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Seidizadeh O, Cairo A, Mancini I, George JN, Peyvandi F. Global prevalence of hereditary thrombotic thrombocytopenic purpura determined by genetic analysis. Blood Adv 2024; 8:4386-4396. [PMID: 38935915 DOI: 10.1182/bloodadvances.2024013421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 06/29/2024] Open
Abstract
ABSTRACT Hereditary thrombotic thrombocytopenic purpura (hTTP) is a rare autosomal recessive, life-threatening disorder caused by a severe deficiency of the plasma enzyme, ADAMTS13. The current estimated prevalence of hTTP in different regions of the world, 0.5 to 2.0 patients per million, is determined by the frequency of diagnosed patients. To evaluate more accurately the worldwide prevalence of hTTP, and also the prevalence within distinct ethnic groups, we used data available in exome and genome sequencing of 807 162 (730 947 exomes, 76 215 genomes) subjects reported recently by the Genome Aggregation Database (gnomAD-v4.1). Among 1 614 324 analyzed alleles in the gnomAD population we identified 6321 distinct ADAMTS13 variants. Of these, 758 were defined as pathogenic; 140 (18%) variants had been previously reported and 618 (82%) were novel (predicted as pathogenic). In total 10 154 alleles (0.6%) were carrying the reported or predicted pathogenic variants; 7759 (77%) with previously reported variants. Considering all 758 pathogenic variants and also only the 140 previously reported variants, we estimated a global hTTP prevalence of 40 and 23 cases per 106, respectively. Considering only the 140 previously reported variants, the highest estimated prevalence was in East Asians (42 per 106). The estimated prevalences of other populations were: Finnish, 32 per 106; non-Finnish Europeans, 28 per 106; Admixed Americans, 19 per 106; Africans/African Americans, 6 per 106; and South Asians, 4 per 106. The lowest prevalences were Middle Eastern, 1 per 106 and Ashkenazi Jews, 0.7 per 106. This population-based genetic epidemiology study reports that hTTP prevalence is substantially higher than the currently estimated prevalence based on diagnosed patients. Many patients with hTTP may not be diagnosed or may have died during the neonatal period.
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Affiliation(s)
- Omid Seidizadeh
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Andrea Cairo
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Ilaria Mancini
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - James N George
- Departments of Medicine, Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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2
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Fujimura Y. Hereditary TTP/Upshaw-Schulman syndrome: the ductus arteriosus controls newborn survival. Int J Hematol 2024; 119:532-540. [PMID: 38536644 DOI: 10.1007/s12185-024-03731-1] [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: 12/07/2023] [Revised: 02/01/2024] [Accepted: 02/04/2024] [Indexed: 05/05/2024]
Abstract
Hereditary TTP (hTTP), termed Upshaw-Schulman syndrome, is an ultra-rare disorder caused by a severe deficiency of plasma ADAMTS13 activity that allows circulation of ultra-large von Willebrand factor (UL-VWF) multimers. The greatest risk for hTTP is in their first days after birth, when 35-50% of patients will have severe hemolysis, jaundice, and thrombocytopenia. It is often fatal without effective treatment. In utero, fetal blood flowing from the pulmonary artery through the ductus arteriosus (DA) to the aorta is under low-shear-force. At birth, blood flow through the DA reverses to a left-to-right shunt, and the diameter of the DA begins to decrease due to hyper-oxygenated blood and decreased plasma prostaglandin E2. This causes turbulent circulation that unfolds UL-VWF, allowing platelet aggregation. If the DA closes promptly, hTTP newborns survive, but if it remains patent, turbulent circulation persists, triggering microvascular thrombosis. hTTP is commonly diagnosed as hemolytic disease of the fetus and newborn (HDFN) caused by anti-red cell antibodies and treated with exchange blood transfusion, which prevents kernicterus even when the diagnosis of hTTP is missed. The diagnosis of newborn-onset hTTP should be considered because HDFN does not cause severe thrombocytopenia, which might be effectively treated with recombinant ADAMTS13.
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Affiliation(s)
- Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyo-Cho 840, Kashihara, Nara, Japan.
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Osaka, Japan.
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3
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Matsumoto M, Miyakawa Y, Kokame K, Ueda Y, Wada H, Higasa S, Yagi H, Ogawa Y, Sakai K, Miyata T, Morishita E, Fujimura Y. Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) in Japan 2023. Int J Hematol 2023; 118:529-546. [PMID: 37689812 PMCID: PMC10615956 DOI: 10.1007/s12185-023-03657-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) can rapidly become a life-threatening condition, and the importance of its appropriate diagnosis and treatment cannot be overstated. Until recently, TTP has mainly been diagnosed by clinical findings such as thrombocytopenia and hemolytic anemia. In addition to these clinical findings, however, reduced activity of a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13 (ADAMTS13) below 10% has become internationally accepted as a diagnostic criterion for TTP. TTP is classified as immune-mediated TTP (iTTP) if the patient is positive for anti-ADAMTS13 autoantibodies, and as congenital TTP (cTTP) if ADAMTS13 gene abnormalities are detected. Fresh frozen plasma (FFP) transfusion is performed in patients with cTTP to supplement ADAMTS13. Plasma exchange therapy using FFP is conducted in patients with iTTP to supplement ADAMTS13 and to remove both anti-ADAMTS13 autoantibodies and unusually large von Willebrand factor (VWF) multimers. To suppress autoantibody production, corticosteroid therapy is administered in conjunction with plasma exchange. The monoclonal anti-CD-20 antibody rituximab is effective in patients with iTTP. In addition, caplacizumab, an anti-VWF A1 domain nanobody, has a novel mechanism of action, involving direct inhibition of platelet glycoprotein Ib-VWF binding. The recommended first-line treatments of iTTP in Japan are plasma exchange and corticosteroids, as well as caplacizumab.
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Affiliation(s)
- Masanori Matsumoto
- Department of Blood Transfusion Medicine and Department of Hematology, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara, 634-8521, Japan.
| | | | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hideo Wada
- Department of General Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo Medical University, Nishinomiya, Japan
| | - Hideo Yagi
- Department of Hematology and Oncology, Nara Prefecture General Medical Center, Nara, Japan
| | | | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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4
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Nusrat S, Beg K, Khan O, Sinha A, George J. Hereditary Thrombotic Thrombocytopenic Purpura. Genes (Basel) 2023; 14:1956. [PMID: 37895305 PMCID: PMC10606562 DOI: 10.3390/genes14101956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/29/2023] Open
Abstract
Hereditary thrombotic thrombocytopenic purpura (hTTP), also known as Upshaw-Schulman syndrome, is a rare genetic disorder caused by mutations in the ADAMTS13 gene that leads to decreased or absent production of the plasma von Willebrand factor (VWF)-cleaving metalloprotease ADAMTS13. The result is circulating ultra-large multimers of VWF that can cause microthrombi, intravascular occlusion and organ damage, especially at times of turbulent circulation. Patients with hTTP may have many overt or clinically silent manifestations, and a high index of suspicion is required for diagnosis. For the treatment of hTTP, the goal is simply replacement of ADAMTS13. The primary treatment is prophylaxis with plasma infusions or plasma-derived factor VIII products, providing sufficient ADAMTS13 to prevent acute episodes. When acute episodes occur, prophylaxis is intensified. Recombinant ADAMTS13, which is near to approval, will immediately be the most effective and also the most convenient treatment. In this review, we discuss the possible clinical manifestations of this rare disease and the relevant differential diagnoses in different age groups. An extensive discussion on prophylaxis and treatment strategies is also presented. Unique real patient cases have been added to highlight critical aspects of hTTP manifestations, diagnosis and treatment.
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Affiliation(s)
- Sanober Nusrat
- Hematology-Oncology Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Kisha Beg
- Jimmy Everest Section of Pediatric Hematology-Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Osman Khan
- Jimmy Everest Section of Pediatric Hematology-Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Arpan Sinha
- Jimmy Everest Section of Pediatric Hematology-Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - James George
- Hematology-Oncology Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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5
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Stubbs MJ, Kendall G, Scully M. Recombinant ADAMTS13 in Severe Neonatal Thrombotic Thrombocytopenic Purpura. N Engl J Med 2022; 387:2391-2392. [PMID: 36546635 DOI: 10.1056/nejmc2210781] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Giles Kendall
- University College London Hospitals, London, United Kingdom
| | - Marie Scully
- University College London Hospitals, London, United Kingdom
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6
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George JN. Hereditary thrombotic thrombocytopenic purpura: The risk for death at birth. Res Pract Thromb Haemost 2022; 6:e12840. [PMID: 36397935 PMCID: PMC9663672 DOI: 10.1002/rth2.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- James N. George
- Hematology‐Oncology Section, Department of Medicine, Department of Biostatistics & Epidemiology, Hudson College of Public Health The University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
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7
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Liu J, Zhang Y, Li Z, Li Z, Zhang L, Jian S, Wang C, Song Y, Lv Z, Tang X, Gou L, Xiao J. Early indicators of neonatal-onset hereditary thrombotic thrombocytopenia purpura. Res Pract Thromb Haemost 2022; 6:e12820. [PMID: 36254256 PMCID: PMC9561421 DOI: 10.1002/rth2.12820] [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: 03/30/2022] [Revised: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 11/11/2022] Open
Abstract
Background Neonatal‐onset hereditary thrombotic thrombocytopenia purpura (hTTP) is often misdiagnosed due to its rarity. It begins with jaundice, similar to infants with ABO incompatibility. Objective To explore early indicators of neonatal‐onset hTTP. Methods This study was a retrospective case series of newborns with hTTP and ABO incompatibility. We compared the clinical characteristics and laboratory test results in these two groups. Results This study included four hTTP patients and 20 ABO‐incompatible newborns. All patients manifested disease during the neonatal period. There were equal numbers of males and females in each group. hTTP newborns showed earlier (median difference, 57.0 h; 95% confidence interval [CI], 24.0–65.0) and more severe hyperbilirubinemia (mean difference, 8.0 mg/dl; 95% CI, 3.8–12.1) than ABO‐incompatible newborns. In hTTP newborns, anemia was more common within 7 days after birth than in ABO‐incompatible newborns (odds ratio, 25.4; 95% CI, 1.2–551.6), and platelet counts were lower than in ABO‐incompatible newborns (17 ± 12 × 109/L vs. 291 ± 76 × 109/L). The levels of serum creatinine (median difference, 51.8 μmol/L; 95% CI, 16.0–109.4) and blood urea nitrogen (median difference, 5.7 mmol/L; 95% CI, 2.8–38.7) were higher in hTTP newborns than in ABO‐incompatible newborns. There were no significant differences in white blood cell counts, C‐reactive protein, alanine aminotransferase, or albumin levels. Conclusions Severe jaundice soon after birth, early anemia, and severe thrombocytopenia were more common in newborns with hTTP than ABO incompatibility. These are distinguishing early features of hTTP.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Zhuo Li
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Zhenghong Li
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Lejia Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Shan Jian
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Changyan Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Yuqing Song
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Zichao Lv
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Xiaoyan Tang
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Lijuan Gou
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Juan Xiao
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
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8
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Fujimura Y, Holland LZ. COVID-19 microthrombosis: unusually large VWF multimers are a platform for activation of the alternative complement pathway under cytokine storm. Int J Hematol 2022; 115:457-469. [PMID: 35316498 PMCID: PMC8938647 DOI: 10.1007/s12185-022-03324-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 02/08/2023]
Abstract
ADAMTS13, a metalloproteinase, specifically cleaves unusually large multimers of von Willebrand factor (VWF), newly released from vascular endothelial cells. The ratio of ADAMTS13 activity to VWF antigen (ADAMTS13/VWF) and indicators of the alternative complement pathway (C3a and sC5b-9) are both related to the severity of COVID-19. The ADAMTS13/VWF ratio is generally moderately decreased (0.18–0.35) in patients with severe COVID-19. When these patients experience cytokine storms, both interleukin-8 and TNFα stimulate VWF release from vascular endothelial cells, while interleukin-6 inhibits both production of ADAMTS13 and its interaction with VWF, resulting in localized severe deficiency of ADAMTS13 activity. Platelet factor 4 and thrombospondin-1, both released upon platelet activation, bind to the VWF-A2 domain and enhance the blockade of ADAMTS13 function. Thus, the released unusually-large VWF multimers remain associated with the vascular endothelial cell surface, via anchoring with syndecan-1 in the glycocalyx. Unfolding of the VWF-A2 domain, which has high sequence homology with complement factor B, allows the domain to bind to activated complement C3b, providing a platform for complement activation of the alternative pathway. The resultant C3a and C5a generate tissue factor-rich neutrophil extracellular traps (NETs), which induce the mixed immunothrombosis, fibrin clots and platelet aggregates typically seen in patients with severe COVID-19.
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Affiliation(s)
- Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyocho-840, Kashihara City, Nara, Japan.
| | - Linda Z Holland
- Marine Biology Research Division, Scripps Institution Oceanography, University California San Diego, 4400 Hubbs Hall, La Jolla, CA, 92093-0202, USA
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9
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Borogovac A, Reese JA, Gupta S, George JN. Morbidities and mortality in patients with hereditary thrombotic thrombocytopenic purpura. Blood Adv 2022; 6:750-759. [PMID: 34807988 PMCID: PMC8945298 DOI: 10.1182/bloodadvances.2021005760] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
Hereditary thrombotic thrombocytopenic purpura (hTTP) is a rare disorder caused by severe ADAMTS13 deficiency. Major morbidities and death at a young age are common. Although replacement of ADAMTS13 can prevent morbidities and death, current regimens of plasma prophylaxis are insufficient. We identified 226 patients with hTTP in 96 reports published from 2001 through 2020. Age at diagnosis was reported for 202 patients; 117 were female and 85 were male. The difference was caused by diagnosis of 34 women during pregnancy, suggesting that many men and nulliparous women are not diagnosed. Eighty-three patients had severe jaundice at birth; hTTP was suspected and effectively treated in only 3 infants. Of the 217 patients who survived infancy, 73 (34%) had major morbidities defined as stroke, kidney injury, or cardiac injury that occurred at a median age of 21 years. Sixty-two patients had stroke; 13 strokes occurred in children age 10 years or younger. Of the 54 patients who survived their initial major morbidity and were subsequently observed, 37 (69%) had sustained or subsequent major morbidities. Of the 39 patients who were observed after age 40 years, 20 (51%) had experienced a major morbidity. Compared with an age- and sex-matched US population, probability of survival was lower at all ages beginning at birth. Prophylaxis was initiated in 45 patients with a major morbidity; in 11 (28%), a major morbidity recurred after prophylaxis had begun. Increased recognition of hTTP and more effective prophylaxis started at a younger age are required to improve health outcomes.
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Affiliation(s)
- Azra Borogovac
- Hematology-Oncology Section, Department of Medicine, College of Medicine, and
| | - Jessica A. Reese
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Samiksha Gupta
- Hematology-Oncology Section, Department of Medicine, College of Medicine, and
| | - James N. George
- Hematology-Oncology Section, Department of Medicine, College of Medicine, and
- Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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10
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Annual incidence and severity of acute episodes in hereditary thrombotic thrombocytopenic purpura. Blood 2021; 137:3563-3575. [PMID: 33649760 DOI: 10.1182/blood.2020009801] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/05/2021] [Indexed: 12/15/2022] Open
Abstract
Hereditary thrombotic thrombocytopenic purpura (hTTP) is a rare thrombotic microangiopathy characterized by severe congenital ADAMTS13 deficiency and recurring acute episodes causing morbidity and premature death. Information on the annual incidence and severity of acute episodes in patients with hTTP is largely lacking. This study reports prospective data on 87 patients from the Hereditary TTP Registry (clinicaltrials.gov #NCT01257269) for survival, frequency, and severity of acute episodes from enrollment until December 2019. The 87 patients, followed up for a median of 4.2 years (range, 0.01-15 years), had a median age at overt disease onset and at clinical diagnosis of 4.6 years and 18 years (range, 0.0-70 years for both), respectively. Forty-three patients received regular plasma prophylaxis, whereas 22 did not, and treatment changed over time or was unknown in the remaining 22. Forty-three patients experienced 131 acute episodes, of which 91 (69%) occurred in patients receiving regular prophylaxis. This resulted in an annual incidence of acute episodes of 0.36 (95% confidence interval [CI], 0.29-0.44) with regular plasma treatment and of 0.41 (95% CI, 0.30-0.56) without regular plasma treatment. More than one-third of acute episodes (n = 51) were documented in children <10 years of age at enrollment and were often triggered by infections. Their annual incidence of acute episodes was significantly higher than in patients aged >40 years (1.18 [95% CI, 0.88-1.55] vs 0.14 [95% CI, 0.08-0.23]). The prophylactic plasma infusion regimens used were insufficient to prevent acute episodes in many patients. Such regimens are burdensome, and caregivers, patients, and their guardians are reluctant to start regular plasma infusions, from which children particularly would benefit.
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11
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Sakai K, Fujimura Y, Miyata T, Isonishi A, Kokame K, Matsumoto M. Current prophylactic plasma infusion protocols do not adequately prevent long-term cumulative organ damage in the Japanese congenital thrombotic thrombocytopenic purpura cohort. Br J Haematol 2021; 194:444-452. [PMID: 34046888 DOI: 10.1111/bjh.17560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 01/02/2023]
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP), known as Upshaw-Schulman syndrome, is an ultrarare thrombotic disorder caused by ADAMTS13 gene mutations; however, its long-term outcomes have not been widely studied. A questionnaire survey was administered to physicians of patients in the Japanese cTTP registry to characterise these outcomes. We analysed 55 patients in remission, with 41 cases receiving prophylactic fresh frozen plasma (FFP; median dosage: 13·2 ml/kg per month) and 14 receiving on-demand FFP. Patients receiving prophylactic FFP were considered as having a more severe form of the disease and had lower platelet counts and higher serum creatinine levels than those receiving on-demand FFP (median 138 × 109 /l vs. 243 × 109 /l, P = 0·003 and 0·71 mg/dl vs 0·58 mg/dl, P = 0·009, respectively). Patients who received prophylactic FFP more commonly developed organ damage, including renal impairment, cerebral infarctions, and cardiac hypofunction, than those who did not. Adverse FFP-related events were seen in 78% of the prophylactic FFP group, with allergic reactions being most common. Since current protocols for FFP administration to the prophylactic FFP group in Japan may be insufficient for preventing cumulative organ damage, a higher dosage of ADAMTS13 supply using recombinant ADAMTS13 agent is needed in these patients.
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Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan.,Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ayami Isonishi
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
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12
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Siddiqui A, Journeycake JM, Borogovac A, George JN. Recognizing and managing hereditary and acquired thrombotic thrombocytopenic purpura in infants and children. Pediatr Blood Cancer 2021; 68:e28949. [PMID: 33660913 DOI: 10.1002/pbc.28949] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/29/2020] [Accepted: 12/20/2020] [Indexed: 11/11/2022]
Abstract
We describe how infants and children with hereditary and acquired autoimmune thrombotic thrombocytopenic purpura (TTP) initially present and how they can be promptly diagnosed and effectively managed. These are uncommon disorders that are commonly misdiagnosed and can be rapidly fatal. TTP is caused by a severe deficiency of the plasma protease, A disintegrin and Metalloprotease with a ThromboSpondin type 1 motif, member 13 (ADAMTS13). Measurement of ADAMTS13 activity is becoming easily accessible. A common presentation of hereditary TTP is neonatal severe hemolysis and hyperbilirubinemia. However, the median age of diagnosis is not until 5.5 years. Plasma is effective treatment for exacerbations and for prophylaxis. Plasma may be replaced by recombinant ADAMTS13 when it becomes available. Acquired TTP is more frequent in older children, in whom it is more common in girls and is commonly associated with systemic lupus erythematosus. For acquired TTP, plasma exchange and immunosuppression are the current treatment for acute episodes; caplacizumab is now commonly used in adults and may replace plasma exchange.
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Affiliation(s)
- Anam Siddiqui
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.,Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Janna M Journeycake
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Azra Borogovac
- Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - James N George
- Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.,Department of Biostatistics & Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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13
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Chou SC, Lin DT, Lin CY, Huang YC, Hsieh HN, Shen MC. First reported case of congenital thrombotic thrombocytopenic purpura in Taiwan with novel mutation of ADAMTS13 gene. Int J Hematol 2021; 113:760-764. [PMID: 33387295 DOI: 10.1007/s12185-020-03068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/27/2022]
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is a rare disease that is defined as biallelic mutations of ADAMTS13 causing persistent absence of ADAMTS13 activity. The confirmed diagnosis requires a genetic study, and cTTP has never been previously reported in Taiwan. Our patient was a 29-year-old Taiwanese woman who presented with severe hyperbilirubinemia at birth. She had severe thrombocytopenia and hemolytic anemia at the age of 1, and another acute TTP event at the age of 7 triggered by an upper airway infection. Regular plasma replacement was started at age 12 based on a presumptive diagnosis of cTTP. Clinical diagnosis of cTTP, with undetectable ADAMTS13 activity and absence of ADAMTS13 inhibitor, was confirmed at age 27. A genetic study showed a previously reported mutation c.1921G to A, inherited from her father, and a maternally inherited, novel mutation at exon 12, c.1435+1dupG, which results in a splicing site change and frame shift. Reports of cTTP from East Asia, except Japan, are scarce. Some prevalent ADAMTS13 mutations are also race or region specific. With this report, we hope to raise awareness among physicians in Taiwan, promote early, proper diagnosis of cTTP, and reveal the true prevalence of cTTP in the Taiwanese population.
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Affiliation(s)
- Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Tasmn Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Yeh Lin
- Division of Hematology and Oncology, Changhua Christian Hospital, Nanhsiao St 135, Changhua City, Changhua County, Taiwan
| | - Ying-Chih Huang
- Division of Hematology and Oncology, Changhua Christian Hospital, Nanhsiao St 135, Changhua City, Changhua County, Taiwan
| | - Han-Ni Hsieh
- Division of Hematology and Oncology, Changhua Christian Hospital, Nanhsiao St 135, Changhua City, Changhua County, Taiwan
| | - Ming-Ching Shen
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Division of Hematology and Oncology, Changhua Christian Hospital, Nanhsiao St 135, Changhua City, Changhua County, Taiwan.
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Sakai K, Fujimura Y, Nagata Y, Higasa S, Moriyama M, Isonishi A, Konno M, Kajiwara M, Ogawa Y, Kaburagi S, Hara T, Kokame K, Miyata T, Hatakeyama K, Matsumoto M. Success and limitations of plasma treatment in pregnant women with congenital thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2929-2941. [PMID: 33433066 DOI: 10.1111/jth.15064] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congenital thrombotic thrombocytopenic purpura (cTTP), otherwise known as Upshaw-Schulman syndrome, is an extremely rare hereditary disease. Pregnancy is identified as a trigger for TTP episodes in patients with cTTP. OBJECTIVES To investigate the ideal management of pregnant patients with cTTP. PATIENTS/METHODS We identified 21 patients with a reproductive history (38 pregnancies) in a Japanese cTTP registry. Fetal outcomes were compared between two groups: group 1 (n = 12), pregnancy after diagnosis of confirmed cTTP by ADAMTS13 gene analysis; and group 2 (n = 26), pregnancy before diagnosis of confirmed cTTP. RESULTS In group 1, ADAMTS13 activity was closely monitored until delivery in most cases. Among 10 pregnancies in group 1, prophylactic fresh frozen plasma (FFP) infusions during pregnancy were performed to replenish ADAMTS13. In group 2, prophylactic FFP infusions were not administrated in 23 pregnancies and FFP test infusions were performed in only three pregnancies. The live birth rate of group 1 was significantly higher than that of group 2 (91.7% vs 50.0%, respectively, P = .027). The fetal survival rates of women without FFP infusions were dramatically decreased after 20 weeks of gestation. The FFP infusion dosage in group 1 was generally higher than 5 mL/kg/wk by 20 weeks of gestation. CONCLUSIONS Our results indicate that FFP infusions of more than 5 mL/kg/wk should be initiated as soon as patients become pregnant. However, even with these infusions, patients with repeated TTP episodes before pregnancy might have difficulty giving birth successfully. Recombinant ADAMTS13 products might be new treatment options for pregnant patients with cTTP.
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Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - Yasuyuki Nagata
- Division of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Masato Moriyama
- Department of Medical Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Ayami Isonishi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Mutsuko Konno
- Department of Pediatrics, Sapporo-Kosei General Hospital, Sapporo, Japan
| | - Michiko Kajiwara
- Center for Blood Transfusion and Cell Therapy, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shigehiko Kaburagi
- Department of Internal Medicine, Sano Memorial Clinic, Fujinomiya, Japan
| | - Tomoko Hara
- Division of Hematology, Tokushima Red Cross Hospital, Komatsushima, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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15
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Lämmle B. Clinical Problem Solving and Using New Paths in the Laboratory: Learning from Case Studies. Hamostaseologie 2020; 40:414-419. [DOI: 10.1055/a-1191-7198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractThree selected casuistic studies of individual patient problems from my long-standing professional experience are presented. I intend to highlight the potential contribution of case studies, including new approaches of laboratory investigation, for the advancement of pathophysiological knowledge and would encourage to “rehabilitate” the low academic profile generally attributed to “case reports.”
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Affiliation(s)
- Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- Haemostasis Research Unit, University College London, London, United Kingdom
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