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Issa L, Sandakly N, El Koubayati G, Khalil M, Haddad F. Renal Involvement in Thrombotic Thrombocytopenic Purpura: Is It Time to Challenge the Old Paradigm? Cureus 2024; 16:e60259. [PMID: 38872662 PMCID: PMC11170236 DOI: 10.7759/cureus.60259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/15/2024] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is clinical-pathological entity characterized by microangiopathic hemolytic anemia associated with end-organ dysfunction. Traditionally, TTP was characterized by the classic pentad of fever, thrombocytopenia, hemolytic anemia, renal impairment, and neurological manifestations. However, this classic pentad is only observed in 40% of cases. We herein describe the case of a female patient who presented with epigastric pain and vomiting and found to have TTP without the classic pentad but with rapidly progressive renal dysfunction.
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Affiliation(s)
- Lea Issa
- Internal Medicine, Faculty of Medicine, Lebanese University, Beirut, LBN
| | - Nicolas Sandakly
- Internal Medicine, Faculty of Medicine, Lebanese University, Beirut, LBN
| | | | - Majd Khalil
- Cardiology, Lebanese Hospital Geitaoui, Beirut, LBN
| | - Fady Haddad
- Internal Medicine and Clinical Immunology, Lebanese Hospital Geitaoui, Beirut, LBN
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2
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Brooks MB, Goggs R, Frye AH, Armato J, Forman M, Hertl J, Koch M, Loftus JP, Lucy J, Mattison B, Merriam J, Shropshire S, Van Vertloo L, Viall A, LeVine DN. A prospective cohort study to identify clinical diagnostic and prognostic markers of primary immune thrombocytopenia in dogs. J Vet Intern Med 2024; 38:1022-1034. [PMID: 38205735 PMCID: PMC10937499 DOI: 10.1111/jvim.16985] [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: 05/24/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Primary immune thrombocytopenia (pITP) in dogs presents a diagnostic challenge, and clinical markers of severity are lacking. OBJECTIVES Identify clinicopathologic features that differentiate pITP from secondary ITP (sITP) and markers related to bleeding severity, transfusion, and survival of dogs with pITP. ANIMALS Ninety-eight thrombocytopenic dogs (58 pITP and 40 sITP). METHODS Client-owned dogs with platelet counts <50 000/μL were enrolled in a prospective, multi-institution cohort study. History and treatment information, through a maximum of 7 days, was recorded on standard data forms. Bleeding severity was scored daily using a bleeding assessment tool (DOGiBAT). At-admission blood samples were collected for CBC, biochemistry, C-reactive protein concentration, and coagulation panels, and to measure platelet surface-associated immunoglobulin G (PSAIg) and expression of platelet membrane proteins and phospholipids. Dogs with evidence of coincident disease were classified as sITP. RESULTS No definitive pITP diagnostic test was found. However, pITP cases were characterized by lower platelet counts, D dimer concentrations, and platelet membrane protein expression than sITP cases. Differentiation between pITP and sITP was further enhanced using logistic regression modeling combining patient sex, coagulation profile, platelet count, D dimer, and PSAIg. A second model of pITP severity indicated that low hematocrit and high BUN concentration were associated with non-survival. Low hematocrit at admission, but not platelet count or DOGiBAT score, was associated with transfusion. CONCLUSIONS AND CLINICAL IMPORTANCE Pending validation studies, models constructed from at-admission clinicopathologic findings may improve differentiation of pITP from sITP and identify the most severe pITP cases at the time of presentation.
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Affiliation(s)
- Marjory B. Brooks
- Population Medicine & Diagnostic SciencesCornell University, 240 Farrier RoadIthaca, New York 14853USA
| | - Robert Goggs
- Clinical Sciences, C3‐502D Clinical Programs CenterCornell University, 930 Campus RoadIthaca, New York 14853‐0001USA
| | - Amelia H. Frye
- Population Medicine & Diagnostic SciencesCornell University, 240 Farrier RoadIthaca, New York 14853USA
| | - Jessica Armato
- Internal MedicineCornell University Veterinary SpecialistsStamfordConnecticutUSA
| | - Marnin Forman
- Internal MedicineCornell University Veterinary SpecialistsStamfordConnecticutUSA
| | - Julia Hertl
- Population Medicine & Diagnostic SciencesCornell University, 240 Farrier RoadIthaca, New York 14853USA
| | - Michael Koch
- Veterinary Internal Medicine ConsultingRochesterNew YorkUSA
| | - John P. Loftus
- Clinical SciencesCollege of Veterinary Medicine, Cornell University, 930 Campus RoadIthaca, New York 14853USA
| | - John Lucy
- Internal Medicine, Oradell Animal HospitalParamusNew JerseyUSA
| | - Brandi Mattison
- Arizona Veterinary Emergency & Critical Care CenterPeoriaArizonaUSA
| | - Julia Merriam
- Blue Pearl Pet Hospital NorthfieldNorthfieldIllinoisUSA
| | | | - Laura Van Vertloo
- Veterinary Clinical SciencesCollege of Veterinary Medicine, Iowa State UniversityAmesIowaUSA
| | - Austin Viall
- Department of Pathology, Microbiology and ImmunologyUniversity of California, DavisDavisCaliforniaUSA
| | - Dana N. LeVine
- Veterinary Clinical SciencesCollege of Veterinary Medicine, Auburn University, 1600 S 16th StAuburn, Alabama 36849USA
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3
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Hu L, Wang J, Jin X, Lu G, Fang M, Shen J, Tung TH, Shen B. Stress-induced hyperglycemia is associated with the mortality of thrombotic thrombocytopenic purpura patients. Diabetol Metab Syndr 2024; 16:44. [PMID: 38360738 PMCID: PMC10870494 DOI: 10.1186/s13098-024-01275-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy with a rapid progression and high mortality rate. We aimed to explore early risk factors for mortality in patients with TTP. METHODS We conducted a retrospective analysis of 42 TTP patients that were admitted to our hospital between 2000 and 2021, with a median age of 49 (29-63) years. Risk factors for mortality were evaluated using multivariate logistic regression. Receiver operating characteristic curve analysis was used to determine the cut-off value of glucose for predicting mortality in patients, which was validated by comparison to a similar cohort in the published literature. RESULTS Elevated glucose level and reduced red blood cells (RBC) counts were risk factors for mortality in patients with TTP (glucose, odds ratio and 95% confidence interval: 2.476 [1.368-4.484]; RBC, odds ratio and 95% confidence interval: 0.095 [0.011-0.799]). The area under the curve of glucose was 0.827, and the cut-off value was 9.2 mmol/L, with a sensitivity of 75.0% and specificity of 95.8%. A total of 26 cases from the validation cohort had a sensitivity of 71.0% and a specificity of 84.0%. The change trends of the TTP-related laboratory indices differed during hospitalization. CONCLUSION Hyperglycemia at admission and unstable blood glucose levels during hospitalization may be potential predictors of mortality for TTP patients. The improved prognosis was associated with the recovery of platelet counts and a significant decrease in serum lactate dehydrogenase after five days of treatment.
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Affiliation(s)
- Lingling Hu
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Jing Wang
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Xiaxia Jin
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Guoguang Lu
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Meidan Fang
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China
| | - Jian Shen
- Department of Hematology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China.
| | - Bo Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, 150 Ximen Road, Linhai, Taizhou, Zhejiang Province, China.
- Key Laboratory of System Medicine and Precision Diagnosis and Treatment of Taizhou, Taizhou, China.
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Lester W. Immune thrombotic thrombocytopenic purpura in patients over 60 years of age: Diagnostic pitfalls and treatment strategy. Br J Haematol 2023; 203:704-705. [PMID: 37749067 DOI: 10.1111/bjh.19123] [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: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
Real-world registry studies of older patients with iTTP highlight diagnostic difficulties in comparison to patients less than 60 years of age with greater risk of renal injury, atypical neurological features and less profound cytopenia, which can result in diagnostic delays. However, there is no clear signal of significantly increased toxicity from full active treatment. Commentary on: Gómez-Seguí et al. Immune thrombotic thrombocytopenic purpura in older patients: results from the Spanish TTP Registry (REPTT). Br J Haematol 2023;203:860-871.
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Affiliation(s)
- Will Lester
- University Hospitals Birmingham, Birmingham, UK
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5
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Gómez-Seguí I, Francés Aracil E, Mingot-Castellano ME, Vara Pampliega M, Goterris Viciedo R, García Candel F, Pascual Izquierdo C, Del Río Garma J, Guerra Domínguez L, Vicuña Andrés I, Garcia-Arroba Peinado J, Zalba Marcos S, Vidan Estévez JM, González Arias E, Campuzano Saavedra V, García Gala JM, Ortega Sanchez S, Martínez Nieto J, Pardo Gambarte L, Solé Rodríguez M, Fernández-Docampo M, Avila Idrovo LF, Hernández L, Cid J, de la Rubia Comos J. Immune thrombotic thrombocytopenic purpura in older patients: Results from the Spanish TTP Registry (REPTT). Br J Haematol 2023; 203:860-871. [PMID: 37723363 DOI: 10.1111/bjh.19109] [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: 06/06/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is an ultra-rare disease that seldom occurs in the elderly. Few reports have studied the clinical course of iTTP in older patients. In this study, we have analysed the clinical characteristics at presentation and response to therapy in a series of 44 patients with iTTP ≥60 years at diagnosis from the Spanish TTP Registry and compared them with 209 patients with <60 years at diagnosis from the same Registry. Similar symptoms and laboratory results were described in both groups, except for a higher incidence of renal dysfunction among older patients (23% vs. 43.1%; p = 0.008). Front-line treatment in patients ≥60 years was like that administered in younger patients. Also, no evidence of a difference in clinical response and overall survival was seen in both groups. Of note, 14 and 25 patients ≥60 years received treatment with caplacizumab and rituximab, respectively, showing a favourable safety and efficacy profile, like that observed in patients <60 years.
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Affiliation(s)
- I Gómez-Seguí
- H. Universitario y Politécnico La Fe, Valencia, Spain
| | | | - M E Mingot-Castellano
- Hematology Department, Instituto de Biomedicina de Sevilla, H. U. Virgen del Rocio, Sevilla, Spain
| | | | | | | | | | - J Del Río Garma
- Complejo Hospitalario Universitario de Orense, Ourense, Spain
| | | | | | | | | | | | | | | | | | - S Ortega Sanchez
- Banc de Sang i Teixits, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Martínez Nieto
- Instituto de Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | | | | | - J Cid
- H. Clínic, Barcelona, Spain
| | - J de la Rubia Comos
- H. Universitario y Politécnico La Fe, Valencia, Spain
- Hematology Department, Universidad Católica "San Vicente Mártir", Valencia, Spain
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Zafrani L, Canet E, Walter-Petrich A, Joly-Laffargue B, Veyradier A, Faguer S, Bigé N, Calvet L, Mayaux J, Grangé S, Rafat C, Poulain C, Klouche K, Perez P, Pène F, Pichereau C, Duceau B, Mariotte E, Chevret S, Azoulay E. Magnesium sulphate in patients with thrombotic thrombocytopenic purpura (MAGMAT): a randomised, double-blind, superiority trial. Intensive Care Med 2023; 49:1293-1304. [PMID: 37867165 DOI: 10.1007/s00134-023-07178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/24/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Studies have suggested benefits from magnesium sulphate in thrombotic thrombocytopenic purpura (TTP). We aimed to measure the effects of magnesium sulphate supplementation on TTP recovery. METHODS In this multicenter, randomised, double-blind, controlled, superiority study, we enrolled adults with a clinical diagnosis of TTP. Patients were randomly allocated to receive magnesium sulphate (6 g intravenously followed by a continuous infusion of 6 g/24 h for 3 days) or placebo, in addition to the standard treatment. The primary outcome was the median time to platelet normalisation (defined as a platelet count ≥ 150 G/L). Efficacy and safety were assessed by intention-to-treat. RESULTS Overall, we enrolled 74 participants, including one who withdrew his/her consent. Seventy-three patients were further analyzed, 35 (48%) allocated to magnesium sulphate and 38 (52%) to placebo. The median time to platelet normalisation was 4 days (95% confidence interval [CI], 3-4) in the magnesium sulphate group and 4 days (95% CI 3-5) in the placebo group. The cause-specific hazard ratio of response was 0.93 (95% CI 0.58-1.48, p = 0.75). The number of patients with ≥ 1 serious adverse reactions was similar in the two groups. By day 90, four patients in the magnesium sulphate group and two patients in the placebo group had died (p = 0.42). The most frequent adverse event was low blood pressure occurring in 34% in the magnesium sulphate group and 29% in the placebo group (p = 0.80). CONCLUSION Among patients with TTP, the addition of magnesium sulphate to the standard of care did not result in a significant improvement in time to platelet normalisation.
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Affiliation(s)
- Lara Zafrani
- Department of Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France.
- INSERM U944, Saint-Louis Research Institute, University of Paris Cité, Paris, France.
| | - Emmanuel Canet
- Department of Medical Intensive Care Unit, Nantes University Hospital, Nantes University, Nantes, France
| | - Anouk Walter-Petrich
- Department of Biostatistics, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, INSERM S 717, Paris, France
| | - Bérangère Joly-Laffargue
- Service d'Hématologie Biologique, Lariboisière Hospital and EA3518, Institut de Recherche Saint-Louis, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Agnès Veyradier
- Service d'Hématologie Biologique, Lariboisière Hospital and EA3518, Institut de Recherche Saint-Louis, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Stanislas Faguer
- Department of Nephrology and Organ Transplantation, National Reference Center for Rare Kidney Diseases, University Hospital of Toulouse, INSERM UMR 1297 (I2MC), Toulouse, France
| | - Naïke Bigé
- Department of Medical Intensive Care Unit, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Laure Calvet
- Department of Medical Intensive Care Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Julien Mayaux
- Department of Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Steven Grangé
- Department of Nephrology, Rouen University Hospital, Rouen, France
| | - Cédric Rafat
- Service de Soins Intensifs Néphrologiques et Rein Aigu (SINRA), French Intensive Renal Network, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Coralie Poulain
- Department of Nephrology Internal Medicine Dialysis Transplantation, Amiens University Medical Center, F-80054, Amiens, France
| | - Kada Klouche
- Intensive Care Medicine Department, Lapeyronie University Hospital, Montpellier, France
| | - Pierre Perez
- Medical Intensive Care Unit, Brabois Hospital, Vandoeuvre Les Nancy, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Assistance Publique -Hôpitaux de Paris, University of Paris Cité, Cochin Institute, INSERM U1016, CNRS UMR8104, Paris, France
| | - Claire Pichereau
- Department of Intensive Care Unit, Poissy Saint Germain en Laye Hospital, Poissy, France
| | - Baptiste Duceau
- Department of Anesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Eric Mariotte
- Department of Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Sylvie Chevret
- Department of Biostatistics, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, INSERM S 717, Paris, France
| | - Elie Azoulay
- Department of Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France
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Sukumar S, Mazepa MA, Chaturvedi S. Cardiovascular Disease and Stroke in Immune TTP-Challenges and Opportunities. J Clin Med 2023; 12:5961. [PMID: 37762903 PMCID: PMC10531888 DOI: 10.3390/jcm12185961] [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: 06/29/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Advances in the management of immune thrombotic thrombocytopenic purpura (iTTP) have dramatically improved outcomes of acute TTP episodes, and TTP is now treated as a chronic, relapsing disorder. It is now recognized that iTTP survivors are at high risk for vascular disease, with stroke and myocardial infarction occurring at younger ages than in the general population, and cardiovascular disease is the leading cause of premature death in this population. iTTP appears to have a phenotype of accelerated vascular aging with a particular predilection for cerebral circulation, and stroke is much more common than myocardial infarction. In addition to traditional cardiovascular risk factors, low ADAMTS13 activity during clinical remission may be a risk factor for some of these outcomes, such as stroke. Recent studies also suggest that Black patients, who are disproportionately affected by iTTP in the United States, are at higher risk of adverse cardiovascular outcomes, likely due to multifactorial reasons. Additional research is required to establish the risk factors and mechanisms underlying these complications in order to institute optimal screening strategies and identify interventions to improve outcomes.
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Affiliation(s)
- Senthil Sukumar
- Division of Hematology/Oncology, Department of Medicine, Baylor College of Medicine, Houston, TX 77098, USA;
| | - Marshall A. Mazepa
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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8
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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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9
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Joseph A, Joly BS, Picod A, Veyradier A, Coppo P. The Specificities of Thrombotic Thrombocytopenic Purpura at Extreme Ages: A Narrative Review. J Clin Med 2023; 12:jcm12093068. [PMID: 37176509 PMCID: PMC10179719 DOI: 10.3390/jcm12093068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy (TMA) related to a severe ADAMTS13 deficiency, the specific von Willebrand factor (VWF)-cleaving protease. This deficiency is often immune-mediated (iTTP) and related to the presence of anti-ADAMTS13 autoantibodies that enhance its clearance or inhibit its VWF processing activity. iTTP management may be challenging at extreme ages of life. International cohorts of people with TTP report delayed diagnoses and misdiagnoses in children and elderly people. Child-onset iTTP shares many features with adult-onset iTTP: a female predominance, an idiopathic presentation, and the presence of neurological disorders and therapeutic strategies. Long-term follow-ups and a transition from childhood to adulthood are crucial to preventing iTTP relapses, in order to identify the occurrence of other autoimmune disorders and psychosocial sequelae. In contrast, older iTTP patients have an atypical clinical presentation, with delirium, an atypical neurological presentation, and severe renal and cardiac damages. They also have a poorer response to treatment and prognosis. Long-term sequelae are highly prevalent in older patients. Prediction scores for iTTP diagnoses are not used for children and have a lower sensitivity and specificity in patients over 60 years old. ADAMTS13 remains the unique biological marker that is able to definitely confirm or rule out the diagnosis of iTTP and predict relapses during follow-ups.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Bérangère S Joly
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Adrien Picod
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Department, Saint-Antoine hospital, Public Assistance Hospitals of Paris, 75571 Paris, France
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10
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Mahmoud AA, Abdelhay A, Mostafa M, Yassin H, Jadhav N, Kouides P. Treatment delay and outcomes in elderly thrombotic thrombocytopenic purpura patients: A nationwide analysis. Am J Hematol 2023. [PMID: 37052189 DOI: 10.1002/ajh.26926] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 03/29/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Amir A Mahmoud
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Mariam Mostafa
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Heba Yassin
- Department of Hematology, University Hospitals Sussex NHS Foundations, Sussex, UK
| | - Nagesh Jadhav
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Peter Kouides
- Department of Hematology, Rochester General Hospital, Rochester, New York, USA
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11
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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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de Castro JTDS, Appenzeller S, Colella MP, Yamaguti-Hayakawa G, Paula EVD, Annichinno-Bizzachi J, Cendes F, Fabiano R, Orsi FA. Neurological manifestations in thrombotic microangiopathy: Imaging features, risk factors and clinical course. PLoS One 2022; 17:e0272290. [PMID: 36129939 PMCID: PMC9491546 DOI: 10.1371/journal.pone.0272290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 07/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Thrombotic microangiopathy (TMA) is a group of microvascular occlusive disorders that presents with neurological involvement in up to 87% of the cases. Although the central nervous system (CNS) is an important target organ in TMA, the role of neurological manifestations in the disease clinical course is not well established. In this study, we described the neurological manifestations and CNS radiological aspects in patients with a first, acute TMA event. We also examined the association between severe neurological involvement and adverse clinical outcomes in TMA. Methods A cohort of patients diagnosed with a first TMA event between 1995 and 2016 was included, their medical charts and imaging tests were retrospectively evaluated. Results A total of 49 patients were included, 85.7% were women and the mean age was 36.5 years-old (SD 13.0). Neurological manifestations were described in 85.7% of the patients, most of them (88%) were considered severe and consisted of confusion, compromised sensorimotor function, stupor, seizures, and personality change. Imaging tests were performed in 62% of the patients with neurological manifestations and detected acute CNS lesions, such as posterior reversible encephalopathy syndrome, hemorrhagic and ischemic stroke were observed, in 7 (27%) of them. While the need for intensive care unit admission was greater and longer among patients with severe neurological manifestations, the number of plasma exchange sessions, the total duration of hospitalization and in-hospital death were similar between groups. Conclusions Severe neurological manifestations are common in first TMA events and are responsible for a worse disease presentation at admission. While the effect of neurological manifestations on acute TMA clinical course seems to be modest, these manifestations may have an important impact on the development of chronic cognitive impairment, which highlights the need for proper diagnosis and treatment.
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Affiliation(s)
- José Thiago de Souza de Castro
- School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Department of Radiology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- * E-mail:
| | - Simone Appenzeller
- Rheumatology Unit, School of Medical Science, University of Campinas, Campinas, São Paulo, Brazil
| | - Marina Pereira Colella
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Gabriela Yamaguti-Hayakawa
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Erich Vinícius De Paula
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Joyce Annichinno-Bizzachi
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernando Cendes
- Department of Neurology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Reis Fabiano
- School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Department of Radiology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
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Adeyemi A, Razakariasa F, Chiorean A, de Passos Sousa R. Epidemiology, treatment patterns, clinical outcomes, and disease burden among patients with immune-mediated thrombotic thrombocytopenic purpura in the United States. Res Pract Thromb Haemost 2022; 6:e12802. [PMID: 36176310 PMCID: PMC9481884 DOI: 10.1002/rth2.12802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 11/11/2022] Open
Abstract
Background Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy. Due to its rarity, epidemiology and real-world outcomes data are scarce. Objectives The aim was to assess epidemiology, treatment patterns, clinical outcomes, and disease burden in patients with iTTP in the United States. Methods This longitudinal, retrospective observational study of the Optum-Humedica database included patients with an iTTP diagnosis (≥1 documented ADAMTS13 activity less than 10% or one or more iTTP episodes) from January 2007 to December 2019. Results Of 666 patients with an iTTP diagnosis between October 2015 and December 2019, 302 (45%) had one or more iTTP episodes. The pooled annual incidence of documented iTTP during this period was 3.43/million, and the annual incidence of one or more iTTP episodes was 1.81/million. Patients with one or more iTTP episodes received a median of six therapeutic plasma exchange (TPE) sessions per episode; 86% received corticosteroids, and 59% received rituximab. Exacerbations occurred in 17% (52/302) and relapse in 11% (34/302); 34% (103/302) had one or more thromboembolic events. Mortality rates during the study period were 25% (167/666) among all patients with iTTP diagnosis, and 14% (41/302) among patients with one or more iTTP episodes. In the assessment of disease burden (January 2007 to September 2019), patients in the iTTP cohort (n = 514) presented with a mean of 14 comorbidities, compared with 3 in a matched non-iTTP cohort (n = 2570). In a cluster analysis, duration of iTTP episode and mortality rate were greater in older versus younger patients. Conclusions Despite treatment with TPE and immunosuppressants, patients with iTTP have high risk of morbidity and mortality, demonstrating the need for more effective therapies.
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Affiliation(s)
- Ayoade Adeyemi
- Sanofi Cambridge Massachusetts USA.,Present address: Alexion Boston Massachusetts USA
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Heeb SR, Schaller M, Kremer Hovinga JA. Naturally Occurring Anti-Idiotypic Antibodies Portray a Largely Private Repertoire in Immune-Mediated Thrombotic Thrombocytopenic Purpura. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:2497-2507. [PMID: 35589126 DOI: 10.4049/jimmunol.2100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/29/2022] [Indexed: 12/30/2022]
Abstract
Rare immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening disease resulting from a severe autoantibody-mediated ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs, member 13) deficiency. Acute iTTP episodes are medical emergencies, but when treated appropriately &gt;95% of patients survive. However, at least half of survivors will eventually experience a relapse. How remission of an initial episode is achieved and factors contributing to reemergence of anti-ADAMTS13 Abs and a relapsing course are poorly understood. In acquired hemophilia and systemic lupus erythematosus, anti-idiotypic Abs counteracting and neutralizing pathogenic autoantibodies contribute to remission. We selected and amplified the splenic anti-idiotypic IgG<sub>1</sub> Fab κ/λ repertoire of two relapsing iTTP patients on previously generated monoclonal inhibitory anti-ADAMTS13 Fabs by phage display to explore whether anti-idiotypic Abs have a role in iTTP. We obtained 27 single anti-idiotypic Fab clones, half of which had unique sequences, although both patients shared four H chain V region genes (V<sub>H</sub>1-69*01, V<sub>H</sub>3-15*01, V<sub>H</sub>3-23*01, and V<sub>H</sub>3-49*03). Anti-idiotypic Fab pools of both patients fully neutralized the inhibitor capacity of the monoclonal anti-ADAMTS13 Abs used for their selection. Preincubation of plasma samples of 22 unrelated iTTP patients stratified according to functional ADAMTS13 inhibitor titers (&gt;2 Bethesda units/ml, or 1-2 Bethesda units/ml), with anti-idiotypic Fab pools neutralized functional ADAMTS13 inhibitors and restored ADAMTS13 activity in 18-45% of those cases. Taken together, we present evidence for the presence of an anti-idiotypic immune response in iTTP patients. The interindividual generalizability of this response is limited despite relatively uniform pathogenic anti-ADAMTS13 Abs recognizing a dominant epitope in the ADAMTS13 spacer domain.
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Affiliation(s)
- Silvan R Heeb
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Monica Schaller
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and Department for BioMedical Research, 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; and Department for BioMedical Research, University of Bern, Bern, Switzerland
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15
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Joseph A, Eloit M, Azoulay E, Kaplanski G, Provot F, Presne C, Wynckel A, Grangé S, Rondeau É, Pène F, Delmas Y, Lautrette A, Barbet C, Mousson C, Coindre J, Perez P, Jamme M, Augusto J, Poullin P, Jacobs F, El Karoui K, Vigneau C, Ulrich M, Kanouni T, Le Quintrec M, Hamidou M, Ville S, Charvet‐Rumpler A, Ojeda‐Uribe M, Godmer P, Fremeaux‐Bacchi V, Veyradier A, Halimi J, Coppo P. Immune‐mediated thrombotic thrombocytopenic purpura prognosis is affected by blood pressure. Res Pract Thromb Haemost 2022; 6:e12702. [PMID: 35599703 PMCID: PMC9115975 DOI: 10.1002/rth2.12702] [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: 11/10/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 12/28/2022] Open
Abstract
Background The prevalence, prognostic role, and diagnostic value of blood pressure in immune-mediated thrombotic thrombocytopenic purpura (iTTP) and other thrombotic microangiopathies (TMAs) remain unclear. Methods Using a national cohort of iTTP (n = 368), Shigatoxin-induced hemolytic uremic syndrome (n = 86), atypical hemolytic uremic syndrome (n = 84), and hypertension-related thrombotic microangiopathy (n = 25), we sought to compare the cohort's blood pressure profile to assess its impact on prognosis and diagnostic performances. Results Patients with iTTP had lower blood pressure than patients with other TMAs, systolic (130 [interquartile range (IQR) 118-143] vs 161 [IQR 142-180] mmHg) and diastolic (76 [IQR 69-83] vs 92 [IQR 79-105] mmHg, both p < 0.001). The best threshold for iTTP diagnosis corresponded to a systolic blood pressure <150 mmHg. iTTP patients presenting with hypertension had a significantly poorer survival (hazard ratio 1.80, 95% confidence interval 1.07-3.04), and this effect remained significant after multivariable adjustment (hazard ratio = 1.14, 95% confidence interval 1.00-1.30). Addition of a blood pressure criterion modestly improved the French clinical score to predict a severe A disintegrin and metalloprotease with thrombospondin type 1 deficiency in patients with an intermediate score (i.e., either platelet count <30 × 109/L or serum creatinine <200 µM). Conclusions Elevated blood pressure at admission affects the prognosis of iTTP patients and may help discriminate them from other TMA patients. Particular attention should be paid to blood pressure and its management in these patients.
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Affiliation(s)
- Adrien Joseph
- INSERM, U1138, INSERM, Équipe 11 labellisée Ligue Nationale Contre le Cancer, Centre de Recherche des Cordeliers Paris France
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Martin Eloit
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et Thérapie Cellulaire CHRU de Tours Tours France
| | - Elie Azoulay
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Gilles Kaplanski
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Hôpital la Conception Marseille France
| | - François Provot
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Albert‐Calmette Lille France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Nord Amiens France
| | - Alain Wynckel
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Maison Blanche Reims France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale CHU Charles Nicolle Rouen France
| | - Éric Rondeau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Urgences Néphrologiques et Transplantation Rénale Hôpital Tenon Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Intensive–Réanimation Hôpital Cochin APHP Centre & Université de Paris Paris France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Bordeaux Bordeaux France
| | - Alexandre Lautrette
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Gabriel Montpied Clermont‐Ferrand France
| | - Christelle Barbet
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Christiane Mousson
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Dijon Dijon France
| | - Jean‐Philippe Coindre
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CH Le Mans Le Mans France
| | - Pierre Perez
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Polyvalente CHU de Nancy Nancy France
| | - Matthieu Jamme
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Centre Hospitalier Intercommunal Poissy Saint‐Germain Poissy France
| | - Jean‐François Augusto
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Dialyse et Transplantation CHU Larrey Angers France
| | - Pascale Poullin
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’hémaphérèse et d’autotransfusion Hôpital la Conception Marseille France
| | - Frédéric Jacobs
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Antoine Béclère Clamart France
| | - Khalil El Karoui
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie et Transplantation rénale Groupe Hospitalier Henri‐Mondor Créteil France
| | - Cécile Vigneau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)–UMR_S 1085 Rennes France
| | - Marc Ulrich
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Jean Bernard Valenciennes France
| | - Tarik Kanouni
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Unité d’Hémaphérèse Service d’Hématologie CHU de Montpellier Montpellier France
| | - Moglie Le Quintrec
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Montpellier Montpellier France
| | - Mohamed Hamidou
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne CHU de Nantes Nantes France
| | - Simon Ville
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Nantes Nantes France
| | - Anne Charvet‐Rumpler
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Centre Hospitalier Régional Universitaire Hôpital Jean Minjoz Besançon France
| | - Mario Ojeda‐Uribe
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et de Thérapie Cellulaire Groupe Hospitalier Region Mulhouse‐Sud‐Alsace (GHRMSA) Mulhouse France
| | - Pascal Godmer
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Centre Hospitalier Bretagne Atlantique de Vannes Vannes France
| | - Véronique Fremeaux‐Bacchi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Immunologie Biologique Hôpital Européen Georges Pompidou, AP‐HP Paris France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Biologique Hôpital Lariboisière, AP‐HP Paris France
| | - Jean‐Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Hôpital Saint‐Antoine AP‐HP Paris France
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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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Albo Z, Mathew C, Catton R, Silver B, Moonis M. Thrombotic Thrombocytopenic Purpura (ADAMTS13 [a Disintegrin and Metalloproteinase With a Thrombospondin Type 1 Motif, Member 13] Deficiency) as Cause of Recurrent Multiterritory Ischemic Strokes. Stroke 2022; 53:e237-e240. [PMID: 35341321 DOI: 10.1161/strokeaha.121.034434] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Zimbul Albo
- Department of Neurology (Z.A., R.C., B.S., M.M.), University of Massachusetts Medical School, Worcester
- Now with: Department of Neurology, Tufts University Medical School, MA (Z.A.)
| | - Carol Mathew
- Hematology and Oncology (C.M.), University of Massachusetts Medical School, Worcester
- Now with: Hematology and Oncology, University of Florida, Gainesville (C.M.)
| | - Raymond Catton
- Department of Neurology (Z.A., R.C., B.S., M.M.), University of Massachusetts Medical School, Worcester
| | - Brian Silver
- Department of Neurology (Z.A., R.C., B.S., M.M.), University of Massachusetts Medical School, Worcester
| | - Majaz Moonis
- Department of Neurology (Z.A., R.C., B.S., M.M.), University of Massachusetts Medical School, Worcester
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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: 19] [Impact Index Per Article: 9.5] [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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Prével R, Delmas Y, Guillotin V, Gruson D, Rivière E. Complement Blockade Is a Promising Therapeutic Approach in a Subset of Critically Ill Adult Patients with Complement-Mediated Hemolytic Uremic Syndromes. J Clin Med 2022; 11:jcm11030790. [PMID: 35160242 PMCID: PMC8837052 DOI: 10.3390/jcm11030790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) gathers consumptive thrombocytopenia, mechanical haemolytic anemia, and organ damage. Hemolytic uremic syndromes (HUS) are historically classified as primary or secondary to another disease once thrombotic thrombocytopenic purpura (TTP), Shiga-toxin HUS, and cobalamin C-related HUS have been ruled out. Complement genetics studies reinforced the link between complement dysregulation and primary HUS, contributing to reclassifying some pregnancy- and/or post-partum-associated HUS and to revealing complement involvement in severe and/or refractory hypertensive emergencies. By contrast, no firm evidence allows a plausible association to be drawn between complement dysregulation and Shiga-toxin HUS or other secondary HUS. Nevertheless, rare complement gene variants are prevalent in healthy individuals, thus providing an indication that an investigation into complement dysregulation should be carefully balanced and that the results should be cautiously interpreted with the help of a trained geneticist. Several authors have suggested reclassifying HUS in two entities, regardless of they are complement-mediated or not, since the use of eculizumab, an anti-C5 antibody, dramatically lowers the proportion of patients who die or suffer from end-stage renal disease within the year following diagnosis. Safety and the ideal timing of eculizumab discontinuation is currently under investigation, and the long-term consequences of HUS should be closely monitored over time once patients exit emergency departments.
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Affiliation(s)
- Renaud Prével
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-(0)5-56-79-55-17; Fax: +33-(0)5-56-79-54-18
| | - Yahsou Delmas
- CHU Bordeaux, Nephrology Transplantation Dialysis Apheresis Unit, F-33076 Bordeaux, France;
| | - Vivien Guillotin
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
| | - Etienne Rivière
- CHU Bordeaux, Internal Medicine Department, F-33000 Bordeaux, France;
- University Bordeaux, Biology of Cardiovascular Diseases, InsermU1034, F-33604 Pessac, France
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20
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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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21
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Autoimmune-mediated renal disease and hypertension. Clin Sci (Lond) 2021; 135:2165-2196. [PMID: 34533582 DOI: 10.1042/cs20200955] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 12/18/2022]
Abstract
Hypertension is a major risk factor for cardiovascular disease, chronic kidney disease (CKD), and mortality. Troublingly, hypertension is highly prevalent in patients with autoimmune renal disease and hastens renal functional decline. Although progress has been made over the past two decades in understanding the inflammatory contributions to essential hypertension more broadly, the mechanisms active in autoimmune-mediated renal diseases remain grossly understudied. This Review provides an overview of the pathogenesis of each of the major autoimmune diseases affecting the kidney that are associated with hypertension, and describes the current state of knowledge regarding hypertension in these diseases and their management. Specifically, discussion focuses on Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN), Immunoglobulin A (IgA) Nephropathy, Idiopathic Membranous Nephropathy (IMN), Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated glomerulonephritis, and Thrombotic Thrombocytopenic Purpura (TTP). A summary of disease-specific animal models found to exhibit hypertension is also included to highlight opportunities for much needed further investigation of underlying mechanisms and novel therapeutic approaches.
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22
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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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23
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Travert B, Rafat C, Mariani P, Cointe A, Dossier A, Coppo P, Joseph A. Shiga Toxin-Associated Hemolytic Uremic Syndrome: Specificities of Adult Patients and Implications for Critical Care Management. Toxins (Basel) 2021; 13:306. [PMID: 33925836 PMCID: PMC8145702 DOI: 10.3390/toxins13050306] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 01/28/2023] Open
Abstract
Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) is a form of thrombotic microangiopathy secondary to an infection by an enterohemorrhagic E. coli. Historically considered a pediatric disease, its presentation has been described as typical, with bloody diarrhea at the forefront. However, in adults, the clinical presentation is more diverse and makes the early diagnosis hazardous. In this review, we review the epidemiology, most important outbreaks, physiopathology, clinical presentation and prognosis of STEC-HUS, focusing on the differential features between pediatric and adult disease. We show that the clinical presentation of STEC-HUS in adults is far from typical and marked by the prevalence of neurological symptoms and a poorer prognosis. Of note, we highlight knowledge gaps and the need for studies dedicated to adult patients. The differences between pediatric and adult patients have implications for the treatment of this disease, which remains a public health threat and lack a specific treatment.
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Affiliation(s)
- Benoit Travert
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (B.T.); (A.D.)
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
| | - Cédric Rafat
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75020 Paris, France
| | - Patricia Mariani
- Service de Microbiologie, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 75019 Paris, France; (P.M.); (A.C.)
| | - Aurélie Cointe
- Service de Microbiologie, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 75019 Paris, France; (P.M.); (A.C.)
| | - Antoine Dossier
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (B.T.); (A.D.)
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
- Service d’Hématologie, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France
| | - Adrien Joseph
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
- Médecine Intensive Réanimation, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, 75010 Paris, France
- Centre de Recherche des Cordeliers, Équipe Labellisée par la Ligue Contre le Cancer, Inserm U1138, Université de Paris, Sorbonne Université, 75006 Paris, France
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24
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Bécel G, Faict S, Picod A, Bouzid R, Veyradier A, Coppo P. Thrombotic Thrombocytopenic Purpura: When Basic Science Meets Clinical Research. Hamostaseologie 2021; 41:283-293. [PMID: 33607665 DOI: 10.1055/a-1332-3066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The therapeutic landscape of thrombotic thrombocytopenic purpura (TTP) is rapidly changing with the recent availability of new targeted therapies. This progressive shift from empiricism to pathophysiology-based treatments reflects an intensive interaction between the continuous findings in the field of basic science and an efficient collaborative clinical research and represents a convincing example of the strength of translational medicine. Despite the rarity of TTP, national and international efforts could circumvent this limitation and shed light on the epidemiology, clinical presentation, prognosis, and long-term outcome of this disease. Importantly, they also provided high-quality results and practice changing studies for the benefit of patients. We report here the most recent therapeutic findings that allowed progressively improving the prognostic of TTP, both at the acute phase and through long-term outcome.
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Affiliation(s)
- Gaëlle Bécel
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Sylvia Faict
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Adrien Picod
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Raïda Bouzid
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Hématologie Biologique, Groupe Hospitalier Saint-Louis-Lariboisière, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | - Paul Coppo
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Paris, France
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25
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Prevel R, Roubaud-Baudron C, Tellier E, Le Besnerais M, Kaplanski G, Veyradier A, Benhamou Y, Coppo P. [Endothelial dysfunction in thrombotic thrombocytopenic purpura: therapeutic perspectives]. Rev Med Interne 2021; 42:202-209. [PMID: 33455838 DOI: 10.1016/j.revmed.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/19/2020] [Accepted: 12/26/2020] [Indexed: 01/05/2023]
Abstract
Immune Thrombotic Thrombocytopenic Purpura (iTTP) is a rare but severe disease with a mortality rate of almost 100 % in the absence of adequate treatment. iTTP is caused by a severe deficiency in ADAMTS13 activity due to the production of inhibitory antibodies. Age has been shown to be a major prognostic factor. iTTP patients in the elderly (60yo and over) have more frequent organ involvement, especially heart and kidney failures compared with younger patients. They also have non-specific neurologic symptoms leading to a delayed diagnosis. Factors influencing this impaired survival among older patients remain unknown so far. Alteration of the functional capacity of involved organs could be part of the explanation as could be the consequences of vascular aging. In fact, severe ADAMTS13 deficiency is necessary but likely not sufficient for iTTP physiopathology. A second hit leading to endothelial activation is thought to play a central role in iTTP. Interestingly, the mechanisms involved in endothelial activation may share common features with those involved in vascular aging, potentially leading to endothelial dysfunction. It could thus be interesting to better investigate the causes of mid- and long-term mortality among older iTTP patients to confirm whether inflammation and endothelial activation really impact vascular aging and long-term mortality in those patients, in addition to their presumed role at iTTP acute phase. If so, further insights into the mechanisms involved could lead to new therapeutic targets.
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Affiliation(s)
- R Prevel
- CHU Bordeaux, Pôle de Gérontologie Clinique, 33000 Bordeaux, France; CHU Bordeaux, FHU Acronim 33000 Bordeaux, France; University Bordeaux, INSERM 1045 CRCTB 33000 Bordeaux, France
| | - C Roubaud-Baudron
- CHU Bordeaux, Pôle de Gérontologie Clinique, 33000 Bordeaux, France; University Bordeaux, INSERM UMR 1053 Bariton 33000 Bordeaux, France
| | - E Tellier
- Vascular Research Center of Marseille, Inserm, UMRS_1076, Aix-Marseille Université, Marseille, France
| | - M Le Besnerais
- Service de Médecine Interne, CHU Charles Nicolle, Rouen, France; INSERM U1096, UFR médecine pharmacie Rouen, Rouen, France
| | - G Kaplanski
- Vascular Research Center of Marseille, Inserm, UMRS_1076, Aix-Marseille Université, Marseille, France; Aix-Marseille université, 13284, Service de médecine interne, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13385 Marseille cedex 05, France; Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France
| | - A Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France; Hématologie biologique, Hôpital Lariboisière, AP-HP, Université Paris Diderot, Paris, France
| | - Y Benhamou
- Service de Médecine Interne, CHU Charles Nicolle, Rouen, France; INSERM U1096, UFR médecine pharmacie Rouen, Rouen, France; Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France
| | - P Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France; Service d'Hématologie, Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), AP-HP.6, Paris, France.
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26
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Picod A, Veyradier A, Coppo P. Should all patients with immune-mediated thrombotic thrombocytopenic purpura receive caplacizumab? J Thromb Haemost 2021; 19:58-67. [PMID: 33236389 DOI: 10.1111/jth.15194] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disease that causes systemic platelet-rich microthrombi with multiorgan damage. The historical treatment is based on therapeutic plasma exchange (TPE) and immunosuppression. Despite survival rates exceeding 85%, unfavorable outcomes including refractoriness, death, and exacerbations of the disease during treatment still calls for a better management strategy. Caplacizumab (Cablivi) appeared recently as a new treatment in iTTP. By inhibiting binding of von Willebrand factor to platelets, caplacizumab prevents platelets aggregation and the formation of microthrombi. Two pivotal randomized controlled trials have provided positive results where the use of caplacizumab is associated with faster platelet count recovery and less unfavorable outcomes. The other strength of this agent is an impressive alleviation in the burden of care, consisting in less TPE sessions and lower volumes of plasma to achieve remission, as well as substantial shortening in the length of hospitalization. However, since the recent approval of caplacizumab for the treatment of iTTP on the basis of these studies, debates remain regarding its systematic use in this indication. Should all patients be benefited from caplacizumab? Should we reserve caplacizumab only to the more severe patients? Should caplacizumab be initiated frontline or as a salvage therapy? If applicable, how should we select patients for caplacizumab? Last, is caplacizumab treatment cost-effective? This review aims at addressing these specific questions at a time when iTTP is entering the area of targeted therapies.
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Affiliation(s)
- Adrien Picod
- Centre National de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre National de Référence des MicroAngiopathies Thrombotiques, Paris, France
- Service d'hématologie biologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
- EA-3518, Institut de recherche Saint Louis, Université de Paris, France
| | - Paul Coppo
- Centre National de Référence des MicroAngiopathies Thrombotiques, Paris, France
- Service d'hématologie, Hôpital Saint-Antoine, Assistance publique - Hôpitaux de Paris, Sorbonne-Université (AP-HP.6), Paris, France
- INSERM UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
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27
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Benhamou Y, Sauvètre G, Grangé S, Veyradier A, Coppo P. La maladie thrombo-embolique veineuse au cours du purpura thrombotique thrombocytopénique autoimmun est associée à un traitement prolongé par échanges plasmatiques. Rev Med Interne 2020; 41:809-813. [DOI: 10.1016/j.revmed.2020.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/29/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
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28
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Schmidt J, Zafrani L, Lemiale V, Stepanian A, Joly B, Azoulay E, Mariotte E. The clinical picture of thrombotic microangiopathy in patients older than 60 years of age. Br J Haematol 2020; 192:e25-e28. [PMID: 33216950 DOI: 10.1111/bjh.17176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Julien Schmidt
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Alain Stepanian
- Hematology and Hemostasis Laboratory, APHP, Lariboisière Hospital, Paris, France
| | - Bérangère Joly
- Hematology and Hemostasis Laboratory, APHP, Lariboisière Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France
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29
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Van de Louw A, Cohrs A, Leslie D. Clinical Features and Outcome of Thrombotic Microangiopathies: Comparison between Patients with and without Malignancy. Thromb Haemost 2020; 121:565-572. [PMID: 33186993 DOI: 10.1055/s-0040-1720974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Thrombotic microangiopathy (TMA) is an uncommon complication of cancers, related to the malignancy itself, antineoplastic drugs, or hematopoietic stem cell transplant. It was reported mostly as case series but large data are lacking. We used the large U.S. MarketScan database to compare TMA between patients with and without malignancy. Adult patients hospitalized between 2005 and 2014 with a diagnosis of TMA were included; cancer patients were defined by a diagnosis of cancer within 1 year prior to or during the admission with TMA. Associated inpatient diagnoses, procedures, hospital mortality, and long-term survival were collected. We included 3,227 patients; 617 (19.1%) had cancer (age 54 [44-60] years, 58% female), which was a new diagnosis for 23% of patients. Two-thirds of cancer patients had solid tumors (mostly pancreas, lung, breast, colorectal, and hepatobiliary, half of them metastatic) and one-third had hematological malignancies (lymphoma, acute leukemia, and multiple myeloma); TMA patients with cancer were older, more often men, had more noncancer-related comorbidities, and developed more sepsis and coagulopathy than TMA patients without cancer. Hospital mortality was significantly higher in cancer patients (16.6% vs. 6.1%, p < 0.001) and reached 30% in transplant recipients; malignancy was an independent risk factor for hospital mortality in multivariate analysis and sensitivity analyses excluding patients with metastases or patients who did not undergo plasmapheresis led to similar results. Malignancy was also associated with decreased long-term survival.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Austin Cohrs
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Douglas Leslie
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
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30
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Liu A, Dhaliwal N, Upreti H, Kasmani J, Dane K, Moliterno A, Braunstein E, Brodsky R, Chaturvedi S. Reduced sensitivity of PLASMIC and French scores for the diagnosis of thrombotic thrombocytopenic purpura in older individuals. Transfusion 2020; 61:266-273. [PMID: 33179792 DOI: 10.1111/trf.16188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder characterized by thrombocytopenia, microangiopathic hemolysis, and ischemic organ failure. The PLASMIC and French TTP scores can help guide clinical decisions when ADAMTS13 testing is not immediately available. Older individuals often present atypically, but the impact of age on these tools is not known. STUDY DESIGN AND METHODS We calculated the sensitivity and specificity of the PLASMIC and French TTP scores in patients enrolled in the Johns Hopkins thrombotic microangiopathy (TMA) registry. RESULTS Of 257 patients with TMA enrolled in the registry, we excluded patients less than 18 years of age (n = 19), with prior TMA (n = 81) or who initially presented at another hospital (n = 25). The remaining 132 patients (75 with TTP and 57 with other TMA) were analyzed. Sensitivity of a French score of 2 decreased with age and was 72.2%, 61.5%, and 46.2% for ages 18 to 39, 40 to 59, and ≥ 60 years old, respectively. A PLASMIC score ≥ 5 had higher sensitivity than the French score but this also decreased with age; sensitivity was 91.4% (95% confidence interval [CI], 76.9-98.2), 78.3% (95% CI, 56.3-92.5), and 76.9% (95% CI, 46.2-95.0) for patients 18 to 39, 40 to 59, and ≥ 60 years old, respectively. Older patients had higher platelet counts and serum creatinine than the youngest group, contributing to the loss in sensitivity. CONCLUSION The PLASMIC and French TTP scores have reduced sensitivity at age ≥ 60 years and are less reliable in identifying TTP in older patients. A high index of suspicion and availability of rapid ADAMTS13 assays is required to correctly diagnose all patients with TTP.
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Affiliation(s)
- Angela Liu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Noor Dhaliwal
- Maulana Azad Medical College, University of Delhi, New Delhi, India
| | | | - Jamil Kasmani
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Dane
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alison Moliterno
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Kucukyurt S, Eskazan AE. Assessment and Monitoring of Patients with Immune-Mediated Thrombotic Thrombocytopenic Purpura (iTTP): Strategies to Improve Outcomes. J Blood Med 2020; 11:319-326. [PMID: 33061729 PMCID: PMC7532071 DOI: 10.2147/jbm.s205630] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acquired or immune-mediated TTP (iTTP) is a life-threatening thrombotic microangiopathy, characterized by the presence of microangiopathic hemolytic anemia and severe thrombocytopenia, and a variable degree of ischemic organ damage, related to a severe deficiency of ADAMTS13, which is a serine metalloprotease necessary for cleavage of large vWF multimers. There has been a dramatic decrease in mortality rates with the recognition of the pathophysiology of iTTP over the years. Although therapeutic plasma exchange (TPE) together with corticosteroids are the backbone of the upfront treatment of patients with iTTP with successful outcomes, patients may remain refractory and/or relapse following an initial response to this treatment. Methods We performed a review regarding the pathogenesis, diagnosis, treatment strategies, monitoring, and prognosis of iTTP. Results There are several new treatment strategies, which can be used among these patients, helping in improving outcomes of iTTP. Rituximab has been shown to be a safe and effective adjunct to TPE, especially in patients with refractory and/or relapse as well as it is increasingly used preemptively to prevent exacerbation or recurrence. Recently, caplacizumab, a nanobody targeting vWF, was approved as an addition to the current regimen of TPE and immunomodulation for patients of iTTP. Conclusion Specific predictors of relapse in patients in remission can be relevant for an optimal patient management. Different models including ADAMTS13 biomarkers can provide a new screening strategy to identify patients who may predict outcomes and the risk of relapse, benefit from preemptive therapy prior to relapse.
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Affiliation(s)
- Selin Kucukyurt
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Gogia P, Gbujie E, Benge E, Bhasin S. Thrombotic Thrombocytopenic Purpura: Revisiting a Miss and an Inevitable Consequence. Cureus 2020; 12:e9283. [PMID: 32699732 PMCID: PMC7372183 DOI: 10.7759/cureus.9283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/19/2020] [Indexed: 12/15/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is typically characterized by the symptomatic pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, and renal failure. Atypical TTP is the diagnosis used to describe the subset of patients with TTP who present with symptoms that deviate from the classic pentad. We report a case an 86-year-old woman who presented to the emergency department complaining of chest pain for one day. She was reportedly on antibiotics for sinus infection. Physical examination revealed multiple bilateral superficial hematomas, predominantly on her extremities. On admission, her lab values were as follows: platelet count of 6,000/cubic millimeter, hemoglobin of 10.4 grams/deciliter, leukocyte count of 5100 cells/cubic millimeter, total bilirubin of 2.3 milligrams/deciliter, and troponin-I of 5.190 nanograms/milliliter. Peripheral blood smear was normal and did not reveal any schistocytes. The patient was admitted to the intensive care unit with a diagnosis of a non-ST-elevation myocardial infarction and a presumed diagnosis of immune thrombocytopenic purpura from antibiotic use. She was treated with intravenous solumedrol and a high-intensity statin. On the third day of her admission, the patient's mental functioning deteriorated and was intubated to protect her airway. A second peripheral smear revealed schistocytes, and subsequent laboratory studies supported the diagnosis of TTP. Plasma exchange therapy was planned. However, the patient succumbed to cardiac arrest before it could be initiated. The diagnosis was later confirmed with an ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) assay. This case serves as an example of one of the many ways in which TTP can present, and emphasizes the importance of considering TTP as a differential diagnosis.
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Affiliation(s)
- Pooja Gogia
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Ezioma Gbujie
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Elizabeth Benge
- Internal Medicine, St. George's University School of Medicine, Bethesda, USA
| | - Sidharth Bhasin
- Internal Medicine, Saint Peter's University Hospital/Rutgers University, New Brunswick, USA
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Pregnancy and non-pregnancy related immune thrombotic thrombocytopenic purpura in women of reproductive age. J Thromb Thrombolysis 2020; 51:187-193. [PMID: 32388825 DOI: 10.1007/s11239-020-02133-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pregnancy is a precipitating factor for immune thrombotic thrombocytopenic purpura (iTTP). We compared the clinical course and outcomes of iTTP in women of reproductive age, between those with pregnancy- and non-pregnancy-related iTTP. A review of all reproductive-aged women diagnosed with iTTP during 2010-2019 in seven university hospitals in Israel. Of 42 cases of iTTP, 12 (28.6%) were pregnancy-related. At presentation, the laboratory profiles did not differ significantly between those with pregnancy- and non-pregnancy-related iTTP, including hemoglobin (median 8.4 vs 8.0 g/dL), platelet count (12.5 vs. 11.5 X 109/L); and levels of bilirubin (1.23 vs. 1.82 mg/dL), lactate dehydrogenase (1615 vs. 1701 U/L), creatinine (0.61 vs. 0.79 mg/dL) and anti-ADAMTS13 antibodies titer (75 vs. 82 U/mL). The proportions of women with renal, neurologic, or hepatic involvement were similar between the groups. Cardiac involvement was more common among those with pregnancy-related disease (25.0% vs. 3.3%, P = 0.06). The median number of courses of plasma-exchange therapy was 11 for both groups. All the women were treated with parenteral corticosteroids and the rate of adjunctive treatments did not differ between the groups (P = 0.30). Four women (one-third) with pregnancy-related disease had preeclampsia. Two women (16.7%) with pregnancy-related iTTP died during the acute episode (P = 0.07); no deaths were observed in the non-pregnancy-related group. Among reproductive-aged women with iTTP, most clinical and laboratory profiles were similar between those with pregnancy- and non-pregnancy-related disease. However, the higher rates of cardiac involvement and mortality among women with pregnancy-related iTTP highlight its challenging management.
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Agosti P, Mancini I, Gianniello F, Bucciarelli P, Artoni A, Ferrari B, Pontiggia S, Trisolini SM, Facchini L, Carbone C, Peyvandi F. Prevalence of the age-related diseases in older patients with acquired thrombotic thrombocytopenic purpura. Eur J Intern Med 2020; 75:79-83. [PMID: 32201091 DOI: 10.1016/j.ejim.2020.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The prevalence of older patients with acquired thrombotic thrombocytopenic purpura (TTP) is increasing. There is scarce information on the prevalence of multimorbidity, polypharmacy and age-related diseases in aging TTP patients. This study aimed to evaluate the prevalence of multimorbidity and polypharmacy in a population of acquired TTP patients aged 65 years or more compared with a group of age-matched controls. METHODS Acquired TTP patients enrolled in the Milan TTP registry from December 1st 1999 to March 31th 2018 and aged 65 years or more at the date of last follow-up were evaluated. Controls were Italian healthy individuals recruited from 2006 to March 31th 2018 among friends and non-consanguineous relatives of patients tested for thrombophilia screening at the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center of Milan. RESULTS 36 TTP patients and 127 age-matched controls were included. Compared with controls, TTP patients had a higher prevalence of multimorbidity and polypharmacy. They also showed a higher prevalence of autoimmune diseases, osteoporosis and arterial hypertension and were more chronically treated with corticosteroids and antiplatelets for primary cardiovascular prevention. All these results were confirmed after adjusting for sex. Compared with the general elderly population, TTP patients showed a higher prevalence of ischemic heart disease and stroke. CONCLUSIONS Our findings suggest that a careful comprehensive geriatric assessment of acquired TTP patients is necessary. It is important to look for other autoimmune diseases and such age-related comorbidities as osteoporosis, arterial hypertension, ischemic heart disease and cerebrovascular disease.
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Affiliation(s)
- Pasquale Agosti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano,Via Pace 9, Milan, 20122, Italy
| | - Ilaria Mancini
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano,Via Pace 9, Milan, 20122, Italy
| | - Francesca Gianniello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Barbara Ferrari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Silvia Pontiggia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy
| | - Silvia Maria Trisolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Luca Facchini
- Hematology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Cecilia Carbone
- UO Ematologia, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano,Via Pace 9, Milan, 20122, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, Italy.
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Chauvel F, Reboul P, Cariou S, Aglae C, Renaud S, Trusson R, Garo F, Ahmadpoor P, Prelipcean C, Pambrun E, Moranne O. Use of double filtration plasmapheresis for the treatment of acquired thrombocytopenic thrombotic purpura. Ther Apher Dial 2020; 24:709-717. [DOI: 10.1111/1744-9987.13477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/14/2020] [Accepted: 01/23/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Femie Chauvel
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Pascal Reboul
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Sylvain Cariou
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Cédric Aglae
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Sophie Renaud
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Rémi Trusson
- Service de Réanimation, CHU Carémeau, Nîmes, Université de Montpellier‐Nîmes Nîmes France
| | - Florian Garo
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Pedram Ahmadpoor
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Camelia Prelipcean
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Emilie Pambrun
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
| | - Olivier Moranne
- Service Nephrologie‐Dialyse‐Aphérèse, CHU Carémeau, Université de Montpellier‐Nîmes Nîmes France
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