1
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Uchihara M, Sakai K, Shibata K, Saito K, Lammle B, Matsumoto M. Immune-mediated thrombotic thrombocytopenic purpura with ischaemic cerebral infarction preceding onset of thrombocytopenia and microangiopathic haemolytic anaemia: A case report. Br J Haematol 2024. [PMID: 39160065 DOI: 10.1111/bjh.19717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 08/09/2024] [Indexed: 08/21/2024]
Affiliation(s)
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Koki Shibata
- Department of Hematology, Nara Medical University, Kashihara, Japan
| | - Kenki Saito
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Bernhard Lammle
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Haemostasis Research Unit, University College London, London, UK
| | - Masanori Matsumoto
- Department of Hematology, Nara Medical University, Kashihara, Japan
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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2
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Pinheiro Maux Lessa M, Soares Ferreira Junior A, Graton M, Simon E, Ledbetter L, Onwuemene OA. Managing surgical relapse risk in acquired thrombotic thrombocytopenic purpura: a systematic review. Res Pract Thromb Haemost 2024; 8:102478. [PMID: 39114263 PMCID: PMC11305326 DOI: 10.1016/j.rpth.2024.102478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/30/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
•Thrombotic thrombocytopenic purpura (TTP) may relapse after surgery.•In a systematic review, we assessed preoperative TTP prophylaxis.•Pre-emptive ADAMTS-13 activity measurement prior to surgery may improve relapse risk.•Preoperative TTP prophylaxis may lower surgical relapse risk.
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Affiliation(s)
- Morgana Pinheiro Maux Lessa
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Alexandre Soares Ferreira Junior
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
- General and Applied Biology Program, Institute of Biosciences (IBB), Sao Paulo State University (UNESP), Botucatu, Brazil
| | - Margaret Graton
- Duke University Medical Center Library, Durham, North Carolina, USA
| | - Erin Simon
- Duke University Medical Center Library, Durham, North Carolina, USA
| | - Leila Ledbetter
- Duke University Medical Center Library, Durham, North Carolina, USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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3
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Prasannan N, Dragunaite B, Subhan M, Thomas M, de Groot R, Singh D, Vanhoorelbeke K, Scully M. Peak ADAMTS13 activity to assess ADAMTS13 conformation and risk of relapse in immune-mediated thrombotic thrombocytopenic purpura. Blood 2024; 143:2644-2653. [PMID: 38502824 DOI: 10.1182/blood.2023023269] [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: 11/27/2023] [Revised: 02/22/2024] [Accepted: 03/14/2024] [Indexed: 03/21/2024] Open
Abstract
ABSTRACT Previous studies have demonstrated that >38% of patients with immune-mediated thrombotic thrombocytopenic purpura in remission with activity >50% had an open ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13) conformation. We assessed ADAMTS13 conformation in remission (ADAMTS13 activity >60%), focusing on peak ADAMTS13 activity levels and longitudinal assessment in 420 samples across 157 patients. Fewer cases had an open conformation at peak ADAMTS13 activity than unselected remission samples with ADAMTS13 activity >60% (23% vs 43%). Patients with a closed ADAMTS13 conformation at peak ADAMTS13 activity had an eightfold lower relapse rate in the subsequent year (9% vs 46%) and a fivefold lower relapse rate within 2 years (23% vs 62%) compared with cases with an open conformation. Patients with an open conformation at peak ADAMTS13 activity required preemptive anti-CD20 treatment earlier than those with a closed conformation (median, 10 vs 25 months). Longitudinally, an open conformation was evident at, and often preceded relapse. When the conformation was already open before relapse, an increase in the conformation index at relapse was seen despite the undetectable anti-ADAMTS13 immunoglobulin G (IgG) antibody. In cases with detectable anti-ADAMTS13 IgG antibody, these became undetectable before achieving a closed conformation, highlighting the relapse risk even with undetectable anti-ADAMTS13 IgG antibody and the clinical utility of open/closed during monitoring. To our knowledge, this is the first study to show an association between relapse risk and ADAMTS13 conformation when activity levels are at a peak. The open conformation identifies antibody-mediated subclinical disease that is not detectable by the current ADAMTS13 testing.
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Affiliation(s)
- Nithya Prasannan
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Haemostasis Research Unit, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Bertina Dragunaite
- Haemostasis Research Unit, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Maryam Subhan
- Haemostasis Research Unit, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Mari Thomas
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Haemostasis Research Unit, Institute of Cardiovascular Science, University College London, London, United Kingdom
- National Institute for Health Research Cardiometabolic Programme, Cardiovascular BRC, University College London Hospital/University College London, London, United Kingdom
| | - Rens de Groot
- Haemostasis Research Unit, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Deepak Singh
- Special Coagulation, Health Services Laboratories, London, United Kingdom
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinary Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Marie Scully
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Haemostasis Research Unit, Institute of Cardiovascular Science, University College London, London, United Kingdom
- National Institute for Health Research Cardiometabolic Programme, Cardiovascular BRC, University College London Hospital/University College London, London, United Kingdom
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4
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Rispens T, Huijbers MG. The unique properties of IgG4 and its roles in health and disease. Nat Rev Immunol 2023; 23:763-778. [PMID: 37095254 PMCID: PMC10123589 DOI: 10.1038/s41577-023-00871-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/26/2023]
Abstract
IgG4 is the least abundant subclass of IgG in human serum and has unique functional features. IgG4 is largely unable to activate antibody-dependent immune effector responses and, furthermore, undergoes Fab (fragment antigen binding)-arm exchange, rendering it bispecific for antigen binding and functionally monovalent. These properties of IgG4 have a blocking effect, either on the immune response or on the target protein of IgG4. In this Review, we discuss the unique structural characteristics of IgG4 and how these contribute to its roles in health and disease. We highlight how, depending on the setting, IgG4 responses can be beneficial (for example, in responses to allergens or parasites) or detrimental (for example, in autoimmune diseases, in antitumour responses and in anti-biologic responses). The development of novel models for studying IgG4 (patho)physiology and understanding how IgG4 responses are regulated could offer insights into novel treatment strategies for these IgG4-associated disease settings.
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Affiliation(s)
- Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Maartje G Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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5
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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6
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Bonnez Q, Sakai K, Vanhoorelbeke K. ADAMTS13 and Non-ADAMTS13 Biomarkers in Immune-Mediated Thrombotic Thrombocytopenic Purpura. J Clin Med 2023; 12:6169. [PMID: 37834813 PMCID: PMC10573396 DOI: 10.3390/jcm12196169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare medical emergency for which a correct and early diagnosis is essential. As a severe deficiency in A Disintegrin And Metalloproteinase with ThromboSpondin type 1 repeats, member 13 (ADAMTS13) is the underlying pathophysiology, diagnostic strategies require timely monitoring of ADAMTS13 parameters to differentiate TTP from alternative thrombotic microangiopathies (TMAs) and to guide initial patient management. Assays for conventional ADAMTS13 testing focus on the enzyme activity and presence of (inhibitory) anti-ADAMTS13 antibodies to discriminate immune-mediated TTP (iTTP) from congenital TTP and guide patient management. However, diagnosis of iTTP remains challenging when patients present borderline ADAMTS13 activity. Therefore, additional biomarkers would be helpful to support correct clinical judgment. Over the last few years, the evaluation of ADAMTS13 conformation has proven to be a valuable tool to confirm the diagnosis of acute iTTP when ADAMST13 activity is between 10 and 20%. Screening of ADAMTS13 conformation during long-term patient follow-up suggests it is a surrogate marker for undetectable antibodies. Moreover, some non-ADAMTS13 parameters gained notable interest in predicting disease outcome, proposing meticulous follow-up of iTTP patients. This review summarizes non-ADAMTS13 biomarkers for which inclusion in routine clinical testing could largely benefit differential diagnosis and follow-up of iTTP patients.
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Affiliation(s)
- Quintijn Bonnez
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
| | - Kazuya Sakai
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Japan
| | - Karen Vanhoorelbeke
- Department of Chemistry, KU Leuven Campus Kulak Kortrijk, 8500 Kortrijk, Belgium
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7
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Aggarwal A, White D, Pavord S, Thomas W, Desborough MJR. Daratumumab for refractory immune-mediated thrombotic thrombocytopenic purpura. Br J Haematol 2023. [PMID: 37183296 DOI: 10.1111/bjh.18854] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Asha Aggarwal
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Danielle White
- Department of Clinical Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sue Pavord
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Will Thomas
- Department of Clinical Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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8
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iTTP: more long-term consequences. Blood 2023; 141:216-217. [PMID: 36656614 DOI: 10.1182/blood.2022018789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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