1
|
Calderon-Valverde G, Quiros-Meza M, Alfaro-Murillo A. Systemic Lupus Erythematosus Presenting With Cold-Antibody Autoimmune Hemolysis and Nephritis: A Case Report. Cureus 2024; 16:e67148. [PMID: 39295688 PMCID: PMC11408651 DOI: 10.7759/cureus.67148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2024] [Indexed: 09/21/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a multifaceted autoimmune disorder that presents with a wide array of clinical features, including autoimmune hemolysis and nephritis. Autoimmune hemolysis in SLE is typically linked to warm antibodies, but the occurrence of cold agglutinin syndrome (CAS), driven by cold-reactive antibodies, is exceptionally rare. Lupus nephritis (LN) is among the most severe complications of SLE, characterized by immune complex-mediated glomerulonephritis, which often leads to considerable morbidity and mortality. Nephritis in SLE is a major indicator of chronic kidney disease, with many patients experiencing progressive renal damage over time. Early diagnosis and individualized treatment approaches are crucial for effectively managing these intertwined conditions. This case report presents a distinct clinical scenario involving a 53-year-old Hispanic female diagnosed with SLE, who concurrently presented with CAS and nephritis. The patient's initial symptoms included chest pain, severe macrocytic anemia, elevated creatinine levels, and evidence of active hemolysis. CAS was diagnosed through a positive direct antiglobulin test for C3d and elevated cold agglutinin titers. Further comprehensive assessments revealed dysgammaglobulinemia, hypocomplementemia, and positive anti-Ro antibodies, with a renal biopsy confirming LN (ISN/RPS Class IV and Class V). The patient exhibited a favorable response to a treatment regimen comprising high-dose steroids and anti-CD20 therapy, resulting in the complete cessation of hemolysis and a >50% decrease in proteinuria after six months. This case underscores the rarity of CAS in the context of SLE, particularly when coupled with nephritis, and highlights the need for tailored treatment strategies. Anti-CD20 therapy, as used in primary CAS management, emerges as a promising option for this unique presentation, offering insights into the complex interplay of autoimmune conditions.
Collapse
Affiliation(s)
| | - Mariana Quiros-Meza
- Rheumatology, Universidad de Costa Rica - Hospital San Juan de Dios, San Jose, CRI
| | | |
Collapse
|
2
|
Kuter DJ, Piatek C, Röth A, Siddiqui A, Numerof RP, Dummer W. Fostamatinib for warm antibody autoimmune hemolytic anemia: Phase 3, randomized, double-blind, placebo-controlled, global study (FORWARD). Am J Hematol 2024; 99:79-87. [PMID: 37929318 DOI: 10.1002/ajh.27144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/18/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023]
Abstract
Warm antibody autoimmune hemolytic anemia (wAIHA) is characterized by hemolysis and symptomatic anemia with no approved treatment options. Fostamatinib is an oral spleen tyrosine kinase inhibitor approved in the US and Europe for treatment of adults with chronic immune thrombocytopenia. In this phase 3 study, patients with an insufficient response to ≥1 prior wAIHA treatment were randomized to fostamatinib or placebo. The primary endpoint was the proportion of patients to achieve a durable hemoglobin (Hgb) response (Hgb ≥10 g/dL and increase from baseline of ≥2 g/dL on 3 consecutive visits) during the 24-week treatment period. Ninety patients were randomized, 45 to each arm. Of the fostamatinib-treated patients, 35.6% achieved a durable Hgb response versus 26.7% on placebo (p = .398). A post hoc analysis revealed a large placebo response in Eastern European patients. Significantly more patients on fostamatinib from North America, Australia and Western Europe exhibited a durable Hgb response compared to placebo (36% vs. 10.7%, p = .030). After censoring for Hgb values impacted by steroid rescue received during screening and excluding 2 placebo patients found to likely not have wAIHA, a reanalysis demonstrated a difference in durable Hgb response between fostamatinib and placebo (15/45 [33.3%] vs. 6/43 [14.0%], p = .0395). At least 1 AE was reported in 42 (93.3%) and 40 (88.9%) patients receiving fostamatinib and placebo, respectively. The most common AEs in the fostamatinib group were diarrhea (26.7%), hypertension (24.4%), and fatigue (15.6%). In this study, fostamatinib demonstrated a clinically meaningful benefit for patients in Western regions, and no new safety signals were identified.
Collapse
Affiliation(s)
- David J Kuter
- Department of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Caroline Piatek
- Division of Hematology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California, USA
| | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Asif Siddiqui
- Department of Development, Rigel Pharmaceuticals, Inc., South San Francisco, California, USA
| | - Robert P Numerof
- Department of Development, Rigel Pharmaceuticals, Inc., South San Francisco, California, USA
| | - Wolfgang Dummer
- Department of Development, Rigel Pharmaceuticals, Inc., South San Francisco, California, USA
| |
Collapse
|
3
|
Cvetković Z, Pantić N, Cvetković M, Virijević M, Sabljić N, Marinković G, Milosavljević V, Pravdić Z, Suvajdžić-Vuković N, Mitrović M. The Role of the Spleen and the Place of Splenectomy in Autoimmune Hemolytic Anemia-A Review of Current Knowledge. Diagnostics (Basel) 2023; 13:2891. [PMID: 37761258 PMCID: PMC10527817 DOI: 10.3390/diagnostics13182891] [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: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare, very heterogeneous, and sometimes life-threatening acquired hematologic disease characterized by increased red blood cell (RBC) destruction by autoantibodies (autoAbs), either with or without complement involvement. Recent studies have shown that the involvement of T- and B-cell dysregulation and an imbalance of T-helper 2 (Th2) and Th17 phenotypes play major roles in the pathogenesis of AIHA. AIHA can be primary (idiopathic) but is more often secondary, triggered by infections or drug use or as a part of other diseases. As the location of origin of autoAbs and the location of autoAb-mediated RBC clearance, as well as the location of extramedullary hematopoiesis, the spleen is crucially involved in all the steps of AIHA pathobiology. Splenectomy, which was the established second-line therapeutic option in corticosteroid-resistant AIHA patients for decades, has become less common due to increasing knowledge of immunopathogenesis and the introduction of targeted therapy. This article provides a comprehensive overview of current knowledge regarding the place of the spleen in the immunological background of AIHA and the rapidly growing spectrum of novel therapeutic approaches. Furthermore, this review emphasizes the still-existing expediency of laparoscopic splenectomy with appropriate perioperative thromboprophylaxis and the prevention of infection as a safe and reliable therapeutic option in the context of the limited availability of rituximab and other novel therapies.
Collapse
Affiliation(s)
- Zorica Cvetković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Pantić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Cvetković
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marijana Virijević
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nikica Sabljić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Gligorije Marinković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
| | - Vladimir Milosavljević
- Department for HPB Surgery, University Hospital Medical Center Bežanijska Kosa, 11070 Belgrade, Serbia
| | - Zlatko Pravdić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nada Suvajdžić-Vuković
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Mitrović
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| |
Collapse
|
4
|
Ananyeva LP, Garzanova LA, Koneva OA, Starovoytova MN, Desinova OV, Ovsyannikova OB, Shayakhmetova RU, Cherkasova MV, Aleksankin AP, Nasonov EL. Anti-topoisomerase 1 Antibody Level Changes after B Cell Depletion Therapy in Systemic Sclerosis. DOKL BIOCHEM BIOPHYS 2023; 511:212-218. [PMID: 37833608 PMCID: PMC10739332 DOI: 10.1134/s1607672923700266] [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: 03/25/2023] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 10/15/2023]
Abstract
The aim of our study was to assess the relationship between the changes of antinuclear autoantibodies (ANAs) and autoantibodies to topoisomerase 1 (anti-Topo 1) in systemic sclerosis (SSs) patients on rituximab (RTX) therapy. The prospective study included 88 patients (73 women) with a mean age of 47 (17-71) years. The mean disease duration was 5.9 ± 4.8 years. The mean follow-up period was more than 2 years (27 (12-42) months). We documented a statistically significant change in skin score, the disease activity index, improvement of pulmonary function and reduction of mean dose of prednisolone after RTX treatment. There was a significant decrease in the number of patients with high levels of ANA and overall decrease of the ANA and anti-Topo 1 levels. A moderate positive statistically significant correlation was found between ANA and anti-Topo 1 (r = 0.403). In the group of patients positive for anti-Topo 1 there were a more pronounced depletion of B lymphocytes, significantly higher increase in forced vital capacity and diffusion capacity, decrease in the disease activity index, compared with patients negative for anti-Topo 1. We observed the decline in the level of ANA and anti-Topo 1 in SSc patients after RTX therapy, and it was correlated by an improvement of the main outcome parameters of the disease. Therefore, anti-Topo 1 positivity could be considered as a predictor of a better response to RTX treatment, especially in SSc patients with hyperproduction of anti-Topo 1.
Collapse
Affiliation(s)
- L P Ananyeva
- Nasonova Research Institute of Rheumatology, Moscow, Russia.
| | - L A Garzanova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - O A Koneva
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | | | - O V Desinova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | | | | | - M V Cherkasova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - A P Aleksankin
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - E L Nasonov
- Nasonova Research Institute of Rheumatology, Moscow, Russia
- Sechenov First Moscow State Medical University of the Ministry of Health Care of the Russian Federation (Sechenov University), Moscow, Russia
| |
Collapse
|
5
|
Kuter DJ, Rogers KA, Boxer MA, Choi M, Agajanian R, Arnold DM, Broome CM, Field JJ, Murakhovskaya I, Numerof R, Tong S. Fostamatinib for the treatment of warm antibody autoimmune hemolytic anemia: Phase 2, multicenter, open-label study. Am J Hematol 2022; 97:691-699. [PMID: 35179251 PMCID: PMC9313871 DOI: 10.1002/ajh.26508] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/15/2022]
Abstract
Patients with relapsed warm antibody autoimmune hemolytic anemia (wAIHA) have limited treatment options. Fostamatinib is a potent, orally administered spleen tyrosine kinase inhibitor approved in the United States and Europe for the treatment of adults with chronic immune thrombocytopenia (ITP). This phase 2 study evaluated the response to fostamatinib, administered at 150 mg BID orally with or without food in adults with wAIHA and active hemolysis with hemoglobin (Hgb) <10 g/dL who had failed at least one prior treatment. Hemoglobin levels and safety assessments were performed at visits every 2 weeks. The primary endpoint was Hgb >10 g/dL with an increase of ≥2 g/dL from baseline by week 24 without rescue therapy or red blood cell transfusion. Eleven of 24 (46%) patients achieved the primary endpoint. Increases in median Hgb were detected at week 2 and sustained over time. Median lactate dehydrogenase levels and reticulocyte counts generally declined over time with little change in median haptoglobin levels. The most common adverse events (AEs) were diarrhea (42%), fatigue (42%), hypertension (27%), dizziness (27%), and insomnia (23%). AEs were manageable and consistent with the fostamatinib safety database of over 3900 patients across multiple diseases (rheumatoid arthritis, B-cell lymphoma, COVID-19, and ITP). No new safety signals were detected. Fostamatinib may be a promising therapeutic option for wAIHA. A randomized, double-blind, phase 3 study is nearing completion.
Collapse
Affiliation(s)
- David J. Kuter
- Division of Hematology Massachusetts General Hospital Boston Massachusetts USA
| | - Kerry A. Rogers
- Division of Hematology, Department of Medicine The Ohio State University Columbus Ohio USA
| | - Michael A. Boxer
- Division of Hematology‐Oncology Arizona Oncology Tucson Arizona USA
| | - Michael Choi
- Moores Cancer Center University of California San Diego La Jolla California USA
| | - Richy Agajanian
- Division of Hematology‐Oncology The Oncology Institute of Hope and Innovation Downey California USA
| | - Donald M. Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Catherine M. Broome
- Lombardi Cancer Center, Division of Hematology MedStar Georgetown University Hospital Washington District of Columbia USA
| | - Joshua J. Field
- Blood Center of Wisconsin Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Irina Murakhovskaya
- Department of Medicine (Hematology) Albert Einstein College of Medicine Bronx New York USA
| | - Robert Numerof
- Development and Medical Affairs Rigel Pharmaceuticals, Inc South San Francisco California USA
| | - Sandra Tong
- Development and Medical Affairs Rigel Pharmaceuticals, Inc South San Francisco California USA
| |
Collapse
|
6
|
Calhoun B, Moore A, Dickey A, Shoemaker DM. Systemic loxoscelism induced warm autoimmune hemolytic anemia: clinical series and review. Hematology 2022; 27:543-554. [PMID: 35544675 DOI: 10.1080/16078454.2022.2065086] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Describe the development of warm autoimmune hemolytic anemia warm (AIHA) secondary to a brown recluse spider (Loxosceles reclusa) bite is known as systemic loxoscelism; and review epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. METHODS Cases series of two cases of warm AIHA due to systemic loxoscelism and a review of the current literature: epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. RESULTS Presented here are two cases of warm AIHA due to systemic loxoscelism. Each patient was generally healthy appearing and presented with symptomatic anemia in the setting of brown recluse spider bites. Both patients were eventually found to have warm AIHA. Upon recognition of the diagnosis, the patients were started on corticosteroids and aggressive intravenous fluid hydration. In addition, they received transfusions of packed red blood cells. Their clinical courses improved, and they recovered to eventually be discharged home. CONCLUSION Envenomation by a brown recluse spider, Loxosceles reclusa, can result in systemic loxoscelism which can cause warm AIHA. The diagnosis of warm AIHA is confirmed by the direct antiglobulin/Coomb's test. Warm AIHA can be a life-threatening disease process. Hemodynamic support with intravenous fluids and RBC transfusion is the initial step in the management of these patients. Corticosteroids are the mainstay of current management. Second line treatments include rituximab. Rarely patients require splenectomy for refractory disease. Corticosteroids should be tapered over a three-month period.
Collapse
Affiliation(s)
- Brandon Calhoun
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Andrew Moore
- SEHealth Cancer Center, SEHealth, Cape Girardeau, MO, USA
| | - Andrew Dickey
- SEHealth Cancer Center, SEHealth, Cape Girardeau, MO, USA
| | - D Matthew Shoemaker
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| |
Collapse
|
7
|
Hwang SR, Saliba AN, Wolanskyj-Spinner AP. Immunotherapy-associated Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:365-380. [PMID: 35339260 DOI: 10.1016/j.hoc.2021.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Over the past decade, the role of immunotherapy treatment in cancer has expanded; specifically, indications for immune checkpoint inhibitors (ICI) have multiplied and are used as first-line therapy. ICIs include cytotoxic T-lymphocyte-associated protein 4 and programmed cell death protein 1 inhibitors, as monotherapies or in combination. Autoimmune hemolytic anemia (AIHA) has emerged as a rare yet serious immune-related adverse event in ICI use. This review describes diagnosis and management of immunotherapy related AIHA (ir-AIHA) including an algorithmic approach based on severity of anemia. Suggested mechanisms are discussed, guidance on ICI resumption provided and prognosis reviewed including risk of recurrence.
Collapse
Affiliation(s)
- Steven R Hwang
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First street Southwest, Rochester, Minnesota 55905, USA; Division of Medical Oncology, Department of Oncology, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First street Southwest, Rochester, Minnesota 55905, USA; Division of Medical Oncology, Department of Oncology, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA
| | - Alexandra P Wolanskyj-Spinner
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First street Southwest, Rochester, Minnesota 55905, USA; Mayo Clinic Alix School of Medicine, Mayo Clinic College of Medicine and Science, 200 First Street Southwest, Rochester, Minnesota 55905, USA.
| |
Collapse
|
8
|
Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodriguez-Salas G, Londono J. A Practical Perspective of the Hematologic Manifestations of Systemic Lupus Erythematosus. Cureus 2022; 14:e22938. [PMID: 35399432 PMCID: PMC8986464 DOI: 10.7759/cureus.22938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with an unknown etiology that can affect any organ or system of the human body. Hematological, renal, or central nervous system manifestations in these patients result in great morbidity because high doses of glucocorticoids, cytotoxic medications, or biological drugs are required to control these manifestations. It is noteworthy that hematological involvement predominates during the first years of the disease and tends to last over time, with the premise that it may be the initial manifestation of the disease. Clear examples of this are the cases of hemolytic anemia and immune thrombocytopenia that can be initially classified as idiopathic or primary to be later classified as secondary when associated with infections, medications, neoplasms, or autoimmune diseases. The spectrum of hematologic manifestations in SLE is very broad, including lymphopenia, anemia, thrombocytopenia, or pancytopenia. In some cases, lymphadenopathy and splenomegaly are also identified. The vast majority of these manifestations denote high disease activity. However, many of these alterations have a multifactorial cause that must be taken into account to adopt a more complete therapeutic approach. The objective of this review is to characterize in detail the hematological manifestations of SLE to offer clinicians a practical vision of its diagnosis and treatment.
Collapse
|
9
|
Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Clinical and surgical outcomes of splenectomy for autoimmune hemolytic anemia. Surg Endosc 2022; 36:5863-5872. [PMID: 35194660 DOI: 10.1007/s00464-022-09116-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION We investigated short and long-term remission rates after splenectomy in patients with primary and secondary autoimmune hemolytic anemia (AIHA). METHODS All adults who underwent splenectomy for primary or secondary AIHA at a single center (2004-2018) were retrospectively reviewed. Short-term response was determined at 30-day postoperatively and long-term at one year. Complete response was defined as hemoglobin > 10 g/dL without hemolysis, transfusions, or need for additional medical therapy for > 6 months. RESULTS Short-term complete response was attained in 22 of 36 patients (61%), partial response in 3 (8%), no response in 11 (31%). The response rate at 1 year was complete in 14/36 (39%), partial in 14 (39%), and 8 non-response (22%). At last available follow-up (median 33.1 months (IQR 19-59), 16/37 patients had experienced a complete response (43%), 14 partial response (38%), 7 non-response (19%). 80% of partial responders with primary AIHA required maintenance therapy compared to 100% with secondary AIHA. CONCLUSION Splenectomy is associated with short- and long-term improvement in anemia and hemolysis in the majority of patients with AIHA. Immunosuppressants remain important supplemental therapy.
Collapse
|
11
|
Szpakowski JL, Tucker LY, Baer DM, Pauly MP. Hepatotoxicity during legacy cancer chemotherapy in patients infected with hepatitis C virus: A retrospective cohort study. CANADIAN LIVER JOURNAL 2022; 5:43-60. [PMID: 35990784 PMCID: PMC9231429 DOI: 10.3138/canlivj-2021-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/04/2023]
Abstract
BACKGROUND The rates and causes of significant hepatotoxicity with cancer chemotherapy (CCT) in patients infected with hepatitis C virus (HCV) are incompletely characterized. METHODS We compared rates of grade 3 or 4 hepatotoxicity, defined as elevated transaminases, during CCT in patients who are mono-infected with HCV compared with rates in controls matched on demographics, diagnosis, and rituximab use. We excluded patients with hepatobiliary cancers, hepatitis B virus or human immunodeficiency virus infection. Hepatotoxicity was attributed to a medical cause, cancer progression, or CCT, including HCV flare. RESULTS Patients with HCV (n = 196) had a higher rate of cirrhosis than the 1,130 matched controls (21.9% versus 4%; P <0.001). Their higher rate of overall hepatotoxicity (8.7% versus 4.5% of controls, P = 0.01) was due to higher rate of CCT-related hepatotoxicity (4.1% versus 1.2%, P = 0.01). On multivariable analysis, the largest risk factor for overall hepatotoxicity was cirrhosis, and the only risk factor for CCT-related hepatotoxicity was HCV infection. Among those with HCV, the only significant risk factor for hepatotoxicity was rituximab use. Hepatotoxicity caused by CCT delayed or altered treatment in only 3 HCV patients and 1 control (1.5% versus 0.1%, P = 0.01). CONCLUSIONS Most patients with HCV can safely be treated with cancer chemotherapy. Cirrhosis and HCV infection contributed to increased hepatotoxicity in subjects on CCT. Among HCV patients, rituximab use was the major risk factor for increased hepatotoxicity. Hepatotoxicity due to CCT itself rarely altered or delayed CCT. Nonetheless, HCV-positive patients should be monitored carefully during CCT.
Collapse
Affiliation(s)
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - David M Baer
- Kaiser Permanente Medical Center, Oakland, California, USA
| | - Mary Pat Pauly
- Kaiser Permanente Medical Center, Sacramento, California, USA
| |
Collapse
|
12
|
Abstract
Advances in understanding the ways in which the immune system fails to control tumor growth or prevent autoimmunity have led to the development of powerful therapeutic strategies to treat these diseases. In contrast to conventional therapies that have a broadly suppressive effect, immunotherapies are more akin to targeted therapies because they are mechanistically driven and are typically developed with the goal of "drugging" a specific underlying pathway or phenotype. This means that their effects and toxicities are, at least in theory, more straightforward to anticipate. The development of functionalized antibodies, genetically engineered T cells, and immune checkpoint inhibitors continues to accelerate, illuminating new biology and bringing new treatment to patients. In the following sections, we provide an overview of immunotherapeutic concepts, highlight recent advances in the field of immunotherapies, and discuss controversies and future directions, particularly as these pertain to hematologic oncology or blood-related diseases. We conclude by illustrating how original research published in this journal fits into and contributes to the overall framework of advances in immunotherapy.
Collapse
Affiliation(s)
- Stefanie Lesch
- Center for Cellular Immunotherapies, University of Pennsylvania School of Medicine, Philadelphia, PA; and
- Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saar Gill
- Center for Cellular Immunotherapies, University of Pennsylvania School of Medicine, Philadelphia, PA; and
- Division of Hematology-Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
13
|
ÖZCAN A, CANSEVER M, YILMAZ E, ÜNAL E, KARAKÜKÇÜ M, PATIROĞLU T. The spectrum of underlying diseases in children with autoimmune hemolytic anemia. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.985008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
14
|
Abstract
BACKGROUND Primary autoimmune haemolytic anaemia (AIHA) is an autoantibody mediated condition characterised by a variable disease course. A myriad of immunomodulatory agents have been employed but there is a paucity of evidence to support their use or compare their effectiveness. OBJECTIVES To determine the effects of various disease-modifying treatment modalities in people with AHIHA. SEARCH METHODS We searched MEDLINE (Ovid) (1946 to 2021), Embase (Ovid) (1974 to 2021), Latin American and Caribbean Health Sciences Literature (LILACS) (1982 to 2021), and the Cochrane Library (CENTRAL). Clinical trial registries and relevant conference proceedings were also reviewed. Records were included as of 7 March 2021. We did not impose any language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing immunosuppressive or immunomodulatory treatments against no treatment, placebo, or another immunosuppressive or immunomodulatory treatment, for people of all age with idiopathic AIHA. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The prioritised pre-defined outcomes included complete haematological response at 12 months, frequency of adverse events at two, six and 12 months, partial haematological response at 12 months, overall survival at six and 12 months, relapse-free survival (RFS) at six and 12 months, red blood cel (RBC) transfusion requirement after treatment at 12 months, and quality of life (QOL) as measured by validated instruments at 12 months. Based on data availability, we were only able to perform meta-analysis on frequency of complete haematological response. MAIN RESULTS Two trials were included, enrolling a total of 104 adult participants (96 randomised) with warm AIHA in the setting of tertiary referral centres, both comparing the effectiveness between rituximab (375 mg/m2 weekly for four weeks, or 1000 mg for two doses two weeks apart) plus glucocorticoid (prednisolone 1.5 or 1mg/kg/day with taper) and glucocorticoid monotherapy. The average age of participants in the two trials were 67 and 71, respectively. One of the included studies had good methodological quality with low risk of bias, whereas the other study had high risk of performance and detection bias due to lack of blinding. Compared with glucocorticoid alone, adding rituximab may result in a large increase of complete response at 12 months (n = 96, risk ratio (RR) 2.13, 95% confidence interval (CI) 1.34 to 3.40, GRADE: low-certainty evidence). Rates of adverse effects at prespecified time-points were not reported. Limited data on partial haematological response were reported. The evidence is very uncertain about the effect of adding rituximab to glucocorticoids on partial haematological response at 12 months (n = 32; study = 1; RR 3.00, 95% CI 0.13 to 68.57; GRADE very low-certainty evidence). RBC transfusion need at 12 months was reported in one study, with four participants (mean number of packed red cell units 4.0 ± 2.82) from the rituximab group and five participants from the placebo (corticosteroid only) (mean number of packed red cell units 5.6 ± 4.15) group requiring transfusion, indicating very uncertain evidence about the effect of adding rituximab to glucocorticoids (n = 32, RR 0.80, 95% CI 0.26 to 2.45, GRADE very low-certainty evidence). The other study did not report transfusion requirement at prespecified time points but reported no difference in transfusion requirement between the two groups when comparing responders from enrolment to end of response or to the end of study follow-up (34 units versus 30 units, median [range]: 0 [1 to 6] versus 0 [1 to 5], P = 0·81). Overall survival and RFS rates at prespecified time-points were not explicitly reported in either study. Data on QOL were not available. AUTHORS' CONCLUSIONS Available literature on the effectiveness of immunomodulatory therapy for primary AIHA is restricted to comparison between rituximab plus glucocorticoid and glucocorticoid alone, in patients with newly diagnosed warm AIHA, calling for need for additional studies. The current result suggests that combinatory therapy with rituximab and glucocorticoid may increase the rate of complete haematological response over glucocorticoid monotherapy.
Collapse
Affiliation(s)
- Anthony Pak-Yin Liu
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Daniel Kl Cheuk
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| |
Collapse
|
15
|
Raso S, Napolitano M, Arrigo G, Reale F, Lucchesi A, Silimbani P, Maggio A, Calvaruso G, Consoli U, Mannina D, Giordano G, Santoro M, Accurso V, Siragusa S. Antimicrobial prophylaxis in patients with immune thrombocytopenia treated with rituximab: a retrospective multicenter analysis. Ann Hematol 2021; 100:653-659. [PMID: 33495923 DOI: 10.1007/s00277-021-04438-7] [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] [Received: 01/10/2021] [Accepted: 01/19/2021] [Indexed: 11/28/2022]
Abstract
The primary aim of this study was to describe the use of primary anti-infective prophylaxis (AP) in common clinical practice in patients affected by immune thrombocytopenia (ITP) and treated with RTX. Population studied consisted of patients affected by ITP (age ≥ 18 years) who had received at least one dose of RTX from January 2008 to June 2018. Five Italian haematology centres participated in the current study. Data were retrospectively collected: demographic data (age, gender), concomitant comorbidities and previous therapies for ITP, characteristics of AP, the occurrence of infections and their management. The ITP cohort consisted of 67 patients sub-grouped into two categories according to the administration of AP: (1) treated with AP (N= 34; 51%) and (2) not treated with AP (N=33, 49%). AP consisted of combined trimethoprim/sulfamethoxazole (TMP/SMX) and acyclovir (AC) in half of patients. TPM/SMX as a single agent was adopted in 32% patients and one patient received only AC. Overall, infections were experienced in 15% of patients during follow-up with a similar proportion in the 2 groups (treated and not treated) of patients (14.7% vs 15%). Clinical course of infections was however, less severe in patients treated with AP, where all infections were grade 2 and did not require hospitalization. In neither group of patients was reported Pneumocystis pneumonia. In conclusion, despite the absence of clear evidence, our analysis shows that AP in patients with ITP receiving RTX is frequently adopted, even if in the absence of well-defined criteria. Prophylaxis administration is quite consistent within the same haematological Center; thus, it seems related to clinicians' experience.
Collapse
Affiliation(s)
- Simona Raso
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
| | - Mariasanta Napolitano
- Policlinico Paolo Giaccone, Unit of Haematology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Giulia Arrigo
- Policlinico Paolo Giaccone, Unit of Haematology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Francesco Reale
- Institute for Educational Technology, National Research Council of Italy, Palermo, Italy
| | - Alessandro Lucchesi
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Paolo Silimbani
- Oncology Pharmacy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Aurelio Maggio
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Giuseppina Calvaruso
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Ugo Consoli
- Unit of Haematology, G.Garibaldi Hospital, Catania, Italy
| | - Donato Mannina
- Unit of Haematology, Azienda Ospedaliera Papardo, Messina, Italy
| | - Giulio Giordano
- Division of Internal Medicine, Hematology Service, Regional Hospital "A. Cardarelli", Campobasso, Italy
| | - Marco Santoro
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.,Policlinico Paolo Giaccone, Unit of Haematology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Vincenzo Accurso
- Policlinico Paolo Giaccone, Unit of Haematology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Sergio Siragusa
- Policlinico Paolo Giaccone, Unit of Haematology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy
| |
Collapse
|
16
|
Rituximab Use in Warm and Cold Autoimmune Hemolytic Anemia. J Clin Med 2020; 9:jcm9124034. [PMID: 33322221 PMCID: PMC7763062 DOI: 10.3390/jcm9124034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Autoimmune hemolytic anemia is a rare condition characterized by destruction of red blood cells with and without involvement of complement. It is associated with significant morbidity and mortality. In warm autoimmune hemolytic anemia, less than 50% of patients remain in long-term remission following initial steroid therapy and subsequent therapies are required. Cold agglutinin disease is a clonal hematologic disorder that requires therapy in the majority of patients and responds poorly to steroids and alkylators. Rituximab has a favorable toxicity profile and has demonstrated efficacy in autoimmune hemolytic anemia in first-line as well as relapsed settings. Rituximab is the preferred therapy for steroid refractory warm autoimmune hemolytic anemia (wAIHA) and as part of the first- and second-line treatment of cold agglutinin disease. This article reviews the mechanism of action of rituximab and the current literature on its role in the management of primary and secondary warm autoimmune hemolytic anemia and cold agglutinin disease.
Collapse
|
17
|
Kasinathan G, Sathar J. Mixed-type autoimmune hemolytic anaemia presenting as multiple thromboses: A case report. Ann Med Surg (Lond) 2020; 60:323-326. [PMID: 33204423 PMCID: PMC7653202 DOI: 10.1016/j.amsu.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/01/2020] [Accepted: 11/01/2020] [Indexed: 11/13/2022] Open
Abstract
Autoimmune hemolytic anaemia (AIHA) is a heterogenous disorder characterised by the presence of IgG or IgM pathological autoantibodies that target antigens of erythrocytes resulting in active hemolysis. Case presentation: A 40-year-old gentleman presented to a medical centre with chest pain and right sided hemiparesis for a week. He was pale and jaundiced. The power of the right upper and lower limbs was 3/5. His spleen was palpable. His complete blood count revealed macrocytic anaemia of 7.6 g/dL. The brain Magnetic Resonance Imaging (MRI) showed left fronto-parietal infarction. The right cardiac and left carotid angiogram revealed thromboses involving the right coronary and left internal carotid artery respectively. At the cardiology department, he was transfused with two units of red blood cells without his anemia being investigated and a stent was deployed to the left internal carotid artery. He was referred to the hematology department in which his peripheral blood smear revealed hemolysis and his direct antiglobulin test was positive. He responded to a course of steroids and direct oral anticoagulation and is in complete remission for the past 18 months. Conclusion: It is always imperative to investigate the cause of anaemia and consider hemolysis in a patient presenting with multiple unexplained thromboses.
Collapse
Affiliation(s)
- Ganesh Kasinathan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| |
Collapse
|
18
|
Herishanu Y, Levi S, Kamdjou T, Bornstein Y, Ram R, Benyamini N, Varon D, Avivi I, Perry C. Obinutuzumab in the treatment of autoimmune haemolytic anaemia and immune thrombocytopenia in patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma. Br J Haematol 2020; 192:e1-e4. [PMID: 33095444 DOI: 10.1111/bjh.17105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/20/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Yair Herishanu
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Shai Levi
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Talia Kamdjou
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Yotam Bornstein
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ron Ram
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Noam Benyamini
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David Varon
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Coagulation unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Irit Avivi
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Chava Perry
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| |
Collapse
|
19
|
Hwang SR, O'Dowd T, Markovic SN, Wolanskyj‐Spinner AP. Recurrent checkpoint inhibitor-induced warm agglutinin autoimmune hemolytic anemia in a patient with metastatic melanoma. Am J Hematol 2020; 95:E169-E171. [PMID: 32243616 DOI: 10.1002/ajh.25812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022]
Affiliation(s)
| | - Timothy O'Dowd
- Department of MedicineMayo Clinic Rochester Minnesota USA
| | | | | |
Collapse
|
20
|
Knops N, Emonds MP, Herman J, Levtchenko E, Mekahli D, Pirenne J, Van Geet C, Dierickx D. Bortezomib for autoimmune hemolytic anemia after intestinal transplantation. Pediatr Transplant 2020; 24:e13700. [PMID: 32166874 DOI: 10.1111/petr.13700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/03/2019] [Accepted: 02/24/2020] [Indexed: 01/19/2023]
Abstract
AIHA is rare in the general population and associated with a mortality of 8%. In contrast, AIHA occurs in up to 12.2% of cases after intestinal transplantation and is associated with mortality up to 50%. Treatment entails a "step-up" approach including corticosteroids, IvIg, plasmapheresis, and rituximab. However, AIHA after transplantation often is refractory to this strategy, contributing to a poor outcome. We describe a child with microvillous inclusion disease who developed AIHA 1 year after multivisceral transplantation that was refractory to standard therapy and was subsequently treated with bortezomib.We observed remission of AIHA within 1 week after the start of bortezomib. Bortezomib was associated with transient diarrhea, leucopenia, and elevated liver enzymes. Three years later, he remains in remission without important complications. Published data on bortezomib for autoimmune cytopenias outside SOT are discussed. This is the first report to support bortezomib as an important therapeutic alternative for AIHA after SOT. The occurrence and treatment of AIHA after SOT, and specifically intestinal transplantation, should be the subject of future registry studies to collect additional experience and explore the optimal therapeutic approach.
Collapse
Affiliation(s)
- Noël Knops
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jean Herman
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Elena Levtchenko
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Djalila Mekahli
- Pediatrics (Pediatric Nephrology and Solid Organ Transplantation), University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration (Woman and Child), KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Pediatrics (Pediatric Hemato-Oncology), University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Daan Dierickx
- Hematology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology (Laboratorium of Experimental Hematology), KU Leuven, Leuven, Belgium
| |
Collapse
|
21
|
Fang LW, Pan H, Shi J. [Ibrutinib treatment for 2 cases of relapsed/refractory autoimmune hemolytic anemia: a pilot study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:412-416. [PMID: 32536139 PMCID: PMC7342072 DOI: 10.3760/cma.j.issn.0253-2727.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Indexed: 11/20/2022]
Abstract
Objective: To explore the efficacy and safety of ibrutinib treatment for relapsed/refractory (R/R) primary autoimmune hemolytic anemia (AIHA) . Methods: Two cases of primary AIHA with relapse events were refractory to glucocorticoid, anti-CD20 monoclonal antibody, immunosuppressive drugs, and splenectomy (case 1 only) . Ibrutinib treatment was administered at an initial dose of 280 mg/d (420 mg/d for case 1 from the 3rd to 8th week) . Results: Both patients achieved transfusion independence and HGB>20 g/L above baseline after 2 weeks (partial response) . For case 1, HGB concentration restored to 113 g/L but with incomplete hemolysis recovery after 10 weeks; HGB reached the level of 118 g/L, also with incomplete hemolysis recovery, after 6 weeks in case 2. They all acquired complete response with incomplete hemolysis recovery (CRi) . The responses sustained 14 weeks and 10 weeks after follow-up at 16 weeks and 12 weeks, respectively. During the treatment, hematologic and nonhematologic toxicity is mild and acceptable. Conclusion: Ibrutinib alone is effective for the 2 R/R primary AIHA cases. We need further clinical trial to identify its efficacy and safety.
Collapse
Affiliation(s)
- L W Fang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Scienes and Peking Union Medical College, Tianjin 300020, China
| | - H Pan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Scienes and Peking Union Medical College, Tianjin 300020, China
| | - J Shi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Scienes and Peking Union Medical College, Tianjin 300020, China
| |
Collapse
|
22
|
Gutiérrez Jomarrón I, López Rubio M, Morado Arias M, Arrizabalaga B, de la Iglesia S, Beneitez D, Sáez MI, Cervera A, Recasens V, Herrera A, Villegas AM. Autoimmune haemolytic anaemias: A retrospective study of 93 patients. Med Clin (Barc) 2020; 154:331-337. [PMID: 31488259 DOI: 10.1016/j.medcli.2019.06.024] [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: 01/31/2019] [Revised: 06/14/2019] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Autoimmune haemolytic anaemia (AIHA) is an infrequent and heterogeneous disease in its pathophysiology and clinical behaviour, therefore it is generally managed empirically. PATIENTS AND METHODS We conducted an observational, retrospective and multicentre study of 93 patients diagnosed with AHAI in 9 Spanish hospitals between 1987 and 2017, with a median follow-up of 28 months. RESULTS Median age of 67 years; 85% AHAI for hot antibodies and 64% primary AHAI. The lowest haemoglobin values at diagnosis related to patients under 45 years of age and serological type IgG+C. Of the patients, 92% received first line treatment, 54% second line, and 27% third line. The warm AHAI were treated in first line with steroids, with overall responses of 83% and complete of 58%. Rituximab in monotherapy or in association with steroids was administered to 34 patients with overall responses close to 100% (complete responses 40-60%), relegating splenectomy to the third line. The immunosuppressive treatment was administered in patients with autoimmune diseases or in corticoid-dependent patients. DISCUSSION We found high rates of response to steroids, with very prolonged treatments that cause side effects and corticoid dependence in a third of patients. The combination of steroids with rituximab in the first line, could be indicated in patients with low levels of haemoglobin and serological type IgG+C. The high relapse rates make necessary the development of randomised studies with new drugs or the combination with existing ones, which allow longer response times and with fewer side effects.
Collapse
|
23
|
Chen M, Zhuang J, Yang C, Zhang L, Wang W, Cai H, Yu Y, Li J, Zhou D, Han B. Rapid response to a single-dose rituximab combined with bortezomib in refractory and relapsed warm autoimmune hemolytic anemia. Ann Hematol 2020; 99:1141-1143. [DOI: 10.1007/s00277-020-03976-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 02/24/2020] [Indexed: 01/09/2023]
|
24
|
Li X, Cai S, Zhong Z, Wang H, Wang L, You Y, Zhang M. Role of autoimmune hemolytic anemia as an initial indicator for chronic myeloid leukemia: A case report. Medicine (Baltimore) 2020; 99:e19256. [PMID: 32118733 PMCID: PMC7478578 DOI: 10.1097/md.0000000000019256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/09/2019] [Accepted: 01/20/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION We report here the case of a patient with chronic myeloid leukemia (CML) in the chronic phase who was diagnosed 1 year after receiving a diagnosis of autoimmune hemolytic anemia (AIHA). The objective was to assess if the CML patient progressed from AIHA and explore the underlying factors of the poor outcome after the achievement of molecular complete remission (MCR). PATIENT CONCERNS A patient with AIHA underwent splenectomy because of poor response to immune inhibitors. The spleen biopsy showed reactive hyperplasia. DIAGNOSIS The patient was diagnosed with CML because of over-expression of the BCR-ABL (P210) gene in the bone marrow (BM), 1 year after receiving the diagnosis of AIHA. INTERVENTIONS The splenectomy was performed as the patient was unresponsive to the standard treatments consisting of immunoglobulin and dexamethasone. The removed spleen was sent for pathological examination. After she was diagnosed with CML, she received imatinib treatment. OUTCOMES The spleen biopsy confirmed the translocation of 22q11/9q34. No BCR-ABL kinase domain mutation was detected and there was no expression of the WT1 or EVI1 genes. After splenectomy, the number of peripheral white blood cells was consistently higher than normal during the total therapy time for CML even though she showed MCR. Two years after CML was diagnosed, the patient died from severe infection. The BM gene array analysis displayed 3 types of chromosomal abnormalities: gain (14q32.33), uniparental disomy (UPD) Xp11.22-p11.1), and UPD Xp11.1-q13.1. LESSONS AIHA may be a clinical phase of CML progression in this patient. Both splenectomy and prolonged oral tyrosine kinase inhibitors may have contributed to the high risk of infection and her subsequent death. In addition, the gain of chromosome 14q32.33 may be related to her poor outcome.
Collapse
Affiliation(s)
- Xiang Li
- Institution of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Sisi Cai
- Institution of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Zhaodong Zhong
- Institution of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Hongxiang Wang
- Institution of Hematology, The central hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Wang
- Institution of Hematology, The central hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong You
- Institution of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Min Zhang
- Institution of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| |
Collapse
|
25
|
Piatek CI, Bocian H, Algaze S, Weitz IC, O'Connell C, Liebman HA. A Retrospective Study of the Combination of Rituximab, Cyclophosphamide and Dexamethasone for the Treatment of Relapsed/Refractory Warm Antibody Autoimmune Hemolytic Anemia. Acta Haematol 2019; 143:244-249. [PMID: 31665725 DOI: 10.1159/000501538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022]
Abstract
The combination of rituximab, cyclophosphamide, and dexamethasone (RCD) is highly effective in the treatment of warm autoimmune hemolytic anemia (WAIHA) associated with chronic lymphocytic leukemia (CLL). We treated a cohort of patients with relapsed/refractory WAIHA, without CLL, with RCD. The primary objective was to evaluate the overall response (OR) of RCD therapy. Complete response (CR) was defined as a hemoglobin (Hgb) ≥12 g/dL. Partial response (PR) was defined as Hgb 10-11.9 g/dL or ≥2 g/dL increase in Hgb. Sustained response was defined as Hgb ≥10 g/dL with no treatment changes. A total of 16 patients with relapsed/refractory WAIHA received RCD (7 primary WAIHA, 9 secondary WAIHA) for a median of 4 cycles (range: 2-6). The median pretreatment Hgb was 10.0 g/dL (range: 4.3-12.2). The median best Hgb achieved was 12.5 g/dL (range: 10.6-15.1) with a median of 2 cycles until best Hgb response. The OR was 94% (11 CR, 4 PR). Two immunocompromised patients were admitted for infections during RCD treatment. There were no deaths during the treatment or follow-up period. Following a response to RCD, 4 patients received noncorticosteroid immune modulation therapy and 4 patients continued on corticosteroid therapy. Seven patients received no additional treatment.
Collapse
Affiliation(s)
- Caroline I Piatek
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA,
- Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA,
| | - Hillel Bocian
- Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
| | - Sandra Algaze
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
- Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
| | - Ilene C Weitz
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
- Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
| | - Casey O'Connell
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
- Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
| | - Howard A Liebman
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
- Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
| |
Collapse
|
26
|
Affiliation(s)
- Robert A Brodsky
- From the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| |
Collapse
|
27
|
Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
|
28
|
Pavo-Blanco M, Novella-Navarro M, Cáliz-Cáliz R, Ferrer-González MA. Rituximab in refractory autoimmune hemolytic anemia in systemic lupus erythematosus. REUMATOLOGIA CLINICA 2018; 14:248-249. [PMID: 28870533 DOI: 10.1016/j.reuma.2017.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 07/26/2017] [Indexed: 06/07/2023]
Affiliation(s)
- María Pavo-Blanco
- Servicio de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España.
| | - Marta Novella-Navarro
- Servicio de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España
| | - Rafael Cáliz-Cáliz
- Servicio de Reumatología, Complejo Hospitalario Universitario de Granada, Granada, España
| | | |
Collapse
|
29
|
Tsang M, Dahlin JL, Sundsted KK. 79-Year-Old Woman With Jaundice and Anemia. Mayo Clin Proc 2018; 93:381-385. [PMID: 29258683 DOI: 10.1016/j.mayocp.2017.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/13/2017] [Accepted: 03/22/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Mazie Tsang
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Jayme L Dahlin
- Resident in Clinical Pathology, Brigham and Women's Hospital, Boston, MA
| | - Karna K Sundsted
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
30
|
Elias S, Kahlon S, Kotzur R, Kaynan N, Mandelboim O. Obinutuzumab activates FcγRI more potently than other anti-CD20 antibodies in chronic lymphocytic leukemia (CLL). Oncoimmunology 2018; 7:e1428158. [PMID: 29872553 PMCID: PMC5980409 DOI: 10.1080/2162402x.2018.1428158] [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: 12/19/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 11/03/2022] Open
Abstract
Treatment with monoclonal antibodies has revolutionized clinical medicine, especially in the fields of cancer and immunology. One of the oldest antibodies, which is widely used for the treatment of lymphomas and autoimmune diseases, is the anti-CD20 antibody rituximab. In recent years, new antibodies against CD20 have been developed including ofatumumab and obinutuzumab. An important mechanism of action of therapeutic monoclonal antibodies is activation of immune cells via Fc receptors (FcγRs). However, surprisingly, little is known about triggering of FcγRs by different therapeutic antibodies in general and anti-CD20 antibodies in particular. Here we establish a reporter assay to assess whether a particular antibody activates a certain Fc receptor. Using this assay we corroborated previous reports demonstrating obinutuzumab's ability to highly activate FcγRIIIa (CD16a). Importantly, we discovered that obinutuzumab also activates FcγRI (CD64) significantly more than rituximab and ofatumumab in response to chronic lymphocytic leukemia (CLL) cells obtained from patients. Mechanistically we show that this is due to the lack of FcγRIIb-mediated internalization of obinutuzumab following binding to CD20. Moreover, we show that obinutuzumab induces increased phagocytosis by primary macrophages in an FcγRI-dependent manner. Beyond the discovery of a new mechanism of obinutuzumab activity, the reporter assay can be applied to other therapeutic antibodies and may assist in developing antibodies with improved immunological properties.
Collapse
Affiliation(s)
- Shlomo Elias
- Department of Hematology, Hadassah - Hebrew University Medical Center, Jerusalem, Israel.,The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Shira Kahlon
- The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Rebecca Kotzur
- Department of Transfusion Medicine, Institute of Immunogenetics, Hannover Medical School, Hannover, Germany
| | - Noah Kaynan
- The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ofer Mandelboim
- The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW Building upon preclinical advances, we are uncovering immunotherapy strategies that are translating into improved outcomes in tumor subsets. Advanced pediatric solid tumors carry poor prognoses and resultant robust efforts to apply immunotherapy advances to pediatric solid tumors are in progress. Here, we discuss recent developments in the field using mAb and mAb-based therapies including checkpoint blockade and chimeric antigen receptors (CARs). RECENT FINDINGS The pediatric solid tumor mAb experience targeting the diganglioside, GD2, for patients with neuroblastoma has been the most compelling to date. GD2 and alternative antigen-specific mAbs are now being incorporated into antibody-drug conjugates, bispecific antibodies and CARs for treatment of solid tumors. CARs in pediatric solid tumors have not yet achieved comparative responses to the hematologic CAR experience; however, novel strategies such as bispecific targeting, intratumoral administration and improved understanding of T-cell biology may yield enhanced CAR-efficacy. Therapeutic effect using single-agent checkpoint blocking antibodies in pediatric solid tumors also remains limited to date. Combinatorial strategies continue to hold promise and the clinical effect in tumor subsets with high antigenic burden is being explored. SUMMARY Pediatric immunotherapy remains at early stages of translation, yet we anticipate that with advanced technology, we will achieve widespread, efficacious use of immunotherapy for pediatric solid tumors.
Collapse
|
32
|
Li Y, Li JP, Li Y, Wang JY, Zhou XL, Mi YC, Zhou K, Peng GX, Ye L, Fan HH, Song L, Li P, Li Q, Zhao X, Yang Y, Gao QY, Yang WR, Jing LP, Zhang FK, Zhang L. [Low-dose rituximab in IgA-mediated autoimmune hemolytic anemia: a case report and literatures review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:63-65. [PMID: 29551038 PMCID: PMC7343125 DOI: 10.3760/cma.j.issn.0253-2727.2018.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - L Zhang
- Therapeutic Center of Anemia, Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| |
Collapse
|
33
|
Evangelatos G, Vlachadami I, Kechagia M, Iliopoulos A. Rituximab and lenalidomide combination treatment for rheumatoid arthritis complicated with myelodysplastic syndrome: A case report. Mediterr J Rheumatol 2017; 28:217-220. [PMID: 32185287 PMCID: PMC7045997 DOI: 10.31138/mjr.28.4.217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 10/29/2017] [Accepted: 11/10/2017] [Indexed: 02/02/2023] Open
Abstract
Rheumatoid arthritis patients might experience several hematologic complications. The development of myelodysplastic syndrome is not clearly associated with RA, even though it has been described in some patients with pre-existing disease. There are only few data available in the literature concerning the therapeutic approach of such patients. Herein, we report a case of RA complicated with progressive MDS, successfully treated with rituximab and lenalidomide combination therapy.
Collapse
Affiliation(s)
| | - Ioanna Vlachadami
- Department of Pathophysiology, General Hospital of Athens "Laiko", Athens, Greece
| | - Maria Kechagia
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| | - Alexios Iliopoulos
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| |
Collapse
|
34
|
Gao QY, Liu CX, Li Y, Peng GX, Li JP, Li Y, Ye L, Fan HH, Song L, Zhang L, Jing LP, Zhou K, Zhao X, Yang WR, Wu ZJ, Yang Y, Xiong YZ, Zhang FK. [A monocentric retrospective study of low-dose rituximab in the treatment of 12 cases refractory or relapsed idiopathic autoimmune hemolytic anemia patients]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:1075-1077. [PMID: 29365406 PMCID: PMC7342200 DOI: 10.3760/cma.j.issn.0253-2727.2017.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Indexed: 12/31/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - F K Zhang
- Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| |
Collapse
|
35
|
Lauda-Maillen M, Catroux M, Roy-Peaud F, Souchaud-Debouverie O, El Masmouhi B, Roblot P. Diagnostic et prise en charge de l’anémie hémolytique auto-immune à l’exclusion des formes secondaires à une cause néoplasique. Adéquation de la prise en charge au PNDS octobre 2009. Rev Med Interne 2017; 38:648-655. [DOI: 10.1016/j.revmed.2017.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/15/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
|
36
|
Ureshino H, Miyahara M. Steroid-Refractory Autoimmune Hemolytic Anemia with Massive Splenomegaly. Am J Med 2017; 130:e393-e394. [PMID: 28389309 DOI: 10.1016/j.amjmed.2017.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Hiroshi Ureshino
- Division of Hematology, Respiratory Medicine, and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan; Department of Internal Medicine, Karatsu Red Cross Hospital, Japan.
| | | |
Collapse
|
37
|
Sys J, Provan D, Schauwvlieghe A, Vanderschueren S, Dierickx D. The role of splenectomy in autoimmune hematological disorders: Outdated or still worth considering? Blood Rev 2017; 31:159-172. [DOI: 10.1016/j.blre.2017.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/12/2016] [Accepted: 01/03/2017] [Indexed: 01/26/2023]
|
38
|
How I treat autoimmune hemolytic anemia. Blood 2017; 129:2971-2979. [PMID: 28360039 DOI: 10.1182/blood-2016-11-693689] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/21/2017] [Indexed: 12/17/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an uncommon entity that presents diagnostic, prognostic, and therapeutic dilemmas despite being a well-recognized entity for over 150 years. This is because of significant differences in the rates of hemolysis and associated diseases and because there is considerable clinical heterogeneity. In addition, there is a lack of clinical trials required to refine and update standardized and evidence-based therapeutic approaches. To aid the clinician in AIHA management, we present four vignettes that represent and highlight distinct clinical presentations with separate diagnostic and therapeutic pathways that we use in our clinical practice setting. We also review the parameters present in diagnostic testing that allow for prognostic insight and present algorithms for both diagnosis and treatment of the AIHA patient in diverse situations. This is done in the hope that this review may offer guidance in regard to personalized therapy recommendations. A section is included for the diagnosis of suspected AIHA with negative test results, a relatively infrequent but challenging situation, in order to assist in the overall evaluation spectrum for these patients.
Collapse
|
39
|
Tandan R, Hehir MK, Waheed W, Howard DB. Rituximab treatment of myasthenia gravis: A systematic review. Muscle Nerve 2017; 56:185-196. [DOI: 10.1002/mus.25597] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Rup Tandan
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Michael K. Hehir
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Waqar Waheed
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Diantha B. Howard
- Center for Clinical and Translational Science; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Burlington Vermont USA
| |
Collapse
|
40
|
Richards AL, Kapp LM, Wang X, Howie HL, Hudson KE. Regulatory T Cells Are Dispensable for Tolerance to RBC Antigens. Front Immunol 2016; 7:348. [PMID: 27698653 PMCID: PMC5027202 DOI: 10.3389/fimmu.2016.00348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/30/2016] [Indexed: 02/03/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) occurs when pathogenic autoantibodies against red blood cell (RBC) antigens are generated. While the basic disease pathology of AIHA is well studied, the underlying mechanism(s) behind the failure in tolerance to RBC autoantigens are poorly understood. Thus, to investigate the tolerance mechanisms required for the establishment and maintenance of tolerance to RBC antigens, we developed a novel murine model. With this model, we evaluated the role of regulatory T cells (Tregs) in tolerance to RBC-specific antigens. Herein, we show that neither sustained depletion of Tregs nor immunization with RBC-specific proteins in conjunction with Treg depletion led to RBC-specific autoantibody generation. Thus, these studies demonstrate that Tregs are not required to prevent autoantibodies to RBCs and suggest that other tolerance mechanisms are likely involved.
Collapse
Affiliation(s)
| | - Linda M Kapp
- Bloodworks Northwest Research Institute , Seattle, WA , USA
| | - Xiaohong Wang
- Bloodworks Northwest Research Institute , Seattle, WA , USA
| | | | | |
Collapse
|
41
|
Liebman HA. Immune modulation for autoimmune disorders: evolution of therapeutics. Semin Hematol 2016; 53 Suppl 1:S23-6. [DOI: 10.1053/j.seminhematol.2016.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
42
|
Bacterial Infections Following Splenectomy for Malignant and Nonmalignant Hematologic Diseases. Mediterr J Hematol Infect Dis 2015; 7:e2015057. [PMID: 26543526 PMCID: PMC4621170 DOI: 10.4084/mjhid.2015.057] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 10/03/2015] [Indexed: 01/19/2023] Open
Abstract
Splenectomy, while often necessary in otherwise healthy patients after major trauma, finds its primary indication for patients with underlying malignant or nonmalignant hematologic diseases. Indications of splenectomy for hematologic diseases have been reducing in the last few years, due to improved diagnostic and therapeutic tools. In high-income countries, there is a clear decrease over calendar time in the incidence of all indication splenectomy except nonmalignant hematologic diseases. However, splenectomy, even if with different modalities including laparoscopic splenectomy and partial splenectomy, continue to be a current surgical practice both in nonmalignant hematologic diseases, such as Immune Thrombocytopenic Purpura (ITP), Autoimmune Hemolytic Anemia (AIHA), Congenital Hemolytic Anemia such as Spherocytosis, Sickle Cell Anemia and Thalassemia and Malignant Hematological Disease, such as lymphoma. Today millions of people in the world are splenectomized. Splenectomy, independently of its cause, induces an early and late increase in the incidence of venous thromboembolism and infections. Infections remain the most dangerous complication of splenectomy. After splenectomy, the levels of antibody are preserved but there is a loss of memory B cells against pneumococcus and tetanus, and the loss of marginal zone monocytes deputed to immunological defense from capsulated bacteria. Commonly, the infections strictly correlated to the absence of the spleen or a decreased or absent splenic function are due to encapsulated bacteria that are the most virulent pathogens in this set of patients. Vaccination with polysaccharide and conjugate vaccines again Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis should be performed before the splenectomy. This practice reduces but does not eliminate the occurrence of overwhelming infections due to capsulated bacteria. At present, most of infections found in splenectomized patients are due to Gram-negative (G-) bacteria. The underlying disease is the most important factor in determining the frequency and severity of infections. So, splenectomy for malignant diseases has the major risk of infections.
Collapse
|
43
|
|