2019; 9:19767. [PMID: 31875006 PMCID: PMC6930209 DOI: 10.1038/s41598-019-56365-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 12/10/2019] [Indexed: 12/11/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired autoimmune disease mediated by antibodies against the patient’s red blood cells. However, the underlying mechanisms for antibody production are not fully understood. Previous studies of etiology and pathogenesis of AIHA mainly focus on autoreactive B cells that have escaped tolerance mechanisms. Few studies have reported the function of TFH and TFR cells in the process of AIHA. The present study aimed to explore the potential mechanism of TFH and TFR cells in the pathogenesis of AIHA. With the model of murine AIHA, increased ratios of TFH:TFR, elevated serum IL-21 and IL-6 levels, and upregulated Bcl-6 and c-Maf expression were reported. Also, adoptive transfer of purified CD4+CXCR5+CD25- T cells from immunized mice promoted the induction of autoantibody in the AIHA mouse model. Altogether, our data demonstrate the important role of TFH cells for control and induction of AIHA. In the light of the key contributions of TFH cells to the immune response in AIHA, strategies aimed at inhibiting the TFH development or function should be emphasized.
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Liu WB, Li S, Yu XL, Dai TY, Gao RL. Research Progress on Chinese Medicine Immunomodulatory Intervention for Chronic Primary Immune Thrombocytopenia: Targeting Cellular Immunity. Chin J Integr Med 2019; 25:483-489. [PMID: 31278626 DOI: 10.1007/s11655-019-3031-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 11/25/2022]
Abstract
Chronic primary immune thrombocytopenia (CITP) is the most common acquired autoimmune disease that seriously threaten the physical and mental health of patients. Compared with Western medicine treatment, the intervention and treatment of Chinese medicine (CM) has shown certain therapeutic advantages. This paper reviewed the new pathogenesis progress on T cell immune abnormality in CITP, and CM studies on interferes effects of cellular immune regulation of CITP in recent years. Qi deficiency failing to control blood and internal obstruction of blood stasis are the two common types of CM syndromes in CITP patients, the corresponding treatments include invigorating Pi (Spleen), supplementing qi, activating blood, as well as tonifying qi and activating yang, regulating Gan (Liver) to invigorate Pi. The authors also mentioned the problems in the research field of CM for CTIP treatment, and put forward new ideas for the research in the future.
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Affiliation(s)
- Wen-Bin Liu
- Institute of Hematology Research, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Sai Li
- Institute of Hematology Research, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Xiao-Ling Yu
- Institute of Hematology Research, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Tie-Ying Dai
- Institute of Hematology Research, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Rui-Lan Gao
- Institute of Hematology Research, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, China.
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Pell J, Greenwood R, Ingram J, Wale K, Thomas I, Kandiyali R, Mumford A, Dick A, Bagot C, Cooper N, Hill Q, Bradbury CA. Trial protocol: a multicentre randomised trial of first-line treatment pathways for newly diagnosed immune thrombocytopenia: standard steroid treatment versus combined steroid and mycophenolate. The FLIGHT trial. BMJ Open 2018; 8:e024427. [PMID: 30341143 PMCID: PMC6196935 DOI: 10.1136/bmjopen-2018-024427] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune condition that may cause thrombocytopenia-related bleeding. Current first-line ITP treatment is with high-dose corticosteroids but frequent side effects, heterogeneous responses and high relapse rates are significant problems with only 20% remaining in sustained remission with this approach. Mycophenolate mofetil (MMF) is often used as the next treatment with efficacy in 50%-80% of patients and good tolerability but can take up to 2 months to work. OBJECTIVE To test the hypothesis that MMF combined with corticosteroid is a more effective first-line treatment for immune thrombocytopenia (ITP) than current standard of corticosteroid alone. METHODS AND ANALYSIS DesignMulticentre, UK-based, open-label, randomised controlled trial. SETTING Haematology departments in secondary care. PARTICIPANTS We plan to recruit 120 patients >16 years old with a diagnosis of ITP and a platelet count <30x109/L who require first-line treatment. Patients will be followed up for a minimum of 12 months following randomisation. PRIMARY OUTCOME Time from randomisation to treatment failure defined as platelets <30x109/L and a need for second-line treatment. SECONDARY OUTCOMES Side effects, bleeding events, remission rates, time to relapse, time to next therapy, cumulative corticosteroid dose, rescue therapy, splenectomy, socioeconomic costs, patient-reported outcomes (quality of life, fatigue, impact of bleeding, care costs). ANALYSIS The sample size of 120 achieves a 91.5% power to detect a doubling of the median time to treatment failure from 5 to 10 months. This will be expressed as an HR with 95% CI, median time to event if more than 50% have had an event and illustrated with Kaplan-Meier curves. Cost-effectiveness will be based on the first 12 months from diagnosis. ETHICS AND DISSEMINATION Ethical approval from NRES Committee South West (IRAS number 225959). EudraCT Number: 2017-001171-23. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03156452.
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Affiliation(s)
- Julie Pell
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - Rosemary Greenwood
- Research and Design Service, South West, University of Bristol, Bristol, UK
| | - Jenny Ingram
- Research and Design Service, South West, University of Bristol, Bristol, UK
| | - Katherine Wale
- Research & Innovation, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - Rebecca Kandiyali
- Research & Innovation, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Mumford
- Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Dick
- Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- UCL-Institute of Ophthalmology, London, UK
| | - Catherine Bagot
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
| | - Nichola Cooper
- Department of Haematology, Imperial College London and Hammersmith Hospital, London, UK
| | - Quentin Hill
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Charlotte Ann Bradbury
- Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Dai L, He L, Wang Z, Bai X, He Y, Cao L, Zhu M, Ruan C. Altered circulating T follicular helper cells in patients with chronic immune thrombocytopenia. Exp Ther Med 2018; 16:2471-2477. [PMID: 30186484 PMCID: PMC6122441 DOI: 10.3892/etm.2018.6508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/01/2018] [Indexed: 12/27/2022] Open
Abstract
The present study aimed to illuminate the role of circulating T follicular helper (TFH) cells in patients diagnosed with chronic immune thrombocytopenia (cITP). Fifty-four patients with cITP and 30 age-matched healthy control subjects were enrolled in the present study. TFH cell frequencies, expression of CD4+ TFH cell-associated cytokines, including interleukin (IL)-2, IL-4, IL-10 and IL-21 and associated regulatory mRNA expression levels including Bcl-6, c-Maf, Blimp-1 and PD-1 pre- and post-treatment with intravenous immunoglobulin and corticosteroids, were detected by flow cytometry, ELISA and reverse transcription-quantitative polymerase chain reaction, respectively. TFH cell frequencies of patients were significantly higher compared with healthy controls pre-treatment (P<0.05). Following treatment, significantly decreased percentages of TFH cells were present in cITP responders (P<0.05). Correlation analysis revealed that the number of TFH cells was negatively correlated with the platelet count in the peripheral blood. Furthermore, analysis of inflammatory cytokines indicated significant differences in serum interleukin (IL)-21 and IL-10 between pretreated patients and healthy controls (P<0.05). Additionally, transcription factor B-cell lymphoma (Bcl)-6, c-Maf and programmed death-ligand (PD)-1 mRNA expression levels were significantly different between cITP patients prior to treatment and the healthy controls (P<0.05). However, the expression levels of Bcl-6, C-Maf and PD-1 mRNA were significantly changed post-treatment (P<0.05). These data demonstrated that circulating TFH cells and CD4+ TFH cell-associated cytokines may serve a role in cITP. The findings suggest that the overactivation of TFH cells may contribute to the immunopathogenesis of cITP, thus blocking the pathway of TFH cells may be reasonable for therapeutic intervention.
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Affiliation(s)
- Lan Dai
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Linyan He
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Zhaoyue Wang
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Xia Bai
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Yang He
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Lijuan Cao
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Mingqing Zhu
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Changgeng Ruan
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
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Audia S, Moulinet T, Ciudad-Bonté M, Samson M, Facy O, Ortega-Deballon P, Saas P, Bonnotte B. Altered distribution and function of splenic innate lymphoid cells in adult chronic immune thrombocytopenia. J Autoimmun 2018; 93:139-144. [PMID: 30055825 DOI: 10.1016/j.jaut.2018.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 01/27/2023]
Abstract
Innate lymphoid cells (ILCs) have been characterized as innate immune cells capable to modulate the immune response in the mucosae. Human ILCs have been rarely described in secondary lymphoid organs except in tonsils. Moreover, their function and phenotype in human secondary lymphoid organs during autoimmune diseases have never been studied. We took advantage of splenectomy as a treatment of immune thrombocytopenia (ITP) to describe and compare splenic ILC from 18 ITP patients to 11 controls. We first confirmed that ILC3 represented the most abundant ILC subset in human non-inflamed spleens, accounting for 90% of total ILC, and that they were mostly constituted of NKp44- cells. On the contrary, proportions of ILC1 and ILC2 in spleens were lower than in blood. Splenic IL-2- and IFN-γ-producing ILC1 were increased in ITP. While the frequencies of total splenic ILC3 were similar in the two groups, splenic GM-CSF-producing ILC3 were increased in ITP. This is the first description of human ILC in a major secondary lymphoid organ during an autoimmune disease, ITP. We observed an expansion of splenic ILC1 that could participate to the Th1 skewing, while the increased production of GM-CSF by splenic ILC3 could stimulate splenic macrophages which play a key role in ITP pathophysiology.
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Affiliation(s)
- Sylvain Audia
- Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-21000 Dijon, France; CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l'adulte, F-21000 Dijon, France.
| | - Thomas Moulinet
- Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-21000 Dijon, France
| | - Marion Ciudad-Bonté
- Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-21000 Dijon, France
| | - Maxime Samson
- Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-21000 Dijon, France; CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l'adulte, F-21000 Dijon, France
| | - Olivier Facy
- CHU Dijon Bourgogne, Service de Chirurgie Digestive, Cancérologique, Générale et d'Urgence, F-21000 Dijon, France
| | - Pablo Ortega-Deballon
- CHU Dijon Bourgogne, Service de Chirurgie Digestive, Cancérologique, Générale et d'Urgence, F-21000 Dijon, France
| | - Philippe Saas
- Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-21000 Dijon, France
| | - Bernard Bonnotte
- Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-21000 Dijon, France; CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l'adulte, F-21000 Dijon, France
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Gensous N, Charrier M, Duluc D, Contin-Bordes C, Truchetet ME, Lazaro E, Duffau P, Blanco P, Richez C. T Follicular Helper Cells in Autoimmune Disorders. Front Immunol 2018; 9:1637. [PMID: 30065726 PMCID: PMC6056609 DOI: 10.3389/fimmu.2018.01637] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/03/2018] [Indexed: 12/14/2022] Open
Abstract
T follicular helper (Tfh) cells are a distinct subset of CD4+ T lymphocytes, specialized in B cell help and in regulation of antibody responses. They are required for the generation of germinal center reactions, where selection of high affinity antibody producing B cells and development of memory B cells occur. Owing to the fundamental role of Tfh cells in adaptive immunity, the stringent control of their production and function is critically important, both for the induction of an optimal humoral response against thymus-dependent antigens but also for the prevention of self-reactivity. Indeed, deregulation of Tfh activities can contribute to a pathogenic autoantibody production and can play an important role in the promotion of autoimmune diseases. In the present review, we briefly introduce the molecular factors involved in Tfh cell formation in the context of a normal immune response, as well as markers associated with their identification (transcription factor, surface marker expression, and cytokine production). We then consider in detail the role of Tfh cells in the pathogenesis of a broad range of autoimmune diseases, with a special focus on systemic lupus erythematosus and rheumatoid arthritis, as well as on the other autoimmune/inflammatory disorders. We summarize the observed alterations in Tfh numbers, activation state, and circulating subset distribution during autoimmune and some other inflammatory disorders. In addition, central role of interleukin-21, major cytokine produced by Tfh cells, is discussed, as well as the involvement of follicular regulatory T cells, which share characteristics with both Tfh and regulatory T cells.
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Affiliation(s)
- Noémie Gensous
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
| | - Manon Charrier
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
| | - Dorothée Duluc
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
| | | | | | - Estibaliz Lazaro
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
| | - Pierre Duffau
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
| | - Patrick Blanco
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
| | - Christophe Richez
- ImmunoConcept, UMR-CNRS 5164, Université de Bordeaux, Bordeaux, France
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Swinkels M, Rijkers M, Voorberg J, Vidarsson G, Leebeek FWG, Jansen AJG. Emerging Concepts in Immune Thrombocytopenia. Front Immunol 2018; 9:880. [PMID: 29760702 PMCID: PMC5937051 DOI: 10.3389/fimmu.2018.00880] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/09/2018] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease defined by low platelet counts which presents with an increased bleeding risk. Several genetic risk factors (e.g., polymorphisms in immunity-related genes) predispose to ITP. Autoantibodies and cytotoxic CD8+ T cells (Tc) mediate the anti-platelet response leading to thrombocytopenia. Both effector arms enhance platelet clearance through phagocytosis by splenic macrophages or dendritic cells and by induction of apoptosis. Meanwhile, platelet production is inhibited by CD8+ Tc targeting megakaryocytes in the bone marrow. CD4+ T helper cells are important for B cell differentiation into autoantibody secreting plasma cells. Regulatory Tc are essential to secure immune tolerance, and reduced levels have been implicated in the development of ITP. Both Fcγ-receptor-dependent and -independent pathways are involved in the etiology of ITP. In this review, we present a simplified model for the pathogenesis of ITP, in which exposure of platelet surface antigens and a loss of tolerance are required for development of chronic anti-platelet responses. We also suggest that infections may comprise an important trigger for the development of auto-immunity against platelets in ITP. Post-translational modification of autoantigens has been firmly implicated in the development of autoimmune disorders like rheumatoid arthritis and type 1 diabetes. Based on these findings, we propose that post-translational modifications of platelet antigens may also contribute to the pathogenesis of ITP.
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Affiliation(s)
- Maurice Swinkels
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maaike Rijkers
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Jan Voorberg
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands.,Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
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41
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Wang S, Guan Y, Wang Y, Li H, Zhang D, Ju M, Hao Y, Song X, Sun B, Dou X, Yang R. Reduced PTEN involved in primary immune thrombocytopenia via contributing to B cell hyper-responsiveness. Mol Immunol 2018; 93:144-151. [DOI: 10.1016/j.molimm.2017.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/26/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
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Guo Z, Liang H, Xu Y, Liu L, Ren X, Zhang S, Wei S, Xu P. The Role of Circulating T Follicular Helper Cells and Regulatory Cells in Non-Small Cell Lung Cancer Patients. Scand J Immunol 2017; 86:107-112. [PMID: 28513867 DOI: 10.1111/sji.12566] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/10/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Z. Guo
- Department of Hematology/Oncology; First Hospital of Tsinghua University; Beijing China
| | - H. Liang
- Department of Thoracic Surgery; Peking University Third Hospital; Beijing China
| | - Y. Xu
- Department of Hematology/Oncology; First Hospital of Tsinghua University; Beijing China
| | - L. Liu
- Department of Hematology/Oncology; First Hospital of Tsinghua University; Beijing China
| | - X. Ren
- Department of Hematology/Oncology; First Hospital of Tsinghua University; Beijing China
| | - S. Zhang
- Department of Hematology/Oncology; First Hospital of Tsinghua University; Beijing China
| | - S. Wei
- Department of Thoracic Surgery; First Hospital of Tsinghua University; Beijing China
| | - P. Xu
- Medical examination center; First Hospital of Tsinghua University; Beijing China
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Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev 2017; 16:620-632. [DOI: 10.1016/j.autrev.2017.04.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023]
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44
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Cines DB, Wasser J, Rodeghiero F, Chong BH, Steurer M, Provan D, Lyons R, Garcia-Chavez J, Carpenter N, Wang X, Eisen M. Safety and efficacy of romiplostim in splenectomized and nonsplenectomized patients with primary immune thrombocytopenia. Haematologica 2017; 102:1342-1351. [PMID: 28411254 PMCID: PMC5541869 DOI: 10.3324/haematol.2016.161968] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/12/2017] [Indexed: 02/02/2023] Open
Abstract
Primary immune thrombocytopenia is an autoimmune disorder characterized by increased platelet destruction and insufficient platelet production without another identified underlying disorder. Splenectomy may alter responsiveness to treatment and/or increase the risk of thrombosis, infection, and pulmonary hypertension. The analysis herein evaluated the safety and efficacy of the thrombopoietin receptor agonist romiplostim in splenectomized and nonsplenectomized adults with primary immune thrombocytopenia. Data were pooled across 13 completed clinical studies in adults with immune thrombocytopenia from 2002-2014. Adverse event rates were adjusted for time of exposure. Results were considered different when 95% confidence intervals were non-overlapping. Safety was analyzed for 1111 patients (395 splenectomized; 716 nonsplenectomized) who received romiplostim or control (placebo or standard of care). At baseline, splenectomized patients had a longer median duration of immune thrombocytopenia and a lower median platelet count, as well as a higher proportion with >3 prior immune thrombocytopenia treatments versus nonsplenectomized patients. In each treatment group, splenectomized patients used rescue medications more often than nonsplenectomized patients. Platelet response rates (≥50×109/L) for romiplostim were 82% (310/376) for splenectomized and 91% (592/648) for nonsplenectomized patients (P<0.001 by Cochran-Mantel-Haenszel test). Platelet responses were stable over time in both subgroups. Exposure-adjusted adverse event rates were higher for control versus romiplostim for both splenectomized (1857 versus 1226 per 100 patient-years) and nonsplenectomized patients (1052 versus 852 per 100 patient-years). In conclusion, responses to romiplostim were seen in both splenectomized and nonsplenectomized patients, and romiplostim was not associated with an increase in the risk of adverse events in splenectomized patients. clinicaltrials.gov Identifier: 00111475(A)(B), 00117143, 00305435, 01143038, 00102323, 00102336, 00415532, 00603642, 00508820, 00907478, 00116688, and 00440037.
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Affiliation(s)
- Douglas B Cines
- Perelman University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Jeffrey Wasser
- University of Connecticut Health Center, Farmington, CT, USA
| | - Francesco Rodeghiero
- Hematology Project Foundation, Vicenza, Italy.,San Bortolo Hospital, Vicenza, Italy
| | - Beng H Chong
- St George Hospital/University of New South Wales, Sydney, Australia
| | | | - Drew Provan
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Roger Lyons
- Texas Oncology and US ONCOLOGY Research, San Antonio, TX
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Audia S, Rossato M, Trad M, Samson M, Santegoets K, Gautheron A, Bekker C, Facy O, Cheynel N, Ortega-Deballon P, Boulin M, Berthier S, Leguy-Seguin V, Martin L, Ciudad M, Janikashvili N, Saas P, Radstake T, Bonnotte B. B cell depleting therapy regulates splenic and circulating T follicular helper cells in immune thrombocytopenia. J Autoimmun 2016; 77:89-95. [PMID: 27863820 DOI: 10.1016/j.jaut.2016.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 11/29/2022]
Abstract
B cells are involved in immune thrombocytopenia (ITP) pathophysiology by producing antiplatelet auto-antibodies. However more than a half of ITP patients do not respond to B cell depletion induced by rituximab (RTX). The persistence of splenic T follicular helper cells (TFH) that we demonstrated to be expanded during ITP and to support B cell differentiation and antiplatelet antibody-production may participate to RTX inefficiency. Whereas it is well established that the survival of TFH depends on B cells in animal models, nothing is known in humans yet. To determine the effect of B cell depletion on human TFH, we quantified B cells and TFH in the spleen and in the blood from ITP patients treated or not with RTX. We showed that B cell depletion led to a dramatic decrease in splenic TFH and in CXCL13 and IL-21, two cytokines predominantly produced by TFH. The absolute count of circulating TFH and serum CXCL13 also decreased after RTX treatment, whatever the therapeutic response. Therefore, we showed that the maintenance of TFH required B cells and that TFH are not involved in the inefficiency of RTX in ITP.
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Affiliation(s)
- Sylvain Audia
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France; Laboratory of Translational Immunology, University Medical Center, Utrecht, The Netherlands; Department of Internal Medicine and Clinical Immunology, Competence Center for Autoimmune Cytopenia, University Hospital, Dijon, France.
| | - Marzia Rossato
- Laboratory of Translational Immunology, University Medical Center, Utrecht, The Netherlands
| | - Malika Trad
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France
| | - Maxime Samson
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France; Department of Internal Medicine and Clinical Immunology, Competence Center for Autoimmune Cytopenia, University Hospital, Dijon, France
| | - Kim Santegoets
- Laboratory of Translational Immunology, University Medical Center, Utrecht, The Netherlands
| | | | - Cornelis Bekker
- Laboratory of Translational Immunology, University Medical Center, Utrecht, The Netherlands
| | - Olivier Facy
- Department of Surgery, University Hospital, Dijon, France
| | | | | | - Mathieu Boulin
- Department of Pharmacy, University Hospital, Dijon, France
| | - Sabine Berthier
- Department of Internal Medicine and Clinical Immunology, Competence Center for Autoimmune Cytopenia, University Hospital, Dijon, France
| | - Vanessa Leguy-Seguin
- Department of Internal Medicine and Clinical Immunology, Competence Center for Autoimmune Cytopenia, University Hospital, Dijon, France
| | - Laurent Martin
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France; Department of Pathology, University Hospital, Dijon, France
| | - Marion Ciudad
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France
| | - Nona Janikashvili
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France
| | - Philippe Saas
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France
| | - Timothy Radstake
- Laboratory of Translational Immunology, University Medical Center, Utrecht, The Netherlands
| | - Bernard Bonnotte
- CR INSERM 1098, University of Bourgogne/Franche-Comté, FHU INCREASE, France; Department of Internal Medicine and Clinical Immunology, Competence Center for Autoimmune Cytopenia, University Hospital, Dijon, France
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46
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Nomura S. Advances in Diagnosis and Treatments for Immune Thrombocytopenia. Clin Med Insights Blood Disord 2016; 9:15-22. [PMID: 27441004 PMCID: PMC4948655 DOI: 10.4137/cmbd.s39643] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/22/2016] [Accepted: 05/24/2016] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired hemorrhagic condition characterized by the accelerated clearance of platelets caused by antiplatelet autoantibodies. A platelet count in peripheral blood <100 × 109/L is the most important criterion for the diagnosis of ITP. However, the platelet count is not the sole diagnostic criterion, and the diagnosis of ITP is dependent on additional findings. ITP can be classified into three types, namely, acute, subchronic, and persistent, based on disease duration. Conventional therapy includes corticosteroids, intravenous immunoglobulin, splenectomy, and watch-and-wait. Second-line treatments for ITP include immunosuppressive therapy [eg, anti-CD20 (rituximab)], with international guidelines, including rituximab as a second-line option. The most recently licensed drugs for ITP are the thrombopoietin receptor agonists (TRAs), such as romiplostim and eltrombopag. TRAs are associated with increased platelet counts and reductions in the number of bleeding events. TRAs are usually considered safe, effective treatments for patients with chronic ITP at risk of bleeding after failure of first-line therapies. Due to the high costs of TRAs, however, it is unclear if patients prefer these agents. In addition, some new agents are under development now. This manuscript summarizes the pathophysiology, diagnosis, and treatment of ITP. The goal of all treatment strategies for ITP is to achieve a platelet count that is associated with adequate hemostasis, rather than a normal platelet count. The decision to treat should be based on the bleeding severity, bleeding risk, activity level, likely side effects of treatment, and patient preferences.
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Affiliation(s)
- Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
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Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder resulting from low platelet counts caused by inadequate production as well as increased destruction by autoimmune mechanisms. As with other autoimmune disorders, chronic ITP is characterized by perturbations of immune homeostasis with hyperactivated effector cells as well as defective regulatory arm of the adaptive immune system, which will be reviewed here. Interestingly, some ITP treatments are associated with restoring the regulatory imbalance, although it remains unclear whether the immune system is redirected to a state of tolerance once treatment is discontinued. Understanding the mechanisms that result in breakdown of immune homeostasis in ITP will help to identify novel pathways for restoring tolerance and inhibiting effector cell responses. This information can then be translated into developing therapies for averting autoimmunity not only in ITP but also many autoimmune disorders.
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Flint SM, Gibson A, Lucas G, Nandigam R, Taylor L, Provan D, Newland AC, Savage CO, Henderson RB. A distinct plasmablast and naïve B-cell phenotype in primary immune thrombocytopenia. Haematologica 2016; 101:698-706. [PMID: 26969086 DOI: 10.3324/haematol.2015.137273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 03/08/2016] [Indexed: 12/28/2022] Open
Abstract
Primary immune thrombocytopenia is an autoimmune disorder in which platelet destruction is a consequence of both B- and T-cell dysregulation. Flow cytometry was used to further characterize the B- and T-cell compartments in a cross-sectional cohort of 26 immune thrombocytopenia patients including antiplatelet antibody positive (n=14) and negative (n=12) patients exposed to a range of therapies, and a cohort of matched healthy volunteers. Markers for B-cell activating factor and its receptors, relevant B-cell activation markers (CD95 and CD21) and markers for CD4(+) T-cell subsets, including circulating T-follicular helper-like cells, were included. Our results indicate that an expanded population of CD95(+) naïve B cells correlated with disease activity in immune thrombocytopenia patients regardless of treatment status. A population of CD21-naïve B cells was specifically expanded in autoantibody-positive immune thrombocytopenia patients. Furthermore, the B-cell maturation antigen, a receptor for B-cell activating factor, was consistently and strongly up-regulated on plasmablasts from immune thrombocytopenia patients. These observations have parallels in other autoantibody-mediated diseases and suggest that loss of peripheral tolerance in naïve B cells may be an important component of immune thrombocytopenia pathogenesis. Moreover, the B-cell maturation antigen represents a potential target for plasma cell directed therapies in immune thrombocytopenia.
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Affiliation(s)
- Shaun M Flint
- Immunoinflammation TAU, GSK, Stevenage, London, UK Department of Medicine, University of Cambridge, London, UK
| | - Adele Gibson
- Immunoinflammation TAU, GSK, Stevenage, London, UK
| | - Geoff Lucas
- Histocompatibility and Immunogenetics Laboratory, NHS Blood & Transplant, London, UK
| | | | - Louise Taylor
- Department of Haematology, Royal London Hospital, London, UK
| | - Drew Provan
- Department of Haematology, Royal London Hospital, London, UK
| | - Adrian C Newland
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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50
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Consolini R, Legitimo A, Caparello MC. The Centenary of Immune Thrombocytopenia - Part 1: Revising Nomenclature and Pathogenesis. Front Pediatr 2016; 4:102. [PMID: 27807534 PMCID: PMC5069646 DOI: 10.3389/fped.2016.00102] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/07/2016] [Indexed: 12/24/2022] Open
Abstract
The natural history of the immune thrombocytopenia (ITP) is interesting and intriguing because it traces different steps underlying autoimmune diseases. The review points out the main steps that have accompanied the stages of its history and the consequential changes related to its terminology. ITP is an autoimmune disease resulting from platelet antibody-mediated destruction and impaired megakaryocyte and platelet production. However, research advances highlight that a complex dysregulation of the immune system is involved in the pathogenesis of this condition. The review examines the role of the multiple immune components involved in the autoimmunity process, focusing on the more recent mechanisms, which could be new promising therapeutic targets for ITP patients.
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Affiliation(s)
- Rita Consolini
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa , Pisa , Italy
| | - Annalisa Legitimo
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa , Pisa , Italy
| | - Maria Costanza Caparello
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa , Pisa , Italy
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