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Castelli M, Micò MC, Grassi A, Algarotti A, Lussana F, Finazzi MC, Rambaldi B, Pavoni C, Rizzuto G, Tebaldi P, Vendemini F, Verna M, Bonanomi S, Biondi A, Balduzzi A, Rambaldi A, Gotti G. Safety and efficacy of narsoplimab in pediatric and adult patients with transplant-associated thrombotic microangiopathy: a real-world experience. Bone Marrow Transplant 2024; 59:1161-1168. [PMID: 38773280 PMCID: PMC11296948 DOI: 10.1038/s41409-024-02305-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication following hematopoietic stem cell transplantation (HSCT). No approved treatments are currently available. This study presents real-world data obtained with narsoplimab, a human immunoglobulin G4 monoclonal antibody that inhibits MASP-2, the effector enzyme of the lectin pathway of the complement system. Between January 2018 and August 2023, 20 (13 adult and 7 pediatric) patients diagnosed with TA-TMA received narsoplimab under an ongoing compassionate use program. The diagnosis was based on internationally defined criteria for pediatric and adult patients. Fifteen patients fulfilled the criteria recently established by an international consensus on TA-TMA. Nineteen patients exhibited high-risk characteristics. Thirteen patients (65%) responded to narsoplimab, achieving transfusion independence and significant clinical improvement. The one-hundred-day Overall Survival (OS) post-TA-TMA diagnosis was 70%, and 100% for responders. Narsoplimab proved to be effective and safe in the treatment of high-risk TA-TMA, with no increased infectious complications or other safety signals of concern across all age groups. The high response rates and the encouraging survival outcomes underscore the potential of narsoplimab as a valuable therapeutic option, particularly for high-risk cases.
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Affiliation(s)
- Marta Castelli
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Caterina Micò
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Grassi
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Alessandra Algarotti
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Lussana
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Chiara Finazzi
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Benedetta Rambaldi
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Pavoni
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Giuliana Rizzuto
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Paola Tebaldi
- Department of Pathology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Marta Verna
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
| | - Sonia Bonanomi
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
| | - Andrea Biondi
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Adriana Balduzzi
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy.
- Department of Oncology and Hematology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy.
| | - Giacomo Gotti
- Department of Pediatrics, Fondazione IRCCS San Gerardo, Monza, Italy
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Tsakiris DA, Gavriilaki E, Chanou I, Meyer SC. Hemostasis and complement in allogeneic hematopoietic stem cell transplantation: clinical significance of two interactive systems. Bone Marrow Transplant 2024:10.1038/s41409-024-02362-8. [PMID: 39004655 DOI: 10.1038/s41409-024-02362-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024]
Abstract
Hematopoietic stem cell transplantation (HCT) represents a curative treatment option for certain malignant and nonmalignant hematological diseases. Conditioning regimens before HCT, the development of graft-versus-host disease (GVHD) in the allogeneic setting, and delayed immune reconstitution contribute to early and late complications by inducing tissue damage or humoral alterations. Hemostasis and/or the complement system are biological regulatory defense systems involving humoral and cellular reactions and are variably involved in these complications after allogeneic HCT. The hemostasis and complement systems have multiple interactions, which have been described both under physiological and pathological conditions. They share common tissue targets, such as the endothelium, which suggests interactions in the pathogenesis of several serious complications in the early or late phase after HCT. Complications in which both systems interfere with each other and thus contribute to disease pathogenesis include transplant-associated thrombotic microangiopathy (HSCT-TMA), sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), and GVHD. Here, we review the current knowledge on changes in hemostasis and complement after allogeneic HCT and how these changes may define clinical impact.
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Affiliation(s)
| | - Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioanna Chanou
- Department of Biomedical Sciences, School of Health Sciences, International Hellenic University, Thessaloniki, Greece
| | - Sara C Meyer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Jin Y, Zhao P, Zhang YY, Ye YS, Zhou F, Wan DM, Chen Y, Zhou J, Li X, Wang Y, Liu Y, Bian ZL, Yang KQ, Li Z, Zhang J, Xu WW, Zhou JY, An ZY, Fu HX, Chen YH, Chen Q, Wu J, Wang JZ, Mo XD, Chen H, Chen Y, Wang Y, Chang YJ, Huang H, Huang XJ, Zhang XH. Clinical characteristics of membranous nephropathy after allogeneic hematopoietic stem cell transplantation: A real-world multicenter study. Ann Hematol 2024:10.1007/s00277-024-05875-w. [PMID: 38990296 DOI: 10.1007/s00277-024-05875-w] [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: 04/10/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024]
Abstract
Membranous nephropathy (MN) is a rare complication that can occur after allogeneic hematopoietic stem cell transplantation (allo-HSCT). MN patients may develop nephrotic syndrome or even kidney failure, which greatly affects their quality of life and prognosis. However, current knowledge regarding MN after allo-HSCT is limited. Thus, a multicenter nested case‒control study was conducted. Patients who had been diagnosed with MN after allo-HSCT were retrospectively identified at 8 HSCT centers. A total of 51 patients with MN after allo-HSCT were included. The median age of MN patients after allo-HSCT was 38 years, and the median duration from HSCT to MN was 18 months. The use of HLA-matched donors (P = 0.0102) and peripheral blood as the graft source (P = 0.0060) were identified as independent predisposing risk factors for the onset of MN after allo-HSCT. Compared to those in the control group, the incidence of extensive chronic graft-versus-host disease was greater in the MN patients (P = 0.0002). A total of 31 patients developed nephrotic syndrome. Patients receiving combination treatments of corticosteroids and immunosuppressants appeared to have better outcomes. In conclusion, MN is a rare but occasionally severe complication following HSCT and may require active treatment.
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Affiliation(s)
- Yue Jin
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yi-Shan Ye
- Department of Hematology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Fang Zhou
- Department of Hematology, Hospital of People's Liberation Army, Jinan, China
| | - Ding-Ming Wan
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Chen
- Department of Hematology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jian Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Yan Wang
- Hematology Department, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yue Liu
- Department of Hematology, Hospital of People's Liberation Army, Jinan, China
| | - Zhi-Lei Bian
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai-Qian Yang
- Department of Hematology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhen Li
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Jian Zhang
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Wen-Wei Xu
- Hematology Department, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Jian-Ying Zhou
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Zhuo-Yu An
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Qi Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jin Wu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - He Huang
- Department of Hematology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.
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Kafa K, Hoell JI. Transplant-associated thrombotic microangiopathy in pediatrics: incidence, risk factors, therapeutic options, and outcome based on data from a single center. Front Oncol 2024; 14:1399696. [PMID: 39050576 PMCID: PMC11266128 DOI: 10.3389/fonc.2024.1399696] [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] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a critical complication of hematopoietic stem cell transplantation. Awareness about TA-TMA has increased in recent years, resulting in the implementation of TA-TMA screening in most centers. Methods Retrospective analysis of children who underwent autologous or allogeneic hematopoietic stem cell transplantation at our center between January 2018 and December 2022 was conducted to evaluate the incidence, clinical features, and outcomes of TA-TMA following the administration of different therapeutic options. Results A total of 45 patients comprised the study cohort, of whom 10 developed TA-TMA with a cumulative incidence of 22% by 100 days after transplantation. Patients with and without TA-TMA in our cohort displayed an overall survival of 80% and 88%, respectively (p = 0.48), and a non-relapse mortality of 0% and 5.7%, respectively (p = 0.12), at 1 year after transplantation. Risk factors for TA-TMA development included allogeneic transplantation and total body irradiation-based conditioning regime. Among the 10 patients with TA-TMA, 7 did not meet the high-risk criteria described by Jodele and colleagues. Of these seven patients, two responded to calcineurin-inhibitor withdrawal without further therapy and five developed multiorgan dysfunction syndrome and were treated with anti-inflammatory steroids (prednisone), and all responded to therapy. The three patients with high-risk TA-TMA were treated with complement blockade or prednisone, and all responded to therapy. Conclusion TA-TMA is a multifactorial complication with high morbidity rates. Patients with high-risk TA-TMA may benefit from complement blockade using eculizumab. No consensus has been reached regarding therapy for patients who do not meet high-risk criteria. Our analysis showed that these patients may respond to anti-inflammatory treatment with prednisone.
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Affiliation(s)
- Kinan Kafa
- Department of Pediatric Hematology and Oncology, University Hospital Halle (Saale), Halle, Germany
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Dolgyras P, Anyfanti P, Lazaridis A, Gavriilaki E, Koletsos N, Triantafyllou A, Barbara N, Mastrogiannis K, Yiannaki E, Papakonstantinou A, Galanapoulou V, Douma S, Gkaliagkousi E. Endothelial dysfunction and complement activation are independently associated with disease duration in patients with systemic vasculitis. Microvasc Res 2024; 154:104692. [PMID: 38705254 DOI: 10.1016/j.mvr.2024.104692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Systemic vasculitis is a heterogenous group of autoimmune diseases characterized by enhanced cardiovascular mortality. Endothelial dysfunction is associated with accelerated vascular damage, representing a core pathophysiologic mechanism contributing to excess CV risk. Recent studies have also shown that complement activation holds significant role in the pathogenesis of Anti-Neutrophilic Cytoplasmic Autoantibody (ANCA) -associated vasculitis (AAV). Given the potential crosstalk between the endothelium and complement, we aimed to assess, for the first time simultaneously, easily accessible biomarkers of endothelial dysfunction and complement activation in SV. METHODS We measured circulating endothelial microvesicles (EMVs) and soluble complement components representative of alternative, classical and terminal activation (C5b-9, C1q, Bb fragments, respectively) in a meticulously selected group of patients with systemic vasculitis, but without cardiovascular disease. Individuals free from systemic diseases, who were matched with patients for cardiovascular risk factors(hypertension, diabetes, smoking, dyslipidemia), comprised the control group. RESULTS We studied 60 individuals (30 in each group). Patients with systemic vasculitis had elevated EMVs, higher levels of C5b-9 [536.4(463.4) vs 1200.94457.3), p = 0.003] and C1q [136.2(146.5 vs 204.2(232.9), p = 0.0129], compared to controls [232.0 (243.5) vs 139.3(52.1), p < 0.001]. In multivariate analysis both EMVs and C5b-9 were independently associated with disease duration (p = 0.005 and p = 0.004 respectively), yet not with disease activity. CONCLUSION Patients with systemic vasculitis exhibit impaired endothelial function and complement activation, both assessed by easily accessible biomarkers, even in the absence of cardiovascular disease manifestations. EMVs and soluble complement components such as C5b-9 and C1q could be used as early biomarkers of endothelial dysfunction and complement activation, respectively, in clinical practice during the course of SV, yet their predictive value in terms of future cardiovascular disease warrants further verification in appropriately designed studies.
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Affiliation(s)
- Panagiotis Dolgyras
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Panagiota Anyfanti
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Lazaridis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Gavriilaki
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Koletsos
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Areti Triantafyllou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaidou Barbara
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Mastrogiannis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efi Yiannaki
- Hematology Laboratory, Theagenion Cancer Center, Thessaloniki, Greece
| | - Anna Papakonstantinou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Stella Douma
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Evangelidis P, Evangelidis N, Kalmoukos P, Kourti M, Tragiannidis A, Gavriilaki E. Genetic Susceptibility in Endothelial Injury Syndromes after Hematopoietic Cell Transplantation and Other Cellular Therapies: Climbing a Steep Hill. Curr Issues Mol Biol 2024; 46:4787-4802. [PMID: 38785556 PMCID: PMC11119915 DOI: 10.3390/cimb46050288] [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: 04/13/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) remains a cornerstone in the management of patients with hematological malignancies. Endothelial injury syndromes, such as HSCT-associated thrombotic microangiopathy (HSCT-TMA), veno-occlusive disease/sinusoidal obstruction syndrome (SOS/VOD), and capillary leak syndrome (CLS), constitute complications after HSCT. Moreover, endothelial damage is prevalent after immunotherapy with chimeric antigen receptor-T (CAR-T) and can be manifested with cytokine release syndrome (CRS) or immune effector cell-associated neurotoxicity syndrome (ICANS). Our literature review aims to investigate the genetic susceptibility in endothelial injury syndromes after HSCT and CAR-T cell therapy. Variations in complement pathway- and endothelial function-related genes have been associated with the development of HSCT-TMA. In these genes, CFHR5, CFHR1, CFHR3, CFI, ADAMTS13, CFB, C3, C4, C5, and MASP1 are included. Thus, patients with these variations might have a predisposition to complement activation, which is also exaggerated by other factors (such as acute graft-versus-host disease, infections, and calcineurin inhibitors). Few studies have examined the genetic susceptibility to SOS/VOD syndrome, and the implicated genes include CFH, methylenetetrahydrofolate reductase, and heparinase. Finally, specific mutations have been associated with the onset of CRS (PFKFB4, CX3CR1) and ICANS (PPM1D, DNMT3A, TE2, ASXL1). More research is essential in this field to achieve better outcomes for our patients.
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Affiliation(s)
- Paschalis Evangelidis
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Nikolaos Evangelidis
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Panagiotis Kalmoukos
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Maria Kourti
- 3rd Department of Pediatrics, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
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7
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [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: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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Hordeaux J, Lamontagne RJ, Song C, Buchlis G, Dyer C, Buza EL, Ramezani A, Wielechowski E, Greig JA, Chichester JA, Bell P, Wilson JM. High-dose systemic adeno-associated virus vector administration causes liver and sinusoidal endothelial cell injury. Mol Ther 2024; 32:952-968. [PMID: 38327046 PMCID: PMC11163197 DOI: 10.1016/j.ymthe.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 12/15/2023] [Accepted: 02/02/2024] [Indexed: 02/09/2024] Open
Abstract
We analyzed retrospective data from toxicology studies involving administration of high doses of adeno-associated virus expressing different therapeutic transgenes to 21 cynomolgus and 15 rhesus macaques. We also conducted prospective studies to investigate acute toxicity following high-dose systemic administration of enhanced green fluorescent protein-expressing adeno-associated virus to 10 rhesus macaques. Toxicity was characterized by transaminitis, thrombocytopenia, and alternative complement pathway activation that peaked on post-administration day 3. Although most animals recovered, some developed ascites, generalized edema, hyperbilirubinemia, and/or coagulopathy that prompted unscheduled euthanasia. Study endpoint livers from animals that recovered and from unscheduled necropsies of those that succumbed to toxicity were analyzed via hypothesis-driven histopathology and unbiased single-nucleus RNA sequencing. All liver cell types expressed high transgene transcript levels at early unscheduled timepoints that subsequently decreased. Thrombocytopenia coincided with sinusoidal platelet microthrombi and sinusoidal endothelial injury identified via immunohistology and single-nucleus RNA sequencing. Acute toxicity, sinusoidal injury, and liver platelet sequestration were similarly observed with therapeutic transgenes and enhanced green fluorescent protein at doses ≥1 × 1014 GC/kg, suggesting it was the consequence of high-dose systemic adeno-associated virus administration, not green fluorescent protein toxicity. These findings highlight a potential toxic effect of high-dose intravenous adeno-associated virus on nonhuman primate liver microvasculature.
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Affiliation(s)
- Juliette Hordeaux
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - R Jason Lamontagne
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Chunjuan Song
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - George Buchlis
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Cecilia Dyer
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Elizabeth L Buza
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ali Ramezani
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Erik Wielechowski
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jenny A Greig
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jessica A Chichester
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Peter Bell
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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9
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Jodele S, Dandoy CE, Aguayo-Hiraldo P, Lane A, Teusink-Cross A, Sabulski A, Mizuno K, Laskin BL, Freedman J, Davies SM. A prospective multi-institutional study of eculizumab to treat high-risk stem cell transplantation-associated TMA. Blood 2024; 143:1112-1123. [PMID: 37946262 PMCID: PMC10972707 DOI: 10.1182/blood.2023022526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
ABSTRACT High-risk, complement mediated, untreated transplant-associated thrombotic microangiopathy (hrTMA) has dismal outcomes due to multi-organ dysfunction syndrome (MODS). The complement C5 blocker eculizumab shows promising results in hrTMA, but has not been prospectively studied in hematopoietic stem cell transplant (HCT) recipients. We performed the first multi-institutional prospective study in children and young adults to evaluate eculizumab as an early targeted intervention for hrTMA/MODS. We hypothesized that eculizumab would more than double survival in HCT recipients with hrTMA, compared to our prior study of prospectively screened, untreated hrTMAs serving as historical controls. HrTMA features (elevated terminal complement (sC5b-9) and proteinuria measured by random urine protein/creatinine ratio (≥1mg/mg)) were required for inclusion. The primary endpoint was survival at 6 six-months from hrTMA diagnosis. Secondary endpoints were cumulative incidence of MODS 6 months after hrTMA diagnosis and 1-year posttransplant survival. Eculizumab dosing included intensive loading, induction, and maintenance phases for up to 24 weeks of therapy. All 21 evaluated study subjects had MODS. Primary and secondary study endpoints were met by demonstrating survival of 71% (P < .0001) 6 months after hrTMA diagnosis and 62% 1 year after transplant. Of fifteen survivors, 11 (73%) fully recovered organ function and are well. Our study demonstrates significant improvement in survival and recovery of organ function in hrTMA using an intensified eculizumab dosing and real time biomarker monitoring. This study serves as a benchmark for planning future studies that should focus on preventative measures or targeted therapy to be initiated prior to organ injury. This trial was registered at www.clinicaltrials.gov as #NCT03518203.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Christopher E. Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paibel Aguayo-Hiraldo
- Division of Bone Marrow Transplantation, Children’s Hospital of Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Adam Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashley Teusink-Cross
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kana Mizuno
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin L. Laskin
- Division of Nephrology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jason Freedman
- Division of Oncology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Stella M. Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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10
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Gavriilaki E, Bousiou Z, Batsis I, Vardi A, Mallouri D, Koravou EE, Konstantinidou G, Spyridis N, Karavalakis G, Noli F, Patriarcheas V, Masmanidou M, Touloumenidou T, Papalexandri A, Poziopoulos C, Yannaki E, Sakellari I, Politou M, Papassotiriou I. Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) and Growth Differentiation Factor-15 (GDF-15) Levels Are Significantly Associated with Endothelial Injury Indices in Adult Allogeneic Hematopoietic Cell Transplantation Recipients. Int J Mol Sci 2023; 25:231. [PMID: 38203404 PMCID: PMC10778584 DOI: 10.3390/ijms25010231] [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: 11/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GvHD) represent life-threatening syndromes after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In both conditions, endothelial dysfunction is a common denominator, and development of relevant biomarkers is of high importance for both diagnosis and prognosis. Despite the fact that soluble urokinase plasminogen activator receptor (suPAR) and growth differentiation factor-15 (GDF-15) have been determined as endothelial injury indices in various clinical settings, their role in HSCT-related complications remains unexplored. In this context, we used immunoenzymatic methods to measure suPAR and GDF-15 levels in HSCT-TMA, acute and/or chronic GVHD, control HSCT recipients, and apparently healthy individuals of similar age and gender. We found considerably greater SuPAR and GDF-15 levels in HSCT-TMA and GVHD patients compared to allo-HSCT and healthy patients. Both GDF-15 and suPAR concentrations were linked to EASIX at day 100 and last follow-up. SuPAR was associated with creatinine and platelets at day 100 and last follow-up, while GDF-15 was associated only with platelets, suggesting that laboratory values do not drive EASIX. SuPAR, but not GDF-15, was related to soluble C5b-9 levels, a sign of increased HSCT-TMA risk. Our study shows for the first time that suPAR and GDF-15 indicate endothelial damage in allo-HSCT recipients. Rigorous validation of these biomarkers in many cohorts may provide utility for their usefulness in identifying and stratifying allo-HSCT recipients with endothelial cell impairment.
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Affiliation(s)
- Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Zoi Bousiou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioannis Batsis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Anna Vardi
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Despina Mallouri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Evaggelia-Evdoxia Koravou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgia Konstantinidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Nikolaos Spyridis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgios Karavalakis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Foteini Noli
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Vasileios Patriarcheas
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Masmanidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Tasoula Touloumenidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Apostolia Papalexandri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Christos Poziopoulos
- Department of Hematology, Metropolitan Hospital, Neo Faliro, 18547 Athens, Greece;
| | - Evangelia Yannaki
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioanna Sakellari
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Politou
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ioannis Papassotiriou
- First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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11
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Koo J, Ziady AG, Reynaud D, Abdullah S, Luebbering N, Kahn S, Langenberg L, Strecker L, Lake K, Dandoy CE, Lane A, Myers KC, Sabulski A, Good S, Nalapareddy K, Solomon M, Siefert ME, Skala E, Jodele S, Davies SM. Increased Body Mass Index Augments Endothelial Injury and Clinical Outcomes after Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:704.e1-704.e8. [PMID: 37625594 PMCID: PMC10840974 DOI: 10.1016/j.jtct.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023]
Abstract
Higher body mass index (BMI) is characterized as a chronic inflammatory state with endothelial dysfunction. Endothelial injury after allogeneic hematopoietic stem cell transplantation (allo-HSCT) puts patients at risk for such complications as transplantation-associated thrombotic microangiopathy (TA-TMA) and acute graft-versus-host-disease (aGVHD). To evaluate the impact of increased BMI on endothelial injury after allo-HSCT in pediatric and young adult patients, we conducted a retrospective cohort study evaluating 476 consecutive allo-HSCT children and young adult recipients age 0 to 20 years. Our analysis was subdivided based on distinct age categories (<2 years and 2 to 20 years). BMI was considered as a variable but was also expressed in standard deviations from the mean adjusted for age and sex (z-score), based on established criteria from the World Health Organization (age <2 years) and the Centers for Disease Control and Prevention (age 2 to 20 years) to account for differences associated with age. Primary endpoints included the incidences of TA-TMA and aGVHD. Increased BMI z-score was associated with TA-TMA after allo-HSCT in patients age <2 years (median, 18.1; IQR, 17 to 20; P = .006) and in patients age 2 to 20 years (median, 18.7; IQR, 16 to 21.9; P = .02). Higher BMI z-score correlated with TA-TMA risk in both age groups, with a BMI z-score of .9 in the younger cohort and .7 (IQR, -.4 to 1.6; P = .04) in the older cohort. Increased BMI z-score was associated with an increased risk of TA-TMA in a multivariate analysis of the entire cohort (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.05 to 1.37; P = .008). Multivariate analysis also demonstrated that patients with BMI in the 85th percentile or greater had an increased risk of developing TA-TMA compared to those with a lower BMI percentile (OR, 2.66; 95% CI, 1.62 to 4.32; P < .001). Baseline and day +7 ST2 levels were elevated in subjects with TA-TMA compared to those without TA-TMA in both age groups. Baseline sC5b-9 concentration was not correlated with BMI z-score, but sC5b-9 concentration was increased markedly by 7 days post-allo-HSCT in patients age <2 years who later developed TA-TMA compared to those who never developed TA-TMA (P = .001). The median BMI z-score was higher for patients with aGVHD compared to patients without aGVHD (.7 [range, -3.9 to 3.9] versus .2 [range, -7.8 to 5.4]; P = .03). We show that high BMI is associated with augmented risk of endothelial injury after HSCT, specifically TA-TMA. These data identify a high-risk population likely to benefit from early interventions to prevent endothelial injury and prompt treatment of established endothelial injury.
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Affiliation(s)
- Jane Koo
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
| | - Assem G Ziady
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Damien Reynaud
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sheyar Abdullah
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Nathan Luebbering
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Seth Kahn
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Department of Politics, Princeton University, Princeton, New Jersey
| | - Lucille Langenberg
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Lauren Strecker
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Kelly Lake
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Adam Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Samantha Good
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kodandaramireddy Nalapareddy
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Solomon
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew E Siefert
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Emily Skala
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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12
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Notarantonio AB, D'aveni-Piney M, Pagliuca S, Ashraf Y, Galimard JE, Xhaard A, Marçais A, Suarez F, Brissot E, Feugier P, Urien S, Bouazza N, Jacquelin S, Meatchi T, Bruneval P, Frémeaux-Bacchi V, Peffault De Latour R, Hermine O, Durey-Dragon MA, Rubio MT. Systemic complement activation influences outcomes after allogeneic hematopoietic cell transplantation: A prospective French multicenter trial. Am J Hematol 2023; 98:1559-1570. [PMID: 37483161 DOI: 10.1002/ajh.27030] [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: 04/17/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023]
Abstract
Complement activation has shown a role in murine models of graft-versus-host disease (GVHD) and in endothelial complications after allogeneic hematopoietic cell transplantation (allo-HSCT). However, its impact on post-transplant outcomes has not been so far fully elucidated. Here, we conducted a prospective multicentric trial (NCT01520623) performing serial measurements of complement proteins, regulators, and CH50 activity for 12 weeks after allo-HSCT in 85 patients receiving a myeloablative conditioning (MAC) regimen for various hematological malignancies. Twenty-six out of 85 patients showed an "activated" complement profile through the classical/lectin pathway, defined as a post-transplant decline of C3/C4 and CH50 activity. Time-dependent Cox regression models demonstrated that complement activation within the first weeks after allo-HSCT was associated with increased non-relapse mortality (hazard ratio [HR]: 3.69, 95% confident interval [CI]: 1.55-8.78, p = .003) and poorer overall survival (HR: 2.72, 95% CI: 1.37-5.39, p = .004) due to increased incidence of grade II-IV acute GVHD and in particular gastrointestinal (GI) GVHD (HR: 36.8, 95% CI: 12.4-109.1, p < .001), higher incidences of thrombotic microangiopathy (HR: 8.58, 95% CI: 2.16-34.08, p = .0022), capillary leak syndrome (HR: 7.36, 95% CI: 2.51-21.66, p = .00028), post-engraftment bacterial infections (HR: 2.37, 95% CI: 1.22-4.63, p = .0108), and EBV reactivation (HR: 3.33, 95% CI: 1.31-8.45, p = .0112). Through specific immune staining, we showed the correlation of deposition of C1q, C3d, C4d, and of C5b9 components on endothelial cells in GI GVHD lesions with the histological grade of GVHD. Altogether these findings define the epidemiology and the clinical impact of complement classical/lectin pathway activation after MAC regimens and provide a rational for the use of complement inhibitory therapeutics in a post-allo-HSCT setting.
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Affiliation(s)
- Anne Béatrice Notarantonio
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Maud D'aveni-Piney
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
| | - Simona Pagliuca
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Yayha Ashraf
- Laboratoire d'Immunologie, Hôpital Européen Georges-Pompidou, Université Paris Cité and UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | | | - Aliénor Xhaard
- BMT Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris VII, Paris, France
| | - Ambroise Marçais
- Service d'Hématologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Felipe Suarez
- Service d'Hématologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Eolia Brissot
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - Pierre Feugier
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Saik Urien
- Unité de Recherche Clinique, Paris Centre Necker Cochin, Hôpital Tarnier, Paris, France
| | - Naim Bouazza
- Unité de Recherche Clinique, Paris Centre Necker Cochin, Hôpital Tarnier, Paris, France
| | - Sébastien Jacquelin
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
| | - Tchao Meatchi
- Service d'Anatomopathologie, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrick Bruneval
- Service d'Anatomopathologie, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Frémeaux-Bacchi
- Laboratoire d'Immunologie, Hôpital Européen Georges-Pompidou, Université Paris Cité and UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Régis Peffault De Latour
- BMT Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris VII, Paris, France
| | - Olivier Hermine
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
- Service d'Hématologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Marie Agnès Durey-Dragon
- Laboratoire d'Immunologie, Hôpital Européen Georges-Pompidou, Université Paris Cité and UMR S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Marie-Thérèse Rubio
- Service d'Hématologie, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, IMoPA, Biopôle de l'Université de Lorraine, Vandoeuvre-les-Nancy, France
- Laboratory of Physiopathology of Hematological Disorders and Their Therapeutic Implications, INSERM U1158 Imagine Institute, Université Paris Cité, Paris, France
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13
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Beckman JD, Sparkenbaugh EM. The invisible string of coagulation, complement, iron, and inflammation in sickle cell disease. Curr Opin Hematol 2023; 30:153-158. [PMID: 37462409 PMCID: PMC10529498 DOI: 10.1097/moh.0000000000000773] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW This review provides an update on recent advances in mechanistic studies of thromboinflammatory mechanisms that contribute to the disease pathology in sickle cell disease (SCD). There is a focus on novel pathways, clinical relevance, and translational potential of these findings. We hope to encourage more advances in this area to reduce organ damage in young patients prior to gene therapy, and to serve the aging SCD patient population. RECENT FINDINGS Novel insights into the roles of neutrophils, the ADAMTS-13/VWF axis, oxidative stress, and the intrinsic coagulation cascade, as well as relevant clinical trials, are discussed. SUMMARY Several studies implicate dysregulation of the ADAMTS-13/VWF axis as playing a major role in vaso-occlusive events (VOE) in SCD. Another highlight is reducing iron overload, which has beneficial effects on erythrocyte and neutrophil function that reduce VOE and inflammation. Multiple studies suggest that targeting HO-1/ROS in erythrocytes, platelets, and endothelium can attenuate disease pathology. New insights into coagulation activation identify intrinsic coagulation factor XII as a central regulator of many thromboinflammatory pathologies in SCD. The complement cascade and modulators of neutrophil function and release of neutrophil extracellular traps are also discussed.
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Affiliation(s)
- Joan D Beckman
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Erica M Sparkenbaugh
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Blood Research Center, Chapel Hill, North Carolina, USA
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Elhadad S, Redmond D, Huang J, Tan A, Laurence J. MASP2 inhibition by narsoplimab suppresses endotheliopathies characteristic of transplant-associated thrombotic microangiopathy: in vitro and ex vivo evidence. Clin Exp Immunol 2023; 213:252-264. [PMID: 37191586 PMCID: PMC10361744 DOI: 10.1093/cei/uxad055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 05/17/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endotheliopathy complicating up to 30% of allogeneic hematopoietic stem cell transplants (alloHSCT). Positive feedback loops among complement, pro-inflammatory, pro-apoptotic, and coagulation cascade likely assume dominant roles at different disease stages. We hypothesized that mannose-binding lectin-associated serine protease 2 (MASP2), principal activator of the lectin complement system, is involved in the microvascular endothelial cell (MVEC) injury characteristic of TA-TMA through pathways that are susceptible to suppression by anti-MASP2 monoclonal antibody narsoplimab. Pre-treatment plasmas from 8 of 9 TA-TMA patients achieving a complete TMA response in a narsoplimab clinical trial activated caspase 8, the initial step in apoptotic injury, in human MVEC. This was reduced to control levels following narsoplimab treatment in 7 of the 8 subjects. Plasmas from 8 individuals in an observational TA-TMA study, but not 8 alloHSCT subjects without TMA, similarly activated caspase 8, which was blocked in vitro by narsoplimab. mRNA sequencing of MVEC exposed to TA-TMA or control plasmas with and without narsoplimab suggested potential mechanisms of action. The top 40 narsoplimab-affected transcripts included upregulation of SerpinB2, which blocks apoptosis by inactivating procaspase 3; CHAC1, which inhibits apoptosis in association with mitigation of oxidative stress responses; and pro-angiogenesis proteins TM4SF18, ASPM, and ESM1. Narsoplimab also suppressed transcripts encoding pro-apoptotic and pro-inflammatory proteins ZNF521, IL1R1, Fibulin-5, aggrecan, SLC14A1, and LOX1, and TMEM204, which disrupts vascular integrity. Our data suggest benefits to narsoplimab use in high-risk TA-TMA and provide a potential mechanistic basis for the clinical efficacy of narsoplimab in this disorder.
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Affiliation(s)
- Sonia Elhadad
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - David Redmond
- Division of Regenerative Medicine, Hartman Institute for Therapeutic Organ Regeneration, Ansary Stem Cell Institute, New York, NY, USA
| | - Jenny Huang
- Division of Regenerative Medicine, Hartman Institute for Therapeutic Organ Regeneration, Ansary Stem Cell Institute, New York, NY, USA
| | - Adrian Tan
- Genomics Resources Core Facility, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey Laurence
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
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Barratt J, Lafayette RA, Zhang H, Tesar V, Rovin BH, Tumlin JA, Reich HN, Floege J. IgA Nephropathy: the Lectin Pathway and Implications for Targeted Therapy. Kidney Int 2023:S0085-2538(23)00395-2. [PMID: 37263354 DOI: 10.1016/j.kint.2023.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 06/03/2023]
Abstract
Many patients with IgA nephropathy (IgAN) progress to end-stage kidney disease even with optimal supportive care. An improved understanding of the pathophysiology of IgAN in recent years has led to the investigation of targeted therapies with acceptable tolerability that may address the underlying causes of IgAN or the pathogenesis of kidney injury. The complement system - particularly the lectin and alternative pathways of complement - have emerged as key mediators of kidney injury in IgAN and possible targets for investigational therapy. This review will focus on the lectin pathway. Examination of kidney biopsies has consistently shown glomerular deposition of mannan-binding lectin (one of six pattern-recognition molecules that activate the lectin pathway) together with IgA1 in up to 50% of patients with IgAN. Glomerular deposition of pattern-recognition molecules for the lectin pathway is associated with more severe glomerular damage and more severe proteinuria and hematuria. Emerging research suggests that the lectin pathway may also contribute to tubulointerstitial fibrosis in IgAN, and that collectin-11 is a key mediator of this association. This review summarizes the growing scientific and clinical evidence supporting the role of the lectin pathway in IgAN and examines the possible therapeutic role of lectin pathway inhibition for these patients.
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Affiliation(s)
| | | | - Hong Zhang
- Peking University Institute of Nephrology, Beijing, China
| | - Vladimir Tesar
- Charles University and General University Hospital, Prague, Czech Republic
| | - Brad H Rovin
- The Ohio State University Wexner Medical Center, Columbus OH, USA
| | | | - Heather N Reich
- University of Toronto and University Health Network, Toronto ON, Canada
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Saad AA. Unveiling the Great Therapeutic Potential of MASPs as Hemostatic Agents. J Hematol 2022; 11:240-245. [PMID: 36632573 PMCID: PMC9822654 DOI: 10.14740/jh1060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/31/2022] [Indexed: 01/04/2023] Open
Affiliation(s)
- Ashraf Abdullah Saad
- Unit of Pediatric Hematologic Oncology and BMT, Sultan Qaboos University Hospital, Muscat, Oman.
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Kurya AU, Aliyu U, Tudu AI, Usman A, Yusuf M, Gupta S, Ali A, Gulfishan M, Singh SK, Hussain I, Abubakar MG. Graft-versus-host disease: Therapeutic prospects of improving the long-term post-transplant outcomes. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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MASP-2 and MASP-3 inhibitors block complement activation, inflammation, and microvascular stasis in a murine model of vaso-occlusion in sickle cell disease. Transl Res 2022; 249:1-12. [PMID: 35878790 PMCID: PMC9996688 DOI: 10.1016/j.trsl.2022.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/21/2022]
Abstract
Patients with sickle cell disease (SCD) have ongoing hemolysis that promotes endothelial injury, complement activation, inflammation, vaso-occlusion, ischemia-reperfusion pathophysiology, and pain. Complement activation markers are increased in SCD in steady-state and further increased during vaso-occlusive crisis (VOC). However, the mechanisms driving complement activation in SCD have not been completely elucidated. Ischemia-reperfusion and heme released from hemoglobin during hemolysis, events that characterize SCD pathophysiology, can activate the lectin pathway (LP) and alternative pathway (AP), respectively. Here we evaluated the role of LP and AP in Townes sickle (SS) mice using inhibitory monoclonal antibodies (mAb) to mannose binding lectin (MBL)-associated serine protease (MASP)-2 or MASP-3, respectively. Townes SS mice were pretreated with MASP-2 mAb, MASP-3 mAb, isotype control mAb, or PBS before they were challenged with hypoxia-reoxygenation or hemoglobin. Pretreatment of SS mice with MASP-2 or MASP-3 mAb, markedly reduced Bb fragments, C4d and C5a in plasma and complement deposition in the liver, kidneys, and lungs collected 4 hours after challenge compared to control mAb-treated mice. Consistent with complement inhibition, hepatic inflammation markers NF-ĸB phospho-p65, VCAM-1, ICAM-1, and E-selectin were significantly reduced in SS mice pretreated with MASP-2 or MASP-3 mAb. Importantly, MASP-2 or MASP-3 mAb pretreatment significantly inhibited microvascular stasis (vaso-occlusion) induced by hypoxia-reoxygenation or hemoglobin. These studies suggest that the LP and the AP are both playing a role in promoting inflammation and vaso-occlusion in SCD. Inhibiting complement activation via the LP or the AP might inhibit inflammation and prevent VOC in SCD patients.
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The Role of Complement in HSCT-TMA: Basic Science to Clinical Practice. Adv Ther 2022; 39:3896-3915. [PMID: 35781192 PMCID: PMC9402756 DOI: 10.1007/s12325-022-02184-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/06/2022] [Indexed: 12/05/2022]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a common complication occurring post-HSCT and is associated with substantial morbidity and mortality if not promptly identified and treated. Emerging evidence suggests a central role for the complement system in the pathogenesis of HSCT-TMA. The complement system has also been shown to interact with other pathways and processes including coagulation and inflammation, all of which are activated following HSCT. Three endothelial cell-damaging “hits” are required for HSCT-TMA genesis: a genetic predisposition or existing damage, an endothelial cell-damaging conditioning regimen, and additional damaging insults. Numerous risk factors for the development of HSCT-TMA have been identified (including primary diagnosis, graft type, and conditioning regimen) and validated lists of relatively simple diagnostic signs and symptoms exist, many utilizing routine clinical and laboratory assessments. Despite the relative ease with which HSCT-TMA can be screened for, it is often overlooked or masked by other common post-transplant conditions. Recent evidence that patients with HSCT-TMA may also concurrently present with these differential diagnoses only serve to further confound its identification and treatment. HSCT-TMA may be treated, or even prevented, by removing or ameliorating triggering “hits”, and recent studies have also shown substantial utility of complement-targeted therapies in this patient population. Further investigation into optimal management and treatment strategies is needed. Greater awareness of TMA post-HSCT is urgently needed to improve patient outcomes; the objective of this article is to clarify current understanding, explain underlying complement biology and provide simple tools to aid the early recognition, management, and monitoring of HSCT-TMA.
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