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Žibřidová K, Souček O, Krčmová LK, Jankovičová K, Gančarčíková M, Pejková MA, Drugda J, Nováková D, Košťál M. Lymphocyte subpopulations: a potential predictor of a response in patients with immune thrombocytopenia. Hematology 2024; 29:2304486. [PMID: 38251842 DOI: 10.1080/16078454.2024.2304486] [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: 09/25/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVES Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder caused by increased platelet destruction and altered production. Despite the well-described pathophysiological background of immune dysregulation, current treatment guidelines consist of monotherapy with different drugs, with no tool to predict which patient is more suitable for each therapeutic modality. METHODS In our study, we attempted to determine differences in the immune setting, comparing the patients' responses to administered therapy. During 12-month follow-up, we assessed blood count, antiplatelet autoantibodies, and T lymphocyte subsets in peripheral blood in 35 patients with ITP (newly diagnosed or relapsed disease). RESULTS Our data show that the value of antiplatelet autoantibodies, the percentage of cytotoxic T lymphocytes, and the immunoregulatory index (IRI, CD4+ / CD8+ T cell ratio) differ significantly by treatment response. Responders have a higher IRI (median 2.1 vs. 1.5 in non-responders, P = 0.04), higher antiplatelet autoantibodies (median 58 vs. 20% in non-responders, P = 0.01) and lower relative CD8+ T cells count (P = 0.02) before treatment. DISCUSSION The results suggest that immunological parameters (antiplatelet autoantibodies, relative CD8+ T cell count and IRI) could be used as prognostic tools for a worse clinical outcome in patients with ITP. CONCLUSION These biomarkers could be utilized for stratification and eventually selection of treatment preferring combination therapy.
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Affiliation(s)
- Kateřina Žibřidová
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Academic Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Ondřej Souček
- Department of Clinical Immunology and Allergology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Lenka Kujovská Krčmová
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Karolína Jankovičová
- Department of Clinical Immunology and Allergology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Markéta Gančarčíková
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Mária Anna Pejková
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Academic Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Jan Drugda
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Academic Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Denisa Nováková
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Academic Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Milan Košťál
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Academic Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
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Nakano TA, Grimes AB, Klaassen RJ, Lambert MP, Neunert C, Rothman JA, Shimano KA, Amend C, Askew M, Badawy SM, Baker JM, Breakey V, Crary S, Davini M, Fritch Lilla S, Gilbert M, Hays T, Hege K, Hillier K, Jacobson-Kelly A, Kaicker S, Kim TO, Kochhar M, Leblanc T, Martinelli M, Nunez M, Remiker A, Schultz C, Sharma R, Grace RF. What is in a name: defining pediatric refractory ITP. Blood Adv 2024; 8:5112-5117. [PMID: 39059013 DOI: 10.1182/bloodadvances.2024012707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/24/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024] Open
Abstract
ABSTRACT There are no agreed upon terminology to define "refractory" pediatric immune thrombocytopenia (ITP). Guidelines are therefore limited to arbitrary and outdated definitions. The Pediatric ITP Consortium of North America held a meeting in 2023 to define this entity. With 100% agreement, the faculty established that pediatric ITP that is refractory to emergent therapy could be defined as no platelet response after treatment with all eligible emergent pharmacotherapies. With 100% agreement, the working group established that pediatric patients with ITP that continue to demonstrate high disease burden and/or no platelet response despite treatment with multiple classes of disease-modifying therapies represent a challenging subset of ITP. These patients are at higher risk of ongoing disease burden and merit additional investigation as well as consideration for clinical trials or novel therapies. Future efforts to define disease burden and disease response will be completed in collaboration with the ITP International Working Group.
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Affiliation(s)
- Taizo A Nakano
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Amanda B Grimes
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, TX
| | | | - Michele P Lambert
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine at UPenn, Philadelphia, PA
| | | | | | | | - Christina Amend
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Megan Askew
- Lisa Dean Moseley Foundation Institute for Cancer and Blood Disorders, Nemours Children's Hospital, Wilmington, DE
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem cell Transplant, Lurie Children's Hospital of Chicago; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M Baker
- The Hospital for Sick Children and Unity Health Toronto (St. Michael's Hospital), Toronto, ON, Canada
| | - Vicky Breakey
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Shelley Crary
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Monica Davini
- University of Arizona, Banner University Medical Center, Tucson, AZ
| | | | - Megan Gilbert
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA
| | - Taru Hays
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Kerry Hege
- Riley Children's Health, Indiana University School of Medicine, Indianapolis, IN
| | - Kirsty Hillier
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, New York, NY
| | - Amanda Jacobson-Kelly
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | | | - Taylor O Kim
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Thierry Leblanc
- Service d'hématologie et d'Immunologie, Hôpital Robert-Debré, L'Assistance publique Hôpitaux de Paris and Université Paris-Cité, Paris, France
| | - Marie Martinelli
- Division of Hematology/Oncology, Oregon Health and Science University, Portland, OR
| | - Mara Nunez
- Division of Hematology, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - Allison Remiker
- Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Corrina Schultz
- Lisa Dean Moseley Foundation Institute for Cancer and Blood Disorders, Nemours Children's Hospital, Wilmington, DE
| | - Ruchika Sharma
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
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3
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Tian H, Zhou L, Dai JW, Li Y, Gu CY, Kong DQ, Yu ZQ, Liu XF, Yin J. Real-world evidence of avatrombopag for the treatment of immune thrombocytopenia intolerant or ineffective to eltrombopag/hetrombopag. Br J Haematol 2024. [PMID: 39367620 DOI: 10.1111/bjh.19800] [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: 04/07/2024] [Accepted: 09/19/2024] [Indexed: 10/06/2024]
Abstract
Due to the limited real-world research on the application of avatrombopag (AVA) for immune thrombocytopenia (ITP) in China, we evaluated the effectiveness and safety of AVA in clinical practice. We included 121 adult ITP patients treated with AVA across three medical centres. Based on the reasons for choosing AVA, these patients were divided into eltrombopag (ELT)/hetrombopag (HET) intolerance group (IG), and ELT/HET unresponsive group (UG). Compared with UG, more patients in IG had a history of liver disease and received fewer treatments before AVA. Amongst all patients, 83% had platelet response (≥30 × 109/L) after AVA and 62% achieved complete response (≥100 × 109/L, CR). Sixty-two percent in IG and 56% in UG were able to discontinue more than one concomitant ITP medication. A total of 17 patients underwent multiple switches of thrombopoietin receptor agonists (TPO-RAs), resulting in an 88% platelet response rate. Sixty-three patients discontinued AVA, 27% were due to unaffordability. AVA was well tolerated in most patients. In the ITP population, AVA proved effective and safe, particularly in patients intolerant or unresponsive to ELT/HET. Patients benefited from TPO-RAs switches, particularly those undergoing multiple switches. However, many patients struggled with the long-term financial burden of AVA.
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Affiliation(s)
- Hong Tian
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- NHC Key Laboratory of Thrombosis and Hemostasis, Suzhou, China
| | - Lu Zhou
- Hematology Department, Affiliated Hospital of Nantong University, Nantong, China
| | - Jia-Wen Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yun Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- NHC Key Laboratory of Thrombosis and Hemostasis, Suzhou, China
| | - Cheng-Yuan Gu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- NHC Key Laboratory of Thrombosis and Hemostasis, Suzhou, China
| | - Dan-Qing Kong
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- NHC Key Laboratory of Thrombosis and Hemostasis, Suzhou, China
| | - Zi-Qiang Yu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- NHC Key Laboratory of Thrombosis and Hemostasis, Suzhou, China
| | - Xiao-Fan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jie Yin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- NHC Key Laboratory of Thrombosis and Hemostasis, Suzhou, China
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Jacobs JW, Booth GS, Raza S, Clark LM, Fasano RM, Gavriilaki E, Abels EA, Binns TC, Duque MA, McQuilten ZK, Mingot-Castellano ME, Savani BN, Sharma D, Tran MH, Tormey CA, Moise KJ, Bloch EM, Adkins BD. Current state and potential applications of neonatal Fc receptor (FcRn) inhibitors in hematologic conditions. Am J Hematol 2024. [PMID: 39324647 DOI: 10.1002/ajh.27487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/02/2024] [Accepted: 09/12/2024] [Indexed: 09/27/2024]
Abstract
The neonatal fragment crystallizable (Fc) receptor (FcRn) transports IgG across mucosal surfaces and the placenta and protects IgG from degradation. Numerous clinical trials are investigating therapeutic FcRn inhibition for various immune-mediated neuromuscular and rheumatologic conditions; however, FcRn inhibition also represents a potential therapy for IgG-mediated hematologic conditions (e.g., immune thrombocytopenia, autoimmune hemolytic anemia, immune thrombotic thrombocytopenic purpura, acquired hemophilia, red blood cell/platelet alloimmunization). Current evidence derived from both in vitro and in vivo studies suggests that FcRn inhibitors effectively reduce total IgG levels without impacting its production or altering the levels of other immunoglobulin isotypes. Moreover, the risk of serious adverse events, including serious infections, appears to be lower than that seen with other commonly used immunomodulatory/immunosuppressive therapies, albeit in the setting of limited clinical trial data. Ultimately, additional clinical trials that include varied patient populations are required prior to incorporating these agents into standard treatment algorithms for most hematologic conditions. However, based on the pathophysiology of IgG-mediated hematologic disorders and the mechanism of action of FcRn inhibitors, these agents may represent a future novel therapeutic strategy for patients with hematologic conditions caused by IgG antibodies.
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Affiliation(s)
- Jeremy W Jacobs
- Division of Transfusion Medicine, Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Garrett S Booth
- Division of Transfusion Medicine, Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sheharyar Raza
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Toronto, Ontario, Canada
| | - Landon M Clark
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ross M Fasano
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapy, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eleni Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elizabeth A Abels
- Department of Obstetrics and Gynecology, Bridgeport Hospital/Yale University, Bridgeport, Connecticut, USA
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Thomas C Binns
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Miriam Andrea Duque
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Zoe K McQuilten
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - María Eva Mingot-Castellano
- Servicio de Hematología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deva Sharma
- Division of Transfusion Medicine, Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, University of California, Irvine, Irvine, California, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kenneth J Moise
- Department of Women's Health, Dell Medical School-University of Texas at Austin, Austin, Texas, USA
- Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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5
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Osuna-Gómez R, Zamora C, Novelli S, Garcia-Pallarols F, Rodriguez Y, Domingo A, Canet M, Olivera P, Mulet M, Cantó E, Valcarcel D, Sanchez-Gonzalez B, Vidal S. Interplay of leucocyte-platelet complexes and clinical response to eltrombopag in immune thrombocytopenia patients. Br J Haematol 2024. [PMID: 39327831 DOI: 10.1111/bjh.19779] [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: 05/16/2024] [Accepted: 09/10/2024] [Indexed: 09/28/2024]
Abstract
Eltrombopag (ELT) is a thrombopoietin-receptor agonist that stimulates platelet (PLT) production in patients with primary immune thrombocytopenia (ITP). One potential mechanism of ELT is modulating the inflammatory response by increasing PLTs binding to leucocytes. This study examined the effect of ELT on leucocyte-PLTs complexes in 38 ITP patients. Patients, predominantly females with a mean age of 59 years, underwent treatments like corticosteroids, intravenous immunoglobulin and splenectomy. Compared to healthy donors, ITP patients exhibited lower percentages of lymphocyte with bound PLTs, but similar monocyte- or neutrophil with bound PLTs. ELT treatment increased PLTs counts and all types of leucocyte with bound PLTs. Network analysis showed dynamic changes in leucocyte with bound PLTs relationships due to ELT. Machine learning indicated that higher percentages of monocytes with bound PLTs were linked to a better clinical response to ELT. A possible mechanism was an increased IL-10 production in monocytes with bound PLTs from responder patients. This study provides insights into the immunological changes in ITP patients undergoing ELT and suggests potential predictive biomarkers for treatment response and disease monitoring.
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Affiliation(s)
- Rubén Osuna-Gómez
- Group of Inflammatory Diseases, Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | - Carlos Zamora
- Group of Inflammatory Diseases, Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | - Silvana Novelli
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Yva Rodriguez
- Hematology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Abel Domingo
- Hematology Department, Hospital de Granollers, Granollers, Spain
| | - Marta Canet
- Hematology Department, Hospital Universitari Mutua Terrassa, Terrassa, Spain
| | | | - Maria Mulet
- Group of Inflammatory Diseases, Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | - Elisabet Cantó
- Group of Inflammatory Diseases, Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | - David Valcarcel
- Hematology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Silvia Vidal
- Group of Inflammatory Diseases, Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
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6
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Zhong K, Pei Y, Yang Z, Zheng Q. Construction of a clinical prediction model for the diagnosis of immune thrombocytopenia based on clinical laboratory parameters. J Cancer Res Clin Oncol 2024; 150:412. [PMID: 39237750 PMCID: PMC11377454 DOI: 10.1007/s00432-024-05914-z] [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: 04/25/2024] [Accepted: 07/31/2024] [Indexed: 09/07/2024]
Abstract
PURPOSE Primary immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by isolated thrombocytopenia that is often misdiagnosed due to the lack of a gold standard for diagnosis and currently relies on exclusionary approaches. This project combines several laboratory parameters to construct a clinical prediction model for adult ITP patients. METHODS A total of 428 patients with thrombocytopenia who visited the West China Hospital of Sichuan University between January 2021 and March 2023 were enrolled. Based on the diagnostic criteria, we divided those patients into an ITP group and a non-ITP group. A total of 34 laboratory parameters were analyzed via univariate analysis and correlation analysis, and the least absolute shrinkage and selection operator regression analysis was used to establish the model. The training and validation sets were divided at a ratio of 7:3, and we used a fivefold cross-validation method to construct the model. RESULTS The model included the following variables: red blood cell, mean corpuscular hemoglobin concentration, red blood cell distribution width-standard deviation, platelet variability index score, immature platelet fraction, lymphocyte absolute value. The prediction model exhibited good performance, with a sensitivity of 0.89 and a specificity of 0.83 in the training set and a sensitivity of 0.90 and a specificity of 0.87 in the validation set. CONCLUSION The clinical prediction model can assess the probability of ITP in thrombocytopenic patients and has good predictive accuracy for the diagnosis of ITP.
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Affiliation(s)
- Kangying Zhong
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Sichuan, China
| | - Yuqing Pei
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Sichuan, China
| | - Ziyan Yang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Sichuan, China
| | - Qin Zheng
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Sichuan, China.
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7
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Shen K, Chen T, Xiao M. MYH9-related inherited thrombocytopenia: the genetic spectrum, underlying mechanisms, clinical phenotypes, diagnosis, and management approaches. Res Pract Thromb Haemost 2024; 8:102552. [PMID: 39309229 PMCID: PMC11415342 DOI: 10.1016/j.rpth.2024.102552] [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: 07/08/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 09/25/2024] Open
Abstract
Inherited thrombocytopenias have been considered exceedingly rare for a long time, but recent advances have facilitated diagnosis and greatly enabled the discovery of new causative genes. MYH9-related disease (MYH9-RD) represents one of the most frequent forms of inherited thrombocytopenia, usually presenting with nonspecific clinical manifestations, which renders it difficult to establish an accurate diagnosis. MYH9-RD is an autosomal dominant-inherited thrombocytopenia caused by deleterious variants in the MYH9 gene encoding the heavy chain of nonmuscle myosin IIA. Patients with MYH9-RD usually present with thrombocytopenia and platelet macrocytosis at birth or in infancy, and most of them may develop one or more extrahematologic manifestations of progressive nephritis, sensorial hearing loss, presenile cataracts, and elevated liver enzymatic levels during childhood and adult life. Here, we have reviewed recent advances in the study of MYH9-RD, which aims to provide an updated and comprehensive summary of the current knowledge and improve our understanding of the genetic spectrum, underlying mechanisms, clinical phenotypes, diagnosis, and management approaches of this rare disease. Importantly, our goal is to enable physicians to better understand this rare disease and highlight the critical role of genetic etiologic analysis in ensuring accurate diagnosis, clinical management, and genetic counseling while avoiding ineffective and potentially harmful therapies for MYH9-RD patients.
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Affiliation(s)
- Kefeng Shen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Chen
- Department of Ophthalmology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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8
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Zhao P, An ZY, Fu HX, Liu HX, Feng CJ, Huang QS, Wu J, Wu YJ, Yang LP, Qu QY, Chen YX, Li ML, Wang CC, Chen Q, Zhu XL, He Y, Zhang YY, Jiang Q, Jiang H, Lu J, Chang YJ, Zhao XS, Zhao XY, Huang XJ, Zhang XH. Safety and efficacy of baricitinib in steroid-resistant or relapsed immune thrombocytopenia: An open-label pilot study. Am J Hematol 2024. [PMID: 38980207 DOI: 10.1002/ajh.27433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 06/13/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
Patients with steroid-resistant or relapsed immune thrombocytopenia (ITP) suffer increased bleeding risk and impaired quality of life. Baricitinib, an oral Janus-associated kinases (JAK) inhibitor, could alleviate both innate and adaptive immune disorders without inducing thrombocytopenia in several autoimmune diseases. Accordingly, an open-label, single-arm, phase 2 trial (NCT05446831) was initiated to explore the safety and efficacy of baricitinib in ITP. Eligible patients were adults with primary ITP who were refractory to corticosteroids and at least one subsequent treatment, and had platelet counts below 30 × 109/L at enrolment. Participants received baricitinib 4 mg daily for 6 months. The primary endpoint was durable response at the 6-month follow-up. A total of 35 patients were enrolled. Durable response was achieved in 20 patients (57.1%, 95% confidence interval, 39.9 to 74.4), and initial response in 23 (65.7%) patients. For patients responding to baricitinib, the median time to response was 12 (IQR 6-20) days, and the median peak platelet count was 94 (IQR 72-128) × 109/L. Among the 27 patients undergoing extend observation, 12 (44.4%) remained responsive for a median duration of approximately 20 weeks after baricitinib discontinuation. Adverse events were reported in 11 (31.4%) patients, including infections in 6 (17.1%) patients during the treatment period. Treatment discontinuation due to an adverse event was reported in 2 (5.7%) patients. Evidence from this pilot study suggested that baricitinib might be a novel candidate for the armamentarium of ITP-modifying agents. Future studies are warranted to validate the safety, efficacy, and optimal dosing of baricitinib in patients with ITP.
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Affiliation(s)
- Peng Zhao
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Zhuo-Yu An
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hai-Xia Fu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People's Hospital, Beijing, China
| | - Cheng-Jie Feng
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Qiu-Sha Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Wu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ye-Jun Wu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Li-Ping Yang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Qing-Yuan Qu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yu-Xiu Chen
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Meng-Lin Li
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Chen-Cong Wang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Qi Chen
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Lu Zhu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yun He
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Qian Jiang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hao Jiang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Lu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ying-Jun Chang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Su Zhao
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiang-Yu Zhao
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
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9
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Hu Y, Wang Z, Ma J, Wang N, Meng J, Dong S, Chen Z, Cheng X, Wu R. The early and rapid response to daratumumab in children with chronic refractory immune thrombocytopenia from a referral single centre of China. Br J Haematol 2024; 205:300-305. [PMID: 38831655 DOI: 10.1111/bjh.19553] [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: 02/12/2024] [Accepted: 05/13/2024] [Indexed: 06/05/2024]
Abstract
Chronic refractory primary immune thrombocytopenia (CRITP) is currently defined as refractory to multiple therapeutic of second-line agents with or without splenectomy, faced with the threat of severe bleeding and challenging to obtain effective treatment. Although stable and effective drug therapy is needed, it is tough to find one. Daratumumab (Dara), an anti-CD38 monoclonal antibody presented the target cloned plasma cells in multiple myeloma, has also been reported to be effective in refractory autoimmune cytopenia in some case or series reports and ongoing clinical trials for adult patients with CRITP. Here, we report the early and durable response of Dara combination with avatrombopag in three CRITP patients (2 male and 1 female aged 12, 5 and 7 years, respectively) in our centre, with a follow-up period of more than 25 weeks. Before Dara, the duration of immune thrombocytopenia was 9, 1.4 and 4 years, respectively, a baseline platelet count of 4, 6, 9 × 109/L, the bleeding score was all above level 2 and the number of previous drugs was >3. The time to response (R: Plt ≥30 × 109/L with at least a twofold increase in the baseline count) of Dara was on Day 45, 6 and 4 and achieved complete response (CR: Plt ≥100 × 109/L) on Day 51, 6 and 8, the sustained response (SR: Plt >30 × 109/L following Dara at ≥75% of the platelet count assessment at follow-up end-point since the patient achieved response) was 48, 175 and 204 days with the follow-up time of 39.1, 25.9 and 29.7 weeks. The bleeding score decreased from grade 3 to grade 0 during follow-up. No significant treatment-related adverse events were found during follow-up. Dara combination with avatrombopag may be a safe and efficacious therapy for children with CRITP, but it needs to be further explored.
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Affiliation(s)
- Yu Hu
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Center, Hematology Center, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Zhifa Wang
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Center, Hematology Center, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Jingyao Ma
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Center, Hematology Center, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Nan Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jinxi Meng
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Center, Hematology Center, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Shuyue Dong
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Center, Hematology Center, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Center, Hematology Center, Ministry of Education, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
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10
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Wang Z, Lang T, Li Y, Zhang X, Abdur M, Mao M. Hypermethylation of the FOXP3 gene regulates Tregs immunodysregulation in chronic idiopathic thrombocytopenic purpura. Allergol Immunopathol (Madr) 2024; 52:30-37. [PMID: 38970262 DOI: 10.15586/aei.v52i4.1091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/29/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Chronic idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a breakdown of immune tolerance; in ITP, the body's immune system mistakenly attacks and destroys platelets. This study aims to investigate the role and underlying mechanisms of FOXP3 in chronic ITP. METHODS Flow cytometry was used to detect the proportion of CD4+CD25+FOXP3+ regulatory T cells (Tregs) in CD4+CD25+ T lymphocytes from 20 patients with chronic ITP (CITP), 20 acute ITP (AITP) controls, and 20 healthy individuals.CD4+CD25+ Treg cells were isolated from peripheral blood of patients with CITP using magnetic beads and then treated with phosphate-buffered saline solution or decitabine (a methylation inhibitor) for 48 h. The levels of interleukin-2 (IL-2), IL-10, and transforming growth factor-beta1 (TGF-β1) in the plasma and CD4+CD25+ Treg cells were assessed by Enzyme-linked-immunosorbent serologic assay and quantitative real-time polymerase chain reaction (qRT-PCR). FOXP3 level was measured by qRT-PCR and Western blot analysis. Methylation-specific PCR (MS-PCR) was adopted to detect the status of FOXP3 methylation. RESULTS The number of Treg cells and the contents of IL-2, IL-10, and TGF-β1 decreased in patients with CITP, compared to the AITP control group and normal group. FOXP3 expression was reduced and FOXP3 methylation increased in patients with CITP, compared to the AITP control group and normal group. Hypermethylation of FOXP3 promoter led to decrease in FOXP3 level in Treg cells. Inhibition of FOXP3 promoter hypermethylation promoted the secretion of IL-2, IL-10, and TGF-β1 in Treg cells. CONCLUSION The number of Treg cells in CITP patients decreased, and the hypermethylation of FOXP3 promoter led to reduction of its expression in Treg cells, thus affecting the immune functioning of Treg cells.
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Affiliation(s)
- Zengsheng Wang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Tao Lang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Yan Li
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Xiaoyan Zhang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Muhubair Abdur
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China;
| | - Min Mao
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
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11
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Pincez T, Fernandes H, Fahd M, Pasquet M, Chahla WA, Granel J, Ducassou S, Thomas C, Garnier N, Jeziorski E, Bayart S, Chastagner P, Cheikh N, Guitton C, Paillard C, Lejeune J, Millot F, Li-Thiao Te V, Mallebranche C, Pellier I, Castelle M, Armari-Alla C, Carausu L, Piguet C, Benadiba J, Pluchart C, Stephan JL, Deparis M, Briandet C, Doré E, Marie-Cardine A, Barlogis V, Leverger G, Héritier S, Aladjidi N, Leblanc T. Pediatric refractory chronic immune thrombocytopenia: Identification, patients' characteristics, and outcome. Am J Hematol 2024; 99:1269-1280. [PMID: 38651646 DOI: 10.1002/ajh.27337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/06/2024] [Indexed: 04/25/2024]
Abstract
Refractory chronic immune thrombocytopenia (r-cITP) is one of the most challenging situations in chronic immune thrombocytopenia (cITP). Pediatric r-cITP is inconsistently defined in literature, contributing to the scarcity of data. Moreover, no evidence is available to guide the choice of treatment. We compared seven definitions of r-cITP including five pediatric definitions in 886 patients with cITP (median [min-max] follow-up 5.3 [1.0-29.3] years). The pediatric definitions identified overlapping groups of various sizes (4%-20%) but with similar characteristics (higher proportion of immunopathological manifestations [IM] and systemic lupus erythematosus [SLE]), suggesting that they adequately captured the population of interest. Based on the 79 patients with r-cITP (median follow-up 3.1 [0-18.2] years) according to the CEREVANCE definition (≥3 second-line treatments), we showed that r-cITP occurred at a rate of 1.15% new patients per year and did not plateau over time. In multivariate analysis, older age was associated with r-cITP. One patient (1%) experienced two grade five bleeding events after meeting r-cITP criteria and while not receiving second-line treatment. The cumulative incidence of continuous complete remission (CCR) at 2 years after r-cITP diagnosis was 9%. In this analysis, splenectomy was associated with a higher cumulative incidence of CCR (hazard ratio: 5.43, 95% confidence interval: 1.48-19.84, p = 7.8 × 10-4). In sum, children with cITP may be diagnosed with r-cITP at any time point of the follow-up and are at increased risk of IM and SLE. Second-line treatments seem to be effective for preventing grade 5 bleeding. Splenectomy may be considered to achieve CCR.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Division of Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec, Canada
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Mony Fahd
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Unit, Robert-Debré University Hospital, AP-HP, Paris, France
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse, France
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Jérome Granel
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Stéphane Ducassou
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes, France
| | - Nathalie Garnier
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, Lyon, France
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes, France
| | - Pascal Chastagner
- Department of Pediatric Hematology and Oncology, Children's University Hospital, Nancy, France
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besançon University Hospital, Besançon, France
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg, France
| | - Julien Lejeune
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours, France
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers, France
| | - Valérie Li-Thiao Te
- Department of Pediatric Hematology/Oncology, Amiens University Hospital, Amiens, France
| | - Coralie Mallebranche
- Pediatric Immuno-Hemato-Oncology, Angers University Hospital, CRCI2NA, UMR Inserm CNRS, Université d'Angers, Université de Nantes, Angers, France
| | - Isabelle Pellier
- Pediatric Immuno-Hemato-Oncology, Angers University Hospital, CRCI2NA, UMR Inserm CNRS, Université d'Angers, Université de Nantes, Angers, France
| | - Martin Castelle
- Pediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Corinne Armari-Alla
- Pediatric Hematology-Oncology Department, Grenoble University Hospital, Grenoble, France
| | - Liana Carausu
- Department of Pediatric Hematology, CHU de Brest, Brest, France
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges, France
| | - Joy Benadiba
- Department of Hematology-Oncology Pediatrics, Nice University Hospital, Nice, France
| | - Claire Pluchart
- Pediatric Hematology-Oncology Unit, Institut Jean Godinot, Reims University Hospital, Reims, France
| | - Jean-Louis Stephan
- Department of Pediatric Oncology, University Hospital of Saint Etienne, North Hospital, Saint Etienne, France
| | - Marianna Deparis
- Pediatric Oncology-Hematology Unit Department, Caen University Hospital, Caen, France
| | - Claire Briandet
- Department of Pediatrics, Dijon University Hospital, Dijon, France
| | - Eric Doré
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen, France
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille, France
| | - Guy Leverger
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Oncology Unit, Hôpital Armand Trousseau, AP-HP, Sorbonne Université Paris, Paris, France
| | - Sébastien Héritier
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Oncology Unit, Hôpital Armand Trousseau, AP-HP, Sorbonne Université Paris, Paris, France
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Thierry Leblanc
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Unit, Robert-Debré University Hospital, AP-HP, Paris, France
- Université Paris-Cité, Paris, France
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12
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Martínez-Carballeira D, Bernardo Á, Caro A, Soto I, Gutiérrez L. Treatment of Immune Thrombocytopenia: Contextualization from a Historical Perspective. Hematol Rep 2024; 16:390-412. [PMID: 39051412 PMCID: PMC11270329 DOI: 10.3390/hematolrep16030039] [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: 05/22/2024] [Revised: 06/12/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by an isolated decrease in platelet count and an increased risk of bleeding. The pathogenesis is complex, affecting multiple components of the immune system and causing both peripheral destruction of platelets and inadequate production in the bone marrow. In this article, we review the treatment of ITP from a historical perspective, discussing first line and second line treatments, and management of refractory disease.
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Affiliation(s)
- Daniel Martínez-Carballeira
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Ángel Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alberto Caro
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
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13
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Zhang Q, Huang M, Thomas ER, Wang L, Liu J, Li X, Luo J, Zou W, Wu J. The role of platelet desialylation as a biomarker in primary immune thrombocytopenia: mechanisms and therapeutic perspectives. Front Immunol 2024; 15:1409461. [PMID: 38979425 PMCID: PMC11228137 DOI: 10.3389/fimmu.2024.1409461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 06/03/2024] [Indexed: 07/10/2024] Open
Abstract
Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterized by the destruction of platelets. Although it was long believed that the critical role of autoantibodies in platelet destruction, primarily through the Fc-dependent platelet clearance pathway, recent findings indicate that the significance of the Fc-independent platelet clearance pathway mediated by hepatocytes, thus shedding light on a previously obscure aspect of ITP pathogenesis. Within this context, the desialylation of platelets has emerged as a pivotal biochemical marker. Consequently, targeting platelet desialylation emerges as a novel therapeutic strategy in the pathogenesis of ITP. Notably, prevailing research has largely focused on antiplatelet antibodies and the glycosylation-associated mechanisms of platelet clearance, while comprehensive analysis of platelet desialylation remains scant. In response, we retrospectively discuss the historical progression, inducing factors, generation process, and molecular regulatory mechanisms underlying platelet desialylation in ITP pathogenesis. By systematically evaluating the most recent research findings, we contribute to a comprehensive understanding of the intricate processes involved. Moreover, our manuscript delves into the potential application of desialylation regulatory strategies in ITP therapy, heralding novel therapeutic avenues. In conclusion, this manuscript not only fills a critical void in existing literature but also paves the way for future research by establishing a systematic theoretical framework. By inspiring new research ideas and offering insights into the development of new therapeutic strategies and targeted drugs, our study is poised to significantly advance the clinical management of ITP.
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Affiliation(s)
- Qianhui Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Miao Huang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Elizabeth Rosalind Thomas
- Department of Microbiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India
| | - Lu Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jia Liu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiang Li
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Jiesi Luo
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Wenjun Zou
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jianming Wu
- School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
- Education Ministry Key Laboratory of Medical Electrophysiology, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China
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14
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Passucci M, Laganà A, Donzelli L, Masucci C, Genoese A, Chistolini A, Baldacci E, Santoro C. Fostamatinib combined with TPO-RAs or steroids as a bridge to monotherapy or as time-limited continuous treatment in relapsed chronic ITP: A single-centre case series. Br J Haematol 2024; 204:2129-2132. [PMID: 38563350 DOI: 10.1111/bjh.19450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/06/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Mauro Passucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Alessandro Laganà
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Livia Donzelli
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Chiara Masucci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Angelo Genoese
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Erminia Baldacci
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
| | - Cristina Santoro
- Hematology, Department of Translational and Precision Medicine, Az. Policlinico Umberto I- Sapienza University, Rome, Italy
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15
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Chen Y, Xu Y, Chi Y, Sun T, Gao Y, Dou X, Han Z, Xue F, Li H, Liu W, Liu X, Dong H, Fu R, Ju M, Dai X, Wang W, Ma Y, Song Z, Gu J, Gong W, Yang R, Zhang L. Efficacy and safety of human umbilical cord-derived mesenchymal stem cells in the treatment of refractory immune thrombocytopenia: a prospective, single arm, phase I trial. Signal Transduct Target Ther 2024; 9:102. [PMID: 38653983 PMCID: PMC11039759 DOI: 10.1038/s41392-024-01793-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/18/2024] [Accepted: 03/02/2024] [Indexed: 04/25/2024] Open
Abstract
Patients with refractory immune thrombocytopenia (ITP) frequently encounter substantial bleeding risks and demonstrate limited responsiveness to existing therapies. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) present a promising alternative, capitalizing on their low immunogenicity and potent immunomodulatory effects for treating diverse autoimmune disorders. This prospective phase I trial enrolled eighteen eligible patients to explore the safety and efficacy of UC-MSCs in treating refractory ITP. The research design included administering UC-MSCs at escalating doses of 0.5 × 106 cells/kg, 1.0 × 106 cells/kg, and 2.0 × 106 cells/kg weekly for four consecutive weeks across three cohorts during the dose-escalation phase, followed by a dose of 2.0 × 106 cells/kg weekly for the dose-expansion phase. Adverse events, platelet counts, and changes in peripheral blood immunity were monitored and recorded throughout the administration and follow-up period. Ultimately, 12 (with an addition of three patients in the 2.0 × 106 cells/kg group due to dose-limiting toxicity) and six patients were enrolled in the dose-escalation and dose-expansion phase, respectively. Thirteen patients (13/18, 72.2%) experienced one or more treatment emergent adverse events. Serious adverse events occurred in four patients (4/18, 22.2%), including gastrointestinal hemorrhage (2/4), profuse menstruation (1/4), and acute myocardial infarction (1/4). The response rates were 41.7% in the dose-escalation phase (5/12, two received 1.0 × 106 cells/kg per week, and three received 2.0 × 106 cells/kg per week) and 50.0% (3/6) in the dose-expansion phase. The overall response rate was 44.4% (8/18) among all enrolled patients. To sum up, UC-MSCs are effective and well tolerated in treating refractory ITP (ClinicalTrials.gov ID: NCT04014166).
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Affiliation(s)
- Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yanmei Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ying Chi
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yuchen Gao
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xueqing Dou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Zhibo Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- National Engineering Research Centre of Cell Products, Tianjin Key Laboratory of Engineering Technologies for Cell Pharmaceutical, AmCellGene Engineering Co., Ltd, Tianjin, 300457, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Huiyuan Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Huan Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Wentian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yueshen Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Zhen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Jundong Gu
- National Engineering Research Centre of Cell Products, Tianjin Key Laboratory of Engineering Technologies for Cell Pharmaceutical, AmCellGene Engineering Co., Ltd, Tianjin, 300457, China
| | - Wei Gong
- National Engineering Research Centre of Cell Products, Tianjin Key Laboratory of Engineering Technologies for Cell Pharmaceutical, AmCellGene Engineering Co., Ltd, Tianjin, 300457, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Centre for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
- Tianjin Institutes of Health Science, Tianjin, 301600, China.
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China.
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16
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Kosmidou A, Gavriilaki E, Tragiannidis A. The Challenge for a Correct Diagnosis of Refractory Thrombocytopenia: ITP or MDS with Isolated Thrombocytopenia? Cancers (Basel) 2024; 16:1462. [PMID: 38672544 PMCID: PMC11048195 DOI: 10.3390/cancers16081462] [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: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia. It is diagnosed in patients with a platelet count below 100,000 per cubic millimeter in whom other causes of thrombocytopenia have been ruled out, and its diagnosis is generally one of exclusion. Clinical manifestations of patients may vary from asymptomatic disease to mild mucocutaneous or life-threatening bleeding. Glucocorticoids are used as first-line treatment for ITP, while other second-line medications, mainly thrombopoietin-receptor agonists (TPO-RA) and rituximab, are given to patients in whom ITP does not remit, or relapses soon after glucocorticoid treatment. Refractoriness of ITP strongly questions its diagnosis and necessitates a thorough clinical and laboratory work-up to decide whether that is the case of refractory ITP or a misdiagnosis. The aim of this review is to summarize the conditions associated with isolated thrombocytopenia and highlight the characteristics of confusing cases. Even though the case of a myelodysplastic syndrome presented with isolated thrombocytopenia (MDS-IT) is relatively rare and not well-established in the literature, it constitutes one of the most predominant misdiagnoses of refractory ITP. MDS-IT patients are thought to present with multilineage dysplasia, normal karyotype and low risk prognostic score, based on IPSS-R. It has been shown that a significant proportion of MDS-IT patients are misdiagnosed as having the more common ITP. Therefore, it is crucial that in confusing cases of persistent thrombocytopenia a detailed diagnostic work-up is applied-including evaluation of peripheral-blood smear, bone marrow examination and cytogenetic testing-to avoid unnecessary therapy delay.
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Affiliation(s)
- Aikaterini Kosmidou
- 2nd Department of Internal Medicine, General Hospital of Kavala, 65500 Kavala, Greece
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
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17
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Liu L, Xiang Y, Shao L, Yuan C, Song X, Sun M, Liu Y, Zhang X, Du S, Hou M, Peng J, Shi Y. E3 ubiquitin ligase casitas B-lineage lymphoma-b modulates T-cell anergic resistance via phosphoinositide 3-kinase signaling in patients with immune thrombocytopenia. J Thromb Haemost 2024; 22:1202-1214. [PMID: 38184203 DOI: 10.1016/j.jtha.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/01/2023] [Accepted: 12/24/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND The E3 ubiquitin ligase casitas B-lineage lymphoma-b (CBLB) is a newly identified component of the ubiquitin-dependent protein degradation system and is considered an important negative regulator of immune cells. CBLB is essential for establishing a threshold of T-cell activation and regulating peripheral T-cell tolerance through various mechanisms. However, the involvement of CBLB in the pathogenesis of immune thrombocytopenia (ITP) is unknown. OBJECTIVES We aimed to investigate the expression and role of CBLB in CD4+ T cells obtained from patients with ITP through quantitative proteomics analyses. METHODS CD4+ T cells were transfected with adenoviral vectors overexpressing CBLB to clarify the effect of CBLB on anergic induction of T cells in patients with ITP. DNA methylation levels of the CBLB promoter and 5' untranslated region (UTR) in patient-derived CD4+ T cells were detected via MassARRAY EpiTYPER assay (Agena Bioscience). RESULTS CD4+ T cells from patients with ITP showed resistance to anergic induction, highly activated phosphoinositide 3-kinase-protein kinase B (AKT) signaling, decreased CBLB expression, and 5' UTR hypermethylation of CBLB. CBLB overexpression in T cells effectively attenuated the elevated phosphorylated protein kinase B level and resistance to anergy. Low-dose decitabine treatment led to significantly elevated levels of CBLB expression in CD4+ T cells from 7 patients showing a partial or complete response. CONCLUSION These results indicate that the 5' UTR hypermethylation of CBLB in CD4+ T cells induces resistance to T-cell anergy in ITP. Thus, the upregulation of CBLB expression by low-dose decitabine treatment may represent a potential therapeutic approach to ITP.
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Affiliation(s)
- Lu Liu
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China; Department of Hematology, Qilu Hospital (Qingdao) of Shandong University, Qingdao, Shandong, China
| | - Yujiao Xiang
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China; Experimental Asthma and Allergy Research Unit, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Linlin Shao
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Chenglu Yuan
- Department of Hematology, Qilu Hospital (Qingdao) of Shandong University, Qingdao, Shandong, China
| | - Xiaofeng Song
- Department of Hand and Foot Surgery, Qilu Hospital (Qingdao) of Shandong University, Qingdao, Shandong, China
| | - Meng Sun
- Jinan Vocational College of Nursing, Jinan, Shandong, China
| | - Yanfeng Liu
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xianlei Zhang
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shenghong Du
- Department of Hematology, Taian Central Hospital, Taian, Shandong, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China; Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Jinan, Shandong, China; Shandong Provincial Clinical Research Center in Hematological Diseases, Jinan, Shandong, China; Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China; Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yan Shi
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, Shandong, China.
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18
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Witkowski M, Ryżewska W, Robak T. Thrombopoietin receptor agonist and rituximab combination therapy in patients with refractory primary immune thrombocytopenia. Blood Coagul Fibrinolysis 2024; 35:108-114. [PMID: 38358901 DOI: 10.1097/mbc.0000000000001283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
The aim of our study was to evaluate the efficacy of this therapy in patients with refractory primary immune thrombocytopenia. It is crucial to develop alternative treatment methods for this patient group in order to achieve better response. This combination therapy combines two different mechanisms of action, which is promising in terms of targeting pathophysiology of immune thrombocytopenia. We conducted a retrospective study, which included all patients who were diagnosed with refractory primary immune thrombocytopenia and received TPO-RA and rituximab at the General Hematology Department, Copernicus Memorial Hospital in Lodz, Poland. We assessed the response, time to response and treatment-free remission (TFR). After 1 month of treatment, the complete response (CR1, PLT >100 g/l) was achieved in 62.5% patients, and response (R1, PLT >30 g/l) was achieved in 62.5% patients. The median PLT was 175 × 10 9 /l. Within 1 month of treatment, 87.5% of patients achieved TFR. Adequately, after 6 months, CR6 and R6 was 62.5 and 75%. The median PLT was 182 × 10 9 /l. Treatment-free remission 6 months after completion was in 50% of patients. The study group achieved response to treatment, which suggests that combination of TPO-RA and rituximab is effective and relatively well tolerated. Prospective study on larger group of patients is needed to better evaluate the efficiency and safety of this treatment.
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Affiliation(s)
- Michał Witkowski
- Department of General Haematology, Copernicus Memorial Hospital, Lodz
| | - Wiktoria Ryżewska
- Jozef Stus Memorial Multispecialty Municipal Hospital, Poznan
- Students' Scientific Circle at the Haematology Clinic
| | - Tadeusz Robak
- Haematology Clinic, Medical University in Lodz, Lodz, Poland
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19
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Ren X, Zhang M, Zhang X, Zhao P, Zhai W. Can low-dose intravenous immunoglobulin be an alternative to high-dose intravenous immunoglobulin in the treatment of children with newly diagnosed immune thrombocytopenia: a systematic review and meta-analysis. BMC Pediatr 2024; 24:199. [PMID: 38515126 PMCID: PMC10956331 DOI: 10.1186/s12887-024-04677-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
Intravenous immunoglobulin (IVIg) is a first-line treatment for children with newly diagnosed immune thrombocytopenia (ITP). Higher doses of IVIg are associated with a more insupportable financial burden to pediatric patients' families and may produce more adverse reactions. Whether low-dose IVIg (LD-IVIg) can replace high-dose IVIg (HD-IVIg) has yet to be established. We conducted a comprehensive literature search from the establishment of the database to May 1, 2023, and eventually included 22 RCTs and 3 cohort studies compared different dosages of IVIg. A total of 1989 patients were included, with 991 patients in the LD-IVIg group and 998 patients in the HD-IVIg group. Our results showed no significant differences between the two groups in the effective rate (LD-IVIg: 91% vs. HD-IVIg: 93%; RR: 0.99; 95%CI: 0.96-1.02) and the durable remission rate (LD-IVIg: 65% vs. HD-IVIg: 67%; RR: 0.97; 95%CI: 0.89-1.07). Similar results were also found in the time of platelet counts (PC) starting to rise (MD: 0.01, 95%CI: -0.06-0.09), rising to normal (MD: 0.16, 95%CI: -0.03-0.35), and achieving hemostasis (MD: 0.11, 95%CI: -0.02-0.23) between the two groups. Subgroup analysis showed the effective rate of 0.6 g/kg was equal to 1 g/kg subgroup (91%) but higher than 0.8 g/kg subgroup (82%), and a combination with glucocorticoid may contribute to effect enhancement (combined with glucocorticoid: 91% vs. IVIg alone: 86%) whether combined with dexamethasone (92%) or methylprednisolone (91%). Besides, the incidence rate of adverse reactions in the LD-IVIg group (3%) was significantly lower than the HD-IVIg group (6%) (RR: 0.61; 95%CI: 0.38-0.98). So low-dose IVIg (≤ 1 g/kg) is effective, safe, and economical, which can replace high-dose IVIg (2 g/kg) as an initial treatment. This systematic review was registered in PROSPERO (CRD42022384604).
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Affiliation(s)
- Xiangge Ren
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The first affiliated hospital of Henan University of Chinese Medicine, No.19, Renmin Road, Jinshui District, Zhengzhou, Henan, China
- College of Pediatrics, Henan University of Chinese Medicine, No.156, Jinshui East Road, Jinshui District, Zhengzhou, Henan, China
| | - Miaomiao Zhang
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The first affiliated hospital of Henan University of Chinese Medicine, No.19, Renmin Road, Jinshui District, Zhengzhou, Henan, China
- College of Pediatrics, Henan University of Chinese Medicine, No.156, Jinshui East Road, Jinshui District, Zhengzhou, Henan, China
| | - Xiaohan Zhang
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The first affiliated hospital of Henan University of Chinese Medicine, No.19, Renmin Road, Jinshui District, Zhengzhou, Henan, China
- College of Pediatrics, Henan University of Chinese Medicine, No.156, Jinshui East Road, Jinshui District, Zhengzhou, Henan, China
| | - Peidong Zhao
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The first affiliated hospital of Henan University of Chinese Medicine, No.19, Renmin Road, Jinshui District, Zhengzhou, Henan, China
- College of Pediatrics, Henan University of Chinese Medicine, No.156, Jinshui East Road, Jinshui District, Zhengzhou, Henan, China
| | - Wensheng Zhai
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The first affiliated hospital of Henan University of Chinese Medicine, No.19, Renmin Road, Jinshui District, Zhengzhou, Henan, China.
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20
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Jiang X, Shu X, Ge Y. Effectiveness and safety of eltrombopag in connective tissue disease patients with refractory immune thrombocytopenia: a retrospective study. Rheumatol Adv Pract 2024; 8:rkae029. [PMID: 38495431 PMCID: PMC10942842 DOI: 10.1093/rap/rkae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Objectives We aimed to investigate the safety and effectiveness of eltrombopag for adult patients with refractory immune thrombocytopenia (ITP) secondary to connective tissue disease (CTD). Methods This is a single-centre, retrospective cohort and propensity score-matched study. Data from CTD-ITP patients treated with eltrombopag between January 2019 and January 2023 were retrospectively analysed. Baseline characteristics and follow-up information were recorded. CTD patients without ITP were matched to identify the risk factors associated with CTD-ITP performed by Logistic regression analysis. Results Twenty patients were enrolled, including 5 systemic lupus erythematosus (SLE), 9 Sjögren's syndrome (SS) and 6 undifferentiated connective tissue disease (UCTD). Nineteen (95%) patients were female, and the median age was 59 years. Logistic regression analysis showed that anaemia (OR = 8.832, P = 0.007) was associated with increased risk of ITP, while non-erosive arthritis (OR = 0.045, P = 0.001) and interstitial lung disease (OR = 0.075, P = 0.031) were associated with reduced risk. Fourteen patients (70%) achieved a complete response (CR) and one (5%) achieved a partial response (PR). The median response time was 14 days. The median platelet count was 8.5 × 109/l at baseline of eltrombopag and increased to 122 × 109/l after 4 weeks. No adverse events were observed. Conclusions Eltrombopag appears to be effective, safe and well-tolerated in refractory ITP patients with CTD; larger studies are needed to confirm the generalizability of these findings.
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Affiliation(s)
- Xiangpin Jiang
- Department of Rheumatology, Jining No. 1 People’s Hospital, Jining, China
| | - Xiaoming Shu
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China
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21
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Nasreddine GM, Farhat S, Hammoud ZM, Saad F, Saad W. Chronic Myelomonocytic Leukemia-Associated Immune Thrombocytopenic Purpura: A Report of a Rare Case and a Review of Literature. Cureus 2024; 16:e55904. [PMID: 38595873 PMCID: PMC11003726 DOI: 10.7759/cureus.55904] [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: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Chronic myelomonocytic leukemia (CMML) presents as a complex hematologic malignancy with myelodysplastic and myeloproliferative features. Our case report explores the rare coexistence of CMML with immune thrombocytopenic purpura (ITP) in a 63-year-old female patient. CMML diagnosis followed World Health Organization criteria, and the patient was classified as having high-risk myelodysplastic syndrome (MDS)-CMML stage 2. Initial treatment with subcutaneous azacytidine for CMML proved partially effective, highlighting persistent severe thrombocytopenia. Subsequent investigations revealed secondary ITP associated with Crohn's disease. Conventional ITP therapies, including high-dose steroids and intravenous immunoglobulin, showed limited efficacy. Eltrombopag, a thrombopoietin receptor agonist, was initiated, resulting in the normalization of platelet counts within six weeks. Our case emphasizes the diagnostic challenges and intricate treatment landscape of CMML-associated ITP, suggesting eltrombopag as a potential therapeutic option in refractory cases. The study contributes to the evolving understanding of the complex interplay between myeloid disorders and immune-mediated hematological conditions, calling for personalized and multidisciplinary approaches to enhance patient outcomes.
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Affiliation(s)
- Ghadir M Nasreddine
- Department of Hematology and Oncology, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Solay Farhat
- Department of Hematology and Oncology, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Zeinab M Hammoud
- Department of Hematology and Oncology, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Firas Saad
- Department of Hematology and Oncology, Morristown Medical Center, New Jersey, USA
| | - Wajih Saad
- Department of Hematology and Oncology, Al-Zahraa Hospital University Medical Center, Beirut, LBN
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22
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Abdelwahab OA, Mechi A, Gahlan S, Hamadein FE, Kadhim H, Ismail D, Soliman Y, El-Samahy M. Efficacy and safety of mycophenolate mofetil in patients with immune thrombocytopenic purpura: a systematic review and meta-analysis. Clin Rheumatol 2024; 43:621-632. [PMID: 37981614 PMCID: PMC10834632 DOI: 10.1007/s10067-023-06820-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Immune thrombocytopenic purpura (ITP) is a challenging disease in its presentation and management as it may cause life-threatening hemorrhaging in vital organs and may resist several lines of treatment. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of mycophenolate mofetil (MMF) in treating patients with ITP. METHODS We systematically searched four electronic databases (PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials) from inception until 10 October 2022. We included all clinical trials, either controlled or single arm, and prospective and retrospective observational studies that evaluate the efficacy and safety of MMF in patients with ITP. We assessed the risk of bias using three tools (ROBINS-I, Cochrane ROB-2, and NIH), each for eligible study design. RESULTS Nine studies were included in this meta-analysis, with a total of 411 patients with ITP. We found that MMF demonstrated an overall response rate of (62.09%; 95% CI = [43.29 to 77.84]) and the complete response rate was (46.75%; 95% CI = [24.84 to 69.99]). The overall proportion of adverse events was (12%; 95% CI = [6 to 24]). After the sensitivity analysis, the overall response rate became 50%; 95% CI = [38 to 63]) and the complete response rate became (32%; 95% CI = [24 to 42]). However, MMF did not appear to affect white blood cell counts or hemoglobin levels significantly. CONCLUSION This systematic review and meta-analysis demonstrate that MMF appears to be an effective and relatively safe treatment option for patients with ITP when combined with steroids and even in those who have not responded to standard therapies (steroid-resistant cases). Further research with well-designed studies is warranted to better understand the factors influencing treatment response and to refine the use of MMF in the management of ITP. An interactive version of our analysis can be accessed from here: https://databoard.shinyapps.io/mycophenolate_meta/.
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Affiliation(s)
- Omar Ahmed Abdelwahab
- Faculty of Medicine, Al-Azhar University, Cairo, 11884, Egypt.
- Medical Research Group of Egypt, Cairo, Egypt.
| | - Ahmed Mechi
- Medical Research Group of Egypt, Cairo, Egypt
- Internal Medicine Department, Medicine College, University of Kufa, Najaf, Iraq
| | - Shereen Gahlan
- Faculty of Medicine, Al-Azhar University, Cairo, 11884, Egypt
- Medical Research Group of Egypt, Cairo, Egypt
| | | | - Hallas Kadhim
- Medical Research Group of Egypt, Cairo, Egypt
- College of Medicine, Al-Muthanna University, Samawah, Iraq
| | - Doaa Ismail
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt
| | - Youssef Soliman
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed El-Samahy
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt
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23
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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24
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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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25
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Liu X, Bai Y, Wang T, Song Y, Sun F, Xia R, Zhu F, Ma J, Lu Q, Ye X, Zhan X, Li L, Guo X, Cheng S, Li Y, Guo Z, Chen Y, Qian S, Qin L, Zhang Q, Cao S, Yang R. Recombinant human thrombopoietin (rhTPO) of different dosing regimens for refractory/relapsed primary immune thrombocytopenia: a multicenter, randomized controlled trial and pharmacokinetics study. Platelets 2023; 34:2157806. [PMID: 36597010 DOI: 10.1080/09537104.2022.2157806] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recombinant human TPO (rhTPO) is effective for refractory/relapsed primary immune thrombocytopenia (ITP), but optimal dosing regimen remains elusive. In this multicenter, randomized, controlled trial, a total of 282 adult ITP patients (mean age 47.3 years; 82 men) with a platelet count ≤30 × 109/L or >30 × 109/L with active bleeding randomly received a once daily (QD) subcutaneous injection of 7500 U (n = 64) or 15000 U rhTPO for 14 injections, or 15000 U or 30000 U rhTPO once every other day (QOD) for 7 injections. The primary outcomes included change from baseline in platelet count and total response rate (TRR) on day 14. On day 14, the median increase of platelet count from baseline was the highest in the 15000-U QD group (167.5 × 109/L, interquartile range [IQR] 23.0-295.0 × 109/L), followed by the 30000-U QOD group (57.5 × 109/L, IQR 9.0-190.0 × 109/L) (ANCOVA P < .001; P = .266 with baseline count as a covariate). The TRR on day 14 was also the highest in the 15000-U QD group (63.2%), followed by the 30000-U QOD group (59.7%). The rate of grade 3 and above adverse events did not differ among the four groups. There were no new safety concerns. All 4 regimens are safe and well-tolerated. The 30000-U QOD regimen is practically indistinguishable in efficacy to the 15000-U QD regimen.
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Affiliation(s)
- Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Yusheng Bai
- Department of Hematology, Traditional Chinese Medical Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, China
| | - Tao Wang
- Department of Hematology, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Yanping Song
- Department of Hematology, Xi'an Central Hospital, Xi'an, Shaanxi, China
| | - Feng Sun
- Department of Hematology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Ruixiang Xia
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Feiyue Zhu
- Department of Hematology, Loudi Central Hospital, Loudi, Hunan, China
| | - Jun Ma
- Department of Hematology, Harbin Institute of Hematology and Oncology, Harbin, Heilongjiang, China
| | - Quanyi Lu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Xu Ye
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xinrong Zhan
- Department of Hematology, Xinxiang Central Hospital, Xinxiang, Henan, China
| | - Linjie Li
- Department of Hematology, Lishui Central Hospital, Lishui, Zhejiang, China
| | - Xinhong Guo
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Shuqin Cheng
- Department of Hematology, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Yan Li
- Department of Hematology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhiqiang Guo
- Department of Hematology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Youhua Chen
- Department of Hematology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, Hubei, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ling Qin
- Department of Hematology, The First Affiliated Hospital of Henan Technology University, Luoyang, Henan, China
| | - Qing Zhang
- Department of Hematology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Sunqiong Cao
- Medical Department, Shenyang Sunshine Pharmaceuticals Co. Ltd, Shenyang, Liaoning, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
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26
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Thakre R, Gharde P, Raghuwanshi M. Idiopathic Thrombocytopenic Purpura: Current Limitations and Management. Cureus 2023; 15:e49313. [PMID: 38143653 PMCID: PMC10748795 DOI: 10.7759/cureus.49313] [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] [Received: 08/21/2023] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenia, is a blood disorder characterized by a reduction in the number of platelets. A reduction in the number of platelets beyond the normal levels leads to several consequences. A severe reduction in blood platelet levels leads to a rash of purple spots on the skin, joints, etc. due to leakage in the small blood vessels, easy bruising, bleeding gums, intestinal bleeding, and hemorrhage. Suppose a case of ITP resolves in fewer than six months. In that case, it is an acute case of ITP. Still, if a case settles in more than six months, it is a case of ITP. The cause of a reduced platelet count can be increased peripheral destruction or impaired production; this is termed an autoimmune condition in which the body's immune system attacks platelets thinking it to be a foreign antigen. ITP in children occurs commonly following a previous viral attack. Even though evaluating patients' reports is useful for understanding and guiding the treatment, these estimates might not be regularly evaluated in clinical settings. First-line drugs in the treatment of ITP are corticosteroids, and long-term use of these drugs has several side effects, such as excessive increase in weight, mental health disturbances, and sleep disturbances; additional therapies to treat hemorrhage are usually momentary. As a result, it is essential to recognize the flaws in current procedures and adopt innovative measures for the management and minimization of difficulties.
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Affiliation(s)
- Rakshanda Thakre
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mohit Raghuwanshi
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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27
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Sarper N, Çam İ, Aylan Gelen S, Sönmez HE, Sakarya Güneş A, Zengin E. Splenic Artery Embolization in a Patient With Intracranial Hemorrhage Due to Refractory Persistent Immune Thrombocytopenia. J Pediatr Hematol Oncol 2023; 45:e988-e992. [PMID: 37526353 DOI: 10.1097/mph.0000000000002718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/09/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Managing intracranial bleeding in patients with refractory immune thrombocytopenia is difficult. OBSERVATION A 16-year-old female refractory to prednisolone, intravenous immunoglobulin, eltrombopag, and cyclosporin exhibited heavy menstrual bleeding requiring packed red blood cell transfusions. Autoimmune antibodies were detected, indicating of lupus, and hydroxychloroquine sulfate was administered. In month 6 following the diagnosis, the patient presented with intracranial hemorrhage. Splenic artery embolization promptly increased platelets, and the patient was discharged without any neurological sequela. In month 5 of embolization, the patient's platelet count continued to exceed 300,000/µL without any medical treatment. CONCLUSIONS Splenic artery embolization is a life-saving procedure in refractory immune thrombocytopenia.
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28
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Yilmaz S, Dağ M, Kizilarslanoğlu MC, Baştürk A. Can Pseudothrombocytopenia be recognised at first look? Medicine (Baltimore) 2023; 102:e35395. [PMID: 37832120 PMCID: PMC10578760 DOI: 10.1097/md.0000000000035395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/05/2023] [Indexed: 10/15/2023] Open
Abstract
Our aim was to determine the laboratory parameters that distinguish pseudothrombocytopenia from true thrombocytopenia. A total of 107 patients who were referred to the adult hematology outpatient clinic with thrombocytopenia and subsequently diagnosed with acute myeloid leukaemia, immune thrombocytopenia and pseudothrombocytopenia were included in our study. Hemogram parameters on admission, platelet value in the control hemogram and peripheral smear findings were recorded. Forty three (40.2%) males and 64 (59.8%) females, were included in our study. There were 25 patients in the leukaemia group, 39 in the immune thrombocytopenia group and 43 in the pseudothrombocytopenia group. Control platelet value and red cell distribution width/platelet ratio were found to be statistically significantly different between the 3 groups. Receiver operating characteristic analysis based on platelet values showed that platelet value ≤ 38,000/µL (86% sensitivity, 78.1% specificity, P < .001), difference between 2 consecutively measured platelet levels ≤ 11. 000/µL (79.1% sensitivity, 79.7% specificity, P < .001), red cell distribution width/platelet ratio ≥ 0.413 (90.7% sensitivity, 78.1% specificity, P < .001) were found to be in favor of true thrombocytopenia. In the differentiation of pseudothrombocytopenia and true thrombocytopenia, the difference between the hemogram parameters at the time of admission and the platelet count in the control blood count may be guiding. This result may reduce patient and physician anxiety and prevent patient referral.
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Affiliation(s)
- Seda Yilmaz
- Department of Internal Medicine, Clinic of Hematology, Konya City Hospital, Konya, Turkey
| | - Mikail Dağ
- Department of Internal Medicine, Şanliurfa Training and Research Hospital, Şanliurfa, Turkey
| | - Muhammet Cemal Kizilarslanoğlu
- Department of Internal Medicine, Division of Geriatrics, University of Health Sciences, Konya City Hospital, Konya, Turkey
| | - Abdulkadir Baştürk
- Department of Internal Medicine, Clinic of Hematology, Konya City Hospital, Konya, Turkey
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29
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Li J, Karakas D, Xue F, Chen Y, Zhu G, Yucel YH, MacParland SA, Zhang H, Semple JW, Freedman J, Shi Q, Ni H. Desialylated Platelet Clearance in the Liver is a Novel Mechanism of Systemic Immunosuppression. RESEARCH (WASHINGTON, D.C.) 2023; 6:0236. [PMID: 37808178 PMCID: PMC10551749 DOI: 10.34133/research.0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023]
Abstract
Platelets are small, versatile blood cells that are critical for hemostasis/thrombosis. Local platelet accumulation is a known contributor to proinflammation in various disease states. However, the anti-inflammatory/immunosuppressive potential of platelets has been poorly explored. Here, we uncovered, unexpectedly, desialylated platelets (dPLTs) down-regulated immune responses against both platelet-associated and -independent antigen challenges. Utilizing multispectral photoacoustic tomography, we tracked dPLT trafficking to gut vasculature and an exclusive Kupffer cell-mediated dPLT clearance in the liver, a process that we identified to be synergistically dependent on platelet glycoprotein Ibα and hepatic Ashwell-Morell receptor. Mechanistically, Kupffer cell clearance of dPLT potentiated a systemic immunosuppressive state with increased anti-inflammatory cytokines and circulating CD4+ regulatory T cells, abolishable by Kupffer cell depletion. Last, in a clinically relevant model of hemophilia A, presensitization with dPLT attenuated anti-factor VIII antibody production after factor VIII ( infusion. As platelet desialylation commonly occurs in daily-aged and activated platelets, these findings open new avenues toward understanding immune homeostasis and potentiate the therapeutic potential of dPLT and engineered dPLT transfusions in controlling autoimmune and alloimmune diseases.
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Affiliation(s)
- June Li
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Canadian Blood Services Centre for Innovation, Toronto, ON, Canada
| | - Danielle Karakas
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
| | - Feng Xue
- Departments of Pediatrics,
Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
| | - Yingyu Chen
- Departments of Pediatrics,
Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
| | - Guangheng Zhu
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
| | - Yeni H. Yucel
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Departments of Ophthalmology and Vision Sciences Medicine,
University of Toronto, Toronto, ON, Canada
- Faculty of Engineering and Architectural Science,
Ryerson University, Toronto, ON, Canada
| | - Sonya A. MacParland
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Multi-Organ Transplant Program,
Toronto General Hospital Research Institute, Toronto, ON, Canada
- Department of Immunology,
University of Toronto, Toronto, ON, Canada
| | - Haibo Zhang
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Critical Care Medicine, Department of Anesthesiology and Pain,
University of Toronto, Toronto, ON, Canada
- Department of Physiology,
University of Toronto, Toronto, ON, Canada
| | - John W. Semple
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Department of Pharmacology,
University of Toronto, Toronto, ON, Canada
- Division of Hematology and Transfusion Medicine,
Lund University, Lund, Sweden
- Clinical Immunology and Transfusion Medicine,
Office of Medical Services, Region Skåne, Lund, Sweden
| | - John Freedman
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine,
University of Toronto, Toronto, ON, Canada
| | - Qizhen Shi
- Departments of Pediatrics,
Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
- Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI, USA
- Midwest Athletes Against Childhood Cancer Fund Research Center, Milwaukee, WI, USA
| | - Heyu Ni
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Canadian Blood Services Centre for Innovation, Toronto, ON, Canada
- Department of Physiology,
University of Toronto, Toronto, ON, Canada
- Department of Medicine,
University of Toronto, Toronto, ON, Canada
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30
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Schifferli A, Le Gavrian G, Aladjidi N, Moulis G, Godeau B, Kühne T. Chronic refractory immune thrombocytopenia in adolescents and young adults. Br J Haematol 2023; 203:36-42. [PMID: 37735549 DOI: 10.1111/bjh.19081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
Defining immune thrombocytopenia (ITP) in two age groups-children and adults-overlooks the specific clinical features and needs of adolescents and young adults (AYAS). We previously reported a high risk of chronic disease at 12 months (50%); however, data on the course of chronic ITP, the risk of refractoriness and treatment strategies in AYAS are limited. Data from patients aged 12-25 years with chronic primary ITP at 12 months were extracted from three large registries between 2004 and 2021. Clinical and laboratory data were evaluated until 48 months of follow-up (FU). Refractory ITP was defined as the administration of ≥3 different lines of therapy. A total of 427 AYAS (64% female) with chronic ITP were included. Overall, 7% and 14% were classified as 'refractory' at 12 and 48 months of FU respectively. The proportion of males was greater in the refractory group than in the non-refractory group (43% vs. 35%). AYAS with refractory disease displayed lower median platelet counts, more bleeding and a higher need for treatment at initial diagnosis and FU than non-refractory patients. This study reveals that refractory ITP is uncommon in AYAS; however, AYAS with refractory ITP display a high disease burden at all time points, including at initial diagnosis.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Gautier Le Gavrian
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Autoimmunes de l'Enfant (CEREVANCE), Pediatric Hematologic Unit, Centre d'Investigation Clinique Plurithématique (CICP) INSERM 1401, University Hospital of Bordeaux, Bordeaux, France
| | - Guillaume Moulis
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Centre d'Investigation Clinique 1436, Équipe PEPSS, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Reference Center for Adult Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hopitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Thomas Kühne
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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31
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Arnold DM, Clerici B, Ilicheva E, Ghanima W. Refractory immune thrombocytopenia in adults: Towards a new definition. Br J Haematol 2023; 203:23-27. [PMID: 37642211 DOI: 10.1111/bjh.19075] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune haematological disorder characterized by immune-mediated thrombocytopenia and a variable risk of bleeding. Despite the availability of multiple treatment options, some patients are considered refractory since they do not achieve a platelet count response to multiple treatments and are at risk of bleeding. The term 'refractory' has been used to identify this patient group; however, with the advent of multiple lines of treatment, its meaning has become ambiguous. To address this issue, we reviewed previous definitions of refractory ITP, solicited the views of ITP experts and collected data from registries to inform a definition. Twenty ITP experts who attended the 7th Expert Meeting of the Intercontinental Cooperative ITP Study Group in September 2022 answered a web-based survey: 95% felt that there was a need for a new definition of refractory ITP for clinical and research purposes. The use of the term refractory, accompanied by a clear indication of the type and timing of failed treatments, was supported by 85% of respondents. Preliminary data on the frequency of refractory patients from the McMaster and Norwegian ITP Registries demonstrated that the proportion of adult ITP patients who had failed first-line therapy, rituximab, thrombopoietin receptor agonists, any immune suppressant medication and splenectomy ranged from 0.4% to 3.8%. We propose a definition of refractory ITP that could be evaluated in future studies.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Bianca Clerici
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Dipartimento di Scienze della Salute, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Università degli Studi di Milano, Milan, Italy
| | | | - Waleed Ghanima
- Department of Research, Østfol Hospital, Sarpsborg, Norway
- Department of Hemato-Oncolology, Østfol Hospital, Sarpsborg, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
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32
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Fu Y, Zhao L, Ye S. Intention to treat: The management of connective tissue disease-related immune thrombocytopenia. Int J Rheum Dis 2023; 26:1885-1888. [PMID: 37807615 DOI: 10.1111/1756-185x.14811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Yakai Fu
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Liling Zhao
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Godeau B. Is splenectomy a good strategy for refractory immune thrombocytopenia in adults? Br J Haematol 2023; 203:86-95. [PMID: 37735555 DOI: 10.1111/bjh.19077] [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: 06/05/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
Rituximab and thrombopoietin receptor agonists (TPO-RAs) have profoundly changed the management of immune thrombocytopenia (ITP) over the last 20 years. Even if most current guidelines put splenectomy, rituximab and TPO-RAs on the same treatment level, most clinicians and patients clearly prefer to postpone splenectomy and to multiply the lines of medical treatment before considering surgery. The management of ITP refractory to rituximab and TPO-RAs is challenging. Splenectomy is currently performed much less frequently because of a better knowledge of its complications, particularly severe late infections and deep vein thrombosis, and the inability to reliably predict its effectiveness. Furthermore, there is a reluctance to propose splenectomy when other treatments have been ineffective, based on the not well-documented risk that splenectomy could not be effective in such a case. The objective of this update was to review the most recent published data on the long-term tolerability and side effects of splenectomy and the predictors of response and efficacy, especially for patients exposed to multiple medical lines. This update can help physicians and patients with failure of multiple lines of therapy make an informed decision on the indication for splenectomy with the help of up-to-date data.
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Affiliation(s)
- Bertrand Godeau
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
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34
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Zehnder JL, Bussel JB, Cooper N. The role of genetics in refractory immune thrombocytopenia. Br J Haematol 2023; 203:62-64. [PMID: 37735556 DOI: 10.1111/bjh.19110] [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: 06/15/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
Patients with refractory immune thrombocytopenia (rITP) have increased morbidity and mortality. Currently, there is limited understanding of the cause of refractoriness and no markers to help direct novel treatment options. Understanding the reason(s) for refractoriness is crucial to determining novel treatment options. The pathogenesis underlying rITP has generally been thought to be an underlying genetic predisposition with an environmental trigger. Familial ITP remains rare, and there are few twin studies, suggesting that a simple genetic cause is unlikely. However, genetic mutations provide the background for several autoimmune diseases. In this review, we explore the evidence of either an inherited genetic cause of rITP or an acquired mutation, in particular one resulting in clonal expansion of cytotoxic T cells.
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Affiliation(s)
- James L Zehnder
- Department of Pathology and Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
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35
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Rodríguez-Rodríguez S, Álvarez-Blanco JM, Sánchez-Díaz S, Rangel-Patiño J, Sierra-Salazar A, Apodaca-Chávez E, Demichelis-Gómez R. Are accessory spleen screening and resection in refractory immune cytopenia an effective strategy or a waste of resources? Ann Hematol 2023; 102:2309-2315. [PMID: 37439893 DOI: 10.1007/s00277-023-05360-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
Splenectomy remains an effective treatment for refractory immune cytopenia (RIC), which encompasses immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Accessory spleens (AS) have been described without identifying specific risk factors. We retrospectively analyzed patients with RIC after splenectomy who underwent splenic scintigraphy (SS) at our institution. Seventy-one patients were included. Sixty-two patients had ITP, five had AIHA, and four had Evans syndrome. Seventy-five percent (n = 53) were women. Eleven patients (15.5%) had an AS detected by SS. A complete response (CR) to first-line steroids (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.37-24.14, p = 0.017) and the absence of Howell-Jolly bodies (HJB) in peripheral blood smear (PBS) (OR 11.37, 95% CI 2.70-47.85, p = 0.001) were found to be risk factors. Patients with both elements had a higher rate of AS (83.3%) when compared to those with one or no factors (p < 0.001). Eight patients (73%) underwent an accessory splenectomy: seven (87.5%) achieved a CR, and none had perioperative complications. The presence of HJB in PBS changed from 25 to 87.5% after accessory splenectomy. We recommend the search for an AS via SS in patients with RIC due to ITP, who had a CR to corticosteroids and the absence of HJB in PBS. Accessory splenectomy is a safe and effective procedure.
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Affiliation(s)
- Sergio Rodríguez-Rodríguez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - José Miguel Álvarez-Blanco
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Susana Sánchez-Díaz
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Juan Rangel-Patiño
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Ana Sierra-Salazar
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Elia Apodaca-Chávez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico
| | - Roberta Demichelis-Gómez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Tlalpan, 14080, Mexico City, ZC, Mexico.
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González-López TJ, Provan D, Bárez A, Bernardo-Gutiérrez A, Bernat S, Martínez-Carballeira D, Jarque-Ramos I, Soto I, Jiménez-Bárcenas R, Fernández-Fuertes F. Primary and secondary immune thrombocytopenia (ITP): Time for a rethink. Blood Rev 2023; 61:101112. [PMID: 37414719 DOI: 10.1016/j.blre.2023.101112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
There are not many publications that provide a holistic view of the management of primary and secondary ITP as a whole, reflecting the similarities and differences between the two. Given the lack of major clinical trials, we believe that comprehensive reviews are much needed to guide the diagnosis and treatment of ITP today. Therefore, our review addresses the contemporary diagnosis and treatment of ITP in adult patients. With respect to primary ITP we especially focus on establishing the management of ITP based on the different and successive lines of treatment. Life-threatening situations, "bridge therapy" to surgery or invasive procedures and refractory ITP are also comprehensively reviewed here. Secondary ITP is studied according to its pathogenesis by establishing three major differential groups: Immune Thrombocytopenia due to Central Defects, Immune Thrombocytopenia due to Blocked Differentiation and Immune Thrombocytopenia due to Defective Peripheral Immune Response. Here we provide an up-to-date snapshot of the current diagnosis and treatment of ITP, including a special interest in addressing rare causes of this disease in our daily clinical practice. The target population of this review is adult patients only and the target audience is medical professionals.
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Affiliation(s)
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Abelardo Bárez
- Department of Hematology. Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de la Plana, Villarreal, Castellón, Spain
| | | | - Isidro Jarque-Ramos
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Central de Asturias, Oviedo, Asturias, Spain
| | | | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
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Liu N, Lv D, Schneider RR, Yang H, Zhang M, Liu Y, Sun M. Intracavitary cardiac metastasis of cervical squamous cell carcinoma with immune thrombocytopenia: a rare case report. Front Oncol 2023; 13:1239606. [PMID: 37711205 PMCID: PMC10499513 DOI: 10.3389/fonc.2023.1239606] [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] [Received: 06/13/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
Cervical cancer is a prevalent gynecological malignancy; however, intracavitary cardiac metastasis of cervical squamous cell carcinoma is exceptionally rare. In addition, the co-occurrence of cervical cancer and right ventricular cancer thrombus with autoimmune diseases is extremely uncommon. Furthermore, the role of immune checkpoint inhibitors in the treatment process of such cases remains controversial. Given the scarcity of reported cases, it is imperative to document and highlight this unique presentation, providing novel insights into diagnosis and management strategies. We present the case of an adult patient diagnosed with cervical cancer and concurrent right ventricular cancer thrombus, accompanied by immune thrombocytopenia (ITP). The patient exhibited resistance to conventional ITP drugs, with suboptimal platelet response. However, upon achieving initial control of the tumor, the patient's platelet counts returned to normal. Notably, the addition of immune checkpoint inhibitors targeting PD-L1 resulted in effective tumor control, accompanied by sustained high platelet levels. Unfortunately, during subsequent anti-tumor therapy, the patient experienced a prolonged platelet rise time, rendering continuous effective anti-tumor therapy and anticoagulant therapy unattainable. This led to a gradual increase in intraventricular thrombosis, ultimately resulting in the patient's demise due to circulatory failure. This rare case sheds light on the potential alleviation of ITP in patients with tumor complications through effective antitumor therapy. The successful control of ITP after tumor management highlights the importance of integrated treatment approaches. Furthermore, the inclusion of immune checkpoint inhibitors demonstrated their potential role in achieving tumor control and maintaining platelet levels. However, the prolonged platelet rise time observed during subsequent therapy underscores the challenges in maintaining both effective anti-tumor therapy and anticoagulant therapy, necessitating careful management strategies. This case report emphasizes the need for a comprehensive evaluation and tailored therapeutic interventions in similar complex scenarios. In summary, this case report offers valuable clinical insights into the management of intracavitary cardiac metastasis of cervical squamous cell carcinoma, the coexistence of immune thrombocytopenia, and the potential implications of immune checkpoint inhibitors in such cases. Understanding these rare occurrences and their clinical impact can contribute to improved diagnostic approaches, therapeutic decision-making, and patient outcomes.
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Affiliation(s)
- Ning Liu
- Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Oncology, Jinan Central Hospital, Shandong University, Jinan, China
| | - Deguan Lv
- Division of Hematology/Oncology, Department of Medicine, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Hongyan Yang
- Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Mingyan Zhang
- Department of Oncology, Jinan Central Hospital, Shandong University, Jinan, China
| | - Yanan Liu
- Department of Oncology, Jinan Central Hospital, Shandong University, Jinan, China
| | - Meili Sun
- Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Oncology, Jinan Central Hospital, Shandong University, Jinan, China
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38
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Hamed EM, Ibrahim ARN, Meabed MH, Khalaf AM, El Demerdash DM, Elgendy MO, Saeed H, Salem HF, Rabea H. Therapeutic Outcomes of High Dose-Dexamethasone versus Prednisolone + Azathioprine, Rituximab, Eltrombopag, and Romiplostim Strategies in Persistent, Chronic, Refractory, and Relapsed Immune Thrombocytopenia Patients. Pharmaceuticals (Basel) 2023; 16:1215. [PMID: 37765023 PMCID: PMC10537035 DOI: 10.3390/ph16091215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Primary immune thrombocytopenia (ITP) is an inflammatory autoimmune disease that can be managed with several treatment options. However, there is a lack of comparative data on the efficacy of these options in different phases of the disease. AIM OF THE STUDY This study aimed to evaluate the efficacy of high-dose Dexamethasone (HD-DXM), Prednisolone + Azathioprine, Rituximab, Eltrombopag, and Romiplostim schedules in persistent, chronic refractory or relapsed Egyptian ITP patients with a platelet count ≤30 × 109/L. The primary outcome measure was a sustained increase in platelet counts over 50 × 109/L for an additional 12 months without additional ITP regimens. The study also aimed to identify a suitable treatment regimen with a long remission duration for each phase of ITP. RESULTS Prednisolone + Azathioprine was significantly more effective in achieving an overall response in persistent patients than Romiplostim, high-dose Dexamethasone, and Rituximab. (90.9% vs. 66.6, [Odds ratio, OR: 5; confidence interval, CI 95% (0.866-28.86)], 45%, [OR: 0.082, CI 95% (0.015-0.448)] and, 25%, [OR: 30, CI 95% (4.24-211.8)], respectively, p-value < 0.01). Eltrombopag was significantly more effective in achieving a durable response in refractory ITP than HD-DXM, Rituximab, and Prednisolone; (80% compared to 32.2% [OR: 0.119, CI 95% (0.035-0.410)], 22.2% [OR:0.071, CI 95% (0.011-0.455)], and 18.1% [OR: 0.056, CI 95% (0.009-0.342)], respectively, p-value < 0.01). CONCLUSIONS Finally, Eltrombopag following HD-DXM showed the highest percentage of patients with complete treatment-free survival times of at least 330 days. These findings could help clinicians choose the most appropriate treatment for their patients with ITP based on the phase of the disease. This trial is registered in clinicaltrials.gov with registration number NCT05861297.
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Affiliation(s)
- Eman Mostafa Hamed
- Department of Clinical Pharmacy, Faculty of Pharmacy, Nahda University (NUB), Beni-Suef 62521, Egypt;
| | - Ahmed R. N. Ibrahim
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia
| | - Mohamed Hussein Meabed
- Department of Pediatrics, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt;
| | - Ahmed M. Khalaf
- Department of Internal Medicine and Clinical Hematology, Beni-Suef University, Beni-Suef 62521, Egypt;
| | - Doaa Mohamed El Demerdash
- Department of Internal Medicine and Clinical Hematology, Faculty of Medicine, Cairo University, Giza 54212, Egypt;
| | - Marwa O. Elgendy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Nahda University (NUB), Beni-Suef 62521, Egypt;
- Department of Clinical Pharmacy, Faculty of Medicine, Beni-Suef University Hospitals, Beni-Suef University, Beni-Suef 62521, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62521, Egypt; (H.S.); (H.R.)
| | - Heba F. Salem
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62521, Egypt;
- Pharmaceutics and Industrial Pharmacy Department, 6 October Technological University, Giza 62521, Egypt
| | - Hoda Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62521, Egypt; (H.S.); (H.R.)
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Goldberg TA, Levy CF. Mycophenolate Mofetil Use in Pediatric Immune Thrombocytopenia Refractory to First-line Therapy: a Single-center Experience. J Pediatr Hematol Oncol 2023; 45:339-343. [PMID: 37314887 DOI: 10.1097/mph.0000000000002688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/05/2023] [Indexed: 06/16/2023]
Abstract
Most children treated for immune thrombocytopenia remit during the first year following diagnosis. For the ∼40% who develop persistent or chronic disease, second-line treatment options include immunomodulation and thrombomimetic agents. While immunomodulators target the underlying mechanism, prolonged immunosuppression may increase the risk of infection. We report the use of the reversible immunomodulating agent mycophenolate mofetil (MMF) in 16 pediatric patients with immune thrombocytopenia refractory to first-line treatment. Using escalating doses up to 2400 mg/m 2 /d, MMF treatment resulted in a 73% response rate. Adverse events were mostly mild and tolerable. Complete responders have been successfully tapered off MMF with sustained responses.
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Affiliation(s)
- Tracie A Goldberg
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Carolyn Fein Levy
- Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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40
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Al-Samkari H, Bussel JB. Common-sense combination therapy in refractory immune thrombocytopaenia. Br J Haematol 2023; 202:728-730. [PMID: 37287116 PMCID: PMC10527081 DOI: 10.1111/bjh.18919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA
| | - James B. Bussel
- Department of Pediatrics, Weill Cornell Medical College,
New York, NY
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41
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Crickx E, Ebbo M, Rivière E, Souchaud-Debouverie O, Terriou L, Audia S, Ruivard M, Asli B, Marolleau JP, Méaux-Ruault N, Gerfaud-Valentin M, Audeguy P, Hamidou M, Corm S, Delbrel X, Fontan J, Lebon D, Mausservey C, Moulis G, Limal N, Michel M, Godeau B, Mahévas M. Combining thrombopoietin receptor agonists with immunosuppressive drugs in adult patients with multirefractory immune thrombocytopenia, an update on the French experience. Br J Haematol 2023; 202:883-889. [PMID: 37247631 DOI: 10.1111/bjh.18893] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023]
Abstract
Combining drugs could be an effective option for treating multirefractory ITP, that is, patients not responding to rituximab, thrombopoietin receptor agonists (TPO-RA) and splenectomy. We conducted a retrospective, multicenter, observational study including multirefractory ITP patients who received a combination of a TPO-RA and an immunosuppressive drug. We included 39 patients (67% women, median age 59 years [range 21-96]), with a median ITP duration of 57 months [3-393] and a median platelet count at initiation of 10 × 109 /L [1-35]. The combination regimen was given for a median duration of 12 months [1-103] and included eltrombopag (51%) or romiplostim (49%), associated with mycophenolate mofetil (54%), azathioprine (36%), cyclophosphamide (5%), cyclosporin (3%) or everolimus (3%). Overall, 30 patients (77%) achieved at least a response (platelet count ≥30 × 109 /L and at least doubling baseline during at least 3 months), including 24 complete responses (platelet count >100 × 109 /L during at least 3 months) with a median time to response of 30 days [7-270] and a median duration of response of 15 months [4-63]. Severe adverse event related to ITP treatment was observed in 31%. In conclusion, this study confirms that some patients with multirefractory ITP can achieve long lasting response with this combination.
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Affiliation(s)
- Etienne Crickx
- Internal Medicine Department, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Imagine Institute, Université Paris Cité, INSERM UMR U1163, Paris, France
| | - Mikael Ebbo
- Internal Medicine Department, Hôpital la Timone, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Etienne Rivière
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
| | | | - Louis Terriou
- Internal Medicine and Clinical Immunology Department, Centre de référence des maladies auto-immunes systémiques rares du nord et nord-ouest de France (CeRAINO), LIRIC INSERM U995, CHU LILLE, Lille, France
| | - Sylvain Audia
- Internal Medicine and Clinical Immunology Department, Centre de référence constitutif des cytopénies auto-immunes, Hôpital François Mitterrand, Centre Hospitalier Universitaire (CHU) Dijon-Bourgogne, Dijon, France
| | - Marc Ruivard
- Internal Medicine Department, Estaing University Hospital, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, Institut Pascal, Clermont-Ferrand, France
| | - Bouchra Asli
- Internal Medicine Department, Sauvegarde Clinic, Lyon, France
| | - Jean-Pierre Marolleau
- Clinical Hematology and Cellular Therapy Department, CHU Amiens-Picardie, EA4666 Equipe Hematim - CURS - UPJV, Amiens, France
| | - Nadine Méaux-Ruault
- Internal Medicine Department, Centre Hospitalier Universitaire Jean-Minjoz, Besançon, France
| | - Mathieu Gerfaud-Valentin
- Internal Medicine Department, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard-Lyon1, Lyon, France
| | | | | | - Selim Corm
- Clinical Hematology Department, Médipole de Savoie, Challes-les-Eaux, France
| | - Xavier Delbrel
- Internal Medicine Department, Centre Hospitalier de Pau, Pau, France
| | - Jean Fontan
- Clinical Hematology Department, CHU Besançon, Besançon, France
| | - Delphine Lebon
- Clinical Hematology and Cellular Therapy Department, CHU Amiens-Picardie, EA4666 Equipe Hematim - CURS - UPJV, Amiens, France
| | - Christelle Mausservey
- Internal Medicine Department, Centre Hospitalier William-Morey, Chalon/Saône, France
| | - Guillaume Moulis
- Internal Medicine Department, CHU de Toulouse, Toulouse, France
- CIC 1436, équipe PEPSS, CHU de Toulouse, Toulouse, France
| | - Nicolas Limal
- Internal Medicine Department, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Marc Michel
- Internal Medicine Department, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Internal Medicine Department, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Matthieu Mahévas
- Internal Medicine Department, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris Cité, Université Paris-Est-Créteil, Créteil, France
- INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
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Lebowa W, Zdziarska J, Sacha T. Avatrombopag increased platelet count in a patient with chronic immune thrombocytopenia refractory to multiple lines of treatment. Blood Coagul Fibrinolysis 2023; 34:327-332. [PMID: 37395226 PMCID: PMC10942213 DOI: 10.1097/mbc.0000000000001232] [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: 04/16/2023] [Accepted: 05/17/2023] [Indexed: 07/04/2023]
Abstract
We present a case of a 30-year-old man suffering from chronic refractory immune thrombocytopenia (ITP) from early childhood. The patient was treated with all the therapeutic methods available in Poland, without platelet response: corticosteroids, intravenous immunoglobulins, splenectomy, cyclophosphamide, vinblastine, azathioprine, mycophenolate mofetil, rituximab, ciclosporin A, romiplostim, and eltrombopag. He continued to function persistently with deep thrombocytopenia, symptoms of hemorrhagic diathesis, and one episode of spontaneous subarachnoid bleeding. In April 2022, at the age of 29, the patient received avatrombopag. Within 4 weeks of starting avatrombopag 20 mg daily for 2 weeks and then 40 mg daily, he reached a platelet (PLT) count of 67 x 10 9 /l. In the next month, platelets fell below 30 x 10 9 /l, but subsequently the count increased to 47 x 10 9 /l, then to 52 x 10 9 /l, and remained stable. The symptoms of cutaneous hemorrhage diathesis have resolved completely since avatrombopag was introduced and did not reappear despite the decrease in PLT count.
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Affiliation(s)
- Weronika Lebowa
- Department of Hematology, University Hospital, Jagiellonian University Medical College
- Jagiellonian University Medical College, Doctoral School of Medical and Health Sciences, Faculty of Medicine, Cracow, Poland
| | - Joanna Zdziarska
- Department of Hematology, University Hospital, Jagiellonian University Medical College
| | - Tomasz Sacha
- Department of Hematology, University Hospital, Jagiellonian University Medical College
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43
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Boleto G, Avouac J, Godeau B, Allanore Y. Severe immune thrombocytopenia in two patients with systemic sclerosis. Joint Bone Spine 2023; 90:105560. [PMID: 36933783 DOI: 10.1016/j.jbspin.2023.105560] [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: 01/16/2023] [Revised: 02/15/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023]
Abstract
Thrombocytopenia in the context of systemic sclerosis (SSc) is rare. It should primarily raise the possibility of scleroderma renal crisis. Immune thrombocytopenia (ITP) is another cause of low platelets that is common in systemic lupus erythematosus, but tremendously rare in patients with SSc. We herein report two cases of severe ITP in patients with SSc. The first case is a 29-year-old woman with very low platelet counts (2×109/L) that did not increase despite receiving corticosteroids, intravenous immunoglobulins (IVig), rituximab and romiplostim. Because of a symptomatic acute subdural haematoma, emergency splenectomy was performed and subsequently platelet counts normalised without neurological sequelae. The second case is a 66-year-old woman in whom self-limited mild epistaxis revealed low platelet counts (8×109/L). The patient did not improve after the use of IVig and corticosteroids. Secondarily rituximab and romiplostim normalised the platelet counts after 8 weeks. To the best of our knowledge this is the first reported case of severe ITP in a patient with diffuse cutaneous SSc and anti-topoisomerase antibodies.
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Affiliation(s)
- Gonçalo Boleto
- Department of Rheumatology, université Paris Cité, Cochin Hospital, Paris, France
| | - Jérôme Avouac
- Department of Rheumatology, université Paris Cité, Cochin Hospital, Paris, France; Inserm U1016, institut Cochin, CNRS UMR8104, Paris, France
| | - Bertrand Godeau
- Centre de référence des cytopénies auto-immunes de l'adulte, service de médecine interne, CHU Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France
| | - Yannick Allanore
- Department of Rheumatology, université Paris Cité, Cochin Hospital, Paris, France; Inserm U1016, institut Cochin, CNRS UMR8104, Paris, France.
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44
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Fang Q, Huang F, Liang J, Chen Y, Li C, Zhang M, Wu X, Luo W. Safety of romiplostim and eltrombopag for children with immune thrombocytopenia: a pharmacovigilance study of the FDA adverse event reporting system database. Expert Opin Drug Saf 2023; 22:707-714. [PMID: 36803342 DOI: 10.1080/14740338.2023.2182288] [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: 09/16/2022] [Accepted: 02/13/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Romiplostim and eltrombopag are thrombopoietin receptor agonists (TPORAs) that have been approved by the FDA on 22 August 2008 and 20 November 2008 for pediatric immune thrombocytopenia (ITP). However, postmarketing pharmacovigilance of TPORAs in children still attracts much attention. We aimed to evaluate the safety of the TPORAs romiplostim and eltrombopag using data from the Adverse Event Reporting System database of FDA (FAERS). RESEARCH DESIGN AND METHODS We conducted a disproportionality analysis and analyzed data from the FAERS database to characterize the key features of adverse events (AEs) associated with TPO-RAs approved for children under 18 years of age. RESULTS Since their approval in the market in 2008, 250 and 298 reports of romiplostim and eltrombopag use in children have been published in the FAERS database, respectively. The most frequent AE associated with romiplostim and eltrombopag was epistaxis. Neutralizing antibodies and vitreous opacities showed the strongest signals for romiplostim and eltrombopag, respectively. CONCLUSIONS The labeled AEs for romiplostim and eltrombopag in children were analyzed. Unlabeled AEs may reflect the potential of new clinical individuals. Early recognition and management of AEs that appear in children treated with romiplostim and eltrombopag are of key importance in clinical practice.
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Affiliation(s)
- Qiongtong Fang
- Department of Pharmacy, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Fuqiang Huang
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiabi Liang
- Department of Pharmacy, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Yishen Chen
- Department of Pharmacy, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Cheng Li
- Department of Pharmacy, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Meirong Zhang
- Department of Pharmacy, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Xinrong Wu
- Department of Pharmacy, General Hospital of Southern Theatre Command of PLA, Guangzhou, Guangdong, China
| | - Wenji Luo
- Department of Pharmacy, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
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45
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Ren X, Zhang M, Zhang X, Zhao P, Zhai W. Low-dose intravenous immunoglobulin for children with newly diagnosed immune thrombocytopenia: protocol of a systematic review and meta-analysis. BMJ Open 2023; 13:e071644. [PMID: 37385744 PMCID: PMC10314640 DOI: 10.1136/bmjopen-2023-071644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/21/2023] [Indexed: 07/01/2023] Open
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIg) is a first-line treatment for children with newly diagnosed immune thrombocytopenia (ITP). However, the cost of IVIg is high. Higher doses of IVIg are associated with a more insupportable financial burden to paediatric patients' families and may produce more adverse reactions. Whether low-dose IVIg can quickly stop bleeding and induce a durable response in treating children with newly diagnosed ITP is not yet established. METHODS AND ANALYSIS We will extensively search five English databases (PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature) and three Chinese databases (CNKI, Wanfang and VIP). International Clinical Trials Registry Platform and ClinicalTrials.gov will also be searched as supplementary. Randomised controlled trials and prospective observational studies compared the efficacy of low-dose IVIg and high-dose or moderate-dose IVIg will be included. The primary outcome is the proportion of patients achieving durable response. Estimates of effect will be pooled with either a random-effect model or a fixed-effect model according to the heterogeneity of studies. If significant heterogeneity exists, we will conduct subgroup analysis and sensitivity analysis to explore the source of heterogeneity and evaluate the robustness of the results. Publication bias will also be assessed, if possible. The risk of bias will be assessed using the Risk of Bias 2 and Risk Of Bias In Non-randomised Studies of Interventions tools. The certainty of evidence will be evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. ETHICS AND DISSEMINATION No ethical approval is required since this systematic review is based on previously published studies. The findings of this study will be presented at international conferences or published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022384604.
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Affiliation(s)
- Xiangge Ren
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Miaomiao Zhang
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Xiaohan Zhang
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Peidong Zhao
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Wensheng Zhai
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
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Du H, Tang Q, Yang J, Yan B, Yang L, Wang M. Genome-wide DNA methylation profiling of CD4 + T lymphocytes identifies differentially methylated loci associated with adult primary refractory immune thrombocytopenia. BMC Med Genomics 2023; 16:124. [PMID: 37291547 PMCID: PMC10251572 DOI: 10.1186/s12920-023-01557-0] [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: 06/08/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND DNA methylation played a crucial role in the pathogenesis of immune thrombocytopenia (ITP). However, genome-wide DNA methylation analysis has not been applied thus far. The present study aimed to provide the first DNA methylation profiling for ITP. METHODS Peripheral blood CD4+ T lymphocytes samples were collected from 4 primary refractory ITP cases and 4 age-matched healthy controls, and DNA methylome profiling was performed using Infinium MethylationEPIC BeadChip. Differentially methylated CpG sites were further validated in another independent cohort of 10 ITP patients and 10 healthy controls using qRT-PCR. RESULTS The DNA methylome profiling identified a total of 260 differentially methylated CpG sites mapping to 72 hypermethylated and 64 hypomethylated genes. These genes were mainly enriched in the actin nucleation of the Arp2/3 complex, vesicle transport, histone H3-K36 demethylation, Th1 and Th2 cell differentiation, and Notch signaling pathway according to the GO and KEGG databases. The mRNA expression of CASP9, C1orf109, and AMD1 were significantly different. CONCLUSIONS Given the altered DNA methylation profiling of ITP, our study provides new insights into its genetic mechanism and suggests candidate biomarkers for the diagnosis and treatment of ITP.
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Affiliation(s)
- Hanzhi Du
- Department of Haematology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qinghua Tang
- Department of Osteoporosis, Xi'an Jiaotong University Affiliated HongHui Hospital, Xi'an, China
| | - Jian Yang
- Department of Clinical Research Centre, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bin Yan
- Department of Clinical Research Centre, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lihong Yang
- Department of Clinical Research Centre, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengchang Wang
- Department of Haematology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Sun M, Wang X, Zhang N, Wang L, Wang X, Fan W, Li Q, Liu Y, Song M, Guo X. Imbalance of follicular regulatory T (Tfr) cells/follicular helper T (Tfh) cells in adult patients with primary immune thrombocytopenia. Exp Biol Med (Maywood) 2023; 248:959-965. [PMID: 37208911 PMCID: PMC10525409 DOI: 10.1177/15353702231168142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/13/2023] [Indexed: 05/21/2023] Open
Abstract
This study is to investigate the role of follicular regulatory T (Tfr) cells/follicular helper T (Tfh) cells imbalance in adult patients with primary immune thrombocytopenia (ITP). Totally, 40 cases of primary ITP patients and 30 healthy controls were enrolled. Blood samples were collected from ITP patients (pre- and post-therapy) and controls. Flow cytometry was used to detect the proportion of Tfr and Tfh cells in peripheral blood. Real-time quantitative polymerase chain reaction (PCR) was performed to detect the mRNA expression levels of FOXP3, BCL-6, and BLIMP-1. Enzyme-linked immunosorbent assay (ELISA) was conducted to detect interleukin (IL)-10 and IL-21 levels. Spearman's correlation was used for correlation analysis. Compared with control, Tfr cell proportion, FOXP3 mRNA, and IL-10 were significantly decreased in the pre-therapy ITP group, but were significantly increased post-therapy. Tfh cell proportion, BCL-6 mRNA, and IL-21 were increased, while BLIMP-1 mRNA was decreased, in the pre-therapy ITP group than the control group. These effects were reversed in the post-therapy ITP group. Moreover, the Tfr/Tfh ratio was decreased in the pre-therapy ITP group than control group, whereas was increased in the post-therapy ITP group than the pre-therapy ITP group. Furthermore, Tfr cell proportion, FOXP3 mRNA, IL-10, and Tfr/Tfh ratio were positively correlated with the platelet count (PLT) in the ITP pre-therapy group. In addition, Tfh cell proportion, BCL-6 mRNA, and IL-21 were negatively correlated with the PLT, while BLIMP-1 mRNA was positively correlated with the PLT. Conclusively, Tfr cell proportion in peripheral blood is decreased and Tfh cell proportion is increased, leading to unbalanced Tfr/Tfh ratio in ITP patients pre-therapy. The imbalance of Tfr/Tfh is recovered post-therapy, suggesting that the Tfr and Tfh cells may be involved in ITP pathogenesis. The abnormal expression of FOXP3, BCL-6, and BLIMP-1 mRNA and the changes in IL-10 and IL-21 levels may be related to the imbalance of Tfr/Tfh.
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Affiliation(s)
- Mingling Sun
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Xiujuan Wang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Ning Zhang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Lei Wang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Xinyou Wang
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Wenxia Fan
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Qinzhi Li
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Ying Liu
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Mengting Song
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
| | - Xinhong Guo
- Hematologic Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Uygur Autonomous Region Research Institute of Hematology, Xinjiang Medical University, Urumqi 830011, China
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Ren L, Liu W, Wu T, Xue F, Mao D, Yu L, Bai H. Diffuse large B‑cell lymphoma and monoclonal gammopathy secondary to immune thrombocytopenic purpura: A case report. Oncol Lett 2023; 25:237. [PMID: 37153052 PMCID: PMC10161323 DOI: 10.3892/ol.2023.13823] [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: 07/21/2022] [Accepted: 11/03/2022] [Indexed: 05/09/2023] Open
Abstract
The present study reports the case of a patient with diffuse large B-cell lymphoma (DLBCL) and monoclonal gammopathy (MG) secondary to immune thrombocytopenia purpura (ITP). The clinical diagnoses and investigations of this case are reported. To the best of our knowledge, this is the first study to report DLBCL and MG secondary to ITP. The patient presented with a rare constellation of diseases, which made the diagnosis and treatment difficult for the physicians. The patient was followed up for 10 years using the morphological examination of bone marrow cells after chemotherapy, and currently continues with follow-up examinations. Treatments and prognoses for ITP, DLBCL and MG are common. However, treatments and prognoses are unclear for patients with all three conditions. The different clinical manifestations and disease processes of DLBCL and MG secondary to ITP cause difficulties for physicians in terms of treatment and prognosis. The present case report describes the comprehensive evaluation, diagnosis and treatment of a patient with DLBCL and MG secondary to, and concurrent with, ITP.
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Affiliation(s)
- Liwei Ren
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Wenhui Liu
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Tao Wu
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Feng Xue
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Dongfeng Mao
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Lingling Yu
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
| | - Hai Bai
- Department of Hematology, The 940th Hospital of The Joint Logistics Support Force of The Chinese People's Liberation Army, Lanzhou, Gansu 730050, P.R. China
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49
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Allegra A, Cicero N, Mirabile G, Giorgianni CM, Gangemi S. Novel Biomarkers for Diagnosis and Monitoring of Immune Thrombocytopenia. Int J Mol Sci 2023; 24:ijms24054438. [PMID: 36901864 PMCID: PMC10003036 DOI: 10.3390/ijms24054438] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/12/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Lower-than-normal platelet counts are a hallmark of the acquired autoimmune illness known as immune thrombocytopenia, which can affect both adults and children. Immune thrombocytopenia patients' care has evolved significantly in recent years, but the disease's diagnosis has not, and it is still only clinically achievable with the elimination of other causes of thrombocytopenia. The lack of a valid biomarker or gold-standard diagnostic test, despite ongoing efforts to find one, adds to the high rate of disease misdiagnosis. However, in recent years, several studies have helped to elucidate a number of features of the disease's etiology, highlighting how the platelet loss is not only caused by an increase in peripheral platelet destruction but also involves a number of humoral and cellular immune system effectors. This made it possible to identify the role of immune-activating substances such cytokines and chemokines, complement, non-coding genetic material, the microbiome, and gene mutations. Furthermore, platelet and megakaryocyte immaturity indices have been emphasized as new disease markers, and prognostic signs and responses to particular types of therapy have been suggested. Our review's goal was to compile information from the literature on novel immune thrombocytopenia biomarkers, markers that will help us improve the management of these patients.
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Affiliation(s)
- Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
- Correspondence:
| | - Nicola Cicero
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Giuseppe Mirabile
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
| | - Concetto Mario Giorgianni
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Sebastiano Gangemi
- Allergy and Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
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Recurrent pain attacks during romiplostim treatment in a patient with ITP carrying a heterozygous MEFV mutation. Int J Hematol 2023; 117:283-286. [PMID: 36149532 DOI: 10.1007/s12185-022-03453-2] [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: 03/08/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 02/03/2023]
Abstract
We report a case of recurrent pain attacks during romiplostim treatment in a woman with immune thrombocytopenia carrying a heterozygous MEFV mutation. Five months after starting treatment with romiplostim for immune thrombocytopenia, she was diagnosed with idiopathic pericarditis. She was switched to eltrombopag, but thrombocytopenia did not improve. Romiplostim was restarted 7 months later, although she then developed recurrent right hypochondrial pain. The pain typically occurred three days after the romiplostim injection and resolved two days later. She had never experienced such recurrent pain before starting romiplostim or after discontinuing it. Genetic analysis showed that she carried a heterozygous R202Q alteration in exon 2 of the MEFV gene. MEFV mutation is known to cause familial Mediterranean fever, which is characterized by symptoms such as recurrent fever, abdominal and chest pain, arthritis, and pericarditis. This case suggests that romiplostim has the potential to trigger recurrent pain/inflammation attacks in individuals with systemic inflammatory abnormalities.
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