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Schimmer RR, Sutter T, Bachofner A, Ranieri E, Rodewald AK, Kremer Hovinga JA, Kimmich N, Trinchero A, Studt JD. Successful management of refractory immune-mediated thrombotic thrombocytopenic purpura during pregnancy and delivery using the anti-VWF nanobody caplacizumab. Br J Haematol 2024; 204:1994-1998. [PMID: 38168722 DOI: 10.1111/bjh.19284] [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: 10/31/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
Pregnancy is a potential trigger of acute thrombotic thrombocytopenic purpura (TTP). The management of pregnancy-associated immune-mediated TTP (iTTP) can be challenging, especially when it is refractory to standard treatment. Caplacizumab, a nanobody to von Willebrand factor (VWF) blocking its A1 domain, is a valuable new therapeutic option. Its use is, however, not approved during pregnancy and breastfeeding. We describe the successful off-label administration of caplacizumab during pregnancy and delivery in a patient with refractory iTTP. The favourable outcome without significant thrombotic or haemorrhagic complications indicates that caplacizumab may be an effective and safe treatment option in refractory iTTP during pregnancy.
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Affiliation(s)
- Roman R Schimmer
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Tabea Sutter
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Adrian Bachofner
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Elisabetta Ranieri
- Department of Obstetrics, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Ann-Kathrin Rodewald
- Department of Pathology and Molecular Pathology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Haematology and Central Haematological Laboratory, Inselspital Bern, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Nina Kimmich
- Department of Obstetrics, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alice Trinchero
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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2
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Bradbury J, Bell J. The TTP specialist nurse: an advocate for patients and professionals. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:284-290. [PMID: 38512783 DOI: 10.12968/bjon.2024.33.6.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening blood disorder with a mortality rate of over 90% if left untreated, multiple long-term complications for survivors, and a lifelong risk of relapse. There is a valuable role for the clinical nurse specialist in both the acute and long-term care of patients with TTP. Historically part of the team caring for patients with TTP, specialist nurses have played a vital role in co-ordinating and facilitating treatment for patients, promoting patient advocacy, supporting continuous service improvement, and delivering education to the wider clinical team to disseminate best practice. In 2021, the TTP specialist nurse role was commissioned within the NHS England National Service Framework for TTP Specialist Centres. This article aims to appraise the role of the TTP specialist nurse and share the multidimensional reach of the role in achieving better outcomes for patients with TTP.
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Affiliation(s)
- Jessica Bradbury
- Clinical Nurse Specialist, Liverpool University Hospitals NHS Foundation Trust
| | - Joanne Bell
- Clinical Nurse Specialist, Liverpool University Hospitals NHS Foundation Trust
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3
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Patır P, Önkibar N, Subari S, Eşkazan AE. Plasma cell-directed therapy strategies in immune-mediated thrombotic thrombocytopenic purpura (iTTP). Transfusion 2024; 64:536-545. [PMID: 38235916 DOI: 10.1111/trf.17716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Püsem Patır
- Department of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Nurtaç Önkibar
- Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Sedef Subari
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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4
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De Waele L, Sakai K, Mancini I, Sinkovits G, Falter T, Inoue T, Agosti P, Rossmann H, Von Auer C, Tersteeg C, De Meyer SF, Joly BS, Veyradier A, Coppo P, Fijnheer R, Peyvandi F, Prohászka Z, Lämmle B, Vanhoorelbeke K. Open ADAMTS-13 conformation index predicts earlier relapse in immune-mediated thrombotic thrombocytopenic purpura. J Thromb Haemost 2024; 22:493-502. [PMID: 37866519 DOI: 10.1016/j.jtha.2023.10.014] [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: 06/13/2023] [Revised: 09/27/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND ADAMTS-13 adopts an open conformation in patients with immune-mediated thrombotic thrombocytopenic purpura (iTTP) in acute phase while being closed in healthy donors. We reported that a substantial number of patients with iTTP in remission with restored ADAMTS-13 activity (>50%) still had an open ADAMTS-13 conformation, although a closed conformation is expected given the extent of remission. OBJECTIVES To investigate whether open ADAMTS-13, represented by a conformation index >0.5, is associated with a risk of earlier ADAMTS-13 and/or clinical relapse. METHODS We collected follow-up data (ADAMTS-13 parameters, ADAMTS-13 and clinical relapse, and treatment) from 81 patients with iTTP in remission with ADAMTS-13 activity >50%. RESULTS During follow-up, 19 ADAMTS-13 and 10 clinical relapses were reported (median follow-up period, 20 months). First, open or closed ADAMTS-13 conformation was dichotomized based on the 0.5 conformation index cutoff. Open ADAMTS-13 (conformation index, >0.5) was not identified as a risk factor for ADAMTS-13 and clinical relapse (log-rank test and Cox regression model). In contrast, by identifying the optimal conformation index cutoff for relapse prediction, using classification and regression tree analysis, a conformation index >0.645 and >0.835 was shown to be a risk factor for ADAMTS-13 relapse (hazard ratio, 3.3; 95% CI, 1.3-8.3; P = .01) and clinical relapse (hazard ratio, 4.4; 95% CI, 1.3-15.3; P = .02), respectively. CONCLUSION Patients with open ADAMTS-13 with a conformation index >0.645 and >0.835 have a >3- and >4-fold higher risk of earlier ADAMTS-13 and clinical relapse, respectively. Hence, ADAMTS-13 conformation index could be used to complement ADAMTS-13 activity monitoring to timely notice ADAMTS-13 relapse and prevent clinical relapse.
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Affiliation(s)
- Laure De Waele
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Kazuya Sakai
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium; Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Ilaria Mancini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - György Sinkovits
- Department of Internal Medicine and Hematology, Semmelweis University and Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Takashi Inoue
- Department of Evidence-Based Medicine, Nara Medical University, Kashihara, Japan
| | - Pasquale Agosti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Charis Von Auer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Bérangère S Joly
- Service d'Hématologie Biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris and EA3518, Institut de Recherche Saint Louis, Université de Paris, Paris, France
| | - Agnès Veyradier
- Service d'Hématologie Biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris and EA3518, Institut de Recherche Saint Louis, Université de Paris, Paris, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d'hématologie, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne Université, Paris, France
| | - Rob Fijnheer
- Department for Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan, Italy
| | - Zoltán Prohászka
- Department of Internal Medicine and Hematology, Semmelweis University and Research Group for Immunology and Haematology, Semmelweis University - Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Haemostasis Research Unit, University College London, London, United Kingdom
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium.
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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6
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Bonnez Q, Sakai K, Vanhoorelbeke K. ADAMTS13 and Non-ADAMTS13 Biomarkers in Immune-Mediated Thrombotic Thrombocytopenic Purpura. J Clin Med 2023; 12:6169. [PMID: 37834813 PMCID: PMC10573396 DOI: 10.3390/jcm12196169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare medical emergency for which a correct and early diagnosis is essential. As a severe deficiency in A Disintegrin And Metalloproteinase with ThromboSpondin type 1 repeats, member 13 (ADAMTS13) is the underlying pathophysiology, diagnostic strategies require timely monitoring of ADAMTS13 parameters to differentiate TTP from alternative thrombotic microangiopathies (TMAs) and to guide initial patient management. Assays for conventional ADAMTS13 testing focus on the enzyme activity and presence of (inhibitory) anti-ADAMTS13 antibodies to discriminate immune-mediated TTP (iTTP) from congenital TTP and guide patient management. However, diagnosis of iTTP remains challenging when patients present borderline ADAMTS13 activity. Therefore, additional biomarkers would be helpful to support correct clinical judgment. Over the last few years, the evaluation of ADAMTS13 conformation has proven to be a valuable tool to confirm the diagnosis of acute iTTP when ADAMST13 activity is between 10 and 20%. Screening of ADAMTS13 conformation during long-term patient follow-up suggests it is a surrogate marker for undetectable antibodies. Moreover, some non-ADAMTS13 parameters gained notable interest in predicting disease outcome, proposing meticulous follow-up of iTTP patients. This review summarizes non-ADAMTS13 biomarkers for which inclusion in routine clinical testing could largely benefit differential diagnosis and follow-up of iTTP patients.
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Affiliation(s)
- Quintijn Bonnez
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
| | - Kazuya Sakai
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan
| | - Karen Vanhoorelbeke
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
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7
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Falter T, Rossmann H, de Waele L, Dekimpe C, von Auer C, Müller-Calleja N, Häuser F, Degreif A, Marandiuc D, Messmer X, Sprinzl M, Lackner KJ, Jurk K, Vanhoorelbeke K, Lämmle B. A novel von Willebrand factor multimer ratio as marker of disease activity in thrombotic thrombocytopenic purpura. Blood Adv 2023; 7:5091-5102. [PMID: 37399489 PMCID: PMC10471935 DOI: 10.1182/bloodadvances.2023010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/05/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP), an autoantibody-mediated severe ADAMTS13 deficiency, is caused by insufficient proteolytic processing of von Willebrand factor (VWF) multimers (MMs) and microvascular thrombi. Recurrence of acute iTTP is associated with persistence or reappearance of ADAMTS13 deficiency. Some patients remain in remission despite recurring or persisting severe ADAMTS13 deficiency. In a prospective 2-year observational study, we investigated VWF MM patterns and ADAMTS13 in patients with iTTP in remission and at acute episodes. Of the 83 patients with iTTP, 16 suffered 22 acute episodes whereas 67 remained in clinical remission during follow-up, including 13 with ADAMTS13 <10% and 54 with ADAMTS13 ≥10%. High -molecular weight to low-molecular weight VWF MM ratio based on sodium dodecyl sulfate-agarose gel electrophoresis was compared with ADAMTS13 activity. VWF MM ratio was significantly higher in patients in remission with <10% compared with ≥10% ADAMTS13 activity. Fourteen samples obtained from 13 to 50 days (interquartile range; median, 39) before acute iTTP onset (ADAMTS13 <10% in 9 patients and 10%-26% in 5) showed VWF MM ratios significantly higher than those from 13 patients remaining in remission with ADAMTS13 <10%. At acute iTTP onset, VWF MM ratio decreased significantly and was low in all patients despite <10% ADAMTS13. The VWF MM ratio does not depend exclusively on ADAMTS13 activity. The disappearance of high molecular weight VWF MMs resulting in low VWF MM ratio at iTTP onset may be explained by consumption of larger VWF MMs in the microcirculation. The very high VWF MM ratio preceding acute iTTP recurrence suggests that VWF processing is hampered more than in patients remaining in remission.
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Affiliation(s)
- Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Laure de Waele
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charlotte Dekimpe
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Charis von Auer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Department of Hematology, Oncology and Pneumology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Nadine Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Friederike Häuser
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Adriana Degreif
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Dana Marandiuc
- Transfusion Center, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Xavier Messmer
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Martin Sprinzl
- Medical Department I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karl J. Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility, KU Leuven Campus Kortrijk, Kortrijk, Belgium
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- University Clinic of Hematology & Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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8
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Dainese C, Valeri F, Bruno B, Borchiellini A. Anti-ADAMTS13 Autoantibodies: From Pathophysiology to Prognostic Impact-A Review for Clinicians. J Clin Med 2023; 12:5630. [PMID: 37685697 PMCID: PMC10488355 DOI: 10.3390/jcm12175630] [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: 06/30/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 09/10/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a fatal disease in which platelet-rich microthrombi cause end-organ ischemia and damage. TTP is caused by markedly reduced ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity. ADAMTS13 autoantibodies (autoAbs) are the major cause of immune TTP (iTTP), determining ADAMTS13 deficiency. The pathophysiology of such autoAbs as well as their prognostic role are continuous objects of scientific studies in iTTP fields. This review aims to provide clinicians with the basic information and updates on autoAbs' structure and function, how they are typically detected in the laboratory and their prognostic implications. This information could be useful in clinical practice and contribute to future research implementations on this specific topic.
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Affiliation(s)
- Cristina Dainese
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città Della Salute e Della Scienza, 10126 Turin, Italy; (F.V.); (A.B.)
- Division of Hematology, AOU Città Della Salute e Della Scienza and University of Turin, 10124 Turin, Italy;
| | - Federica Valeri
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città Della Salute e Della Scienza, 10126 Turin, Italy; (F.V.); (A.B.)
- Division of Hematology, AOU Città Della Salute e Della Scienza and University of Turin, 10124 Turin, Italy;
| | - Benedetto Bruno
- Division of Hematology, AOU Città Della Salute e Della Scienza and University of Turin, 10124 Turin, Italy;
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Alessandra Borchiellini
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città Della Salute e Della Scienza, 10126 Turin, Italy; (F.V.); (A.B.)
- Division of Hematology, AOU Città Della Salute e Della Scienza and University of Turin, 10124 Turin, Italy;
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9
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Oliver M, Patriquin CJ, Pavenski K. Predictors of relapse and prophylactic management of immune thrombotic thrombocytopenic purpura. Transfus Apher Sci 2023; 62:103749. [PMID: 37344323 DOI: 10.1016/j.transci.2023.103749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Affiliation(s)
- Monika Oliver
- Department of Medicine, University of Alberta, Canada; Division of Hematology, University of Alberta Hospital, Canada
| | - Christopher J Patriquin
- Department of Medicine, University of Toronto, Canada; Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
| | - Katerina Pavenski
- Department of Medicine, University of Toronto, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, Canada; Departments of Medicine and Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Canada.
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10
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Mutoh T, Ohashi K, Nagai T, Sugiura A, Kudo M, Fujii H. Upfront rituximab therapy for thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case-based review. Rheumatol Int 2023; 43:373-381. [PMID: 35962219 DOI: 10.1007/s00296-022-05182-5] [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: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of various autoantibodies and deposition of immune complexes on tissues. Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematological disorder that rarely develops in SLE, mainly caused by inhibitory or clearing autoantibody against ADAMTS13. Although B cells play critical roles in the pathogenesis of two diseases, the role of B-cell depletion therapy using rituximab (RTX), a chimeric monoclonal antibody targeting CD20, in the management of TTP associated with SLE remains unclear. We present a 27-year-old woman who manifested TTP and nephritis simultaneously at diagnosis of SLE. This patient successfully responded to high-dose glucocorticoids combined with plasma exchange, and early administration of RTX-induced sustained remission of TTP without relapse over 16 months. This literature review in light of our case demonstrates relationship between early intervention with RTX and better treatment response despite the degree of ADAMTS13 activity. Moreover, we discuss the clinical features in TTP associated with SLE, risk factors for the development of TTP in SLE, and possible outcomes based on RTX dose. It is important to consider upfront RTX as a promising treatment strategy for SLE-associated secondary TTP to improve short-term response and long-term prognosis.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Keiichi Ohashi
- Department of Hematology, Ishinomaki Red Cross Hospital, Ishinomaki, Miyagi, Japan
| | - Taichi Nagai
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
| | - Akira Sugiura
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masataka Kudo
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital, Sendai, Miyagi, Japan
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11
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Comparon C, Galicier L, Rebibou JM, Coppo P, Benhamou Y. Preemptive cyclosporin A in immune-mediated thrombotic thrombocytopenic purpura. Eur J Haematol 2023; 110:157-160. [PMID: 36271897 PMCID: PMC10098822 DOI: 10.1111/ejh.13886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 01/19/2023]
Abstract
Survivors of immune-mediated thrombotic thrombocytopenic purpura (iTTP) are exposed to clinical relapses when a disintegrin and metalloproteinase with thrombospondin type 1 repeats, member 13 (ADAMTS13) activity decreases during follow-up. Although preemptive rituximab usually improves ADAMTS13 activity in this context, 15% of patients experience refractoriness or intolerance to rituximab and require alternative strategies. Here, we addressed whether cyclosporine A (CSA) could improve ADAMTS13 activity and prevent clinical relapses in this context. We treated preemptively with CSA 14 iTTP patients who were unresponsive (n = 11) or intolerant (n = 3) to rituximab. All patients had a severe ADAMTS13 deficiency (activity <20%) and otherwise in clinical remission. ADAMTS13 activity normalized in almost all patients (n = 13, 93%), after a median time of 2.5 months [IQR 1-6] following initiation. Median duration of CSA treatment was 17.5 months [IQR 10-34]. ADAMTS13 activity further declined to undetectable values during follow-up in five patients, but retreatment with rituximab or CSA allowed a recovery in ADAMTS13 activity in three cases. CSA could be stopped durably in two patients, while two others experienced an ADAMTS13 relapse. Severe but reversible side effects requiring cessation of the treatment occurred in two patients. CSA provides high and sustained response rates in patients who are refractory or intolerant to rituximab, with acceptable adverse events.
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Affiliation(s)
- Celine Comparon
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France.,Service de Médecine Interne, CHU Avicenne, Bobigny, France
| | - Lionel Galicier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France.,Service de Médecine Interne, Hôpital Saint Joseph, Marseille, France
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France.,Service d'Hématologie, APHP and Sorbonne Université, Paris, France.,INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France.,Département de Médecine Interne, Normandie Univ, UNIROUEN, INSERM U1096 EnVI, CHU Rouen, Rouen, France
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12
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Long-term risk of relapse in immune-mediated thrombotic thrombocytopenic purpura and the role of anti-CD20 therapy. Blood 2023; 141:285-294. [PMID: 36322971 DOI: 10.1182/blood.2022017023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 01/20/2023] Open
Abstract
Disease relapse is recognized as a risk in immune-mediated thrombotic thrombocytopenic purpura (iTTP) after treatment of the acute presenting episode. Identification of patients at risk of relapse and its patterns are yet to be clearly established. We reviewed patients with iTTP having had >3 years of follow-up over 10 years in the United Kingdom to identify patient characteristics for relapse, assess relapse rates and patterns, and response to anti-CD20 therapy in those with a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) relapses (ADAMTS13 activity of <20% without thrombocytopenia). We identified 443 patients demonstrating relapse rates of 40% at 5-year follow-up. At 10-year follow-up, no difference in relapse was observed irrespective of whether rituximab was used at acute presentation (P = .39). Black Caribbean ethnicity increased the risk of disease relapse in the British population. There was a distinct population of patients (6%) that relapsed early with subsequent frequent relapses occurring on average within 2 years (average time to relapse in subgroup, 1.7 years). Overall, nearly 60% of relapses described were ADAMTS13 relapses, with subsequent treatment reducing the risk of progression to clinical relapses. We demonstrate that iTTP diagnosed in the latter part of the study period had lower rates of clinical relapses (22.6% vs 11.1%, P = .0004) with the advent of regular monitoring and preemptive rituximab. In ADAMTS13 relapses, 96% responded to anti-CD20 therapy, achieving ADAMTS13 activity of >20%. Anti-CD20 therapy was demonstrated to be an effective long-term treatment regardless of relapse pattern and there was no loss of this treatment response after subsequent treatment episodes.
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13
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Mazzierli T, Allegretta F, Maffini E, Allinovi M. Drug-induced thrombotic microangiopathy: An updated review of causative drugs, pathophysiology, and management. Front Pharmacol 2023; 13:1088031. [PMID: 36699080 PMCID: PMC9868185 DOI: 10.3389/fphar.2022.1088031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Drug-induced thrombotic microangiopathy (DITMA) represents 10%-13% of all thrombotic microangiopathy (TMA) cases and about 20%-30% of secondary TMAs, just behind pregnancy-related and infection-related forms. Although the list of drugs potentially involved as causative for TMA are rapidly increasing, the scientific literature on DITMA is quite scarce (mostly as individual case reports or little case series), leading to poor knowledge of pathophysiological mechanisms and clinical management. In this review, we focused on these critical aspects regarding DITMA. We provided an updated list of TMA-associated drugs that we selected from a scientific literature review, including only those drugs with a definite or probable causal association with TMA. The list of drugs is heterogeneous and could help physicians from several different areas to be familiar with DITMA. We describe the clinical features of DITMA, presenting the full spectrum of clinical manifestations, from systemic to kidney-limited forms. We also analyze the association between signs/symptoms (i.e., malignant hypertension, thrombocytopenia) and specific DITMA causative drugs (i.e., interferon, ticlopidine). We highlighted their multiple different pathophysiological mechanisms, being frequently classified as immune-mediated (idiosyncratic) and dose-related/toxic. In particular, to clarify the role of the complement system and genetic deregulation of the related genes, we conducted a revision of the scientific literature searching for DITMA cases who underwent renal biopsy and/or genetic analysis for complement genes. We identified a complement deposition in renal biopsies in half of the patients (37/66; 57%), with some drugs associated with major deposits (i.e., gemcitabine and ramucirumab), particularly in capillary vessels (24/27; 88%), and other with absent deposits (tyrosine kinase inhibitors and intraocular anti-VEGF). We also found out that, differently from other secondary TMAs (such as pregnancy-related-TMA and malignant hypertension TMA), complement genetic pathological mutations are rarely involved in DITMA (2/122, 1.6%). These data suggest a variable non-genetic complement hyperactivation in DITMA, which probably depends on the causative drug involved. Finally, based on recent literature data, we proposed a treatment approach for DITMA, highlighting the importance of drug withdrawal and the role of therapeutic plasma-exchange (TPE), rituximab, and anti-complementary therapy.
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Affiliation(s)
- Tommaso Mazzierli
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy,Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Federica Allegretta
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy,Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Enrico Maffini
- Department of Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy,Correspondence: Marco Allinovi,
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14
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Selvakumar S, Liu A, Chaturvedi S. Immune thrombotic thrombocytopenic purpura: Spotlight on long-term outcomes and survivorship. Front Med (Lausanne) 2023; 10:1137019. [PMID: 36926315 PMCID: PMC10011081 DOI: 10.3389/fmed.2023.1137019] [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: 01/03/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023] Open
Abstract
Advances in diagnosis and treatment have dramatically improved survival of acute immune thrombotic thrombocytopenic purpura (iTTP) and iTTP has evolved from an acute fatal condition to a chronic relapsing disorder. In addition to the risk of iTTP relapse, iTTP survivors are at risk of multiple adverse health outcomes including higher than expected rates of all-cause mortality, increased rates of stroke and other cardiovascular disease, and higher rates of morbidities such as obesity, hypertension, and autoimmune disorders. iTTP survivors also report neurocognitive impairment, depression, and reduced quality of life. Women with iTTP are at risk for recurrent iTTP, preeclampsia, and other maternal and fetal complications in subsequent pregnancies. ADAMTS13 activity during clinical remission has emerged as an important targetable risk factor for iTTP relapse and other outcomes including stroke and all-cause mortality. This review summarizes current literature regarding the epidemiology and potential mechanisms for adverse long-term sequelae of iTTP, outlines current best practices in iTTP survivorship care, and highlights a research agenda to improve long-term iTTP outcomes.
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Affiliation(s)
- Sruthi Selvakumar
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Angela Liu
- Division of Hematology and Oncology, Mount Sinai School of Medicine, New York, NY, United States
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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15
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Gómez-Seguí I, Pascual Izquierdo C, Mingot Castellano ME, de la Rubia Comos J. An update on the pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:17-32. [PMID: 36537217 DOI: 10.1080/17474086.2023.2159803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Severe ADAMTS13 deficiency defines thrombotic thrombocytopenic purpura (TTP). ADAMTS13 is responsible for VWF cleavage. In the absence of this enzyme, widespread thrombi formation occurs, causing microangiopathic anemia and thrombocytopenia and leading to ischemic organ injury. Understanding ADAMTS13 function is crucial to diagnose and manage TTP, both in the immune and hereditary forms. AREAS COVERED The role of ADAMTS13 in coagulation homeostasis and the consequences of its deficiency are detailed. Other factors that modulate the consequences of ADAMTS13 deficiency are explained, such as complement system activation, genetic predisposition, or the presence of an inflammatory status. Clinical suspicion of TTP is crucial to start prompt treatment and avoid mortality and sequelae. Available techniques to diagnose this deficiency and detect autoantibodies or gene mutations are presented, as they have become faster and more available in recent years. EXPERT OPINION A better knowledge of TTP pathophysiology is leading to an improvement in diagnosis and follow-up, as well as a customized treatment in patients with TTP. This scenario is necessary to define the role of new targeted therapies already available or coming soon and the need to better diagnose and monitor at the molecular level the evolution of the disease.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio de Hematología y Hemoterapia, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón, Calle Dr. Esquerdo 46, 28007, Madrid, Spain
| | - María Eva Mingot Castellano
- Servicio de Hematología, Área de Banco de Sangre y Establecimiento de Tejidos, Hospital Universitario Virgen del Rocío, Calle Manuel Siurot s/n, 41013, Sevilla, Spain
| | - Javier de la Rubia Comos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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16
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Scully M, de la Rubia J, Pavenski K, Metjian A, Knöbl P, Peyvandi F, Cataland S, Coppo P, Kremer Hovinga JA, Minkue Mi Edou J, De Passos Sousa R, Callewaert F, Gunawardena S, Lin J. Long-term follow-up of patients treated with caplacizumab and safety and efficacy of repeat caplacizumab use: Post-HERCULES study. J Thromb Haemost 2022; 20:2810-2822. [PMID: 36138517 PMCID: PMC9827931 DOI: 10.1111/jth.15892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/10/2022] [Accepted: 09/19/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Caplacizumab demonstrated efficacy and safety in patients with immune-mediated thrombotic thrombocytopenic purpura (iTTP) in the phase 3 HERCULES trial. However, data on long-term outcomes following caplacizumab treatment are limited. OBJECTIVES The post-HERCULES trial (NCT02878603) evaluated long-term outcomes of patients with iTTP treated with caplacizumab in HERCULES and safety and efficacy of repeated caplacizumab use. PATIENTS/METHODS Over 3 years of follow-up, patients could receive open-label caplacizumab with therapeutic plasma exchange (TPE) and immunosuppressive therapy (IST) in case of recurrence. Adverse events (AEs) were assessed during the overall study period (intention-to-observe [ITO] population) and during recurrences (recurrence population). TTP-related events (TTP-related death, recurrence, major thromboembolic events) were assessed in the efficacy ITO population (patients without recurrence during HERCULES or before post-HERCULES). RESULTS Among 104 enrolled patients, incidences of AEs and serious AEs were similar between patients who had received caplacizumab + TPE + IST during HERCULES (n = 75) and those treated with placebo + TPE + IST (placebo; n = 29). TTP-related events occurred in 8% of patients (4/49) randomized to caplacizumab during HERCULES versus 38% (11/29) randomized to placebo. Nineteen patients had ≥1 recurrence; 13 of these were treated with caplacizumab. The first recurrence episode was resolved or resolving for all patients treated with caplacizumab, including nine patients with repeat caplacizumab use. All second recurrences (6/6) were resolved. Safety profile of caplacizumab for treatment of recurrence was consistent with HERCULES; most bleeding events were nonserious. No major cases of organ dysfunction were observed. CONCLUSIONS Long-term follow-up supports the safety and efficacy of caplacizumab for iTTP and its repeated use for recurrences.
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Affiliation(s)
- Marie Scully
- Department of HaematologyUCLH and NIHR Cardiometabolic BRC, UCLH/UCLLondonUK
- University College London HospitalsLondonUK
| | - Javier de la Rubia
- Hematology Department, Internal MedicineSchool of Medicine and Dentistry, Catholic University of Valencia and Hospital LA FEValenciaSpain
| | - Katerina Pavenski
- Departments of Medicine and Laboratory MedicineSt. Michael's Hospital and University of TorontoTorontoOntarioCanada
| | - Ara Metjian
- Division of Hematology, Department of MedicineUniversity of Colorado–Anschutz Medical CenterDenverColoradoUSA
| | - Paul Knöbl
- Division of Hematology and Hemostasis, Department of Medicine 1Medical University of ViennaViennaAustria
| | - Flora Peyvandi
- Department of Pathophysiology and TransplantationFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Università degli Studi di MilanoMilanItaly
| | - Spero Cataland
- Department of Internal MedicineOhio State UniversityColumbusOhioUSA
| | - Paul Coppo
- Department of HematologyReference Center for Thrombotic Microangiopathies (CNR‐MAT), Saint‐Antoine University Hospital, AP‐HPParisFrance
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology LaboratoryInselspital, Bern University Hospital, University of BernBernSwitzerland
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17
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George JN. Thrombotic Thrombocytopenic Purpura: From 1972 to 2022 and Beyond. Semin Thromb Hemost 2022; 48:926-936. [PMID: 35793688 DOI: 10.1055/s-0042-1749589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This review tells the story of my personal experience with thrombotic thrombocytopenic purpura (TTP). It begins with my first encounter with TTP 50 years ago when 2 sisters presented 2 years apart, both pregnant and both died. At that time, I knew nothing about hereditary TTP (hTTP), the risks of pregnancy, or effective treatments. In 1991, a year after I moved to Oklahoma, therapeutic plasma exchange (TPE) was established as an effective treatment. With the availability of effective treatment, the number of patients presenting with suspected TTP soared. The diagnosis of TTP was imprecise. I worked with the Oklahoma Blood Institute (OBI) to understand the management of TTP. Because the OBI provided all TPE procedures for most of Oklahoma, we saw all consecutive patients within a defined geographic area who were identified at a uniform time early in the course of their TTP, without selection or referral bias. It was an inception cohort; this became the Oklahoma TTP Registry. In 2001, we began a very successful collaboration with the University of Bern, Switzerland, to measure ADAMTS13 activity in all of our patients. From our patients, we learned that acquired, autoimmune TTP (iTTP) is a chronic disease with risks for cognitive impairment and depression. Recognition in 2012 of three sisters with hTTP was reminiscent of the beginning of my story. hTTP has risks for multiple severe morbidities, beginning at birth and especially during pregnancy. Future management of both iTTP and hTTP will be more effective and more convenient.
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Affiliation(s)
- James N George
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, Hematology-Oncology Section, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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18
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Halkidis K, Zheng XL. ADAMTS13 conformations and mechanism of inhibition in immune thrombotic thrombocytopenic purpura. J Thromb Haemost 2022; 20:2197-2203. [PMID: 35842925 PMCID: PMC9587499 DOI: 10.1111/jth.15822] [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: 05/26/2022] [Revised: 06/29/2022] [Accepted: 07/15/2022] [Indexed: 08/31/2023]
Abstract
ADAMTS13, a plasma metalloprotease that cleaves von Willebrand factor, is crucial for normal hemostasis. Acquired autoantibody-mediated deficiency of plasma ADAMTS13 results in a potentially fatal blood disorder, immune thrombotic thrombocytopenic purpura (iTTP). Plasma ADAMTS13 protease appears to exist in multiple conformations. Under physiological conditions, plasma ADAMTS13 exists predominantly in its "closed" conformation (or latent form), which may be activated by lowering pH, ligand binding, and binding of an antibody against the distal domains of ADAMTS13. In patients with iTTP, polyclonal antibodies target at various domains of ADAMTS13. However, nearly all inhibitory antibodies bind the spacer domain, whereas antibodies that bind the distal C-terminal domains may activate ADAMTS13 through removing its allosteric inhibition. Additionally, the anti-C-terminal antibodies may alter the potency of inhibitory antibodies towards ADAMTS13 activity. This review summarizes some of the most recent knowledge about the ADAMTS13 conformation and its mechanism of inhibition by its autoantibodies.
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Affiliation(s)
- Konstantine Halkidis
- Division of Hematologic Malignancies and Cellular Therapeutics, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Institute of Reproductive and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
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19
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Malgaj Vrečko M, Aleš Rigler A, Večerić-Haler Ž. Coronavirus Disease 2019-Associated Thrombotic Microangiopathy: Literature Review. Int J Mol Sci 2022; 23:ijms231911307. [PMID: 36232608 PMCID: PMC9569470 DOI: 10.3390/ijms231911307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) can lead to clinically significant multisystem disorders that also affect the kidney. According to recent data, renal injury in the form of thrombotic microangiopathy (TMA) in native kidneys ranks third in frequency. Our review of global literature revealed 46 cases of TMA in association with COVID-19. Among identified cases, 18 patients presented as thrombotic thrombocytopenic purpura (TTP) and 28 cases presented as atypical hemolytic uremic syndrome (aHUS). Altogether, seven patients with aHUS had previously proven pathogenic or likely pathogenic genetic complement abnormalities. TMA occurred at the time of viremia or even after viral clearance. Infection with COVID-19 resulted in almost no or only mild respiratory symptoms in the majority of patients, while digestive symptoms occurred in almost one-third of patients. Regarding the clinical presentation of COVID-19-associated TMA, the cases showed no major deviations from the known presentation. Patients with TTP were treated with plasma exchange (88.9%) or fresh frozen plasma (11.1%), corticosteroids (88.9%), rituximab (38.9%), and caplacizumab (11.1%). Furthermore, 53.6% of patients with aHUS underwent plasma exchange with or without steroid as initial therapy, and 57.1% of patients received a C5 complement inhibitor. Mortality in the studied cohort was 16.7% for patients with TTP and 10.7% for patients with aHUS. The exact role of COVID-19 in the setting of COVID-19-associated TMA remains unclear. COVID-19 likely represents a second hit of aHUS or TTP that manifests in genetically predisposed individuals. Early identification of the TMA subtype and appropriate prompt and specific treatment could lead to good outcomes comparable to survival and recovery statistics for TMA of all causes.
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Affiliation(s)
- Marija Malgaj Vrečko
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Andreja Aleš Rigler
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Željka Večerić-Haler
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
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20
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Chaturvedi S, Antun AG, Farland AM, Woods R, Metjian A, Park YA, de Ridder G, Gibson B, Kasthuri RS, Liles DK, Akwaa F, Clover T, Baumann Kreuziger L, Sadler JE, Sridharan M, Go RS, McCrae KR, Upreti HV, Liu A, Lim MY, Gangaraju R, Zheng XL, Raval JS, Masias C, Cataland SR, Johnson A, Davis E, Evans MD, Mazepa MA. Race, rituximab, and relapse in TTP. Blood 2022; 140:1335-1344. [PMID: 35797471 PMCID: PMC9710186 DOI: 10.1182/blood.2022016640] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/24/2022] [Indexed: 01/02/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is characterized by recurring episodes of thrombotic microangiopathy, causing ischemic organ impairment. Black patients are overrepresented in iTTP cohorts in the United States, but racial disparities in iTTP outcome and response to therapy have not been studied. Using the United States Thrombotic Microangiopathies Consortium iTTP Registry, we evaluated the impact of race on mortality and relapse-free survival (RFS) in confirmed iTTP in the United States from 1995 to 2020. We separately examined the impact of rituximab therapy and presentation with newly diagnosed (de novo) or relapsed iTTP on RFS by race. A total of 645 participants with 1308 iTTP episodes were available for analysis. Acute iTTP mortality did not differ by race. When all episodes of iTTP were included, Black race was associated with shorter RFS (hazard ratio [HR], 1.60; 95% CI, 1.16-2.21); the addition of rituximab to corticosteroids improved RFS in White (HR, 0.37; 95% CI, 0.18-0.73) but not Black patients (HR, 0.96; 95% CI, 0.71-1.31). In de novo iTTP, rituximab delayed relapse, but Black patients had shorter RFS than White patients, regardless of treatment. In relapsed iTTP, rituximab significantly improved RFS in White but not Black patients. Race affects overall relapse risk and response to rituximab in iTTP. Black patients may require closer monitoring, earlier retreatment, and alternative immunosuppression after rituximab treatment. How race, racism, and social determinants of health contribute to the disparity in relapse risk in iTTP deserves further study.
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Affiliation(s)
| | - Ana G. Antun
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Ryan Woods
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Ara Metjian
- Department of Medicine, University of Colorado, Denver, CO
| | - Yara A. Park
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Geisinger Medical Laboratories, Danville, PA
| | - Briana Gibson
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Raj S. Kasthuri
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Darla K. Liles
- Department of Medicine, East Carolina University, Greenville, NC
| | - Frank Akwaa
- Department of Medicine, University of Rochester, Rochester, NY
| | | | - Lisa Baumann Kreuziger
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - J. Evan Sadler
- Department of Medicine, Washington University, St Louis, MO
| | | | - Ronald S. Go
- Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Harsh Vardhan Upreti
- Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Angela Liu
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ming Y. Lim
- Department of Medicine, University of Utah, Salt Lake City, UT
| | | | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Jay S. Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM
| | | | | | | | - Elizabeth Davis
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Michael D. Evans
- Clinical & Translational Science Institute, University of Minnesota, Minneapolis, MN
| | | | - for the United States Thrombotic Microangiopathies Consortium
- Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Medicine, Emory University, Atlanta, GA
- Department of Medicine, Wake Forest University, Winston-Salem, NC
- Department of Medicine, University of Colorado, Denver, CO
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Geisinger Medical Laboratories, Danville, PA
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, East Carolina University, Greenville, NC
- Department of Medicine, University of Rochester, Rochester, NY
- St Charles Healthcare, Bend, OR
- Versiti Blood Research Institute, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Washington University, St Louis, MO
- Department of Medicine, Mayo Clinic, Rochester, MN
- Department of Medicine, Cleveland Clinic, Cleveland, OH
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Department of Medicine, University of Utah, Salt Lake City, UT
- Department of Medicine, University of Alabama at Birmingham
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
- Department of Pathology, University of New Mexico, Albuquerque, NM
- Baptist Health South Florida, Miami, FL
- Department of Medicine, The Ohio State University, Columbus, OH
- Department of Laboratory Medicine and Pathology
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Clinical & Translational Science Institute, University of Minnesota, Minneapolis, MN
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21
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How I treat immune-mediated thrombotic thrombocytopenic purpura after hospital discharge. Blood 2022; 140:438-444. [PMID: 35667044 DOI: 10.1182/blood.2021014514] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/14/2022] [Indexed: 11/20/2022] Open
Abstract
Immune-mediated thrombocytopenic purpura (iTTP) is a thrombotic microangiopathy characterized by an acquired ADAMTS13 deficiency as a result of the presence of an antibody inhibitor of ADAMTS13 leading to the formation of ultralarge von Willebrand multimers. Treatment of iTTP includes plasma exchange, high-dose glucocorticoids, rituximab, and, more recently, caplacizumab, to prevent the development of exacerbations. There is the risk of both relapse and long-term complications that include neurocognitive deficits and cardiovascular events that occur in patients in remission after recovery from an acute iTTP episode. Data on the risk factors for the development of these complications, the appropriate screening, and treatment are limited due to the paucity of research. This article is a review of the current understanding on the risk factors for exacerbation, relapse, and long-term complications of iTTP and discusses an approach to observing patients with iTTP after hospital discharge and during the long-term follow-up in the outpatient setting.
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22
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Klontz EH. Chop-chop: The future of bacterial enzymes in transfusion medicine. Transfus Med Rev 2022; 36:246-251. [DOI: 10.1016/j.tmrv.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/25/2022] [Indexed: 10/15/2022]
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23
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Efficacy and safety of azathioprine during remission of immune-mediated thrombotic thrombocytopenic purpura. Blood Adv 2022; 6:5463-5466. [PMID: 35772164 PMCID: PMC9631697 DOI: 10.1182/bloodadvances.2022007632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
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24
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Mingot Castellano ME, Pascual Izquierdo C, González A, Viejo Llorente A, Valcarcel Ferreiras D, Sebastián E, García Candel F, Sarmiento Palao H, Gómez Seguí I, de la Rubia J, Cid J, Martínez Nieto J, Hernández Mateo L, Goterris Viciedo R, Fidalgo T, Salinas R, Del Rio-Garma J. Recommendations for the diagnosis and treatment of patients with thrombotic thrombocytopenic purpura. Med Clin (Barc) 2022; 158:630.e1-630.e14. [PMID: 34266669 DOI: 10.1016/j.medcli.2021.03.040] [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: 02/06/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/09/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by the development of microangiopathic haemolytic anaemia, thrombocytopenia, and ischaemic organ dysfunction associated with ADAMTS13 levels lower than 10% in most cases. Recently there have been numerous advances in the field of PTT, new, rapid and accessible techniques capable of quantifying ADAMTS13 activity and inhibitors. The massive sequencing systems facilitate the identification of polymorphisms in the ADAMTS13 gene. In addition, new drugs such as caplacizumab have appeared and relapse prevention strategies are being proposed with the use of rituximab. The existence of TTP patient registries allow a deeper understanding of this disease but the great variability in the diagnosis and treatment makes it necessary to elaborate guidelines that homogenize terminology and clinical practice. The recommendations set out in this document were prepared following the AGREE methodology. The research questions were formulated according to the PICO format. A search of the literature published during the last 10 years was carried out. The recommendations were established by consensus among the entire group, specifying the existing strengths and limitations according to the level of evidence obtained. In conclusion, this document contains recommendations on the management, diagnosis, and treatment of TTP with the ultimate objective of developing guidelines based on the evidence published to date that allow healthcare professionals to optimize TTP treatment.
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Affiliation(s)
| | | | - Ataulfo González
- Servicio de Hematología y Hemoterapia, Hospital Universitario de San Carlos, Madrid, España
| | - Aurora Viejo Llorente
- Servicio de Hematología, Área de Hemoterapia, Hospital Universitario La Paz, Madrid, España
| | - David Valcarcel Ferreiras
- Unidad de Hematología Intensiva y Terapia Celular, Departamento de Hematología, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Faustino García Candel
- Sección de Hemostasia y Trombosis, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Inés Gómez Seguí
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Joan Cid
- Unidad de Aféresis y Terapia Celular, Servicio de Hemoterapia y Hemostasia, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Martínez Nieto
- Servicio de Hematología y Hemostasia, Hospital Universitario Clínico San Carlos. Instituto de Investigación Sanitaria San Carlos (IdissC), Madrid, España
| | - Luis Hernández Mateo
- Servicio de Hematología y Hemoterapia, Hospital General de Alicante, Valencia, España
| | - Rosa Goterris Viciedo
- Servicio de Hematología y Hemoterapia, Hospital Clínico Valencia. INCLIVA, Valencia, España
| | - Teresa Fidalgo
- Departamento de Hematología Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ramon Salinas
- Banc de Sang i Teixits de Catalunya, Barcelona, España
| | - Julio Del Rio-Garma
- Servicio de Transfusión. Servicio de Hematología. Complexo Hospitalario Universitario de Ourense, Galicia, España.
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25
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Buetler VA, Agbariah N, Schild DP, Liechti FD, Wieland A, Andina N, Hammann F, Kremer Hovinga JA. Immune-Mediated Thrombotic Thrombocytopenic Purpura Following mRNA-Based COVID-19 Vaccine BNT162b2: Case Report and Mini-Review of the Literature. Front Med (Lausanne) 2022; 9:890661. [PMID: 35655852 PMCID: PMC9152022 DOI: 10.3389/fmed.2022.890661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/29/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction An increasing number of case reports have associated vaccinations against coronavirus disease 2019 (COVID-19) with immune-mediated thrombotic thrombocytopenic purpura (iTTP), a very rare but potentially life-threatening thrombotic microangiopathy, which leads to ischemic organ dysfunction. Thrombus formation in iTTP is related to a severe deficiency of the specific von Willebrand-factor-cleaving protease ADAMTS13 due to ADAMTS13 autoantibodies. Methods We present a case of iTTP following exposure to the mRNA-based COVID-19 vaccine BNT162b2 (Comirnaty®, Pfizer-BioNTech). In addition, we review previously reported cases in the literature and assess current evidence. Results Apart from our case, twenty cases of iTTP occurring after COVID-19 vaccination had been published until the end of November 2021. There were 11 male and 10 female cases; their median age at diagnosis was 50 years (range 14–84 years). Five patients (24%) had a preexisting history of iTTP. Recombinant adenoviral vector-based vaccines were involved in 19%, mRNA-based vaccines in 81%. The median onset of symptoms after vaccination was 12 days (range 5–37), with 20 cases presenting within 30 days. Treatment included therapeutic plasma exchange in all patients. Additional rituximab, caplacizumab, or both these treatments were given in 43% (9/21), 14% (3/21), and 24% (5/21) of cases, respectively. One patient died, despite a prolonged clinical course in one patient, all surviving patients were in clinical remission at the end of the observational period. Conclusion Clinical features of iTTP following COVID-19 vaccination were in line with those of pre-pandemic iTTP. When timely initiated, an excellent response to standard treatment was seen in all cases. ADAMTS13 activity should be determined pre-vaccination in patients with a history of a previous iTTP episode. None of the reported cases met the WHO criteria for assessing an adverse event following immunization (AEFI) as a consistent causal association to immunization. Further surveillance of safety data and additional case-based assessment are needed.
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Affiliation(s)
- Vanessa Alexandra Buetler
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nada Agbariah
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Deborah Pia Schild
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian D Liechti
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Wieland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicola Andina
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Felix Hammann
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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26
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Bae SH, Kim SH, Bang SM. Recent advances in the management of immune-mediated thrombotic thrombocytopenic purpura. Blood Res 2022; 57:37-43. [PMID: 35483924 PMCID: PMC9057674 DOI: 10.5045/br.2022.2022005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially life-threatening thrombotic microangiopathy caused by autoantibody-mediated severe ADAMTS13 deficiency. TTP should be suspected in patients with microangiopathic hemolytic anemia and thrombocytopenia without a definite cause. Early detection of iTTP and prompt treatment with plasma exchange and corticosteroids are essential. Rituximab administration should be considered for refractory or relapsed iTTP, and can be used as a first-line adjuvant or preemptive therapy. Treatment with caplacizumab, a novel anti-von Willebrand factor nanobody, resulted in a faster time to platelet count response, significant reduction in iTTP-related deaths, and reduced incidence of refractory iTTP. TTP survivors showed a higher rate of chronic morbidities, including cardiovascular disease and neurocognitive impairment, which can lead to a poor quality of life and higher mortality rate. Meticulous long-term follow-up of TTP survivors is crucial.
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Affiliation(s)
- Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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27
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Joly BS, Roose E, Coppo P, Vanhoorelbeke K, Veyradier A. ADAMTS13 conformation is closed in non-immune acquired thrombotic thrombocytopenic purpura of unidentified pathophysiology. Haematologica 2022; 108:638-644. [PMID: 35484652 PMCID: PMC9892849 DOI: 10.3324/haematol.2022.280768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Bérangère S. Joly
- Service d’Hématologie Biologique, Hôpital Lariboisière, AP-HP.Nord, Université de Paris and EA3518, Institut Universitaire d’Hématologie, Hôpital Saint Louis, Université de Paris, Paris, France,A. VEYRADIER -
| | - Elien Roose
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium,A. VEYRADIER -
| | - Paul Coppo
- Département d’Hématologie Clinique, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris and Université Pierre et Marie Curie, Paris, France *BSY and ER contributed equally as co-first authors
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Agnès Veyradier
- Service d'Hématologie biologique, Hôpital Lariboisière, AP-HP.Nord, Université de Paris and EA3518, Institut Universitaire d'Hématologie, Hôpital Saint Louis, Université de Paris, Paris.
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28
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Graça NAG, Joly BS, Voorberg J, Vanhoorelbeke K, Béranger N, Veyradier A, Coppo P. TTP: From empiricism for an enigmatic disease to targeted molecular therapies. Br J Haematol 2022; 197:156-170. [PMID: 35146746 PMCID: PMC9304236 DOI: 10.1111/bjh.18040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022]
Abstract
The 100th anniversary of the first description of Thrombotic Thrombocytopenic Purpura (TTP) as a disease by Dr. Eli Moschcowitz approaches. For many decades, TTP remained mostly a mysterious fatal condition, where diagnosis was often post-mortem. Initially a pentad of symptoms was identified, a pattern that later revealed to be fallible. Sporadic observations led to empiric interventions that allowed for the first impactful breakthrough in TTP treatment, almost 70 years after its first description: the introduction of plasma exchange and infusions as treatments. The main body of knowledge within the field was gathered in the latest three decades: patient registries were set and proved crucial for advancements; the general mechanisms of disease have been described; the diagnosis was refined; new treatments and biomarkers with improvements on prognosis and management were introduced. Further changes and improvements are expected in the upcoming decades. In this review, we provide a brief historic overview of TTP, as an illustrative example of the success of translational medicine enabling to rapidly shift from a management largely based on empiricism to targeted therapies and personalized medicine, for the benefit of patients. Current management options and present and future perspectives in this still evolving field are summarized.
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Affiliation(s)
- Nuno A. G. Graça
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
| | - Bérangère S. Joly
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Nicolas Béranger
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Agnès Veyradier
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
- Service d'HématologieHôpital Saint‐Antoine, AP‐HPParisFrance
- Sorbonne UniversitéUPMC Univ ParisParisFrance
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29
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Koneczny I, Tzartos J, Mané-Damas M, Yilmaz V, Huijbers MG, Lazaridis K, Höftberger R, Tüzün E, Martinez-Martinez P, Tzartos S, Leypoldt F. IgG4 Autoantibodies in Organ-Specific Autoimmunopathies: Reviewing Class Switching, Antibody-Producing Cells, and Specific Immunotherapies. Front Immunol 2022; 13:834342. [PMID: 35401530 PMCID: PMC8986991 DOI: 10.3389/fimmu.2022.834342] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
Organ-specific autoimmunity is often characterized by autoantibodies targeting proteins expressed in the affected tissue. A subgroup of autoimmunopathies has recently emerged that is characterized by predominant autoantibodies of the IgG4 subclass (IgG4-autoimmune diseases; IgG4-AID). This group includes pemphigus vulgaris, thrombotic thrombocytopenic purpura, subtypes of autoimmune encephalitis, inflammatory neuropathies, myasthenia gravis and membranous nephropathy. Although the associated autoantibodies target specific antigens in different organs and thus cause diverse syndromes and diseases, they share surprising similarities in genetic predisposition, disease mechanisms, clinical course and response to therapies. IgG4-AID appear to be distinct from another group of rare immune diseases associated with IgG4, which are the IgG4-related diseases (IgG4-RLD), such as IgG4-related which have distinct clinical and serological properties and are not characterized by antigen-specific IgG4. Importantly, IgG4-AID differ significantly from diseases associated with IgG1 autoantibodies targeting the same organ. This may be due to the unique functional characteristics of IgG4 autoantibodies (e.g. anti-inflammatory and functionally monovalent) that affect how the antibodies cause disease, and the differential response to immunotherapies of the IgG4 producing B cells/plasmablasts. These clinical and pathophysiological clues give important insight in the immunopathogenesis of IgG4-AID. Understanding IgG4 immunobiology is a key step towards the development of novel, IgG4 specific treatments. In this review we therefore summarize current knowledge on IgG4 regulation, the relevance of class switching in the context of health and disease, describe the cellular mechanisms involved in IgG4 production and provide an overview of treatment responses in IgG4-AID.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Inga Koneczny,
| | - John Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Mané-Damas
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Maartje G. Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Konstantinos Lazaridis
- Department of Immunology, Laboratory of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Pilar Martinez-Martinez
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Socrates Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, UKSH Kiel/Lübeck, Kiel University, Kiel, Germany
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30
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Zhou M, Yin J. Complete recovery of deep venous thrombosis from Coombs (+) thrombotic thrombocytopenic purpura: case report. J Cardiothorac Surg 2022; 17:43. [PMID: 35313908 PMCID: PMC8935836 DOI: 10.1186/s13019-022-01789-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 03/13/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute thrombotic thrombocytopenic purpura (TTP) is an aggressive thrombotic microangiopathy that if not treated, can have a 90% mortality rate. Timely, extensive plasma exchange (PEX) has been indicated to reduce the mortality rate to < 10%, but its side effects are not well-known. We present here a case of a patient presented with Comb (+) TTP and developed catheter-associated deep vein thrombosis (DVT). Case presentation A 27-year-young man presented with persistent thrombocytopenia and Coombs positive anemia was firstly diagnosed with Evans syndrome. However, he was refractory to a methylprednisolone pulse therapy with a combination of platelet transfusion and eventually developed microangiopathy of central nerve system. Several pathological manifestations of the disease were prevented by PEX. The immediate start of PEX (1500 mL/d) induced a complete remission of acquired TTP and disappearance of neurological signs and symptoms. However, external iliac and femoro-popliteal venous thrombosis was diagnosed subsequently, inferior vena cava filter (IVC) filter was immediately implanted accompanied with anticoagulation therapy. Meanwhile, PEX session was sustained as well as oral anticoagulant (rivaroxaban). 14 days later, the patient got full recovery. Conclusions Catheter-related DVT under the setting of TTP should be cautious. It is necessary to start anticoagulation and antiplatelet therapy for thrombosis early, especially in such cases when PLT count > 50 × 109/L.
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Affiliation(s)
- Mi Zhou
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Yin
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated With Shandong First Medical University, Jinan, Shandong, China. .,Department of Cardiology, Shandong Province Qianfushan Hospital, Shandong University, Jinan, 250014, China.
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31
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Sukumar S, Brodsky M, Hussain S, Yanek L, Moliterno A, Brodsky R, Cataland SR, Chaturvedi S. Cardiovascular disease is a leading cause of mortality among TTP survivors in clinical remission. Blood Adv 2022; 6:1264-1270. [PMID: 34461629 PMCID: PMC8864652 DOI: 10.1182/bloodadvances.2020004169] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/03/2021] [Indexed: 11/20/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) survivors experience high rates of adverse health sequelae and increased mortality over long-term follow-up. We conducted this multicenter cohort study to evaluate long-term mortality and causes of death in iTTP survivors. Between 2003 and 2020, 222 patients were enrolled in the Ohio State University and Johns Hopkins TTP registries and followed for a median of 4.5 (interquartile range [IQR], 75 0.4-11.5) years. Nine patients died during their first iTTP episode, and 29 patients died during follow-up. Mortality rate was 1.8 times higher than expected from an age-, sex-, and race-adjusted reference population. Cardiovascular disease was a leading primary cause of death (27.6%) tied with relapsed iTTP (27.6%), followed by malignancy (20.7%), infection (13.8%), and other causes (10.3%). Male sex (hazard ratio [HR], 3.74; 95% confidence interval [CI], 1.65-8.48), increasing age (HR, 1.04; 95% CI, 1.01-1.07), and number of iTTP episodes (HR, 1.10; 95% CI, 1.01-1.20) were associated with mortality in a model adjusted for African American race (HR, 0.70; 95% CI, 0.30-1.65), hypertension (HR, 0.47; 95% CI, 0.20-1.08), chronic kidney disease (HR 1.46; 95% CI, 0.65-3.30), and site (HR, 1.46; 95% CI, 0.64-3.30). There was a trend toward shorter survival in patients with lower ADAMTS13 activity during remission (P = .078). Our study highlights the need for survivorship care and investigation focused on cardiovascular disease and early mortality in TTP survivors.
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Affiliation(s)
- Senthil Sukumar
- Division of Hematology, Department of Medicine, The Ohio State University College of Medicine, Columbus, OH
| | | | | | - Lisa Yanek
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Alison Moliterno
- Department of Medicine,
- Division of Hematology, Department of Medicine, and
| | - Robert Brodsky
- Department of Medicine,
- Division of Hematology, Department of Medicine, and
| | - Spero R. Cataland
- Division of Hematology, Department of Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Shruti Chaturvedi
- Department of Medicine,
- Division of Hematology, Department of Medicine, and
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32
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Severe Thrombotic Thrombocytopenic Purpura (TTP) with Organ Failure in Critically Ill Patients. J Clin Med 2022; 11:jcm11041103. [PMID: 35207375 PMCID: PMC8874413 DOI: 10.3390/jcm11041103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 01/27/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multiorgan disorder. Organ dysfunction occurs as a consequence of widespread microvascular thrombosis, especially in the heart, brain and kidney, causing transient or partial occlusion of vessels, resulting in organ ischemia. Intensive care unit (ICU) admission varies between 40% and 100% of patients with TTP, either because of severe organ failure or in order to initiate emergency plasma exchange (PEx). Severe neurologic manifestations and cardiac involvement have been associated with higher mortality. Acute kidney injury, although usually less severe than that in hemolytic and uremic syndrome, is common during TTP. Initial management in the ICU should always be considered in TTP patients. The current treatment of TTP in the acute phase is based on urgent PEx, combined with corticosteroid therapy, B-cell-targeted immunotherapy, rituximab and inhibition of the interaction between ultra-large Von Willebrand factor multimers and platelets, using caplacizumab, a monoclonal antibody. ICU management permits close monitoring and the rapid introduction of life-sustaining therapies. This review details the epidemiology of TTP in the ICU, organ failures of critically ill patients with TTP, and the initial management of TTP patients in the ICU.
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Subhan M, Scully M. Advances in the management of TTP. Blood Rev 2022; 55:100945. [DOI: 10.1016/j.blre.2022.100945] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
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Deucher W, Sukumar S, Cataland SR. Clinical relapse of immune-mediated thrombotic thrombocytopenic purpura following COVID-19 vaccination. Res Pract Thromb Haemost 2022; 6:e12658. [PMID: 35155977 PMCID: PMC8822264 DOI: 10.1002/rth2.12658] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/17/2021] [Accepted: 12/08/2021] [Indexed: 12/13/2022] Open
Abstract
De novo and relapsed immune-mediated thrombotic thrombocytopenic purpura (iTTP) have been documented to have occurred following severe acute respiratory syndrome coronavirus 2 (COVID-19) vaccination. Here, we present a case of a 28-year-old woman who received the tozinameran (BNT162b2, Pfizer-BioNtech) vaccine for COVID-19 and experienced an iTTP relapse during longitudinal follow-up. She received the vaccine 30 months after her initial diagnosis, while she was in clinical remission. She was not in complete ADAMTS-13 remission, as she had undetectable ADAMTS-13 activity during follow-up except for one isolated measurement of 48%. Shortly after vaccination, she developed complaints of bruising, petechiae, ataxia, and an episode of slurred speech. Laboratory testing demonstrated thrombocytopenia, schistocytes, and eventually undetectable ADAMTS-13 activity. She was successfully treated with caplacizumab, rituximab, and corticosteroids without plasma exchange. She achieved complete clinical and ADAMTS-13 remission after treatment. We recommend caution in the administration of COVID-19 vaccines for survivors of iTTP in remission with severely deficient ADAMTS-13 activity.
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[Chinese guideline on the diagnosis and management of thrombotic thrombocytopenic purpura (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:7-12. [PMID: 35231985 PMCID: PMC8980665 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eller K, Knoebl P, Bakkaloglu SA, Menne JJ, Brinkkoetter PT, Grandt L, Thiem U, Coppo P, Scully M, Haller MC. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1229-1234. [PMID: 35195251 PMCID: PMC9217651 DOI: 10.1093/ndt/gfac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Paul Knoebl
- Division of Haematology and Haemostasis, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sevcan A Bakkaloglu
- Department of Paediatric Nephrology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Jan J Menne
- KRH Klinikum Mitte – Location Siloah, Hannover, Germany
| | - Paul T Brinkkoetter
- Department II of Internal Medicine and Centre for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Leonie Grandt
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Ursula Thiem
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Paul Coppo
- Department of Haematology, Reference Centre for Thrombotic Microangiopathies, Saint-Antoine University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Scully
- Department of Haematology, University College London Hospitals, London, UK
| | - Maria C Haller
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
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Westwood JP, Scully M. Management of acquired, immune thrombocytopenic purpura (iTTP): beyond the acute phase. Ther Adv Hematol 2022; 13:20406207221112217. [PMID: 35923772 PMCID: PMC9340390 DOI: 10.1177/20406207221112217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Modern therapy for acute TTP has resulted in a dramatic improvement in
outcomes, with the combination of plasma exchange, immunosuppression,
and caplacizumab being associated with >90% survival rates
following an acute episode. TTP is no longer associated with just the
acute episode, but requires long-term follow-up. There remains
significant morbidity associated with acute TTP, and many patients
suffer marked neuropsychological sequelae, including impairment in
cognitive functioning, affective disorders, and reduction in
health-related quality of life measures. The focus of management
beyond the acute phase centres on relapse prevention,
via careful monitoring of patients and the use
of either ad hoc or regular immunosuppressive therapies. The main
therapy used is rituximab, but despite more limited evidence, other
immunosuppressive therapies may be required to aim for normalisation
of ADAMTS 13 activity. Follow-up with a reduction in ADAMTS 13
activity levels (ADAMTS 13 relapse), rituximab is central to
normalisation of activity levels and prevention of a clinical relapse.
Fundamental to elective therapy is the role of ADAMTS 13 activity
monitoring, and impact of reduced ADAMTS13 activity on end organ
damage. This review discusses monitoring and treatment strategy for
long-term management of TTP, including the variety of therapies
available to maintain remission, prevent relapse and a summary of a
long-term treatment pathway.
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Affiliation(s)
| | - Marie Scully
- Department of Haematology, UCLH, London, UK
- National Institute for Health Research Cardiometabolic Programme, UCLH/UCL Cardiovascular BRC, 250 Euston Road, NW1 2PG London, UK
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Botero JP, Reese JA, George JN, McIntosh JJ. Severe thrombocytopenia and microangiopathic hemolytic anemia in pregnancy: A guide for the consulting hematologist. Am J Hematol 2021; 96:1655-1665. [PMID: 34424560 PMCID: PMC8616841 DOI: 10.1002/ajh.26328] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/13/2022]
Abstract
A hematologist receives a call from a maternal-fetal medicine (MFM) physician about a previously healthy patient who became ill at 25 weeks' gestation. Her mental status is deteriorating. There are signs of fetal distress. Platelet count and hemoglobin are falling. The MFM physician is considering the hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. For the hematologist, everything seems unfamiliar. Our goal is to provide hematologists with the fundamental knowledge required for understanding and managing these patients who become suddenly and seriously ill during pregnancy and in whom thrombocytopenia and microangiopathic hemolytic anemia are part of their presentation.
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Affiliation(s)
- Juliana Perez Botero
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Versiti (Blood Center of Wisconsin), Milwaukee, Wisconsin, USA
| | - Jessica A. Reese
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - James N. George
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, USA
- Hematology-Oncology Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jennifer J. McIntosh
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Updates on thrombotic thrombocytopenic purpura: Recent developments in pathogenesis, treatment and survivorship. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Pavenski K, Huang SHS, Patriquin CJ. Predictors of relapse and preventative strategies in immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:1027-1040. [PMID: 34747320 DOI: 10.1080/17474086.2021.2003703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare autoimmune blood disorder, which presents with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis and is caused by severe deficiency of ADAMTS13. iTTP may result in both acute and chronic complications and is rapidly fatal without expedient treatment. Life-time risk of relapse is approximately 40%. AREAS COVERED A number of predictors of relapse has been described in the literature. The most well-studied predictor of relapse is persistent ADAMTS13 deficiency; however, it is not a perfect marker. Relapse can be prevented by treatment with immunosuppressive medications, with rituximab being the most studied. EXPERT OPINION Patients who recover from iTTP should be regularly assessed, including with ADAMTS13 activity testing. The optimal frequency of assessments has not been established, but every 3 months is recommended. Considering the potential for significant organ damage and mortality associated with iTTP relapse, patients in remission and with persistent ADAMTS13 activity of 10-20% should be prophylactically treated with immunosuppression. Additional markers to precisely identify patients at higher risk of relapse are needed.
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Affiliation(s)
- Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Shih-Han Susan Huang
- Department of Medicine, Division of Nephrology, Western University, London, Canada
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
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Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy. It is caused by a severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs, 13) deficiency due to circulating autoantibodies, and is associated with significant morbidity and mortality. Current treatment options include plasma exchange, immunosuppression, and caplacizumab. When remission is achieved, the risk of relapse is high, especially in patients with persistent ADAMTS13 deficiency. We report the eradication of persistent ADAMTS13 inhibitory autoantibodies and restoration of normal ADAMTS13 activity using the anti-CD38 antibody daratumumab in two patients with iTTP. One patient had a frequently relapsing course, and the other a treatment-refractory first episode. There were no relevant adverse drug reactions.
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43
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[Treatment of immune-mediated thrombotic thrombocytopenic purpura: A decisive turning point]. Transfus Clin Biol 2021; 28:380-385. [PMID: 34464709 DOI: 10.1016/j.tracli.2021.08.347] [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: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening thrombotic microangiopathy characterized by severe deficiency of ADAMTS13, the enzyme that cleaves von Willebrand factor multimers. Recent insights into iTTP pathophysiology have led to the development of new therapies targeting ADAMTS13 replacement, anti-ADAMTS13 antibodies, and von Willebrand factor-platelet interactions. New maximalist therapeutic strategies are emerging based on triple therapy. While plasma exchange remains the cornerstone therapy of the acute phase, the introduction of front-line immunosuppressive treatments, corticosteroids and rituximab, has led to a reduction in exacerbations and relapses but without any significant improvement in survival. Caplacizumab, a bivalent humanized anti-von Willebrand factor nanobody, is poised to revolutionize the treatment of the acute phase. By inhibiting the interaction between von Willebrand factor multimers and platelets, caplacizumab prevents platelets adhesion, prevents the formation of new microthrombi and protects organs from ischemia. Its early combination with plasma exchange and immunosuppressive therapy prevents unfavorable outcomes and reduces the burden of care. Supported by repeated ADAMTS13 assays, rituximab prevents relapse in patients with persistent or recurrent ADAMTS13 deficiency in clinical remission. This review examines how advances in diagnostics and targeted therapies are changing the current treatment paradigm in both the acute and remission phases and are contributing to dramatically improve the iTTP prognosis.
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Van de Louw A, Mariotte E, Darmon M, Cohrs A, Leslie D, Azoulay E. Outcomes in 1096 patients with severe thrombotic thrombocytopenic purpura before the Caplacizumab era. PLoS One 2021; 16:e0256024. [PMID: 34383822 PMCID: PMC8360509 DOI: 10.1371/journal.pone.0256024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/28/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a diagnostic and therapeutic emergency. Therapeutic plasma exchange (TPE) combined with immunosuppression has been the cornerstone of the initial management. To produce optimal benefits, emerging treatments must be used against a background of best standard of care. Clarifying current uncertainties is therefore crucial. METHODS The objective of this study was to analyze a large high-quality database (Marketscan) of TTP patients managed between 2005 and 2014, in the pre-caplacizumab era, in order to assess the impact of time to first TPE and use of first-line rituximab on mortality, and whether mortality declines over time. RESULTS Among the 1096 included patients (median age 46 [IQR 35-55], 70% female), 28.8% received TPE before day 2 in the ICU. Hospital mortality was 7.6% (83 deaths). Mortality was independently associated with older age (hazard ratio [HR], 1.024/year; 95% confidence interval [95%CI], [1.009-1.040]), diagnosis of sepsis (HR, 2.360; 95%CI [1.552-3.588]), and the need for mechanical ventilation (HR, 4.103; 95%CI, [2.749-6.126]). Factors independently associated with lower mortality were TPE at ICU admission (HR, 0.284; 95%CI, [0.112-0.717]), TPE within one day after ICU admission (HR, 0.449; 95%CI, [0.275-0.907]), and early rituximab therapy (HR, 0.229; 95% CI, [0.111-0.471]). Delayed TPE was associated with significantly higher costs. CONCLUSIONS Immediate TPE and early rituximab are associated with improved survival in TTP patients. Improved treatments have led to a decline in mortality over time, and alternate outcome variables such as the use of hospital resources or longer term outcomes therefore need to be considered.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, United States of America
| | - Eric Mariotte
- Intensive Care Department, University of Paris, Saint-Louis Hospital, Paris, France
| | - Michael Darmon
- Intensive Care Department, University of Paris, Saint-Louis Hospital, Paris, France
| | - Austin Cohrs
- Department of Public Health Sciences, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, United States of America
| | - Douglas Leslie
- Department of Public Health Sciences, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, United States of America
| | - Elie Azoulay
- Intensive Care Department, University of Paris, Saint-Louis Hospital, Paris, France
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Gómez-Seguí I, Pascual Izquierdo C, de la Rubia Comos J. Best practices and recommendations for drug regimens and plasma exchange for immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:707-719. [PMID: 34275393 DOI: 10.1080/17474086.2021.1956898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. TTP pathophysiology is based on a severe ADAMTS13 deficiency, and is a medical emergency with fatal outcome if appropriate treatment is not initiated promptly. AREAS COVERED Authors will review the best options currently available to minimize mortality, prevent relapses, and obtain the best clinical response in patients with immune TTP (iTTP). Available bibliography about iTTP treatment has been searched in Library's MEDLINE/PubMed database from January 1990 until April 2021. EXPERT OPINION The generalized use of plasma exchange marked a paradigm in the management of iTTP. In recent years, strenuous efforts have been done for a better understanding of the pathophysiology of this disease, improve diagnosis, optimize treatment, reduce mortality, and prevent recurrences. The administration of front-line rituximab and, more recently, the availability of caplacizumab, the first targeted therapy for iTTP, have been steps toward a further reduction in early mortality and for the prevention of relapses.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio De Hematología Y Hemoterapia, Hospital General , Universitario Gregorio Marañón. Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier de la Rubia Comos
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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A regimen with caplacizumab, immunosuppression, and plasma exchange prevents unfavorable outcomes in immune-mediated TTP. Blood 2021; 137:733-742. [PMID: 33150928 DOI: 10.1182/blood.2020008021] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022] Open
Abstract
The anti-von Willebrand factor nanobody caplacizumab was licensed for adults with immune-mediated thrombotic thrombocytopenic purpura (iTTP) based on prospective controlled trials. However, few data are available on postmarketing surveillance. We treated 90 iTTP patients with a compassionate frontline triplet regimen associating therapeutic plasma exchange (TPE), immunosuppression with corticosteroids and rituximab, and caplacizumab. Outcomes were compared with 180 historical patients treated with the standard frontline treatment (TPE and corticosteroids, with rituximab as salvage therapy). The primary outcome was a composite of refractoriness and death within 30 days since diagnosis. Key secondary outcomes were exacerbations, time to platelet count recovery, the number of TPE, and the volume of plasma required to achieve durable remission. The percentage of patients in the triplet regimen with the composite primary outcome was 2.2% vs 12.2% in historical patients (P = .01). One elderly patient in the triplet regimen died of pulmonary embolism. Patients from this cohort experienced less exacerbations (3.4% vs 44%, P < .01); they recovered durable platelet count 1.8 times faster than historical patients (95% confidence interval, 1.41-2.36; P < .01), with fewer TPE sessions and lower plasma volumes (P < .01 both). The number of days in hospital was 41% lower in the triplet regimen than in the historical cohort (13 vs 22 days; P < .01). Caplacizumab-related adverse events occurred in 46 patients (51%), including 13 major or clinically relevant nonmajor hemorrhagic events. Associating caplacizumab to TPE and immunosuppression, by addressing the 3 processes of iTTP pathophysiology, prevents unfavorable outcomes and alleviates the burden of care.
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Pattern of Brain Injury in Patients With Thrombotic Thrombocytopenic Purpura in the Precaplacizumab Era. Crit Care Med 2021; 49:e931-e940. [PMID: 34166282 DOI: 10.1097/ccm.0000000000005164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe short- and long-term neurologic prognosis of patients with thrombotic thrombocytopenic purpura and to identify clusters associated with evolution. DESIGN Prospective French cohort. SETTING ICU in a reference center. PATIENTS All consecutive patients with newly diagnosed thrombocytopenic purpura. INTERVENTION Comprehensive clinical, biological, and radiological evaluation at admission. Neurocognitive recovery was assessed using Glasgow Outcome Scale (range 1-5, with 1 representing death and 5 representing no or minimal neurologic deficit). MEASUREMENTS AND MAIN RESULTS Among the 130 newly diagnosed patients with thrombocytopenic purpura, 108 (83%; age 43 [30-52]; 73% women) presented with neurologic signs, including headaches (51%), limb weakness, paresthesia, and/or aphasia (49%), pyramidal syndrome (30%), decreased consciousness (20%), seizure (19%), cognitive impairment (34%), cerebellar syndrome (18%), and visual symptoms (20%). A hierarchical cluster analysis identified three distinct groups of patients. Cluster 1 included younger patients (37 [27-48], 41 [32-52], and 48 [35-54], in clusters 1, 2 and 3, respectively; p = 0.045), with a predominance of headaches (75%, 27%, and 36%; p < 0.0001). Cluster 2 patients had ataxic gait and cerebellar syndrome (77%, 0%, and 0%; p < 0.0001) and dizziness (50%, 0%, and 0%; p < 0.0001). Cluster 3 included patients with delirium (36%, 0%, and 9%; p < 0.0001), obtundation (58%, 0%, and 24%; p < 0.0001), and seizure (36%, 0%, and 14%; p < 0.0001). Acute kidney injury was 32%, 68%, and 77%, in clusters 1, 2, and 3, respectively (p < 0.0001). The three clusters did not differ for other biological or brain imaging. After a median follow-up of 34 months (12-71 mo), 100 patients (93%) were alive with full neurocognitive recovery (i.e., Glasgow Outcome Scale score 5) in 89 patients (89%). Patients from cluster 1 more frequently exhibited full recovery (Glasgow Outcome Scale score of 5) compared with clusters 2 and 3, (44 [98%], 13 [65%], and 21 [60%] at 3 mo; p < 0.0001), (44 [100%], 15 [68%], and 23 [69%] at 6 mo; p < 0.0001), and (40 [100%], 15 [79%], and 20 [57%] at 1 yr; p < 0.0001). CONCLUSIONS Initial clinical neurologic evaluation in thrombocytopenic purpura patients distinguishes three groups of patients with different clinical and functional outcomes.
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [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: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Rituximab leads to early elimination of circulating CD20+ T and B lymphocytes in patients with iTTP despite ongoing TPEx. Blood Adv 2021; 4:477-481. [PMID: 32027742 DOI: 10.1182/bloodadvances.2019001148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/30/2019] [Indexed: 11/20/2022] Open
Abstract
Key Points
How TPEx impacts rituximab effectiveness in iTTP patients is not fully understood. In iTTP patients on therapeutic plasma exchange, rituximab eliminates circulating CD20+ B and T cells in 24 hours for at least 1 week.
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50
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Cost savings to hospital of rituximab use in severe autoimmune acquired thrombotic thrombocytopenic purpura. Blood Adv 2021; 4:539-545. [PMID: 32045473 DOI: 10.1182/bloodadvances.2019000827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022] Open
Abstract
Patients with severe autoimmune thrombotic thrombocytopenic purpura (TTP) experience acute hematologic emergencies during disease flares and a lifelong threat for relapse. Rituximab, in addition to steroids and therapeutic plasma exchange (TPE), has been shown to mitigate relapse risk. A barrier to care in initiating rituximab in the inpatient setting has been the presumed excessive cost of medication to the hospital. Retrospectively reviewing TTP admissions from 2004 to 2018 at our academic center, we calculated the actual inpatient cost of care. We then calculated the theoretical cost to the hospital of initiating rituximab in the inpatient setting for both initial TTP and relapse TTP cohorts, with the hypothesis that preventing sufficient future TTP admissions offsets the cost of initiating rituximab in all patients with TTP. At a median follow-up of 55 months in the initial TTP cohort, rituximab use produced a projected cost savings of $905 906 and would have prevented 185 inpatient admission days and saved 137 TPE procedures. In the relapse TTP setting, rituximab use produced a projected cost savings of $425 736 and would have prevented 86 inpatient admission days and saved 64 TPE procedures. From a hospital cost standpoint, cost of rituximab should no longer be a barrier to initiating inpatient rituximab in both initial and relapse TTP settings.
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