1
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Scheinberg P, Clé DV, Kim JS, Nur E, Yenerel MN, Barcellini W, Bonito D, Giai V, Hus M, Lee Y, Lekue CB, Panse J, Ueda Y, Buatois S, Gentile B, Kiialainen A, Patel H, Sreckovic S, Uguen M, Edwards J, Nagy Z, Kulasekararaj AG. Phase 3 randomized COMMODORE 1 trial: Crovalimab versus eculizumab in complement inhibitor-experienced patients with paroxysmal nocturnal hemoglobinuria. Am J Hematol 2024; 99:1757-1767. [PMID: 38924124 DOI: 10.1002/ajh.27413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/10/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024]
Abstract
Crovalimab, a novel C5 inhibitor, allows for low-volume, every-4- week, subcutaneous self-administration. COMMODORE 1 (NCT04432584) is a phase 3, global, randomized trial evaluating crovalimab versus eculizumab in C5 inhibitor-experienced patients with paroxysmal nocturnal hemoglobinuria (PNH). Adults with lactate dehydrogenase ≤1.5 × upper limit of normal and receiving approved eculizumab doses for ≥24 weeks were randomized 1:1 to receive crovalimab (weight-based tiered dosing) or continue eculizumab. The original primary study objective was efficacy; however, given the evolving treatment landscape, target recruitment was not met, and all efficacy endpoints became exploratory, with safety as the new primary objective. Exploratory efficacy endpoints included transfusion avoidance, hemolysis control, breakthrough hemolysis, hemoglobin stabilization, FACIT-Fatigue score, and patient preference (crovalimab vs. eculizumab). Eighty-nine patients were randomized (45 to crovalimab; 44 to eculizumab). During the 24-week primary treatment period, adverse events (AEs) occurred in 77% of patients receiving crovalimab and 67% receiving eculizumab. No AEs led to treatment withdrawal or death, and no meningococcal infections occurred. 16% of crovalimab-treated patients had transient immune complex reactions (also known as Type III hypersensitivity events), an expected risk when switching between C5 inhibitors that bind to different C5 epitopes; most were mild/moderate and all resolved without treatment modification. Crovalimab-treated patients had sustained terminal complement activity inhibition, maintained disease control, and 85% preferred crovalimab over eculizumab. Together with phase 3 COMMODORE 2 results in complement inhibitor-naive patients, these data support crovalimab's favorable benefit-risk profile. Crovalimab is a new C5 inhibitor for PNH that is potentially less burdensome than existing therapies for this lifelong disease.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
| | - Diego Villa Clé
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Erfan Nur
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - Mustafa N Yenerel
- Division of Hematology, Department of Internal Medicine, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Wilma Barcellini
- Hematology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Valentina Giai
- Department of Hematology and Oncology, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marek Hus
- Department of Hemato Oncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - YooJin Lee
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | | | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology (CIO), Cologne, Germany
| | - Yasutaka Ueda
- Department of Hematology and Oncology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Suita, Japan
| | | | | | | | - Himika Patel
- Genentech, Inc., South San Francisco, California, USA
| | | | | | - John Edwards
- Indiana Blood and Marrow Transplantation, Indianapolis, Indiana, USA
| | - Zsolt Nagy
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, London, UK
- National Institute for Health Research and Wellcome King's Clinical Research Facility and King's College London, London, UK
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2
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Young DJ. A growing panoply of options for patients with paroxysmal nocturnal hemoglobinuria. Am J Hematol 2024; 99:1667-1669. [PMID: 39023315 DOI: 10.1002/ajh.27426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024]
Affiliation(s)
- David J Young
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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3
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Gu J, Xu J, Jiao A, Cai N, Gu T, Wu P, Cheng X, Chen B, Chen Y, Liu X. Comprehensive analysis of single-cell transcriptomics and genetic factors reveals the mechanisms and preventive strategies for the progression from pulmonary fibrosis to lung cancer. Int Immunopharmacol 2024; 140:112803. [PMID: 39094357 DOI: 10.1016/j.intimp.2024.112803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/24/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Pulmonary fibrosis (PF) leads to excessive deposition of fibrous connective tissue in the lungs, increasing the risk of lung cancer due to the enhanced activity of fibroblasts (FBs). Fibroblast-mediated collagen fiber deposition creates a tumor-like microenvironment, laying the foundation for tumorigenesis. Clinically, numerous cases of lung cancer induced by pulmonary fibrosis have been observed. In recent years, the study of nucleotide point mutations, which provide more detailed insights than gene expression, has made significant advancements, offering new perspectives for clinical research. METHODS We initially employed Mendelian randomization to ascertain that the initial stage of lung cancer induced by PF belongs to small cell lung cancer (SCLC). Subsequently, pulmonary neuroendocrine cells (PNECs) were identified by using pseudo-time series analysis as cell clusters with carcinogenic potential. We categorized FBs into four groups according to their cellular metabolism, and then analyzed the cellular communication between FBs and PNECs, as well as changes in intracellular pathways of PNECs. Additionally, we examined the characteristic genome of FBs which is significantly associated with PF and investigated the impact of FBs on immune cells in the PF microenvironment. Finally, we explored strategies for preventing the progression from PF to lung cancer. RESULTS The genetic features of cells with carcinogenic potential in PF tissues were revealed, characterized by upregulation of Achaete-Scute Family BHLH Transcription Factor 1 (ASCL1), Homeobox B2 (HOXB2), Teashirt Zinc Finger Homeobox 2 (TSHZ2), Insulinoma-associated 1 (INSM1), and reduced activity of RE1 Silencing Transcription Factor (REST). FBs characterized by high glycolysis and low tricarboxylic acid (TCA) cycling played a key role in the progression of PF. The microenvironment of PF resembles the tumor microenvironment, providing a conducive immunosuppressive environment for the occurrence of cancer cells. In dendritic cells, rs9265808 is a susceptibility locus for progression from pulmonary fibrosis to lung cancer, mutations at this locus increase the expression of Complement Factor B (CFB), and excessive activation of the complement pathway is a crucial factor leading to lung cancer development in patients with pulmonary fibrosis. Ensuring adequate nutritional supply and physical function is one of the effective measures to prevent progression from pulmonary fibrosis to lung cancer. CONCLUSION CFB promotes lung cancer occurrence by inducing the accumulation and polarization of a large number of monocytes/macrophages in the lungs, driving disease progression by reducing the physical fitness of patients with pulmonary fibrosis.
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Affiliation(s)
- Jinghua Gu
- School of Life Sciences, Anhui Medical University, Hefei 230032, China; The First Clinical Medical College of Anhui Medical University, Hefei 230032, China; Henan International Joint Laboratory of Non-coding RNA and Metabolism in Cancer, Henan Provincial Key Laboratory of Long Non-coding RNA and Cancer Metabolism, Translational Research Institute of Henan Provincial People's Hospital and People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jiansheng Xu
- The First Clinical Medical College of Anhui Medical University, Hefei 230032, China
| | - Annan Jiao
- The First Clinical Medical College of Anhui Medical University, Hefei 230032, China; The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
| | - Ningning Cai
- The First Clinical Medical College of Anhui Medical University, Hefei 230032, China
| | - Tianrui Gu
- School of Pharmacy, Zhejiang University, Hangzhou 310058, China
| | - Pengcheng Wu
- School of Life Sciences, Anhui Medical University, Hefei 230032, China
| | - Xinyu Cheng
- School of Life Sciences, Anhui Medical University, Hefei 230032, China
| | - Bo Chen
- The First Clinical Medical College of Anhui Medical University, Hefei 230032, China; The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China.
| | - Yang Chen
- The First Clinical Medical College of Anhui Medical University, Hefei 230032, China; The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China.
| | - Xiaoying Liu
- School of Life Sciences, Anhui Medical University, Hefei 230032, China; Henan International Joint Laboratory of Non-coding RNA and Metabolism in Cancer, Henan Provincial Key Laboratory of Long Non-coding RNA and Cancer Metabolism, Translational Research Institute of Henan Provincial People's Hospital and People's Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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4
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Panse J, Daguindau N, Okuyama S, Peffault de Latour R, Schafhausen P, Straetmans N, Al-Adhami M, Persson E, Wong RSM. Improvements in hematologic markers and decreases in fatigue with pegcetacoplan for patients with paroxysmal nocturnal hemoglobinuria and mild or moderate anemia (hemoglobin ≥10 g/dL) who had received eculizumab or were naive to complement inhibitors. PLoS One 2024; 19:e0306407. [PMID: 39079163 PMCID: PMC11285951 DOI: 10.1371/journal.pone.0306407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/12/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Although complement component 5 inhibitors (C5is) eculizumab and ravulizumab improve paroxysmal nocturnal hemoglobinuria (PNH) outcomes, patients may experience persistent anemia. This post hoc analysis investigated whether the complement component 3-targeted therapy pegcetacoplan also improved hematologic outcomes and reduced fatigue in patients with PNH and mild/moderate anemia. METHODS Patients with PNH and hemoglobin ≥10.0 g/dL at baseline of PADDOCK (N = 6), PRINCE (N = 8), and PEGASUS (N = 11) were included. Before receiving pegcetacoplan, PADDOCK and PRINCE patients were C5i-naive; PEGASUS patients had hemoglobin <10.5 g/dL despite stably dosed eculizumab. Hemoglobin concentrations, percentages of patients with concentrations ≥12 g/dL, and sex-specific normalization were assessed at baseline and after 16 weeks of pegcetacoplan, as were absolute reticulocyte counts (ARCs) and normalization and fatigue scores and normalization. RESULTS From baseline to week 16, mean (SD) hemoglobin concentrations increased in C5i-naive patients (PADDOCK: 10.5 [0.4] to 12.7 [1.1] g/dL; PRINCE: 11.3 [1.0] to 14.0 [1.3] g/dL) and those with suboptimal eculizumab responses (PEGASUS: 10.2 [0.2] to 12.8 [2.6] g/dL). Percentage of patients with hemoglobin ≥12 g/dL increased (PADDOCK: 0 to 60.0% [3 of 5 patients]; PRINCE: 25.0% [2 of 8] to 87.5% [7 of 8]; PEGASUS: 0 to 72.7% [8 of 11]). Sex-specific hemoglobin normalization at week 16 occurred in 40.0% (2 of 5) (PADDOCK), 62.5% (5 of 8) (PRINCE), and 63.6% (7 of 11) (PEGASUS). In all studies, mean ARCs decreased from above normal to normal and ARC normalization increased. Mean Functional Assessment of Chronic Illness Therapy-Fatigue scores improved from below to above or near normal. Two patients had serious adverse events (PEGASUS: post-surgery sepsis, breakthrough hemolysis); breakthrough hemolysis resolved without study discontinuation. CONCLUSION Patients with PNH and mild/moderate anemia who were C5i-naive or who had suboptimal hemoglobin concentrations despite eculizumab treatment had improved hematologic outcomes and reduced fatigue after initiating or switching to pegcetacoplan. TRIAL REGISTRATION Trial registration numbers: PADDOCK (NCT02588833), PRINCE (NCT04085601; EudraCT, 2018-004220-11), PEGASUS (NCT03500549).
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Affiliation(s)
- Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Dusseldorf (ABCD), Aachen, Bonn, Cologne, Germany
| | | | - Sonia Okuyama
- Hematology/Oncology Division, Denver Health and Hospital Authority, Denver, CO, United States of America
| | - Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Assistance Publique—Hôpitaux de Paris, Université de Paris, Paris, France
| | - Philippe Schafhausen
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicole Straetmans
- Department of Hematology, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | | | | | - Raymond Siu Ming Wong
- Sir Y.K. Pao Centre for Cancer & Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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Gurnari C, Awada H, Pagliuca S, Dima D, Ullah F, Kawashima N, Kubota Y, Colak C, Visconte V, Patel BJ, Dhillon V, Marneni N, Balasubramanian SK, Kishtagari A, Bat T, Maciejewski JP. Paroxysmal nocturnal hemoglobinuria-related thrombosis in the era of novel therapies: a 2043-patient-year analysis. Blood 2024; 144:145-155. [PMID: 38513233 DOI: 10.1182/blood.2024023988] [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: 01/18/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
ABSTRACT Thrombophilia is one of the principal features of paroxysmal nocturnal hemoglobinuria (PNH) and constitutes the main cause of disease morbidity/mortality. Anticomplement treatment has revolutionized the natural history of PNH, with control of the hemolytic process and abolition of thrombotic events (TEs). However, no guidelines exist for the management of thromboembolic complications in this setting, with type and duration of anticoagulation depending on individual practices. Besides, a scarcity of data is present on the efficacy of direct oral anticoagulants (DOACs). Herein, we accrued a large real-world cohort of patients with PNH from 4 US centers to explore features, predictors of TE, and anticoagulation strategies. Among 267 patients followed up for a total of 2043 patient-years, 56 (21%) developed TEs. These occurred at disease onset in 43% of cases, involving more frequently the venous system, typically as Budd-Chiari syndrome. Rate of TEs was halved in patients receiving complement inhibitors (21 vs 40 TEs per 1000 patient-years in untreated cases, with a 2-year cumulative incidence of thrombosis of 3.9% vs 18.3%, respectively), and varied according to PNH granulocytes and erythrocytes clone size, type, disease activity parameters, as well as number (≥2 mutations, or less) and variant allelic frequency of PIGA mutations. Anticoagulation with warfarin (39%), DOACs (37%), and low-molecular weight heparin (16%) was administered for a median of 29 months (interquartile range [IQR], 9-61.8). No thrombotic recurrence was observed in 19 patients treated with DOACs at a median observation of 17.1 months (IQR, 8.9-45) whereas 14 cases discontinued anticoagulation without TE recurrence at a median time of 51.4 months (IQR, 29.9-86.8).
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Hussein Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Clinical Hematology, Centre Hospitalier Régional Universitaire Nancy and Unité Mixte de Recherche 7635, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Fauzia Ullah
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Naomi Kawashima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Yasuo Kubota
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Ceylan Colak
- Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Bhumika J Patel
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Vikram Dhillon
- Department of Oncology, Karmanos Cancer Institute/Wayne State University, Detroit, MI
| | - Naimisha Marneni
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Ashwin Kishtagari
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Taha Bat
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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6
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Xu B, Kang B, Chen J, Li S, Zhou J. Factor B inhibitor iptacopan for the treatment of paroxysmal nocturnal hemoglobinuria. Blood Rev 2024; 66:101210. [PMID: 38811284 DOI: 10.1016/j.blre.2024.101210] [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: 01/23/2024] [Revised: 05/14/2024] [Accepted: 05/24/2024] [Indexed: 05/31/2024]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, clonal, complement-mediated hemolytic anemia with a variety of manifestations. Currently, the methods for treating PNH include anti-C5 treatments (eculizumab and ravulizumab) and pegcetacoplan (a targeted C3 inhibitor). On December 5, 2023, the US FDA approved a factor B inhibitor called Fabhalta® (iptacopan), previously known as LNP023, for the treatment of adult patients with PNH, including those who have previously received anti-C5 therapy. The main objective of this review was to elucidate the clinical efficacy and safety of the newly approved factor B inhibitor, iptacopan. Iptacopan plays a proximal role in the alternative complement pathway to control extravascular hemolysis mediated by C3b and intravascular hemolysis mediated by terminal complement. The recommended dosage is 200 mg orally twice daily. The 24-week results of the pivotal phase III open-label trial, APPLY-PNH, demonstrated that among PNH patients who had previously received anti-C5 therapy, 51/60 (estimated percentages 82%) of patients in the iptacopan group showed an increase in hemoglobin of ≥2 g/dL compared to 0/35 (estimated percentages 2%) in the standard treatment group, also, 69% of iptacopan-treated patients achieved hemoglobin levels ≥12 g/dL, while no patients in the standard treatment group reached this level (both p < 0.001). The 48-week results were similar to those observed at 24 weeks. The most common adverse events were headache, infection and diarrhea. There were almost no clinical breakthrough hemolysis. Trials evaluating the long-term safety and efficacy of iptacopan are currently recruiting.
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Affiliation(s)
- Bo Xu
- The First Affiliated Hospital, Hunan Provincial Clinical Medical Research Center for Drug Evaluation of Major Chronic Diseases, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Clinical Pharmacology Research Center, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Key Laboratory of Clinical Pharmacology, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Pharmacy Department, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; School of Pharmaceutical Science, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China
| | - Bo Kang
- The First Affiliated Hospital, Hunan Provincial Clinical Medical Research Center for Drug Evaluation of Major Chronic Diseases, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Clinical Pharmacology Research Center, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Key Laboratory of Clinical Pharmacology, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Pharmacy Department, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China
| | - Jixiang Chen
- The First Affiliated Hospital, Hunan Provincial Clinical Medical Research Center for Drug Evaluation of Major Chronic Diseases, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Clinical Pharmacology Research Center, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Key Laboratory of Clinical Pharmacology, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Pharmacy Department, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; School of Pharmaceutical Science, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China
| | - Shaoqian Li
- The First Affiliated Hospital, Hunan Provincial Clinical Medical Research Center for Drug Evaluation of Major Chronic Diseases, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Clinical Pharmacology Research Center, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Key Laboratory of Clinical Pharmacology, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Pharmacy Department, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The Affiliated Nanhua Hospital, Department of Docimasiology, Hengyang Medical School, University of South China, Hengyang, Hunan 421002, China
| | - Jiecan Zhou
- The First Affiliated Hospital, Hunan Provincial Clinical Medical Research Center for Drug Evaluation of Major Chronic Diseases, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Clinical Pharmacology Research Center, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Hengyang Key Laboratory of Clinical Pharmacology, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; The First Affiliated Hospital, Pharmacy Department, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China; School of Pharmaceutical Science, Hengyang Medical School, University of South China, Hengyang 421001, Hunan, China.
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7
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Plante MM, Wang J, Alhaj Moustafa M. 73-Year-Old Man With Worsening Hematuria. Mayo Clin Proc 2024:S0025-6196(23)00523-2. [PMID: 38912987 DOI: 10.1016/j.mayocp.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 06/25/2024]
Affiliation(s)
- Marie M Plante
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Jing Wang
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Muhamad Alhaj Moustafa
- Advisor to residents and Consultant in Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL.
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8
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Peffault de Latour R, Griffin M, Kelly RJ, Szer J, de Castro C, Horneff R, Tan L, Yeh M, Panse J. Hemolysis events in the phase 3 PEGASUS study of pegcetacoplan in patients with paroxysmal nocturnal hemoglobinuria. Blood Adv 2024; 8:2718-2725. [PMID: 38593241 PMCID: PMC11170155 DOI: 10.1182/bloodadvances.2024012672] [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: 01/16/2024] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
ABSTRACT Patients with paroxysmal nocturnal hemoglobinuria (PNH) experience complement-mediated intravascular hemolysis leading to anemia, fatigue, and potentially life-threatening thrombotic complications. Pegcetacoplan, a C3 inhibitor, demonstrated sustained improvements in hematologic and clinical parameters in the phase 3 PEGASUS trial in patients with PNH who remained anemic despite C5 inhibitor therapy. The present post hoc analysis describes 26 hemolysis adverse events (AEs) experienced in 19 patients during pegcetacoplan therapy in PEGASUS and baseline patient characteristics potentially associated with increased hemolysis risk. Lactate dehydrogenase (LDH) ≥2× the upper limit of normal (ULN) was observed in 19 events, including 2 with LDH ≥10× ULN. All patients experienced decreased hemoglobin during hemolysis (mean decrease, 3.0 g/dL). In 16 events (62%), a potential complement-amplifying condition underlying the event could be identified. Hemolysis AEs led to study discontinuation in 5 patients. However, of 26 hemolysis AEs, 17 (65%) were manageable without pegcetacoplan discontinuation. A greater proportion of patients with hemolysis AEs (n = 19) had key characteristics of higher disease activity at baseline compared to patients without hemolysis AEs (n = 61), namely higher-than-label eculizumab dose (53% vs 23%), detectable CH50 (total complement function; 74% vs 54%), and ≥4 transfusions in the previous 12 months (68% vs 51%). These characteristics may be useful predictors of potential future hemolysis events. This trial was registered at www.ClinicalTrials.gov as #NCT03500549.
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Affiliation(s)
- Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Paris, France
| | - Morag Griffin
- Department of Haematology, St James’s University Hospital, Leeds, United Kingdom
| | - Richard J. Kelly
- Department of Haematology, St James’s University Hospital, Leeds, United Kingdom
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - Carlos de Castro
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University, Durham, NC
| | | | - Lisa Tan
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
- Lisa Tan Pharma Consulting Ltd, Cambridge, United Kingdom
| | | | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology, and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany
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9
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Mulherin BP, Yeh M, Al-Adhami M, Dingli D. Normalization of Hemoglobin, Lactate Dehydrogenase, and Fatigue in Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with Pegcetacoplan. Drugs R D 2024; 24:169-177. [PMID: 38727860 DOI: 10.1007/s40268-024-00463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES We determined normalization rates for hemoglobin, lactate dehydrogenase (LDH), and fatigue in patients with paroxysmal nocturnal hemoglobinuria (PNH) treated with pegcetacoplan (PEG) in the PEGASUS (NCT03500549) and PRINCE (NCT04085601) phase III trials. METHODS Enrolled patients had PNH and hemoglobin < 10.5 g/dL despite ≥ 3 months of eculizumab (ECU) [PEGASUS], or were complement component 5 (C5) inhibitor-naive, receiving supportive care only, with hemoglobin less than the lower limits of normal (LLN) [PRINCE]. Hematologic and fatigue normalization endpoints were hemoglobin greater than or equal to the LLN (females: 12 g/dL; males: 13.6 g/dL) in the absence of transfusion; LDH ≤226 U/L in the absence of transfusion; and Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue ≥ 43.6, the general population norm. Safety was assessed by investigators using standardized terms and definitions for seriousness and severity. RESULTS Hemoglobin normalization occurred in 34.1% (14/41) of PEG-treated patients at Week 16 (randomized controlled period) in PEGASUS (vs. 0% [0/39] of ECU-treated patients) and in 45.7% (16/35) of PEG-treated patients at Week 26 in PRINCE (vs. 0% [0/18] of supportive care-treated patients). At Week 48 (open-label period) in PEGASUS, 24.4% of PEG-treated patients (PEG-to-PEG) and 30.8% of patients treated with ECU through Week 16 who switched to PEG through Week 48 (ECU-to-PEG) had hemoglobin normalization. Rates of LDH normalization in PEGASUS were 70.7% (PEG-treated patients) and 15.4% (ECU-treated patients) at Week 16, and 56.1% (PEG-to-PEG) and 51.3% (ECU-to-PEG) at Week 48. In PRINCE, 67.5% of PEG-treated patients at Week 26 had normalized LDH concentrations. Rates of FACIT-Fatigue score normalization in PEGASUS were 48.8% and 10.3% in PEG- and ECU-treated patients, respectively, at Week 16, and 34.1% and 51.3% in PEG-to-PEG- and ECU-to-PEG-treated patients, respectively, at Week 48. In PRINCE, 68.6% of PEG-treated patients and 11.1% of supportive care patients had FACIT-Fatigue score normalization at Week 26. PEG was safe and well tolerated. Injection site reactions, mostly mild, were the most common adverse event of special interest in PEG-treated patients in the PEGASUS randomized controlled period (36.6%) and in PRINCE (30.4%). CONCLUSION PEG is superior to ECU and supportive care in hemoglobin, LDH, and FACIT-Fatigue score normalization for patients with PNH and persistent anemia despite ≥3 months of treatment with ECU, and in C5 inhibitor-naive patients. CLINICAL TRIAL REGISTRATION The PEGASUS trial (NCT03500549) was registered on 18 August 2018, and the PRINCE trial (NCT04085601) was registered on 11 September 2019.
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Affiliation(s)
- Brian P Mulherin
- Hematology Oncology of Indiana, 8301 Harcourt Rd, Indianapolis, IN, 46260, USA.
- Ascension St. Vincent Carmel, Carmel, IN, USA.
| | - Michael Yeh
- Hematology Oncology of Indiana, 8301 Harcourt Rd, Indianapolis, IN, 46260, USA
| | | | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Fahim SM, Makam AN, Suh K, Carlson JJ, Richardson M, Herce-Hagiwara B, Dickerson R, Pearson SD, Agboola F. Iptacopan and danicopan for paroxysmal nocturnal hemoglobinuria. J Manag Care Spec Pharm 2024; 30:618-623. [PMID: 38824627 PMCID: PMC11145001 DOI: 10.18553/jmcp.2024.30.6.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Affiliation(s)
| | - Anil N. Makam
- Department of Medicine, University of California San Francisco
- University of California San Francisco Philip R. Lee Institute for Health Policy Studies
| | - Kangho Suh
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, PA
| | - Josh J. Carlson
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle
| | | | | | - Ronald Dickerson
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle
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11
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Yu H, Duan S, Wang P, Fu R, Lv Z, Yu Y, Miao P, Shi J, Zhuang N, Hu H, Yuan N, Che S. Health-related quality of life and influencing factors of patients with paroxysmal nocturnal hemoglobinuria in China. Orphanet J Rare Dis 2024; 19:186. [PMID: 38702811 PMCID: PMC11067208 DOI: 10.1186/s13023-024-03178-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 03/30/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is a rare blood disorder, leading to various complications and impairments in patients' health-related quality of life (HRQOL). Limited research has been conducted to evaluate the HRQOL of Chinese patients with PNH. Understanding the HRQOL in this specific population is crucial for providing effective healthcare interventions and improving patient' health outcomes. This study aimed to assess HRQOL of Chinese patients with PNH, and identify key determinants. METHODS A cross-sectional study was conducted during 2022 to recruit patients with PNH in China. The study population was recruited from PNH China, one of the largest public welfare PNH patient mutual aid organization in China. Data were collected via an online questionnaire including the EQ-5D-5L (5L), and social-demographic and clinical characteristics. Descriptive statistics were employed to summarize the characteristics of the participants and their HRQOL. Multiple linear and logistic regression analyses were adopted to explore key factors affecting HRQOL. RESULTS A total of 329 valid questionnaires were collected. The mean (SD) age of the patients was 35.3 (10.0) years, with 52.3% of them being male. The patients reported more problems in Anxiety/Depression (81.5%) and Pain/Discomfort (69.9%) dimensions compared to the other three 5L dimensions. The mean (SD) of 5L health utility score (HUS) and EQ-VAS score were 0.76 (0.21) and 62.61 (19.20), respectively. According to multiple linear regression, initial symptoms (i.e., Anemia [fatigue, tachycardia, shortness of breath, headache] and back pain) and complication of thrombosis were significant influencing factors affecting 5L HUS. Total personal income of the past year, initial symptom of hemoglobinuria and complication of thrombosis were significantly influencing factors of VAS score. Social-demographic and clinical characteristics, such as gender, income, and thrombosis, were also found to be significantly related to certain 5L health problems as well. CONCLUSION Our study manifested the HRQOL of PNH patients in China was markedly compromised, especially in two mental-health related dimensions, and revealed several socio-demographic and clinical factors of their HRQOL. These findings could be used as empirical evidence for enhancing the HRQOL of PNH patients in China.
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Affiliation(s)
- Huaxin Yu
- School of Public Health, Dalian Medical University, Dalian, China
| | - Shengnan Duan
- School of Public Health, Dalian Medical University, Dalian, China
| | - Pei Wang
- School of Public Health, Fudan University, 130 Dong An Road, Shanghai, China
| | - Rong Fu
- Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, China
| | - Zixuan Lv
- School of Public Health, Dalian Medical University, Dalian, China
| | | | | | | | | | | | - Ni Yuan
- School of Public Health, Dalian Medical University, Dalian, China.
- Global Health Research Center, Dalian Medical University, 9 Lvshun South Road, Dalian, Liaoning, China.
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12
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Versino F, Fattizzo B. Complement inhibition in paroxysmal nocturnal hemoglobinuria: From biology to therapy. Int J Lab Hematol 2024; 46 Suppl 1:43-54. [PMID: 38622956 DOI: 10.1111/ijlh.14281] [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: 02/02/2024] [Accepted: 03/23/2024] [Indexed: 04/17/2024]
Abstract
Complement inhibitors are the mainstay of paroxysmal nocturnal hemoglobinuria (PNH) treatment. The anti-C5 monoclonal antibody eculizumab was the first treatment to improve hemolysis, thrombotic risk, and survival in PNH although at the price of a life-long intravenous fortnightly drug. Additionally, suboptimal response may occur in up to 2/3 of patients with persistent anemia due to incomplete control of intravascular hemolysis, development of upstream C3-mediated extravascular hemolysis (EVH), or concomitant bone marrow failure. Ravulizumab, a longer half-life anti-C5 developed from eculizumab, administered every 8 weeks, improved patient convenience, and reduced pharmacokinetic breakthrough hemolysis (BTH) by establishing more stable anti-C5 concentrations. More recently, several other anti-C5 compounds (crovalimab, pozelimab, tesidolumab, cemdisiran, zilucoplan, and coversin) are on study in clinical trials. Upstream inhibition of complement cascade was also explored with the anti-C3 pegcetacoplan, and with the alternative pathway inhibitors iptacopan (anti-factor B) and danicopan (anti-factor D). These drugs efficiently target EVH and are able to improve anemia and transfusion need in suboptimal responders to anti-C5. The route and schedule of administration (twice weekly subcutaneously for pegcetacoplan and twice or thrice oral daily dosing for iptacopan and danicopan, respectively) are very convenient but pose novel issues regarding adherence. Additionally, both anti-C5 and upstream inhibitors do not resolve the unmet need of pharmacodynamic BTH events due to complement amplifying conditions such as infections, traumas, and surgery. In this review, we will recapitulate PNH physiopathology, clinical presentation, and diagnosis and describe available and developing drugs that will lead to a precision medicine approach for this rare though heterogenous disease.
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Affiliation(s)
- Francesco Versino
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and hemato-oncology, University of Milan, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and hemato-oncology, University of Milan, Milan, Italy
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13
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Du W, Mei L. A case report of pegcetacoplan use for a pregnant woman with paroxysmal nocturnal hemoglobinuria. Res Pract Thromb Haemost 2024; 8:102435. [PMID: 38846741 PMCID: PMC11153911 DOI: 10.1016/j.rpth.2024.102435] [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: 03/12/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/09/2024] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH), a rare hematologic disease, is associated with high maternal and fetal mortality rates. Only 1 medication approved for PNH, the complement component 5 inhibitor eculizumab, has published evidence of use during pregnancy. Key Clinical Question What were the circumstances and outcomes of the first use of pegcetacoplan, a complement component 3 inhibitor, by a pregnant woman with PNH? Clinical Approach The patient, with a history of 2 miscarriages and a suboptimal response to eculizumab, had hematologic improvement after switching to pegcetacoplan. She continued pegcetacoplan throughout her pregnancy. At gestational week 30, she developed abruptio placentae and breakthrough hemolysis. She delivered a normal-appearing male infant via emergency cesarean section. The breakthrough hemolysis resolved quickly with short-term intensive pegcetacoplan dosing and add-on eculizumab. To date, her laboratory values remain normal, and she has had no thromboembolic events; her son has not demonstrated growth defects. Conclusion This is the first report of pegcetacoplan treatment for PNH throughout pregnancy. The mother recovered promptly from breakthrough hemolysis that prompted an emergency delivery. Her son, who was born prematurely but healthy, has developed normally.
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Affiliation(s)
- Wei Du
- Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lin Mei
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Patriquin CJ, Bogdanovic A, Griffin M, Kelly RJ, Maciejewski JP, Mulherin B, Peffault de Latour R, Röth A, Selvaratnam V, Szer J, Al-Adhami M, Horneff R, Tan L, Yeh M, Panse J. Safety and Efficacy of Pegcetacoplan in Adult Patients with Paroxysmal Nocturnal Hemoglobinuria over 48 Weeks: 307 Open-Label Extension Study. Adv Ther 2024; 41:2050-2069. [PMID: 38573482 PMCID: PMC11052769 DOI: 10.1007/s12325-024-02827-8] [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: 12/07/2023] [Accepted: 02/19/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, life-threatening disease characterized by complement-mediated hemolysis and thrombosis. Pegcetacoplan, the first targeted complement component 3 (C3) PNH therapy, was safe and efficacious in treatment-naive and pre-treated patients with PNH in five clinical trials. METHODS The 307 open-label extension (OLE) study (NCT03531255) is a non-randomized, multicenter extension study of long-term safety and efficacy of pegcetacoplan in adult patients with PNH who completed a pegcetacoplan parent study. All patients received pegcetacoplan. Outcomes at the 48-week data cutoff (week 48 of 307-OLE or August 27, 2021, whichever was earlier) are reported. Hemoglobin concentrations, Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scores, and transfusion avoidance were measured. Hemoglobin > 12 g/dL and sex-specific hemoglobin normalization (i.e., male, ≥ 13.6 g/dL; female, ≥ 12 g/dL) were assessed as percentage of patients with data available and no transfusions 60 days before data cutoff. Treatment-emergent adverse events, including hemolysis, were reported. RESULTS Data from 137 patients with at least one pegcetacoplan dose at data cutoff were analyzed. Mean (standard deviation [SD]) hemoglobin increased from 8.9 (1.22) g/dL at parent study baseline to 11.6 (2.17) g/dL at 307-OLE entry and 11.6 (1.94) g/dL at data cutoff. At parent study baseline, mean (SD) FACIT-Fatigue score of 34.1 (11.08) was below the general population norm of 43.6; scores improved to 42.8 (8.79) at 307-OLE entry and 42.4 (9.84) at data cutoff. In evaluable patients, hemoglobin > 12 g/dL occurred in 40.2% (43 of 107) and sex-specific hemoglobin normalization occurred in 31.8% (34 of 107) at data cutoff. Transfusion was not required for 114 of 137 patients (83.2%). Hemolysis was reported in 23 patients (16.8%). No thrombotic events or meningococcal infections occurred. CONCLUSION Pegcetacoplan sustained long-term improvements in hemoglobin concentrations, fatigue reduction, and transfusion burden. Long-term safety findings corroborate the favorable profile established for pegcetacoplan. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03531255.
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Affiliation(s)
- Christopher J Patriquin
- Hematology & Apheresis Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada.
| | - Andrija Bogdanovic
- Clinic of Hematology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Morag Griffin
- Department of Haematology, St. James's University Hospital, Leeds, UK
| | - Richard J Kelly
- Department of Haematology, St. James's University Hospital, Leeds, UK
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian Mulherin
- Hematology Oncology of Indiana, Indianapolis, IN, USA
- Ascension St. Vincent Carmel, Carmel, IN, USA
| | - Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Paris, France
- Assistance Publique-Hôpitaux de Paris, Saint-Louis Hospital, Université Paris Cité, Paris, France
| | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | | | - Jeffrey Szer
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | | | - Lisa Tan
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
- Lisa Tan Pharma Consulting Ltd, Cambridge, UK
| | | | - Jens Panse
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
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15
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Kelly RJ, Nishimori H, Horneff R, Hillmen P, Al-Adhami M, Lallier S, Gerber GF. Thrombosis and meningococcal infection rates in pegcetacoplan-treated patients with paroxysmal nocturnal hemoglobinuria in the clinical trial and postmarketing settings. Res Pract Thromb Haemost 2024; 8:102416. [PMID: 38812989 PMCID: PMC11135031 DOI: 10.1016/j.rpth.2024.102416] [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: 12/20/2023] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 05/31/2024] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematologic disease characterized by complement-mediated hemolysis and thrombosis. Complement component 5 (C5) inhibitors have decreased PNH-related thrombosis rates and reduced mortality compared with those of age-matched controls. A small but significantly increased risk of life-threatening Neisseria infections, especially N meningitidis, represents a long-term safety risk of complement inhibition. Objectives To evaluate the rates of thrombosis and meningococcal infections in patients with PNH treated with the complement component 3-targeted therapy pegcetacoplan. Methods Cumulative patient-year exposure to pegcetacoplan was calculated, and thrombotic events and meningococcal infections were reviewed in 7 clinical trials and in the postmarketing setting. The clinical trial protocols and pegcetacoplan labeling required vaccination against Streptococcus pneumoniae, N meningitidis, and Haemophilus influenzae before pegcetacoplan use; the label allowed for prophylactic antibiotic use if pegcetacoplan must be administered before vaccination. Results As of November 13, 2022, 464 patients with PNH had 619.4 patient-years of pegcetacoplan exposure in completed/ongoing clinical trials and the postmarketing setting. Seven thrombotic events were reported: 5 in clinical trials (2 in the same patient) and 2 in the postmarketing setting. The overall thrombosis rate was 1.13 events per 100 patient-years (clinical trials: 1.22 events/100 patient-years in 409.4 years; postmarketing: 0.95 events/100 patient-years in 210.0 years). No infections with meningococcal bacteria were reported. Conclusion Event rates for thrombosis were comparable between pegcetacoplan and previously reported rates of C5 inhibitors in patients with PNH, and no cases of meningococcal infection were reported with pegcetacoplan. Continued follow-up is required.
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Affiliation(s)
| | - Hisakazu Nishimori
- Department of Hematology, Okayama University Hospital, Okayama, Japan
- Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | | | - Peter Hillmen
- Apellis Pharmaceuticals, Inc, Waltham, Massachusetts, USA
| | | | - Stacie Lallier
- Apellis Pharmaceuticals, Inc, Waltham, Massachusetts, USA
| | - Gloria F. Gerber
- Department of Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Țichil I, Mitre I, Zdrenghea MT, Bojan AS, Tomuleasa CI, Cenariu D. A Review of Key Regulators of Steady-State and Ineffective Erythropoiesis. J Clin Med 2024; 13:2585. [PMID: 38731114 PMCID: PMC11084473 DOI: 10.3390/jcm13092585] [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: 03/13/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Erythropoiesis is initiated with the transformation of multipotent hematopoietic stem cells into committed erythroid progenitor cells in the erythroblastic islands of the bone marrow in adults. These cells undergo several stages of differentiation, including erythroblast formation, normoblast formation, and finally, the expulsion of the nucleus to form mature red blood cells. The erythropoietin (EPO) pathway, which is activated by hypoxia, induces stimulation of the erythroid progenitor cells and the promotion of their proliferation and survival as well as maturation and hemoglobin synthesis. The regulation of erythropoiesis is a complex and dynamic interaction of a myriad of factors, such as transcription factors (GATA-1, STAT5), cytokines (IL-3, IL-6, IL-11), iron metabolism and cell cycle regulators. Multiple microRNAs are involved in erythropoiesis, mediating cell growth and development, regulating oxidative stress, erythrocyte maturation and differentiation, hemoglobin synthesis, transferrin function and iron homeostasis. This review aims to explore the physiology of steady-state erythropoiesis and to outline key mechanisms involved in ineffective erythropoiesis linked to anemia, chronic inflammation, stress, and hematological malignancies. Studying aberrations in erythropoiesis in various diseases allows a more in-depth understanding of the heterogeneity within erythroid populations and the development of gene therapies to treat hematological disorders.
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Affiliation(s)
- Ioana Țichil
- Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (I.M.); (M.T.Z.); (A.S.B.); (C.I.T.); (D.C.)
- Department of Haematology, “Ion Chiricuta” Institute of Oncology, 34–36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Ileana Mitre
- Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (I.M.); (M.T.Z.); (A.S.B.); (C.I.T.); (D.C.)
| | - Mihnea Tudor Zdrenghea
- Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (I.M.); (M.T.Z.); (A.S.B.); (C.I.T.); (D.C.)
- Department of Haematology, “Ion Chiricuta” Institute of Oncology, 34–36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Anca Simona Bojan
- Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (I.M.); (M.T.Z.); (A.S.B.); (C.I.T.); (D.C.)
- Department of Haematology, “Ion Chiricuta” Institute of Oncology, 34–36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Ciprian Ionuț Tomuleasa
- Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (I.M.); (M.T.Z.); (A.S.B.); (C.I.T.); (D.C.)
- Department of Haematology, “Ion Chiricuta” Institute of Oncology, 34–36 Republicii Street, 400015 Cluj-Napoca, Romania
- MEDFUTURE—Research Centre for Advanced Medicine, 8 Louis Pasteur Street, 400347 Cluj-Napoca, Romania
| | - Diana Cenariu
- Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (I.M.); (M.T.Z.); (A.S.B.); (C.I.T.); (D.C.)
- MEDFUTURE—Research Centre for Advanced Medicine, 8 Louis Pasteur Street, 400347 Cluj-Napoca, Romania
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Bicskó RR, Illés Á, Hevessy Z, Ivády G, Kerekes G, Méhes G, Csépány T, Gergely L. Eculizumab Treatment of Massive Hemolysis Occurring in a Rare Co-Existence of Paroxysmal Nocturnal Hemoglobinuria and Myasthenia Gravis. Hematol Rep 2024; 16:255-259. [PMID: 38651454 PMCID: PMC11036238 DOI: 10.3390/hematolrep16020025] [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: 02/05/2024] [Revised: 04/02/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
The co-occurrence of myasthenia gravis (MG) and paroxysmal nocturnal hemoglobinuria (PNH) is rare; only one case has been published so far. We report a 63-year-old Caucasian female patient who was diagnosed with MG at the age of 43. Thymoma was also detected, and so it was surgically resected, which resulted in reasonable disease control for nearly 20 years. Slight hemolysis began to emerge, and then myasthenia symptoms progressed, so immunosuppressive therapy was started. Due to progressive disease and respiratory failure, the patient underwent plasmapheresis, and ventilatory support was stopped. Marked hemolysis was present, and diagnostic tests confirmed PNH with type III PNH cells. Her myasthenia symptoms aggravated, mechanical ventilation had to be started again, and due to the respiratory acidosis, massive hemolysis occurred. After two plasmapheresis sessions, the patient received eculizumab at 600 mg, resulting in prompt hemolysis control. After the second dose of the treatment, the patient was extubated. Still, due to their inability to cough, she developed another respiratory failure and pneumonia-sepsis, resulting in the patient's death. This case highlights the rare association between these two serious diseases and similar immune-mediated pathophysiology mechanisms involving the complement system.
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Affiliation(s)
- Ráhel Réka Bicskó
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
| | - Árpád Illés
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
| | - Zsuzsanna Hevessy
- Department of Laboratory Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Z.H.); (G.I.)
| | - Gergely Ivády
- Department of Laboratory Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Z.H.); (G.I.)
| | - György Kerekes
- Intensive Care Unit, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Gábor Méhes
- Department of Pathology, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Tünde Csépány
- Department of Neurology, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Lajos Gergely
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
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Wilson K, Rich C, Hakimi Z, Horneff R, Fishman J, Mellor J, Earl L, Taylor Y, Simons A, Conyers J, Mulherin B, Majerus E, Röth A. Pegcetacoplan in paroxysmal nocturnal haemoglobinuria: Its use, its clinical effectiveness, and its influence on health-related quality of life and productivity. Eur J Haematol 2024; 112:516-529. [PMID: 37994576 DOI: 10.1111/ejh.14139] [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: 09/29/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES To describe real-world use/effectiveness of pegcetacoplan (PEG) in paroxysmal nocturnal haemoglobinuria (PNH). METHODS Data were drawn from the Adelphi PNH Disease Specific Programme™, a cross-sectional survey conducted in France, Italy, Germany, Spain and the United States from January to November 2022. Patients had a confirmed PNH diagnosis and received PEG for ≥1 month. Physicians reported patient characteristics, treatment use/satisfaction and their perception of patients' fatigue and health-related quality of life (HRQoL). Patients reported treatment satisfaction and completed questionnaires assessing fatigue, HRQoL and productivity. Descriptive statistics were reported. RESULTS Overall, 14 physicians provided data for 61 patients who had received 1080 mg/dose PEG for 1.3-14.8 months. At data collection compared to PEG initiation: haemoglobin was 2.5 g/dL higher on average; proportion of patients with lactate dehydrogenase (LDH) ≥1.5 × upper limit of normal was reduced by 27.4%; physician-perceived fatigue was lower and HRQoL better. Physician- and patient-reported treatment satisfaction was high for >90% of patients. Physicians and patients were more satisfied with PEG than previously prescribed C5 complement inhibitors. Mean work impairment and activity impairment in the 7 days prior to data collection were 32.9% and 22.4%, respectively. CONCLUSIONS These real-world data support the effectiveness of PEG through positive effects on haemoglobin, LDH, fatigue and HRQoL.
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Affiliation(s)
| | | | | | | | - Jesse Fishman
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | | | | | | | | | | | - Brian Mulherin
- Hematology Oncology of Indiana, Indianapolis, Indiana, USA
| | - Elaine Majerus
- Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, West German Cancer Center, University of Duisburg-Essen, Essen, Germany
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Evangelidis P, Evangelidis N, Vlachaki E, Gavriilaki E. What is the role of complement in bystander hemolysis? Old concept, new insights. Expert Rev Hematol 2024; 17:107-116. [PMID: 38708453 DOI: 10.1080/17474086.2024.2348662] [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: 01/07/2024] [Accepted: 04/24/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Bystander hemolysis occurs when antigen-negative red blood cells (RBCs) are lysed by the complement system. Many clinical entities including passenger lymphocyte syndrome, hyperhemolysis following blood transfusion, and paroxysmal nocturnal hemoglobinuria are complicated by bystander hemolysis. AREAS COVERED The review provides data about the role of the complement system in the pathogenesis of bystander hemolysis. Moreover, future perspectives on the understanding and management of this syndrome are described. EXPERT OPINION Complement system can be activated via classical, alternative, and lectin pathways. Classical pathway activation is mediated by antigen-antibody (autoantibodies and alloantibodies against autologous RBCs, infectious agents) complexes. Alternative pathway initiation is triggered by heme, RBC microvesicles, and endothelial injury that is a result of intravascular hemolysis. Thus, C5b is formed, binds with C6-C9 compomers, and MAC (C5b-9) is formulated in bystander RBCs membranes, leading to cell lysis. Intravascular hemolysis, results in activation of the alternative pathway, establishing a vicious cycle between complement activation and bystander hemolysis. C5 inhibitors have been used effectively in patients with hyperhemolysis syndrome and other entities characterized by bystander hemolysis.
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Affiliation(s)
- Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Adult Thalassemia Unit, 2nd Department of Internal Medicine, Aristotle University of Thessaloniki, Hippocration General Hospital, Thessaloniki, Greece
| | - Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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20
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Waheed A, Shammo J, Dingli D. Paroxysmal nocturnal hemoglobinuria: Review of the patient experience and treatment landscape. Blood Rev 2024; 64:101158. [PMID: 38071133 DOI: 10.1016/j.blre.2023.101158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 03/12/2024]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder caused by complement-mediated hemolysis and thrombosis through the alternative pathway. The most common symptom of PNH is fatigue due to chronic anemia, which can negatively impact quality of life (QoL) and affect overall well-being. The currently approved therapies for PNH significantly limit intravascular hemolysis (IVH) and reduce the risk of thrombosis; however, they are associated with an infusion schedule that can become burdensome, and not all patients experience complete disease control. Several new complement inhibitors are in development that address the need for convenient routes of administration and aim to provide better disease control. With the variety of new treatment options on the horizon, hematologic markers as well as QoL concerns, patient opinion, and lifestyle factors should be considered to choose the optimal PNH treatment for each specific patient.
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Affiliation(s)
- Anem Waheed
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Jamile Shammo
- Division of Hematology Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
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21
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Beckmann L, Faizy TD, Flottmann F, Fiehler J, Bokemeyer C, Well L, Beitzen-Heineke A, Langer F. Multisite Thrombosis in a Patient with Paroxysmal Nocturnal Hemoglobinuria. Hamostaseologie 2024. [PMID: 38335997 DOI: 10.1055/a-2231-5277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024] Open
Abstract
CASE Paroxysmal nocturnal hemoglobinuria (PNH) is an extremely rare bone marrow disorder caused by acquired mutations in the phosphatidylinositol glycan class A gene, which lead to a partial or total loss of the cellular complement regulators CD55 and CD59.1 In addition to complement-mediated hemolysis and cytopenia, venous and arterial thromboses at multiple and/or unusual sites are a common complication and occur in up to 44% of patients in historic PNH cohorts.1 2.
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Affiliation(s)
- Lennart Beckmann
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Lennart Well
- Zentrum für Radiologie und Endoskopie, Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Antonia Beitzen-Heineke
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
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22
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Wang L, Hu Q, Yang Y, Chen M, Yang C, Han B. COVID-19 vaccination prevents a more severe course and treatment with complement inhibitors reduce worsening hemolysis during the Omicron pandemic in patients with PNH: a single-center study. Ann Med 2024; 55:2274510. [PMID: 38163328 PMCID: PMC10763918 DOI: 10.1080/07853890.2023.2274510] [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: 06/27/2023] [Accepted: 10/16/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVE Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disease characterized by chronic complement-mediated hemolysis. The concentrated outbreak of coronavirus disease 2019 (COVID-19) in China after 6 December 2022, provided an opportunity to observe the disease course of PNH during an active Omicron infection epidemic. PATIENTS AND METHOD Patients diagnosed with PNH at Peking Union Medical College Hospital (PUMCH) before 6 December 2022, were followed up until 10 April 2023. Clinical data related to coronavirus infection and hemolysis were recorded. Factors influencing the infection and severity rate of Omicron, as well as hemolysis provocation, were analyzed. RESULTS In total, 131 patients with PNH were included in this retrospective analysis; 87.8% were infected with Omicron. Among them, 15.7% met the criteria for severity, and 1 patient died (0.87%). No protective factors were identified against Omicron infections. However, patients with severe Omicron infection (n = 18) had a lower vaccination rate than those with non-severe infection (n = 97; p = 0.015). Among those infected (n = 115) with Omicron, there was a significant increase in lactate dehydrogenase (LDH) levels compared with those in the uninfected group (n = 16, p = 0.000). Patients with severe infections (n = 18) had even higher LDH increase rates than those without severe infections (n = 97; p = 0.002). 10 (37.0%) patients treated with complement inhibitors developed breakthrough hemolysis (BTH). Patients treated with complement inhibitors (n = 27) exhibited less severe hemolysis than treatment-naïve patients (n = 104; p = 0.003). CONCLUSIONS Omicron infection exacerbates hemolytic attacks in patients with PNH. Vaccination helps mitigate the severity of Omicron infection, and using complement inhibitors reduces hemolysis exacerbation.
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Affiliation(s)
- Leyu Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuan Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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23
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Cheng WY, Fishman J, Yenikomshian M, Mahendran M, Kunzweiler C, Vu JD, Duh MS. Dosing Patterns of Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with Ravulizumab in the United States: A Retrospective Claims-Based Analysis. Adv Ther 2024; 41:413-430. [PMID: 37999832 PMCID: PMC10796480 DOI: 10.1007/s12325-023-02725-5] [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: 08/11/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Complement factor 5 inhibitors eculizumab and, recently, ravulizumab are standard therapies for paroxysmal nocturnal hemoglobinuria (PNH). However, some patients experience suboptimal response and may benefit from dosage adjustments. Ravulizumab is administered less frequently than eculizumab on the basis of patient's body weight. This retrospective analysis of insurance claims investigated ravulizumab dosing patterns among patients with PNH from the USA. METHODS Patients aged ≥ 12 years with ≥ 2 ravulizumab infusions between June 21, 2019 and May 6, 2021, and ≥ 6 months of continuous clinical activity prior to first ravulizumab infusion (index date) were identified from the Symphony Health Integrated Dataverse (IDV®) database. Observed mean (standard deviation, SD) ravulizumab doses administered were reported and stratified by previous eculizumab use. Scenarios adjusting for patients' body weights (unavailable in Symphony Health IDV) based on the US general population distribution were performed to estimate percentages of patients receiving label-recommended doses. RESULTS Among 433 patients (mean [SD] age 47 [17] years), the mean (SD) loading dose was 3316.3 (2931.7) mg, greater than the maximal label-recommended loading dose (3000 mg for patients ≥ 100 kg). The mean (SD) loading doses were 3581.3 (3673.7) mg for eculizumab-naive versus 3093.1 (2096.8) mg for eculizumab-experienced patients. Over a mean (SD) treatment period of 11.8 (6.9) months, the mean (SD) average maintenance dose was 3403.7 (1024.4) mg, falling between label-recommended maintenance dose categories (3300 mg for ≥ 60 to < 100 kg; 3600 mg for ≥ 100 kg). Estimated percentages of patients receiving label-recommended loading and maintenance doses were 23.1% and 39.2%, respectively; 59.1% and 28.4% were estimated to receive above label-recommended loading and average maintenance doses, respectively. CONCLUSION Although limited by missing clinical characteristics including body weight, this study of ravulizumab dosing patterns in patients with PNH identified potential deviations from label-recommended dosing, warranting further investigations of treatment response to complement inhibitors in PNH.
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Affiliation(s)
- Wendy Y Cheng
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | | | | | - Malena Mahendran
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | - Colin Kunzweiler
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | - Jensen Duy Vu
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA
| | - Mei Sheng Duh
- Analysis Group, Inc., 111 Huntington Ave, 14th Floor, Boston, MA, USA.
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24
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Zhang B, Chu R, Huang C, Song X, Wang J, Li L, Xu Y, Ma Y. Progress in the Management of Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Review. J Womens Health (Larchmt) 2024; 33:98-104. [PMID: 37917919 DOI: 10.1089/jwh.2023.0164] [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] [Indexed: 11/04/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired complement-mediated hemolytic disease characterized by intravascular hemolysis, thrombosis, smooth muscle dystonia, and so on. Thrombosis is the principal cause of death in PNH patients. During the perinatal period, pregnant PNH patients have increased morbidity and mortality with a heightened risk of complications, including significant preterm birth. The management of pregnancy complicated by PNH is difficult. Therefore, early diagnosis, standardized treatment protocols, and improving perinatal outcomes are crucial. However, there is a lack of consensus on treating patients with PNH during pregnancy. This article reviews 32 studies of pregnancy affected by PNH, focusing on the clinical presentation, diagnosis, and treatment strategies of PNH, to provide guidance for obstetricians on how to handle pregnant patients with PNH, and to offer academic support for the management of PNH patients. We found that Eculizumab has become the primary choice for treating PNH, effectively controlling intravascular hemolysis and reducing the frequency of blood transfusions necessary to stabilize the condition, with no severe threat to the safety of the mother and fetus.
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Affiliation(s)
- Bei Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P.R. China
| | - Changzhen Huang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Xiao Song
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, P.R. China
| | - Jianye Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Liang Li
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, P.R. China
| | - Yintao Xu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
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25
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Zoowa R, Shah R, Pradhan D, Karmacharya S, Bhandari D. Candida krusei pneumonia in graft-versus-host disease after allogeneic hematopoietic stem cell transplant for paroxysmal nocturnal hemoglobinuria: a case report. Ann Med Surg (Lond) 2023; 85:6168-6172. [PMID: 38098551 PMCID: PMC10718395 DOI: 10.1097/ms9.0000000000001374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/24/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction and importance Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder caused by a somatic mutation of PIGA (phosphatidylinositol glycan anchor biosynthesis, class A) gene that leads to the destruction of blood cells. Allogeneic haematopoietic stem cell transplant (HSCT) is a treatment option for PHN, but it can cause graft-versus-host disease (GVHD). Long-term immunosuppression as a treatment of GVHD increases the risk for invasive fungal infections such as Candida krusei pneumonia. Case presentation We present the case of a 22-year-old male with C. krusei pneumonia in a known case of chronic GVHD following HSCT for PNH undergoing long-term immunosuppressive therapy. The patient presented with progressive shortness of breath, productive cough, palpitations, and difficulty swallowing. On examination, he had skin rashes and oral lesions, along with signs of severe malnutrition. Diagnosis was made on the basis of radiological imaging and fungal culture. Discussion The combination of PNH, GVHD, and HSCT created an immunocompromised state, making the patient susceptible to opportunistic infections, including fungal pneumonia. Early recognition of this condition is challenging due to its non-specific symptoms and potential overlap with other post-transplant complications. Timely diagnosis and appropriate treatment, including antifungal therapy and immunosuppression management, are crucial for optimising patient outcomes. Conclusion This case highlights the importance of early recognition and timely treatment of fungal infections in patients with severe conditions such as GVHD following HSCT for PNH. Timely treatment with appropriate antifungals is necessary for optimal outcomes. Additionally, more research with long-term follow-up and monitoring is necessary to address the necessary knowledge gaps in this field.
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Affiliation(s)
- Ronit Zoowa
- Nepalese Army Institute of Health Sciences, Sanobharyang
| | - Ravi Shah
- Nepalese Army Institute of Health Sciences, Sanobharyang
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26
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [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: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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27
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Wang X, Xu GH, Yu J, Li H, Zhang JY, Huang WF. When cirrhosis meets paroxysmal nocturnal hemoglobinuria: What kind of "fireworks" scenario will occur? Clin Res Hepatol Gastroenterol 2023; 47:102173. [PMID: 37352924 DOI: 10.1016/j.clinre.2023.102173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/21/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Xu Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Gui-Hua Xu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Juan Yu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hua Li
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Jin-Yan Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Wei-Feng Huang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou, China.
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28
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Yamakawa PE, Fonseca AR, Guerreiro da Silva IDC, Gonçalves MV, Marchioni DM, Carioca AAF, Michonneau D, Arrais-Rodrigues C. Biochemical phenotyping of paroxysmal nocturnal hemoglobinuria reveals solute carriers and β-oxidation deficiencies. PLoS One 2023; 18:e0289285. [PMID: 37527257 PMCID: PMC10393180 DOI: 10.1371/journal.pone.0289285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/11/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal disease of hematopoietic cells with a variable clinical spectrum characterized by intravascular hemolysis, high risk of thrombosis, and cytopenias. To understand the biochemical shifts underlying PNH, this study aimed to search for the dysfunctional pathways involved in PNH physiopathology by comparing the systemic metabolic profiles of affected patients to healthy controls and the metabolomic profiles before and after the administration of eculizumab in PNH patients undergoing treatment. METHODS Plasma metabolic profiles, comprising 186 specific annotated metabolites, were quantified using targeted quantitative electrospray ionization tandem mass spectrometry in 23 PNH patients and 166 population-based controls. In addition, samples from 12 PNH patients on regular eculizumab maintenance therapy collected before and 24 hours after eculizumab infusion were also analyzed. RESULTS In the PNH group, levels of the long-chain acylcarnitines metabolites were significantly higher as compared to the controls, while levels of histidine, taurine, glutamate, glutamine, aspartate and phosphatidylcholines were significantly lower in the PNH group. These differences suggest altered acylcarnitine balance, reduction in the amino acids participating in the glycogenesis pathway and impaired glutaminolysis. In 12 PNH patients who were receiving regular eculizumab therapy, the concentrations of acylcarnitine C6:1, the C14:1/C6 ratio (reflecting the impaired action of the medium-chain acyl-Co A dehydrogenase), and the C4/C6 ratio (reflecting the impaired action of short-chain acyl-Co A dehydrogenase) were significantly reduced immediately before eculizumab infusion, revealing impairments in the Acyl CoA metabolism, and reached levels similar to those in the healthy controls 24 hours after infusion. CONCLUSIONS We demonstrated significant differences in the metabolomes of the PNH patients compared to healthy controls. Eculizumab infusion seemed to improve deficiencies in the acyl CoA metabolism and may have a role in the mitochondrial oxidative process of long and medium-chain fatty acids, reducing oxidative stress, and inflammation.
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Affiliation(s)
| | - Ana Rita Fonseca
- Hematology Division, Universidade Federal de São Paulo, São Paulo, Brazil
- Oncology Department, Hospital Sírio Libanês, São Paulo, Brazil
| | | | | | - Dirce Maria Marchioni
- Nutrition Department, School of Public Health, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - David Michonneau
- Hematology and Bone Marrow Transplant Department of the Saint-Louis Hospital, Paris, France
| | - Celso Arrais-Rodrigues
- Hematology Division, Universidade Federal de São Paulo, São Paulo, Brazil
- Hematology Department, Hospital Nove de Julho, DASA, São Paulo, Brazil
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29
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Yang H, Chai X, Gong Y, Zhang X, Wang L, Zhou X, Chen X, Xu J, Xu D, He G, Li J. Severe hemolytic exacerbations of Chinese PNH patients infected SARS-CoV-2 Omicron. Immun Inflamm Dis 2023; 11:e966. [PMID: 37647437 PMCID: PMC10408369 DOI: 10.1002/iid3.966] [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: 06/03/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by hemolytic anemia, bone marrow failure, thrombophilia. COVID-19, caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with many variants including Omicron. METHODS This study collected demographic and clinical data of 20 PNH patients with SARS-CoV-2 Omicron infection. RESULTS They all were with high disease activity, and LDH level exceeded any documented since the diagnosis of PNH, and those reported in the literature for previously stable treatment with complement inhibitors. D-dimer level elevated in 10 patients. 2 patients developed mild pulmonary artery hypertension. Glomerular filtration rate declined in 5 patients. 1 patient developed acute renal failure and underwent hemodialysis. Anemia and hemolysis were improved in 5 patients treated with eculizumab. CONCLUSIONS Hemolytic exacerbation of PNH with COVID-19 is severe and eculizumab may be an effective treatment.
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Affiliation(s)
- Hui Yang
- Key Laboratory of Hematology of Nanjing Medical University, Department of HematologyCollaborative Innovation Center for Cancer Personalize, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province HospitalNanjingJiangsuChina
| | - Xingxing Chai
- Department of HematologyThe Second People's Hospital of LianyungangLianyungangJiangsuChina
| | - Yuemin Gong
- Key Laboratory of Hematology of Nanjing Medical University, Department of HematologyCollaborative Innovation Center for Cancer Personalize, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province HospitalNanjingJiangsuChina
| | - Xinyu Zhang
- Key Laboratory of Hematology of Nanjing Medical University, Department of HematologyCollaborative Innovation Center for Cancer Personalize, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province HospitalNanjingJiangsuChina
| | - Lingling Wang
- Department of HematologyWuxi People's Hospital Affiliated to Nanjing Medical UniversityWuxiJiangsuChina
| | - Xin Zhou
- Department of HematologyWuxi People's Hospital Affiliated to Nanjing Medical UniversityWuxiJiangsuChina
| | - Xiaoyu Chen
- Key Laboratory of Hematology of Nanjing Medical University, Department of HematologyCollaborative Innovation Center for Cancer Personalize, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province HospitalNanjingJiangsuChina
| | - Jinge Xu
- Department of HematologyThe Second Affiliated Hospital of Xuzhou Medical UniversityXuzhouJiangsuChina
| | - Dan Xu
- Department of HematologyFuning People's HospitalYanchengJiangsuChina
| | - Guangsheng He
- Key Laboratory of Hematology of Nanjing Medical University, Department of HematologyCollaborative Innovation Center for Cancer Personalize, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province HospitalNanjingJiangsuChina
| | - Jianyong Li
- Key Laboratory of Hematology of Nanjing Medical University, Department of HematologyCollaborative Innovation Center for Cancer Personalize, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province HospitalNanjingJiangsuChina
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Rovó A, Gavillet M, Drexler B, Keller P, Schneider JS, Colucci G, Beauverd Y, van Dorland HA, Pollak M, Schmidt A, De Gottardi A, Bissig M, Lehmann T, Duchosal MA, Zeerleder S. Swiss Survey on current practices and opinions on clinical constellations triggering the search for PNH clones. Front Med (Lausanne) 2023; 10:1200431. [PMID: 37564039 PMCID: PMC10410560 DOI: 10.3389/fmed.2023.1200431] [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: 04/04/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
This national survey investigated the current practice in Switzerland by collecting participants' opinions on paroxysmal nocturnal hemoglobinuria (PNH) clone assessment and clinical practice. Aim This study aimed to investigate clinical indications prompting PNH clones' assessment and physician's accessibility of a flow cytometry facility, and also to understand clinical attitudes on the follow-up (FU) of patients with PNH clones. Methods The survey includes 16 multiple-choice questions related to PNH and targets physicians with a definite level of experience in the topic using two screener questions. Opinion on clinical management was collected using hypothetical clinical situations. Each participant had the option of being contacted to further discuss the survey results. This was an online survey, and 264 physicians were contacted through email once a week for 5 weeks from September 2020. Results In total, 64 physicians (24.2%) from 23 institutions participated (81.3% hematologists and 67.2% from university hospitals). All had access to flow cytometry for PNH clone testing, with 76.6% having access within their own institution. The main reasons to assess for PNH clones were unexplained thrombosis and/or hemolysis, and/or aplastic anemia (AA). Patients in FU for PNH clones were more likely to be aplastic anemia (AA) and symptomatic PNH. In total, 61% of the participants investigated PNH clones repetitively during FU in AA/myelodysplastic syndromes patients, even when there was no PNH clone found at diagnosis, and 75% of the participants tested at least once a year during FU. Opinions related to clinical management were scattered. Conclusion The need to adhere to guidelines for the assessment, interpretation, and reporting of PNH clones emerges as the most important finding, as well as consensus for the management of less well-defined clinical situations. Even though there are several international guidelines, clear information addressing specific topics such as the type of anticoagulant to use and its duration, as well as the indication for treatment with complement inhibitors in some borderline situations are needed. The analysis and the discussion of this survey provide the basis for understanding the unmet needs of PNH clone assessment and clinical practice in Switzerland.
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Affiliation(s)
- Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Jenny Sarah Schneider
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Yan Beauverd
- Division of Hematology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Matthias Pollak
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Adrian Schmidt
- Department of Internal Medicine, Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zürich, Switzerland
| | - Andrea De Gottardi
- Servizio di Gastroenterología e Epatologia, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland
| | - Marina Bissig
- Department of Medical Oncology and Hematology, University Hospital of Zürich, Zürich, Switzerland
| | - Thomas Lehmann
- Kantonsspital St. Gallen, Clinic for Medical Oncology and Hematology, St. Gallen, Switzerland
| | - Michel A. Duchosal
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Sacha Zeerleder
- Department of Hematology, Kantonsspital Luzern, Lucerne and University of Bern, Bern, Switzerland
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Chen YY, Liu H, Li LY, Li LJ, Wang HQ, Song J, Wu YH, Guan J, Xing LM, Wang GJ, Qu W, Liu H, Wang XM, Shao ZH, Fu R. [Role and clinical significance of MUC4 gene mutations in thrombotic events in patients with classic paroxysmal nocturnal hemoglobinuria]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:561-566. [PMID: 37749036 PMCID: PMC10509626 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Indexed: 09/27/2023]
Abstract
Objective: This study aimed to investigate the role and clinical significance of MUC4 gene mutations in thrombotic events in patients with classic paroxysmal nocturnal hemoglobinuria (PNH) patients. Methods: A retrospective analysis was conducted on the clinical data and gene sequencing results of 45 patients with classic PNH admitted to the Department of Hematology, Tianjin Medical University General Hospital, from June 2018 to February 2022. MUC4 gene mutations in patients with classic PNH were summarized, and the risk factors for thrombotic events in these patients were analyzed. Additionally, the effects of MUC4 gene mutations on the cumulative incidence and survival of thrombotic events in patients with classic PNH were determined. Results: The detection rate of MUC4 gene mutations in patients with classic PNH who experienced thrombotic events (thrombotic group) was 68.8% (11/16), which was significantly higher than that in the non-thrombotic group [10.3% (3/29) ] (P<0.001). All mutations occurred in exon 2. MUC4 mutation (OR=20.815, P=0.010) was identified as an independent risk factor for thrombotic events in patients with classic PNH. The cumulative incidence of thrombotic events was 78.6% (11/14) in the MUC4 gene mutation group (mutation group) and 16.1% (5/31) in the non-mutation group, showing a statistically significant difference between the two groups (P<0.001). Survival analysis showed a lower overall survival (OS) rate in the thrombotic group compared with that in the non-thrombotic group [ (34.4±25.2) % vs. (62.7±19.3) % ] (P=0.045). The OS rate of patients was (41.7±29.9) % in the mutation group and (59.1±18.3) % in the non-mutation group (P=0.487) . Conclusion: MUC4 gene mutations are associated with an increased incidence of thrombotic events in classic PNH patients, highlighting their role as independent risk factors for thrombosis in this population. These mutations can be considered a novel predictive factor that aids in evaluating the risk of thrombosis in patients with classic PNH.
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Affiliation(s)
- Y Y Chen
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L Y Li
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L J Li
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Q Wang
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Song
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y H Wu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Guan
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L M Xing
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - G J Wang
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - W Qu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - X M Wang
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Z H Shao
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - R Fu
- Tianjin Medical University General Hospital, Tianjin 300052, China
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Adhikari S, Sapkota S, Shrestha S, Karki K, Shrestha A. Eculizumab for paroxysmal nocturnal haemoglobinuria: catastrophic health expenditure in Nepalese patients. Orphanet J Rare Dis 2023; 18:172. [PMID: 37391775 DOI: 10.1186/s13023-023-02779-2] [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: 11/12/2022] [Accepted: 06/18/2023] [Indexed: 07/02/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) results from a mutation in the phosphatidylinositol glycan class-A gene which causes uncontrolled complement activation with resultant intravascular hemolysis and its sequelae. Eculizumab is a terminal complement inhibitor that blocks this complement activation and has revolutionized the treatment of PNH but comes with an enormous price which can have catastrophic health expenditure in low-middle income countries (LMIC) like Nepal. Here, we discuss the potential way forwards in the treatment of PNH in Nepal and other LMICs.
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Affiliation(s)
| | - Surendra Sapkota
- Department of Internal Medicine, Ascension Saint Agnes Hospital, Baltimore, MD, USA
| | - Suraj Shrestha
- Maharajgunj Medical College, Institute of Medicine, Kathmandu, Nepal.
| | - Kshitiz Karki
- Annapurna Neurological Institute and Allied Sciences, Kathmandu, Nepal
| | - Anjan Shrestha
- Department of Hematology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Röth A, Ichikawa S, Ito Y, Kim JS, Nagy Z, Obara N, Panse J, Schrezenmeier H, Sica S, Soret J, Usuki K, Yoon SS, Balachandran N, Buri M, Lundberg P, Patel H, Shinomiya K, Sostelly A, Nishimura JI. Crovalimab treatment in patients with paroxysmal nocturnal haemoglobinuria: Long-term results from the phase I/II COMPOSER trial. Eur J Haematol 2023. [PMID: 37321625 DOI: 10.1111/ejh.14011] [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: 01/16/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES This study reports long-term outcomes from the open-label extension (OLE) period of the Phase I/II COMPOSER trial (NCT03157635) that evaluated crovalimab in patients with paroxysmal nocturnal haemoglobinuria, who were treatment-naive or switched from eculizumab at enrolment. METHODS COMPOSER consists of four sequential parts followed by the OLE. The primary OLE objective was to assess long-term crovalimab safety, with a secondary objective to assess crovalimab pharmacokinetics and pharmacodynamics. Exploratory efficacy endpoints included change in lactate dehydrogenase (LDH), transfusion avoidance, haemoglobin stabilisation and breakthrough haemolysis (BTH). RESULTS A total 43 of 44 patients entered the OLE after completing the primary treatment period. Overall, 14 of 44 (32%) experienced treatment-related adverse events. Steady state exposure levels of crovalimab and terminal complement inhibition were maintained over the OLE. During the OLE, mean normalised LDH was generally maintained at ≤1.5× upper limit of normal, transfusion avoidance was achieved in 83%-92% of patients and haemoglobin stabilisation was reached in 79%-88% of patients across each 24-week interval. Five BTH events occurred with none leading to withdrawal. CONCLUSIONS Over a 3-year median treatment duration, crovalimab was well tolerated and sustained C5 inhibition was achieved. Intravascular haemolysis control, haemoglobin stabilisation and transfusion avoidance were maintained, signifying long-term crovalimab efficacy.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Satoshi Ichikawa
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Yoshikazu Ito
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Zsolt Nagy
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Naoshi Obara
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Juliette Soret
- Centre d'Investigations Cliniques, Hôpital Saint-Louis, Paris, France
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | | | - Muriel Buri
- Biostatistics Oncology Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pontus Lundberg
- Oncology Biomarker Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Himika Patel
- Product Development Hematology, Genentech, Inc., South San Francisco, California, USA
| | - Kenji Shinomiya
- Primary Clinical Science and Strategy, Chugai Pharmaceutical Co., Tokyo, Japan
| | | | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
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Bortolotti M, Barcellini W, Fattizzo B. Molecular pharmacology in complement-mediated hemolytic disorders. Eur J Haematol 2023. [PMID: 37308291 DOI: 10.1111/ejh.14026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
In the last decade, a deeper understanding of the pathogenesis of complement mediated hemolytic disorders, such as paroxysmal nocturnal hemoglobinuria (PNH), cold agglutinin disease (CAD), warm type autoimmune hemolytic anemia (AIHA) with complement activation (wAIHA), and atypical hemolytic uremic syndrome (aHUS), paved the way to the therapeutic shift from purely supportive approaches to complement-targeted therapies. This resulted in a significant improvement in disease management, survival, and quality of life. In this review, we will provide a snapshot of novel therapies for complement-mediated hemolytic anemias with a focus on those ready to use in clinical practice. C5 inhibitors eculizumab and the long-acting ravulizumab, are the established gold standard for untreated PNH patients, whilst the C3 inhibitor pegcetacoplan should be considered for suboptimal responders to anti-C5 drugs. Several additional compounds targeting the complement cascade at different levels (other C5 inhibitors, factor B and D inhibitors) are under active investigation with promising results. In CAD, immunosuppression with rituximab remains the first-line. However, recently FDA and EMA approved the anti-C1s monoclonal antibody, sutimlimab, that showed dramatic responses and whose regulatory approval is soon awaited in many countries. Other drugs under investigation in AIHA include the C3 inhibitor pegcetacoplan, and the anti-C1q ANX005 for warm AIHA with complement activation. Finally, aHUS is an indication for complement inhibitors. Eculizumab and ravulizumab have been approved, whilst other C5 inhibitors, and novel lectin pathway inhibitors are under active investigation in this disease.
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Affiliation(s)
- Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
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Sarmoko, Ramadhanti M, Zulkepli NA. CD59: Biological function and its potential for drug target action. GENE REPORTS 2023. [DOI: 10.1016/j.genrep.2023.101772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Ariceta G. Pharmacological and clinical profile of ravulizumab 100 mg/mL formulation for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Expert Rev Clin Pharmacol 2023; 16:401-410. [PMID: 37128905 DOI: 10.1080/17512433.2023.2209317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are two rare and severe conditions caused by chronic complement (C') system dysregulation. Treatment with eculizumab, a recombinant, humanized monoclonal antibody against complement C5, changed the natural history of both diseases inducing remission and improving patient outcome. Ravulizumab, a new long-acting next-generation C5 inhibitor has been recently approved for treatment of PNH and aHUS. AREAS COVERED Main characteristics of ravulizumab are described: composition, dosing, efficacy and safety profile. Further, an overview of seminal studies and clinical trials using ravulizumab to treat PNH and aHUS in children and adults is detailed. Literature review was performed using the following key words: paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and ravulizumab. EXPERT OPINION Ravulizumab profile to treat PNH and aHUS is equivalent to eculizumab in efficacy and safety but allows extended dosing interval to every 4-8 weeks based on patient weight, and requires reduced infusion time. Less travels to infusion centers and medical visits and decreasing job and school absences, significantly increases patient and families' QoL, while reducing cost. Further infusion time is reduced Ravulizumab will possibly become the treatment of choice for patients with PNH and aHUS on chronic C5 inhibition.
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Affiliation(s)
- Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autonoma Barcelona, Spain
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Fishman J, Kuranz S, Yeh MM, Brzozowski K, Chen H. Changes in Hematologic Lab Measures Observed in Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with C5 Inhibitors, Ravulizumab and Eculizumab: Real-World Evidence from a US Based EMR Network. Hematol Rep 2023; 15:266-282. [PMID: 37092521 PMCID: PMC10123631 DOI: 10.3390/hematolrep15020027] [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: 02/02/2023] [Revised: 03/13/2023] [Accepted: 04/17/2023] [Indexed: 04/25/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH), a rare acquired hematologic disorder, can be treated with C5 inhibitors (C5i) such as eculizumab or ravulizumab. This retrospective study is the first to describe real-world treatment patterns and changes in hematologic PNH-monitoring laboratory tests among C5i-treated US patients. Data were extracted from TriNetX Dataworks Network and included patients with a PNH diagnosis between 1 January 2010, and 20 August 2021. Patients were stratified into three cohorts based on their C5i usage: eculizumab, ravulizumab (prior eculizumab), and ravulizumab (eculizumab naïve). Hematological markers (hemoglobin [Hb], lactate dehydrogenase [LDH], and absolute reticulocyte count [ARC]) and relevant clinical events (e.g., breakthrough hemolysis [BTH], complement-amplifying conditions [CAC], thrombosis, infection, and all-cause mortality) were captured any time within 12 months post-index treatment. Of the 143 (eculizumab), 43 (ravulizumab, prior eculizumab), and 33 (ravulizumab, eculizumab naïve) patients, mean age across cohorts was 42-51 years, 55-61% were female, 63-73% were White, and 33-40% had aplastic anemia. Among all cohorts 12 months post-C5i treatment, 50-82% remained anemic, 8-32% required ≥1 transfusion, and 13-59% had BTH, of which 33%-54% had CACs. Additionally, thrombosis was seen in 7-15% of patients, infection in 20-25%, and mortality in 1-7%. These findings suggest many C5i-treated patients experience suboptimal disease control.
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Affiliation(s)
- Jesse Fishman
- Apellis Pharmaceuticals, Inc., Waltham, MA 02451, USA
| | | | - Michael M Yeh
- Apellis Pharmaceuticals, Inc., Waltham, MA 02451, USA
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Boshkos MC, Fives KR, Phrathep DD, Healey KD, Patel M. Breakthrough Hemolysis Associated With COVID-19 Vaccination and Active COVID-19 Infection in a Patient With Paroxysmal Nocturnal Hemoglobinuria Maintained on Pegcetacoplan: A Case Report. Cureus 2023; 15:e36240. [PMID: 37065335 PMCID: PMC10103799 DOI: 10.7759/cureus.36240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 03/18/2023] Open
Abstract
Breakthrough hemolysis (BTH) is the return of hemolytic disease resulting in an overall increase in complement activation in a patient being treated for paroxysmal nocturnal hemoglobinuria (PNH) with complement inhibitors (CI). BTH after COVID-19 vaccination has only been reported in PNH patients treated with the traditional C5 CI eculizumab and ravulizumab. We report on a new association of BTH in a newly COVID-19 vaccinated, previously stable PNH patient treated with pegcetacoplan, a C3 CI. The patient is a 29-year-old female diagnosed with PNH in 2017 and was started on eculizumab but was switched to pegcetacoplan in 2021 after continuing to exhibit symptomatic hemolysis. Subsequently, the patient returned to PNH remission serologically and symptomatically until her first COVID-19 vaccination. Since then, her lactate dehydrogenase (LDH) and hemoglobin counts have not fully returned to previous baseline levels, with significant exacerbations after her second COVID-19 vaccine and de novo COVID-19 infection. As of May 2022, the patient requires packed red blood cell transfusions every two to three months and has undergone a bone marrow transplant evaluation. This case study suggests that the administration of the upstream C3 CI, pegcetacoplan, is associated with active extravascular hemolysis in the setting of COVID-19 vaccinations and active COVID-19 infection. The pathophysiology of this hemolysis is unclear as hemolysis could be related to the underlying complement factor deficiency or amplification of complement factors causing extravascular hemolysis. There are conflicting reports in the literature regarding the mechanism by which COVID-19 vaccination and infection cause BTH in PNH patients, regardless of the choice of CI treatment. Bringing awareness to this case of BTH secondary to COVID-19 in a PNH patient treated with pegcetacoplan can further warrant the investigation of the role of COVID-19 in complement disruption and its role in BTH.
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Girmenia C, Barcellini W, Bianchi P, Di Bona E, Iori AP, Notaro R, Sica S, Zanella A, De Vivo A, Barosi G, Risitano A. Management of infection in PNH patients treated with eculizumab or other complement inhibitors: Unmet clinical needs. Blood Rev 2023; 58:101013. [PMID: 36117056 DOI: 10.1016/j.blre.2022.101013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/21/2022] [Accepted: 09/01/2022] [Indexed: 11/02/2022]
Abstract
This article presents the results of group discussion among an ad hoc constituted panel of experts aimed at identifying and addressing unmet clinical needs (UCNs) in the management of infectious risk associated with eculizumab or new terminal complement inhibitors (CIs) in paroxysmal nocturnal hemoglobinuria (PNH). With the Delphi technique, the most clinically relevant UCNs in PNH patients candidate to or on terminal CI were selected. They resulted to be: optimizing the infection prevention measures; developing non pharmacological infectious risk-mitigation strategies; improving the management of disease exacerbation during infectious complications. For each of these issues consensus opinions were provided and, when appropriate, proposals for advancement in clinical practice were addressed. The hope is that this comprehensive overview will serve to improve the practice of CIs therapy and inform the design and implementation of new studies in the field.
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Affiliation(s)
- Corrado Girmenia
- Hematology, Department of Hematology, Oncology and Dermatology, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
| | - Wilma Barcellini
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit, Milan, Italy
| | - Paola Bianchi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit, Milan, Italy
| | - Eros Di Bona
- Division of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Anna Paola Iori
- Department of Hematology, Oncology and Dermatology, Azienda Policlinico Umberto I, Rome, Italy
| | - Rosario Notaro
- Azienda Ospedaliera Universitaria Careggi, Firenze, Italy; Instituto per lo Studio, la Prevenzione e la Rete Oncologica, Firenze, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Alberto Zanella
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit, Milan, Italy
| | - Antonio De Vivo
- Hematology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Giovanni Barosi
- Center for the Study of Myeloifbrosis, IRCCS policlinico S. Matteo Foundation, Pavia, Italy
| | - Antonio Risitano
- Federico II University of Naples, Naples, Italy; AORN Moscati, Avellino, Italy
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Biggart R, Davies C, Joshi N. A Review of Systemic Hematological Manifestations and Stent Thrombosis. Cardiol Rev 2023; Publish Ahead of Print:e000535. [PMID: 36825903 DOI: 10.1097/crd.0000000000000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Stent thrombosis (ST) has significant morbidity and mortality following percutaneous coronary intervention (PCI). ST is uncommon making the identification of nonprocedural predictors challenging. Numerous case reports of ST in both benign and malignant hematological conditions exist. Given ST could be a Herald event of an undiagnosed condition and condition-specific treatment may be available, it is important to consider specialist testing in an unexplained ST. This review included a case presentation of ST in previously undiagnosed paroxysmal nocturnal hemoglobinuria (PNH) and a literature review of ST in other acquired thrombophilias including myeloproliferative disorders (MPNs), antiphospholipid syndrome, hematological malignancies, and heparin-induced thrombocytopenia (HIT). Inherited thrombophilias and common pitfalls in thrombophilia and coagulation testing are also discussed. The cardiac-hematology landscape is becoming increasingly complex and there is a paucity of how to best manage ST in these patients. There is clear variability in practice and the use of multidisciplinary input between cardiologists and hematologists is essential.
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Affiliation(s)
- Rachael Biggart
- From the Bristol Haematology & Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, England
| | - Claire Davies
- Great Western Hospitals NHS Foundation Trust, Bristol, England
| | - Nikhil Joshi
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust 22 Horfield Rd, Bristol BS2 8ED, Bristol, England
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Biomarkers and laboratory assessments for monitoring the treatment of patients with paroxysmal nocturnal hemoglobinuria: Differences between terminal and proximal complement inhibition. Blood Rev 2023; 59:101041. [PMID: 36732204 DOI: 10.1016/j.blre.2023.101041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, life-threatening, acquired disease in which blood cells lacking complement regulatory proteins are destroyed because of uncontrolled complement activity. Since 2007, terminal complement inhibitors have revolutionized the treatment of this disease. However, patients treated with these inhibitors can still experience anemia because of C3-mediated extravascular hemolysis and clinically relevant levels of breakthrough or residual intravascular hemolysis. Proximal complement inhibitors, which are only just beginning to emerge, have the potential to address this problem by targeting components of the pathway upstream of C5, thereby protecting patients against both intra- and extravascular hemolysis. In this review, we describe different biomarkers that can be used to monitor complement pathway blockade and discuss key laboratory assessments for evaluating treatment efficacy. We also consider how these assessments are affected by each class of inhibitor and highlight how evolving treatment goals may influence the relative importance of these assessments.
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Fattizzo B, Motta I. Rise of the planet of rare anemias: An update on emerging treatment strategies. Front Med (Lausanne) 2023; 9:1097426. [PMID: 36698833 PMCID: PMC9868867 DOI: 10.3389/fmed.2022.1097426] [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: 11/13/2022] [Accepted: 12/14/2022] [Indexed: 01/12/2023] Open
Abstract
Therapeutic options for rare congenital (hemoglobinopathies, membrane and enzyme defects, congenital dyserythropoietic anemia) and acquired anemias [warm autoimmune hemolytic anemia (wAIHA), cold agglutinin disease CAD, paroxysmal nocturnal hemoglobinuria (PNH), and aplastic anemia (AA)] are rapidly expanding. The use of luspatercept, mitapivat and etavopivat in beta-thalassemia and pyruvate kinase deficiency (PKD) improves transfusion dependence, alleviating iron overload and long-term complications. Voxelotor, mitapivat, and etavopivat reduce vaso-occlusive crises in sickle cell disease (SCD). Gene therapy represents a fascinating approach, although patient selection, the toxicity of the conditioning regimens, and the possible long-term safety are still open issues. For acquired forms, wAIHA and CAD will soon benefit from targeted therapies beyond rituximab, including B-cell/plasma cell targeting agents (parsaclisib, rilzabrutinib, and isatuximab for wAIHA), complement inhibitors (pegcetacoplan and sutimlimab for CAD, ANX005 for wAIHA with complement activation), and inhibitors of extravascular hemolysis in the reticuloendothelial system (fostamatinib and FcRn inhibitors in wAIHA). PNH treatment is moving from the intravenous anti-C5 eculizumab to its long-term analog ravulizumab, and to subcutaneous and oral proximal inhibitors (anti-C3 pegcetacoplan, factor D and factor B inhibitors danicopan and iptacopan). These drugs have the potential to improve patient convenience and ameliorate residual anemia, although patient compliance becomes pivotal, and long-term safety requires further investigation. Finally, the addition of eltrombopag significantly ameliorated AA outcomes, and data regarding the alternative agent romiplostim are emerging. The accelerated evolution of treatment strategies will need further effort to identify the best candidate for each treatment in the precision medicine era.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Ematologia, Milan, Italy,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy,*Correspondence: Bruno Fattizzo,
| | - Irene Motta
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Medicina ad Indirizzo Metabolico, Milan, Italy,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Chatzileontiadou S, Hatjiharissi E, Angelopoulou M, Asimakopoulos JV, Loutsidi NE, Chatzikonstantinou T, Zikos P, Bouchla A, Bezirgiannidou Z, Kouvata E, Frouzaki C, Chaloudis P, Sotiropoulos D, Douka V, Sirigou A, Mandala E, Psyllaki M, Papadaki HA, Marinakis T, Viniou NA, Kokkori S, Kontopidou F, Skepetari A, Vassilopoulos G, Kotsianidis I, Pappa V, Lalayanni C, Baltadakis I, Delimpassi S, Pagoni M, Papaioannou M. Thromboembolic events in patients with paroxysmal nocturnal hemoglobinuria (PNH): Real world data of a Greek nationwide multicenter retrospective study. Front Oncol 2023; 13:1128994. [PMID: 36959785 PMCID: PMC10028290 DOI: 10.3389/fonc.2023.1128994] [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] [Received: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
Thrombosis is the most common and a life-threatening complication in patients with Paroxysmal Nocturnal Hemoglobinuria. One-third of patients with PNH experience at least one thromboembolic event during the course of the disease, with thrombosis being the most common cause of death in these patients. The mechanism of thrombosis in PNH is complex and continues to be of great research interest. Since the introduction of C5 complement inhibitors in the treatment of PNH, the incidence of thromboembolic events has decreased substantially. We retrospectively analyzed data concerning the thrombotic episodes of 41 patients with PNH from 14 different national hematology centers in Greece. Sixteen patients (39%) experienced at least one episode of thrombosis, including, seven (43.8%) at diagnosis, seven (43.8%) during the course of the disease and two (12.5%) patients prior to PNH diagnosis. Nearly half of these individuals (n=7, 43.8%) had multiple episodes of thrombosis during the course of their disease. The most common sites of thrombosis were intra-abdominal veins. Three out of 26 patients developed thrombosis while on eculizumab. In none of the 16 patients, the thrombotic event was fatal. Our findings, despite the small number of patients, confirmed that thrombosis continues to be a significant complication of PNH affecting more than one third of the patients.
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Affiliation(s)
- S. Chatzileontiadou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E. Hatjiharissi
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M. Angelopoulou
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - J. V. Asimakopoulos
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - N. E. Loutsidi
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - T. Chatzikonstantinou
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - P. Zikos
- Department of Hematology, General Hospital of Patras “Aghios Andreas”, Patras, Greece
| | - A. Bouchla
- Second Department of Internal Medicine and Research Unit, Hematology Unit, University General Hospital, “Attikon”, Athens, Greece
| | - Z. Bezirgiannidou
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - E. Kouvata
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - C. Frouzaki
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P. Chaloudis
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D. Sotiropoulos
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - V. Douka
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - A. Sirigou
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - E. Mandala
- Forth Department of Medicine, Aristotle University of Thessaloniki, “Hippokration” Hospital, Thessaloniki, Greece
| | - M. Psyllaki
- Department of Hematology, University of Crete School of Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - H. A. Papadaki
- Department of Hematology, University of Crete School of Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - T. Marinakis
- Department of Hematology, “G. Gennimatas” General Hospital, Athens, Greece
| | - N. A. Viniou
- Hematology Unit, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - S. Kokkori
- Hematology Laboratory, University General Hospital “Attikon”, Athens, Greece
| | - F. Kontopidou
- 2nd Department of Internal Medicine, Medical School, University of Athens, Hippokration General Hospital, Athens, Greece
| | - A. Skepetari
- 2nd Department of Internal Medicine, Medical School, University of Athens, Hippokration General Hospital, Athens, Greece
| | - G. Vassilopoulos
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - I. Kotsianidis
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - V. Pappa
- Second Department of Internal Medicine and Research Unit, Hematology Unit, University General Hospital, “Attikon”, Athens, Greece
| | - C. Lalayanni
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - I. Baltadakis
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - S. Delimpassi
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - M. Pagoni
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - M. Papaioannou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- *Correspondence: M. Papaioannou,
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Iordan I, Jinga DC, Popescu CD, Vlădăreanu AM. Complicaţii mediate imunologic ale anticorpilor monoclonali folosiţi în oncohematologie. ONCOLOG-HEMATOLOG.RO 2023. [DOI: 10.26416/onhe.62.1.2023.7747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Wang R, Guo X, Tang Y, Qi X. Portal vein thrombosis as the first presentation of paroxysmal nocturnal hemoglobinuria. Drug Discov Ther 2022; 16:200-203. [PMID: 35989282 DOI: 10.5582/ddt.2022.01033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired clonal hematopoietic stem cell disorder, characterized by hemolytic anemia, bone marrow failure and thrombosis. Portal vein thrombosis (PVT) is relatively rare in patients with PNH. In this paper, we reported PVT as the first clinical presentation of PNH in a female patient. PVT related symptoms resolved after anticoagulation therapy.
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Affiliation(s)
- Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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Vinogradova MA, Kulagin AD, Shmakov RG. Pregnancy in paroxysmal nocturnal hemoglobinuria: from survival to life. TERAPEVT ARKH 2022; 94:859-864. [DOI: 10.26442/00403660.2022.07.201714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/22/2022]
Abstract
Background. Pregnancy in paroxysmal nocturnal hemoglobinuria (PNH) patients has historically been a high-risk situation. The combination of chronic complement-mediated hemolysis caused by the disease and physiological activation of the complement system during pregnancy, significantly worsened the prognosis for the life. For a long time, there were no effective methods for the PNH treatment, and pregnancy in patients seemed to be extremely risky, as it significantly increased the risk of life-threatening complications. The advent of targeted therapy with eculizumab turned the prognosis of this disease upside down: patients began not only to survive, but also to live comparable to healthy people. A comparative analysis of the course and outcomes of pregnancy in patients with PNH treated with eculizumab and in patients without targeted therapy was carried out.
Aim. The study was to evaluate the course and outcomes of pregnancy in patients with PNH, depending on the therapeutic approach.
Materials and methods. We analyzed data from 57 pregnancies in 49 women (31 used eculizumab, 26 with supportive care only) observed at the Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology or with remote consultation (23 clinics from 19 cities of Russia).
Results. The high probability of pregnancy complications and its adverse outcomes outside of targeted therapy indicates the vital need for its use: all observations were accompanied by complications of varying severity. The course of pregnancy with the eculizumab is generally more favorable: an apparently higher rate of live births and a lower likelihood of complications are registered. Without increasing the incidence of complications, eculizumab significantly improves pregnancy outcomes for both mother and fetus, and does not adversely affect the health of newborns.
Conclusion. Thus, eculizumab allows not only to increase the survival rate of patients with PNH, but also to comprehensively improve their quality of life, including the possibility of safe childbirth.
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Fattizzo B, Bortolotti M, Giannotta JA, Zaninoni A, Consonni D, Barcellini W. Intravascular hemolysis and multitreatment predict thrombosis in patients with autoimmune hemolytic anemia. J Thromb Haemost 2022; 20:1852-1858. [PMID: 35555857 PMCID: PMC9546258 DOI: 10.1111/jth.15757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thrombosis may complicate autoimmune hemolytic anemia (AIHA), but its predictors are still lacking, and no clear-cut indications for anticoagulant prophylaxis are available. OBJECTIVES To characterize frequency and severity of thromboses in AIHA patients and identify risk factors for thrombosis that may advise primary anticoagulant prophylaxis. PATIENTS/METHODS A total of 287 consecutive AIHA patients diagnosed and followed from 1978 at a tertiary Italian center were retrospectively studied; 174 of them were prospectively evaluated from January 2020 until December 2021. AIHA relapse, thrombosis occurrence, and primary anticoagulant prophylaxis were evaluated. RESULTS Thirty-three AIHA patients (11.4%) experienced thrombosis, 70% of whom hospitalized. The cumulative thrombosis incidence was higher in patients with lactate dehydrogenase (LDH) ≥ 1.5 (hazard ratio [HR] 3.22), in those experiencing infections (HR 3.57), receiving transfusions (HR 3.06), rituximab (HR 3.3), or cyclophosphamide (HR 2.67). By multivariable analysis, LDH, transfusions, rituximab, and cyclophosphamide treatment emerged as independent factors associated with thrombosis. Among 174 patients prospectively followed in the past 2 years, we observed 70 acute hemolytic episodes in 45 patients; 33/45 displayed LDH ≥1.5 × upper limit of normal, and 17 received anticoagulant prophylaxis with low molecular weight heparin for a median of 70 days (30-300). In those receiving prophylaxis no thrombotic complications occurred, whereas five thrombotic episodes were registered in the remaining 16 cases. CONCLUSIONS Thrombosis was observed in about 11% of AIHA patients, mainly grade 3, and associated with intravascular hemolysis, need of transfusions, multitreatment, and infections, advising primary anticoagulant prophylaxis in these settings.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico – Haematology UnitMilanItaly
- Università degli Studi di MilanoMilanItaly
| | - Marta Bortolotti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico – Haematology UnitMilanItaly
- Università degli Studi di MilanoMilanItaly
| | | | - Anna Zaninoni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico – Haematology UnitMilanItaly
| | - Dario Consonni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico – Epidemiology UnitMilanItaly
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico – Haematology UnitMilanItaly
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Affiliation(s)
- Rosario Notaro
- From Istituto per lo Studio, la Prevenzione e la Rete Oncologica (R.N.), and the University of Florence (L.L.) - both in Florence, Italy; and the Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (L.L.)
| | - Lucio Luzzatto
- From Istituto per lo Studio, la Prevenzione e la Rete Oncologica (R.N.), and the University of Florence (L.L.) - both in Florence, Italy; and the Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (L.L.)
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Gavriilaki E, Papakonstantinou A, Agrios KA. Novel Insights into Factor D Inhibition. Int J Mol Sci 2022; 23:ijms23137216. [PMID: 35806224 PMCID: PMC9267021 DOI: 10.3390/ijms23137216] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 01/15/2023] Open
Abstract
Complement-mediated diseases or complementopathies, such as Paroxysmal nocturnal hemoglobinuria (PNH), cold agglutinin disease (CAD), and transplant-associated thrombotic microangiopathy (TA-TMA), demand advanced complement diagnostics and therapeutics be adopted in a vast field of medical specialties, such as hematology, transplantation, rheumatology, and nephrology. The miracle of complement inhibitors as “orphan drugs” has dramatically improved morbidity and mortality in patients with otherwise life-threatening complementopathies. Efficacy has been significantly improved by upstream inhibition in patients with PNH. Different molecules may exert diverse characteristics in vitro and in vivo. Further studies remain to show safety and efficacy of upstream inhibition in other complementopathies. In addition, cost and availability issues are major drawbacks of current treatments. Therefore, further developments are warranted to address the unmet clinical needs in the field of complementopathies. This state-of-the-art narrative review aims to delineate novel insights into factor D inhibition as a promising target for complementopathies.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department, G Papanicolaou Hospital, 57010 Thessaloniki, Greece
- Correspondence: (E.G.); (K.A.A.)
| | - Anna Papakonstantinou
- Department of Urology, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Konstantinos A. Agrios
- Department of Chemistry, Villanova University, 800 Lancaster Ave., Villanova, PA 19085, USA
- Correspondence: (E.G.); (K.A.A.)
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Kamura Y, Sakamoto T, Yokoyama Y, Nishikii H, Sakata-Yanagimoto M, Chiba S, Obara N. Hemolysis induced by SARS-CoV-2 mRNA vaccination in patients with paroxysmal nocturnal hemoglobinuria. Int J Hematol 2022; 116:55-59. [PMID: 35668275 PMCID: PMC9169953 DOI: 10.1007/s12185-022-03387-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/27/2022]
Abstract
Autoimmune and complement-related hematological side effects have been observed with messenger ribonucleic acid (mRNA) vaccines. Here, we report the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine-induced hemolysis in patients with paroxysmal nocturnal hemoglobinuria (PNH). We reviewed the medical records of seventeen patients with PNH visiting the University of Tsukuba Hospital who had received two doses of the SARS-CoV-2 mRNA vaccine between May 2021 and November 2021. Twelve patients were being treated with complement inhibitors. The median age of all patients was 62 years (range 29–89 years).; six were males and eleven were females. Fourteen patients received the BNT162b2 vaccine (Pfizer/BioNTech) and three received the mRNA-1273 vaccine (Moderna). The median percentages of PNH clones in erythrocytes and granulocytes were 37.61% (range 8.11–85.71%) and 59.73% (range 3.76–97.82%), respectively. Of the twelve patients receiving complement inhibitors, only one had a hemolytic reaction after vaccination, but it did not meet the definition of breakthrough hemolysis. By contrast, hemolytic attacks were observed in two of the five untreated patients with PNH, and one of them required a blood transfusion. Appropriate administration of complement inhibitors to patients with PNH may prevent hemolysis induced by SARS-CoV-2 mRNA vaccination.
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Affiliation(s)
- Yuya Kamura
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
| | - Tatsuhiro Sakamoto
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuhisa Yokoyama
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hidekazu Nishikii
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Mamiko Sakata-Yanagimoto
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Division of Advanced Hemato-Oncology, Transborder Medical Research Center, University of Tsukuba, Ibaraki, Japan
| | - Shigeru Chiba
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoshi Obara
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan.
- Department of Medical Sciences, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
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