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Bertin L, Gauthier M, Boullenger F, Brocheriou I, Chevallier R, Mary F, Dhote R, Belenfant X. Thrombotic Microangiopathy After Long-Lasting Treatment by Gemcitabine: Description, Evolution and Treatment of a Rare Case. J Med Cases 2024; 15:272-277. [PMID: 39328805 PMCID: PMC11424102 DOI: 10.14740/jmc4253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/16/2024] [Indexed: 09/28/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is an uncommon but severe complication that may occur in cancer patients under gemcitabine chemotherapy. Gemcitabine-induced thrombotic microangiopathy (G-TMA) can clinically and biologically present as atypical hemolytic uremic syndrome, with activation of the complement pathway asking the question of the use of eculizumab. We describe here the case of a patient suffering from metastatic cholangiocarcinoma treated by gemcitabine for 4 years leading to the remission of the underlying neoplasia. Despite an impressive response to therapy, she developed thrombopenia, regenerative anemia, and acute kidney injury leading to the suspicion then diagnosis based on the renal biopsy of a very late G-TMA. Spontaneous evolution after treatment interruption was favorable without dialysis requirement. However, in this case where gemcitabine is the only chemotherapy remaining for a mortal underlying condition, we discussed the re-initiation of gemcitabine under eculizumab treatment. This atypical case of TMA illustrates the importance of recognizing, even belatedly, this rare but serious complication of chemotherapy. It asks the question of rechallenging discontinued chemotherapy notably under eculizumab cover, in this population with a high risk of cancer progression.
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Affiliation(s)
- Lise Bertin
- Nephrology Department, Hospital Andre Gregoire, Montreuil, France
| | - Marion Gauthier
- Nephrology Department, Hospital Andre Gregoire, Montreuil, France
| | - Fanny Boullenger
- Nephrology Department, Hospital Andre Gregoire, Montreuil, France
| | - Isabelle Brocheriou
- Anatomopathology Department, Assistance Publique-Hopitaux de Paris (APHP), Sorbonne University, Hospital Pitie-Salpetriere, Paris, France
| | - Raphaelle Chevallier
- Anatomopathology Department, Assistance Publique-Hopitaux de Paris (APHP), Sorbonne University, Hospital Pitie-Salpetriere, Paris, France
| | - Florence Mary
- Gastroenterology Department, Assistance Publique-Hopitaux de Paris (APHP), Sorbonne University, Hospital Avicenne, Bobigny, France
| | - Robin Dhote
- Internal Medicine Department, Assistance Publique-Hopitaux de Paris (APHP), Sorbonne University, Hospital Avicenne, Bobigny, France
| | - Xavier Belenfant
- Nephrology Department, Hospital Andre Gregoire, Montreuil, France
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Zafar A, Lim MY, Abou-Ismail MY. Eculizumab in the management of drug-induced thrombotic microangiopathy: A scoping review of the literature. Thromb Res 2023; 224:73-79. [PMID: 36871347 DOI: 10.1016/j.thromres.2023.02.012] [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: 11/15/2022] [Revised: 01/16/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
Drug-induced TMA (DI-TMA) is a thrombotic microangiopathy (TMA) caused by certain drugs, usually managed by drug discontinuation and supportive measures. Data on the use of complement-inhibition with eculizumab in DI-TMA is scarce, and its benefit in cases of severe or refractory DI-TMA is unclear. We conducted a comprehensive search in PubMed, Embase and MEDLINE databases (2007-2021). We included articles that reported on DI-TMA patients treated with eculizumab and its clinical outcomes. All other causes of TMA were excluded. We evaluated the outcomes of hematologic recovery, renal recovery, and a composite of both (complete TMA recovery). 35 studies fulfilled our search criteria, which included 69 individual cases of DI-TMA treated with eculizumab. Most cases were secondary to chemotherapeutic agents, and the most implicated drugs were gemcitabine (42/69), carfilzomib (11/69), and bevacizumab (5/69). The median number of eculizumab doses given was 6 (range 1-16). 55/69 (80 %) patients achieved renal recovery, after 28-35 days (5-6 doses). 13/22 (59 %) patients were able to discontinue hemodialysis. 50/68 (74 %) patients achieved complete hematologic recovery after 7-14 days (1-2 doses). 41/68 (60 %) patients met criteria for complete TMA recovery. Eculizumab was safely tolerated in all cases, and appeared to be effective in achieving both hematologic and renal recovery in DI-TMA refractory to drug discontinuation and supportive measures, or with severe manifestations associated with significant morbidity or mortality. Our findings suggest that eculizumab may be considered as a potential treatment for severe or refractory DI-TMA that does not improve after initial management, although larger studies are needed.
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Affiliation(s)
- Aneeqa Zafar
- Division of Hematology, Bone Marrow Transplant and Cellular Therapy, Department of Internal Medicine, University of California, San Francisco, United States of America
| | - Ming Yeong Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health Sciences Center, United States of America
| | - Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health Sciences Center, United States of America.
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Aklilu AM, Shirali AC. Chemotherapy-Associated Thrombotic Microangiopathy. KIDNEY360 2023; 4:409-422. [PMID: 36706238 PMCID: PMC10103319 DOI: 10.34067/kid.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023]
Abstract
Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as antiangiogenesis agents and proteasome inhibitors have been implicated in oncotherapy-associated TMA. Among TMA subtypes, drug-induced TMA is less well-understood. Treatment generally involves withdrawal of the offending agent and supportive care targeting blood pressure and proteinuria reduction. Immunosuppression and therapeutic plasma exchange have not shown clear benefit. The terminal complement inhibitor, eculizumab, has shown promising results in some cases of chemotherapy-associated TMA including in re-exposure. However, the data are limited, and unlike in primary atypical hemolytic uremic syndrome, the role of complement in the pathogenesis of drug-induced TMA is unclear. Larger multicenter studies and unified definitions are needed to elucidate the extent of the problem and potential treatment strategies.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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Van den Eeckhaut L, Hannon H, Schurgers M, Monsaert E, Claes K. Gemcitabine-induced thrombotic microangiopathy treated with eculizumab: a case report. J Gastrointest Oncol 2022; 13:3314-3320. [PMID: 36636054 PMCID: PMC9830318 DOI: 10.21037/jgo-22-509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022] Open
Abstract
Background Gemcitabine is a broadly used chemotherapeutic agent that can cause a rare but life-threatening complication called thrombotic microangiopathy (TMA). Early recognition is crucial as therapy options are limited. Case Description We report the case of a 46-year-old patient with pancreatic adenocarcinoma who presented with severe anemia and thrombocytopenia as well as acute kidney injury. A diagnosis of gemcitabine-induced TMA was made. He became rapidly transfusion and dialysis dependent. Despite discontinuation of gemcitabine and treatment with high-dose corticotherapy as well as plasmapheresis, no improvement in both renal and hematological parameters was seen. Treatment with eculizumab was initiated. One week after the first administration, the patient no longer required packed cells nor platelet transfusions and one month later, dialysis could be discontinued. After five doses, treatment with eculizumab was stopped. Four months later, his serum creatinine was 1 mg/dL. Conclusions This case report illustrates the promising beneficial effects of eculizumab in gemcitabine-induced TMA, both regarding transfusion dependence as well as improvement in renal function, thereby allowing further therapy options in patients with an active malignancy.
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Affiliation(s)
| | - Heidi Hannon
- Department of Nephrology, AZ Maria Middelares, Ghent, Belgium
| | - Marie Schurgers
- Department of Nephrology, AZ Maria Middelares, Ghent, Belgium
| | - Els Monsaert
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
| | - Kathleen Claes
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Hanna RM, Henriksen K, Kalantar-Zadeh K, Ferrey A, Burwick R, Jhaveri KD. Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers. Adv Chronic Kidney Dis 2022; 29:149-160.e1. [PMID: 35817522 DOI: 10.1053/j.ackd.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/11/2022]
Abstract
Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.
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Affiliation(s)
- Ramy M Hanna
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA.
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Kamyar Kalantar-Zadeh
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Antoney Ferrey
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenar D Jhaveri
- Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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Grall M, Daviet F, Chiche NJ, Provot F, Presne C, Coindre JP, Pouteil-Noble C, Karras A, Guerrot D, François A, Benhamou Y, Veyradier A, Frémeaux-Bacchi V, Coppo P, Grangé S. Eculizumab in gemcitabine-induced thrombotic microangiopathy: experience of the French thrombotic microangiopathies reference centre. BMC Nephrol 2021; 22:267. [PMID: 34284729 PMCID: PMC8293501 DOI: 10.1186/s12882-021-02470-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gemcitabine is a broadly prescribed chemotherapy, the use of which can be limited by renal adverse events, including thrombotic microangiopathy (TMA). METHODS This study evaluated the efficacy of eculizumab, a monoclonal antibody targeting the terminal complement pathway, in patients with gemcitabine-induced TMA (G-TMA). We conducted an observational, retrospective, multicenter study in 5 French centres, between 2011 and 2016. RESULTS Twelve patients with a G-TMA treated by eculizumab were included. The main characteristics were acute renal failure (100%), including stage 3 acute kidney injury (AKI, 58%) and renal replacement therapy (17%), hypertension (92%) and diffuse oedema (83%). Eculizumab was started after a median of 15 days (range 4-44) following TMA diagnosis. A median of 4 injections of eculizumab was performed (range 2-22). Complete hematological remission was achieved in 10 patients (83%) and blood transfusion significantly decreased after only one injection of eculizumab (median of 3 packed red blood cells (range 0-10) before treatment vs 0 (range 0-1) after one injection, P < 0.001). Two patients recovered completely renal function (17%), and 8 achieved a partial remission (67%). Compared to a control group of G-TMA without use of eculizumab, renal outcome was more favourable. At the end of the follow up, median eGFR was 45 vs 33 ml/min/1.73m2 respectively in the eculizumab group and in the control group. CONCLUSIONS These results suggest that eculizumab is efficient on haemolysis and reduces transfusion requirement in G-TMA. Moreover, eculizumab may improve renal function recovery.
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Affiliation(s)
- Maximilien Grall
- Medical Intensive Care Unit, Rouen University Hospital, 37 boulevard Gambetta, 76031, Rouen Cedex, France
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
| | - Florence Daviet
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Conception University Hospital, APHM, Marseille, France
| | - Noémie Jourde Chiche
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Conception University Hospital, APHM, Marseille, France
| | - François Provot
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Lille University Hospital, Lille, France
| | - Claire Presne
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Amiens University Hospital, Amiens, France
| | - Jean-Philippe Coindre
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Le Mans General Hospital, Le Mans, France
| | - Claire Pouteil-Noble
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, E. Herriot Hospital, Lyon I university, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Georges Pompidou Hospital, APHP, Paris, France
| | | | - Arnaud François
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Ygal Benhamou
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Internal Medicine, Rouen University Hospital, Rouen, France
| | - Agnès Veyradier
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Biological Hematology, Lariboisière University Hospital, APHP, Paris, France
| | - Véronique Frémeaux-Bacchi
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of immunology, Georges Pompidou Hospital, APHP, Paris, France
| | - Paul Coppo
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Hematology, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
| | - Steven Grangé
- Medical Intensive Care Unit, Rouen University Hospital, 37 boulevard Gambetta, 76031, Rouen Cedex, France.
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France.
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Alhenc-Gelas M, Bidard FC. [Breast cancer-related thrombotic microangiopathy: A review]. Bull Cancer 2021; 108:730-739. [PMID: 34052032 DOI: 10.1016/j.bulcan.2021.03.017] [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: 11/07/2020] [Revised: 03/21/2021] [Accepted: 03/24/2021] [Indexed: 11/15/2022]
Abstract
Thrombotic Microangiopathies (TM) have been described since the 1960s. They are characterized by presence of mechanical haemolytic anemia associated with peripheral thrombocytopenia. TM in cancer can be related to several causes, whose cancer himself: cancer-related microangiopathic haemolytic anaemia (MAHA). Incidence of cancer related MAHA remains unknown. Cancer-related MAHA are mainly observed in mucin-producer adenocarcinomas, such as gastric (half of reported cases) and breast cancer. We conducted a review of all original published cases of TM reported in breast cancer, and we specifically investigated BC-MAHA cases. A Medline search identified 158 MAHA cases including 118 BC-MAHA, and 40 drug-related MAHA. Most of BC-MAHA occur in disseminated cancers, mainly with medullar involvement, and/or bone metastasis. Patients typically suffer from poor general state, bone pain, and/or dyspnea. Laboratory abnormalities such as myelemia or erythromyelemia in peripheral blood are frequently observed. Incidence of coagulation disorders is increased, compared to other MAHA causes. BC-MAHA prognosis is dramatically poor. Treatments classically used in other MAHA causes, such as plasmapheresis or immunoglobulins, are inefficient. Urgent anti-neoplastic therapy may be the only effective treatment, associated to symptomatic therapies (transfusions, blood pressure control).
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Affiliation(s)
- Marion Alhenc-Gelas
- Institut Curie, département d'oncologie médicale, 35, rue Dailly, 92210 Saint-Cloud, France.
| | - François-Clément Bidard
- Institut Curie, département d'oncologie médicale, 35, rue Dailly, 92210 Saint-Cloud, France.
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Efe O, Goyal L, Galway A, Zhu AX, Niles JL, Zonozi R. Treatment of Gemcitabine-Induced Thrombotic Microangiopathy Followed by Gemcitabine Rechallenge With Eculizumab. Kidney Int Rep 2021; 6:1464-1468. [PMID: 34013127 PMCID: PMC8116759 DOI: 10.1016/j.ekir.2021.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 10/26/2022] Open
Affiliation(s)
- Orhan Efe
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lipika Goyal
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aralee Galway
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew X Zhu
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John L Niles
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Reza Zonozi
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Palma LMP, Sridharan M, Sethi S. Complement in Secondary Thrombotic Microangiopathy. Kidney Int Rep 2020; 6:11-23. [PMID: 33102952 PMCID: PMC7575444 DOI: 10.1016/j.ekir.2020.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a condition characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA) with varying degrees of organ damage in the setting of normal international normalized ratio and activated partial thromboplastin time. Complement has been implicated in the etiology of TMA, which are classified as primary TMA when genetic and acquired defects in complement proteins are the primary drivers of TMA (complement-mediated TMA or atypical hemolytic uremic syndrome, aHUS) or secondary TMA, when complement activation occurs in the context of other disease processes, such as infection, malignant hypertension, autoimmune disease, malignancy, transplantation, pregnancy, and drugs. It is important to recognize that this classification is not absolute because genetic variants in complement genes have been identified in patients with secondary TMA, and distinguishing complement/genetic-mediated TMA from secondary causes of TMA can be challenging and lead to potentially harmful delays in treatment. In this review, we focus on data supporting the involvement of complement in aHUS and in secondary forms of TMA associated with malignant hypertension, drugs, autoimmune diseases, pregnancy, and infections. In aHUS, genetic variants in complement genes are found in up to 60% of patients, whereas in the secondary forms, the finding of genetic defects is variable, ranging from almost 60% in TMA associated with malignant hypertension to less than 10% in drug-induced TMA. On the basis of these findings, a new approach to management of TMA is proposed.
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Affiliation(s)
| | - Meera Sridharan
- Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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