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Trisolini SM, Laganà A, Capria S. Immune Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, Therapy and Open Issues. Mediterr J Hematol Infect Dis 2024; 16:e2024060. [PMID: 38984099 PMCID: PMC11232686 DOI: 10.4084/mjhid.2024.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 06/19/2024] [Indexed: 07/11/2024] Open
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury due to microvascular platelet-rich thrombi. iTTP pathophysiology is based on a severe ADAMTS13 deficiency, the specific von Willebrand factor (vWF)-cleaving protease, due to anti-ADAMTS13 autoantibodies. Early diagnosis and treatment reduce the mortality. Frontline therapy includes daily plasma exchange (PEX) with fresh frozen plasma replacement and immunosuppression with corticosteroids. Caplacizumab has recently been added to frontline therapy. Caplacizumab is a nanobody that binds to the A1 domain of vWF, blocking the interaction of ultra-large vWF multimers with the platelet and thereby preventing the formation of platelet-rich thrombi. Caplacizumab reduces mortality due to ischemic events, refractoriness, and exacerbations after PEX discontinuation. Until now, the criteria for response to treatment mainly took into account the normalization of platelet count and discontinuation of PEX; with the use of caplacizumab leading to rapid normalization of platelet count, it has been necessary to redefine the response criteria, taking into account also the underlying autoimmune disease. Monitoring of ADAMTS13 activity is important to identify cases with a low value of activity (<10IU/L), requiring the optimization of immunosuppressive therapy with the addition of Rituximab. Rituximab is effective in patients with refractory disease or relapsing disease. Currently, the use of Rituximab has expanded, both in frontline treatment and during follow-up, as a pre-emptive approach. Some patients do not achieve ADAMTS13 remission following the acute phase despite steroids and rituximab treatment, requiring an individualized immunosuppressive approach to prevent clinical relapse. In iTTP, there is an increased risk of venous thrombotic events (VTEs) as well as arterial thrombotic events, and most occur after platelet normalization. Until now, there has been no consensus on the use of pharmacological thromboprophylaxis in patients on caplacizumab because the drug is known to increase bleeding risk.
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Affiliation(s)
- Silvia Maria Trisolini
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
| | - Alessandro Laganà
- Resident Doctor at the Department of Hematology, University "Sapienza" of Rome, Rome, Italy
| | - Saveria Capria
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
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Wang R, Jiang Y, He M, Xu J. EASIX is an effective marker in predicting mortality of traumatic brain injury patients. Eur J Med Res 2024; 29:300. [PMID: 38807251 PMCID: PMC11134687 DOI: 10.1186/s40001-024-01899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The Endothelial Activation and Stress Index (EASIX) is a novel marker of endothelial injury and correlates with survival of various patients. The endothelial dysfunction plays an important role on the pathophysiological process of traumatic brain injury (TBI). This study was designed to explore the prognostic value of EASIX on TBI patients. METHODS 358 TBI patients hospitalized in the West China hospital between October 2018 and October 2022 were enrolled for this study. The EASIX was calculated based on the formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelets (109 cells/L). The univariate and multivariate logistic regression with forward method was performed to explore the association between EASIX and mortality. A prognostic model was developed combining significant risk factors in the multivariate logistic regression. The receiver operating characteristic (ROC) curve was used to compare the predictive accuracy of the EASIX and the developed model. RESULTS The 30-day mortality of enrolled 358 TBI patients was 51.1%. Non-survivors had higher EASIX than survivors (p < 0.001). The multivariate logistic regression confirmed seven risk factors for mortality of TBI including injury mechanism (p = 0.010), GCS (p < 0.001), glucose (p < 0.001), EASIX (p = 0.017), subdural hematoma (p = 0.012), coagulopathy (p = 0.001). The AUC of EASIX, SOFA, GCS was 0.747, 0.748 and 0.774, respectively. The AUC of developed predictive model was 0.874 with the sensitivity of 0.913 and specificity of 0.686. CONCLUSIONS The EASIX is a reliable marker for predicting mortality of TBI patients. The predictive model incorporating EASIX is helpful for clinicians to evaluate the mortality risk of TBI patients.
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Affiliation(s)
- Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Yuelin Jiang
- West China Clinical Medical College of Sichuan University, Chengdu, Sichuan, China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.
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Allen C, Ito S, Butt A, Purcell A, Richmond R, Tormey CA, Krumholz HM, Cuker A, Goshua G. Cost-effectiveness of rapid vs in-house vs send-out ADAMTS13 testing for immune thrombotic thrombocytopenic purpura. Blood Adv 2024; 8:2279-2289. [PMID: 38502197 PMCID: PMC11116991 DOI: 10.1182/bloodadvances.2024012608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
ABSTRACT While awaiting confirmatory results, empiric therapy for patients suspected to have immune thrombotic thrombocytopenic purpura (iTTP) provides benefits and also accrues risks and costs. Rapid assays for ADAMTS13 may be able to avoid the cost and risk exposure associated with empiric treatment. We conducted, to our knowledge, the first cost-effectiveness evaluation of testing strategies with rapid vs traditional ADAMTS13 assays in patients with intermediate- to high-risk PLASMIC scores, with and without caplacizumab use. We built a Markov cohort simulation with 4 clinical base-case analyses: (1) intermediate-risk PLASMIC score with caplacizumab; (2) intermediate-risk PLASMIC score without caplacizumab; (3) high-risk PLASMIC score with caplacizumab; and (4) high-risk PLASMIC score without caplacizumab. Each of these evaluated 3 testing strategies: (1) rapid assay (<1-hour turnaround); (2) in-house fluorescence resonance energy transfer (FRET)-based assay (24-hour turnaround); and (3) send-out FRET-based assay (72-hour turnaround). The primary outcome was the incremental net monetary benefit reported over a 3-day time horizon and across accepted willingness-to-pay thresholds in US dollars per quality-adjusted life-year (QALY). While accruing the same amount of QALYs, the rapid assay strategy saved up to $46 820 (95% CI, $41 961-$52 486) per patient tested. No parameter variation changed the outcome. In probabilistic sensitivity analyses, the rapid assay strategy was favored in 100% (3 base cases and scenario analyses) and 99% (1 base-case and scenario analysis) across 100 000 Monte Carlo iterations within each. Rapid ADAMTS13 testing for patients with intermediate- or high-risk PLASMIC scores yields significant per patient cost savings, achieved by reducing the costs associated with unnecessary therapeutic plasma exchange and caplacizumab therapy in patients without iTTP.
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Affiliation(s)
- Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Ayesha Butt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | | | | | - Christopher A. Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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Song Y, Lee SY, Chee YL, Jen WY. Hypertensive Emergency with Thrombotic Microangiopathy or TTP? A Case Series and Literature Review. J Clin Med 2024; 13:1880. [PMID: 38610645 PMCID: PMC11012678 DOI: 10.3390/jcm13071880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is associated with both hypertensive emergency and primary thrombocytopenia purpura (TTP). However, their clinical management is vastly different, with the latter necessitating urgent plasma exchange (PEX). We report two cases of hypertension-associated TMA (HTN-TMA) and a literature review of the clinical management of malignant hypertension. We suggest that in patients presenting with hypertensive emergency associated with TMA, a clinical diagnosis of HTN-TMA should be made, with emergent treatment to lower blood pressure started immediately. Although TTP is a differential diagnosis for TMA, PEX should not be started concurrently in the absence of other supporting evidence for TTP.
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Affiliation(s)
- Yang Song
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
| | - Shi Yan Lee
- Division of Gastroenterology & Hepatology, Department of Medicine, National University Hospital, Singapore 119074, Singapore;
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
| | - Wei-Ying Jen
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119074, Singapore; (Y.-L.C.); (W.-Y.J.)
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Muñoz NG, Ortega S, Solanich X, Cid J, Díaz M, Moreno AB, Ancochea Á, Santos M, Hernández I, Sanchez JM, Luaña A, García J, Escoda L, Medina L, Ferrer GJ, López J, Céspedes R, Díaz JA, Pons V, Valcárcel D, Grifols JR. Diagnosis and clinical management of thrombotic thrombocytopenic purpura (TTP): a consensus statement from the TTP Catalan group. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:176-184. [PMID: 37677097 PMCID: PMC10920070 DOI: 10.2450/bloodtransfus.522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a low prevalence disease characterized by severe deficiency of the enzyme ADAMTS13, leading to the development of thrombotic microangiopathy (TMA) and often resulting in severe organ disfunction. TTP is an extremely serious condition and, therefore, timely and appropriate treatment is critical to prevent life-threatening complications.Over the past 25 years, significant advances in the understanding of the pathophysiology of immune TTP have led to the development of readily available techniques for measuring ADAMTS13 levels, as well as new drugs that are particularly effective in the acute phase and in preventing relapses. These developments have improved the course of the disease.Given the complexity of the disease and its various clinical and laboratory manifestations, early diagnosis and treatment can be challenging.To address this challenge, a group of experienced professionals from the Catalan TTP group have developed this consensus statement to standardize terminology, diagnosis, treatment and follow up for immune TTP, based on currently available scientific evidence in the field. This guidance document aims to provide healthcare professionals with a comprehensive tool to make more accurate and timely diagnosis of TTP and improve patient outcomes.
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Affiliation(s)
- Nadia García Muñoz
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary of Bellvitge, L’Hospitalet de Llobregat, Catalonia, Spain
| | - Sandra Ortega
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary of Bellvitge, L’Hospitalet de Llobregat, Catalonia, Spain
| | - Xavier Solanich
- Internal Medicine, Hospital Universitary of Bellvitge, L’Hospitalet de Llobregat, Catalonia, Spain
| | - Joan Cid
- Hemotherapy and Hemostasis, ICMHO, Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Maribel Díaz
- Hemostasis and Erythropathology Pathology Department CDB, Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Ana B. Moreno
- Hemostasis and Erythropathology Pathology Department CDB, Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Águeda Ancochea
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary Germans Trias I Pujol, Badalona, Catalonia, Spain
| | - Mireia Santos
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary Germans Trias I Pujol, Badalona, Catalonia, Spain
| | - Inés Hernández
- Hemathology, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Juan M. Sanchez
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary Arnau de Vilanova, Lleida, Catalonia, Spain
| | - Armando Luaña
- Hemathology, Hospital Universitary Arnau de Vilanova, Lleida, Catalonia, Spain
| | - Jose García
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary de Tarragona Joan XIII, University Rovira i Virgili, Catalonia, Spain
| | - Lourdes Escoda
- Hemathology, Catalan Institute of Oncology Tarragona Hospital Universitary de Tarragona Joan XIII, University Rovira i Virgili, Tarragona, Catalonia, Spain
| | - Laura Medina
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Gonzalo J. Ferrer
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Jordi López
- Hemathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Roberto Céspedes
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Doctor Josep Trueta, Girona, Catalonia, Spain
| | - Johana A. Díaz
- Hemathology, Catalan Institute of Oncology, Hospital Doctor Josep Trueta, Girona, Catalonia, Spain
| | - Verónica Pons
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary de la Vall d’Hebron, Barcelona, Catalonia, Spain
| | - David Valcárcel
- Hemathology, VHIO, Hospital Universitary de la Vall d’Hebron, Barcelona, Catalonia, Spain
| | - Joan R. Grifols
- Medical Direction, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Barcelona, Catalonia, Spain
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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8
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Picod A, Zafrani L, Azoulay E. Immune-mediated thrombotic thrombocytopenic purpura: don't miss the boat. Intensive Care Med 2024; 50:287-290. [PMID: 38193904 DOI: 10.1007/s00134-023-07300-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Adrien Picod
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Lara Zafrani
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.
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Leisring J, Brodsky SV, Parikh SV. Clinical Evaluation and Management of Thrombotic Microangiopathy. Arthritis Rheumatol 2024; 76:153-165. [PMID: 37610060 DOI: 10.1002/art.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
Thrombotic microangiopathy (TMA) refers to a diverse group of diseases that share clinical and histopathologic features. TMA is clinically characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and organ injury that stems from endothelial damage and vascular occlusion. There are several disease states with distinct pathophysiological mechanisms that manifest as TMA. These conditions are associated with significant morbidity and mortality and require urgent recognition and treatment. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are traditionally considered to be primary forms of TMA, but TMA more commonly occurs in association with a coexisting condition such as infection, pregnancy, autoimmune disease, or malignant hypertension, among others. Determining the cause of TMA is a diagnostic challenge because of limited availability of disease-specific testing. However, identifying the underlying etiology is imperative as treatment strategies differ. Our understanding of the conditions that cause TMA is evolving. Recent advances have led to improved comprehension of the varying pathogenic mechanisms that drive TMA. Development of targeted therapeutics has resulted in significant improvements in patient outcomes. In this article, we review the pathogenesis and clinical features of the different TMA-causing conditions. We outline a practical approach to diagnosis and management and discuss empiric and disease-specific treatment strategies.
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Affiliation(s)
- Joshua Leisring
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Samir V Parikh
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Seguí IG, Mingot Castellano ME, Izquierdo CP, de la Rubia J. Should we consider caplacizumab as routine treatment for acute thrombotic thrombocytopenic purpura? An expert perspective on the pros and cons. Expert Rev Hematol 2024; 17:9-25. [PMID: 38353182 DOI: 10.1080/17474086.2024.2318347] [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: 11/15/2023] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening disorder. Caplacizumab has been the latest drug incorporated into the initial treatment of acute episodes, allowing for faster platelet recovery and a decrease in refractoriness, exacerbation, thromboembolic events, and mortality. However, caplacizumab is also associated with a bleeding risk and higher treatment costs, which prevent many centers from using it universally. AREAS COVERED Studies that included iTTP and/or caplacizumab to date were selected for this review using PubMed and MEDLINE platforms. We describe outcomes in the pre-caplacizumab era and after it, highlighting the benefits and risks of its use early in frontline, and also pointing out special situations that require careful management. EXPERT OPINION It is clear that the availability of caplacizumab has significantly and favorably impacted the management of iTTP patients. Whether this improvement is cost-effective still remains uncertain, and data on long-term sequelae and different healthcare systems will help to clarify this point. In addition, evidence of the bleeding/thrombotic risk of iTTP patients under this drug needs to be better addressed in future studies.
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Affiliation(s)
- Inés Gómez Seguí
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
| | | | | | - Javier de la Rubia
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
- Internal Medicine, Universidad Católica "San Vicente Mártir", Valencia, Spain
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de Boisriou I, Ellouze S, Kassasseya C, Feral-Pierssens AL, Gerlier C, Chauvin A, Beaune S, Dubreucq E, Pereira L, Chocron R, Khellaf M, Mariotte É, Zafrani L, Peyrony O. Misdiagnosis of thrombotic microangiopathy in the emergency department: a multicenter retrospective study. Intern Emerg Med 2024; 19:115-124. [PMID: 37914919 DOI: 10.1007/s11739-023-03457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/08/2023] [Indexed: 11/03/2023]
Abstract
To estimate the rate of inappropriate diagnosis in patients who visited the ED with thrombotic microangiopathy (TMA) and to assess the factors and outcomes associated with emergency department (ED) misdiagnosis. Retrospective multicenter study of adult patients admitted to the intensive care unit (ICU) for TMA from 2012 to 2021 who had previously attended the ED for a reason related to TMA. Patient characteristics and outcomes were compared in a univariate analysis based on whether a TMA diagnosis was mentioned in the ED or not. Forty patients were included. The diagnosis of TMA was not mentioned in the ED in 16 patients (40%). Patients for whom the diagnosis was mentioned in the ED had more frequently a request for schistocytes research, and therefore had more often objectified schistocytes. They also had more frequently a troponin dosage in the ED (even if the difference was not significant), an ECG performed or interpreted, and were admitted more quickly in the ICU (0 [0-0] vs 2 [0-2] days; P = 0.002). Hemoglobin levels decreased significantly in both groups, and creatinine levels increased significantly in the misdiagnosis group between ED arrival and ICU admission. In patients with a final diagnosis of TTP, the time to platelets durable recovery was shorter for those in whom the diagnosis was mentioned in the ED without reaching statistical significance (7 [5-11] vs 14 [5-21] days; P = 0.3).
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Affiliation(s)
| | - Sami Ellouze
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Christian Kassasseya
- Emergency Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Camille Gerlier
- Emergency Department, Groupe Hospitalier Paris-Saint-Joseph, Paris, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sebastien Beaune
- Emergency Department, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Versailles St Quentin- UFR Simone Veil santé, Montigny-le-Bretonneux, France
| | - Evelyne Dubreucq
- Emergency Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Pereira
- Emergency Department, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Richard Chocron
- Emergency Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMR-S970, Paris Cardiovascular Research Center, Team "Integrative Epidemiology of Cardiovascular Diseases", Université Paris Cité, Paris, France
| | - Mehdi Khellaf
- Emergency Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Éric Mariotte
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France.
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12
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van Doorn DPC, Abdul-Hamid MA, Frenken LAM, van Paassen P, Timmermans SAMEG. The spectrum of thrombotic microangiopathy related to monoclonal gammopathy. Clin Kidney J 2024; 17:sfad306. [PMID: 38250251 PMCID: PMC10797488 DOI: 10.1093/ckj/sfad306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 01/23/2024] Open
Abstract
Background Recent studies showed a high prevalence of monoclonal gammopathy (MG) in patients with thrombotic microangiopathy (TMA) aged over 50 years and suggested that complement dysregulation is pivotal for the disease to develop. Here, we studied this premise in seven patients with TMA and coexisting MG. Methods Patients with TMA on kidney biopsy and/or peripheral blood were recruited from the prospective COMPETE cohort (NCT04745195) and Limburg Renal Registry. Patients were screened for complement dysregulation, including genetics/factor H autoantibodies (FHAA) and functional ex vivo testing on microvascular endothelial cells. Results Seven (8%) out of 84 patients with TMA presented with a coexisting MG. MG clustered in patients aged over 50 years (n/N = 6/32, 19%). C4 and/or C3 levels were low in three patients, while four patients presented with normal complement levels. None of the patients carried rare variants in complement genes. Massive ex vivo C5b9 formation on the endothelium was noted in one patient; purified IgG from this patient caused massive ex vivo C5b9 formation via the alternative pathway of complement activation, pointing to complement dysregulation in the fluid phase. Kidney biopsies from other nephropathies linked to MG rarely exhibited concurrent TMA (n/N = 1/27, 4%). Conclusions MG clustered in patients with TMA aged over 50 years. TMA and coexisting MG represents a heterogeneous disease spectrum, including a small subset of patients who may present with complement dysregulation.
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Affiliation(s)
- Daan P C van Doorn
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Myrurgia A Abdul-Hamid
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leon A M Frenken
- Department of Internal Medicine, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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13
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Terra POC, De Santis GC, Prado Júnior BDPA, Oliveira LC. Outcomes of thrombotic thrombocytopenic purpura patients submitted to therapeutic plasma exchange in a single center in Brazil. Hematol Transfus Cell Ther 2023:S2531-1379(23)02606-8. [PMID: 38614932 DOI: 10.1016/j.htct.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/18/2023] [Accepted: 11/29/2023] [Indexed: 04/15/2024] Open
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (iTTP) is characterized by acute systemic microvascular thrombosis and is associated with a high morbidity and mortality, especially in delayed diagnosis (later than 6-7 days from symptoms). iTTP data in Brazil is scarce, so we aimed to characterize the clinical presentation and identify predictors of death risk in patients with this disease in Brazil. METHODS In this single-center retrospective study the patients who underwent therapeutic plasma exchange (TPE) for presumptive or confirmed iTTP were evaluated regarding the epidemiological, clinical, laboratorial characteristics and management. RESULTS A total of 50 patients (90 % female), with median age (IQR) of 34.1 (27-47) years, were enrolled, of which 12 (24 %) died. The most frequent symptoms were neurological (96 %), bleeding (76 %), gastrointestinal (52 %), fever (38 %), and cardiovascular (22 %). Neurological focal deficit and cardiovascular symptoms were more frequently observed in the non-survivor group (P = 0.0019 and P = 0.007, respectively). The mean ± SD number of days from beginning of symptoms to first TPE was 12.22 ± 7.91. We identified an association regarding mortality rate with a score MITS ≥ 2 points (P = 0.04), a higher indirect bilirubin (P = 0.0006), a higher number of transfused red blood cell units (P = 0.025), and platelet transfusion (P = 0.027). CONCLUSION Delayed diagnosis appears to be associated with a higher frequency of neurological symptoms and mortality. Intensity of hemolysis and signs of organ ischemia, such as cardiovascular symptoms and focal neurological deficit, are indicators of death risk.
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Affiliation(s)
- Patrícia Oliveira Cunha Terra
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.
| | - Gil Cunha De Santis
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Benedito de Pina Almeida Prado Júnior
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Luciana Correa Oliveira
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil; Regional Blood Center of Ribeirão Preto, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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14
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Story CM, Gerber GF, Chaturvedi S. Medical consult: aHUS, TTP? How to distinguish and what to do. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:745-753. [PMID: 38066937 PMCID: PMC10727109 DOI: 10.1182/hematology.2023000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) caused by an autoantibody-mediated deficiency of ADAMTS13 and atypical hemolytic syndrome (aHUS) caused by alternative complement dysregulation are the most common primary thrombotic microangiopathies (TMAs). The evaluation of a patient with TMA is a medical emergency since it is critical to quickly distinguish iTTP and aHUS from other causes of TMA. Untreated iTTP is rapidly fatal, and delays in initiating complement inhibition in aHUS increase the risk of irreversible renal failure. An ADAMTS13 activity level of less than 10% is diagnostic of iTTP in the appropriate clinical setting. In settings where rapid-turnaround ADAMTS13 testing is not available, clinical features and clinical prediction tools are useful to identify patients who should receive emergent plasma exchange. We present an evidence-based approach to the initial (first 24 hours) diagnosis and management of iTTP and review the clinical and laboratory features that can be used to identify patients with aHUS who will benefit from early C5 blockade. We also discuss the potential use of complement blockade to improve outcomes in selected patients with secondary TMA.
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Affiliation(s)
- Charlotte M Story
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gloria F Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Addad VV, Palma LMP, Vaisbich MH, Pacheco Barbosa AM, da Rocha NC, de Almeida Cardoso MM, de Almeida JTC, de Paula de Sordi MA, Machado-Rugolo J, Arantes LF, de Andrade LGM. A comprehensive model for assessing and classifying patients with thrombotic microangiopathy: the TMA-INSIGHT score. Thromb J 2023; 21:119. [PMID: 37993892 PMCID: PMC10664252 DOI: 10.1186/s12959-023-00564-6] [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: 08/15/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Thrombotic Microangiopathy (TMA) is a syndrome characterized by the presence of anemia, thrombocytopenia and organ damage and has multiple etiologies. The primary aim is to develop an algorithm to classify TMA (TMA-INSIGHT score). METHODS This was a single-center retrospective cohort study including hospitalized patients with TMA at a single center. We included all consecutive patients diagnosed with TMA between 2012 and 2021. TMA was defined based on the presence of anemia (hemoglobin level < 10 g/dL) and thrombocytopenia (platelet count < 150,000/µL), signs of hemolysis, and organ damage. We classified patients in eight categories: infections; Malignant Hypertension; Transplant; Malignancy; Pregnancy; Thrombotic Thrombocytopenic Purpura (TTP); Shiga toxin-mediated hemolytic uremic syndrome (STEC-SHU) and Complement Mediated TMA (aHUS). We fitted a model to classify patients using clinical characteristics, biochemical exams, and mean arterial pressure at presentation. RESULTS We retrospectively retrieved TMA phenotypes using automatic strategies in electronic health records in almost 10 years (n = 2407). Secondary TMA was found in 97.5% of the patients. Primary TMA was found in 2.47% of the patients (TTP and aHUS). The best model was LightGBM with accuracy of 0.979, and multiclass ROC-AUC of 0.966. The predictions had higher accuracy in most TMA classes, although the confidence was lower in aHUS and STEC-HUS cases. CONCLUSION Secondary conditions were the most common etiologies of TMA. We retrieved comorbidities, associated conditions, and mean arterial pressure to fit a model to predict TMA and define TMA phenotypic characteristics. This is the first multiclass model to predict TMA including primary and secondary conditions.
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Affiliation(s)
- Vanessa Vilani Addad
- Department of Internal Medicine - UNESP, Univ Estadual Paulista, Rubião Jr, s/n, Botucatu/SP, 18618-687, Brazil
| | - Lilian Monteiro Pereira Palma
- Department of Pediatrics, Universidade Estadual de Campinas, R. Tessália Vieira de Camargo, 126 - Cidade Universitária, Campinas/SP, 13083-887, Brazil
| | - Maria Helena Vaisbich
- Pediatric Nephrology Service, Child Institute, University of São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, São Paulo, SP, 05403-000, Brazil
| | | | - Naila Camila da Rocha
- Department of Internal Medicine - UNESP, Univ Estadual Paulista, Rubião Jr, s/n, Botucatu/SP, 18618-687, Brazil
| | | | | | | | - Juliana Machado-Rugolo
- Health Technology Assessment Center of Hospital das Clínicas - HCFMB, Botucatu, SP, Brazil
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16
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Bruno V, Barth D, Jauhal A. Complement-Mediated Thrombotic Microangiopathy in Pregnancy: An Educational Case Report. Can J Kidney Health Dis 2023; 10:20543581231209009. [PMID: 37942411 PMCID: PMC10629310 DOI: 10.1177/20543581231209009] [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: 06/09/2023] [Accepted: 09/06/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale Thrombotic microangiopathy (TMA) is a spectrum of rare diseases characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ damage. Differentiating pre-eclampsia, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome and atypical hemolytic uremic syndrome (aHUS) during pregnancy may be diagnostically challenging yet important as the treatment pathways differ. Most cases of aHUS are associated with dysregulation of the complement alternative pathway, for which current guidelines recommend prompt treatment with complement C5 inhibitor to prevent chronic sequelae. Here, we report a case of pregnancy-associated aHUS (p-aHUS) to highlight the challenging aspects of the diagnostic process and the importance of prompt treatment with complement inhibition to reduce the risk of poor outcomes. Presenting concerns A 28-year-old woman was admitted to a local hospital for induction of vaginal delivery of twins at 34 weeks and 3 days of gestational age, due to intrauterine growth restriction (IUGR). She was previously healthy, and this current pregnancy was uncomplicated, except for the IUGR. Approximately, 10 hours after her induced delivery, she developed vomiting, epigastric pain, and hypertension. Diagnosis She was initially suspected of having fulminant liver failure in the context of acute fatty liver of pregnancy versus pre-eclampsia/HELLP syndrome, due to evidence of elevated liver enzymes, acute kidney injury (AKI), thrombocytopenia, and hemoglobin levels trending down, for which the patient was initially treated conservatively. On day 2 post-delivery, she was transferred to our hospital for possible liver biopsy and management of liver failure. Upon transfer, dialysis was started due to anuric AKI; at the same time, her liver function spontaneously improved, while platelet count remained very low and hemoglobin levels continued to trend down. A full TMA work-up revealed low C3 levels; secondary causes of TMA were ruled out. The patient received a final diagnosis of p-aHUS. Complement genetic tests were also performed and did not identify any pathogenic variants. Interventions Given the final diagnosis of p-aHUS, the patient was started on a C5 inhibitor (day 8 post-delivery). Her platelet count quickly normalized 2 days after the first dose, while the hemoglobin levels remained low for a longer period, likely due to retained products of conception. Outcomes The patient was able to completely discontinue dialysis after approximately 3 months, however, her kidney function did not recover completely, despite all the other TMA markers normalizing (platelets count in range, negative hemolysis markers, and normal hemoglobin levels). Her estimated glomerular filtration rate (eGFR) was 23 mL/min/1.73 m2 at the 6-month follow-up. Teaching points The diagnosis of p-aHUS can be challenging due to frequent overlapping symptoms and signs with other forms of pregnancy-associated TMA, leading to a delay of the treatment, which can affect the patient's outcome. Failure of TMA to improve in the postpartum period or occurring at this time, with negative ADAMTS13 and antiphospholipid antibody syndrome (APLAS) serologies should favor the diagnosis of p-aHUS. Early treatment with C5 inhibition should be considered in women with a diagnosis of p-aHUS. Patients need multidisciplinary and likely tertiary/quaternary care at centers where clinical experience, access to diagnostics and treatment initiation can begin without delay.
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Affiliation(s)
- Valentina Bruno
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada
- Cell Biology Program, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - David Barth
- Division of Medical Oncology and Hematology, University Health Network, Temerty Faculty of Medicine, University of Toronto, ON, Canada
- Departments of Medicine and Laboratory Medicine & Pathobiology, University of Toronto, ON, Canada
| | - Arenn Jauhal
- Division of Nephrology, Department of Medicine, Glomerulonephritis Clinic, Toronto General Hospital, University Health Network, Temerty Faculty of Medicine, University of Toronto, ON, Canada
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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18
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Matsumoto M, Miyakawa Y, Kokame K, Ueda Y, Wada H, Higasa S, Yagi H, Ogawa Y, Sakai K, Miyata T, Morishita E, Fujimura Y. Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) in Japan 2023. Int J Hematol 2023; 118:529-546. [PMID: 37689812 PMCID: PMC10615956 DOI: 10.1007/s12185-023-03657-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) can rapidly become a life-threatening condition, and the importance of its appropriate diagnosis and treatment cannot be overstated. Until recently, TTP has mainly been diagnosed by clinical findings such as thrombocytopenia and hemolytic anemia. In addition to these clinical findings, however, reduced activity of a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13 (ADAMTS13) below 10% has become internationally accepted as a diagnostic criterion for TTP. TTP is classified as immune-mediated TTP (iTTP) if the patient is positive for anti-ADAMTS13 autoantibodies, and as congenital TTP (cTTP) if ADAMTS13 gene abnormalities are detected. Fresh frozen plasma (FFP) transfusion is performed in patients with cTTP to supplement ADAMTS13. Plasma exchange therapy using FFP is conducted in patients with iTTP to supplement ADAMTS13 and to remove both anti-ADAMTS13 autoantibodies and unusually large von Willebrand factor (VWF) multimers. To suppress autoantibody production, corticosteroid therapy is administered in conjunction with plasma exchange. The monoclonal anti-CD-20 antibody rituximab is effective in patients with iTTP. In addition, caplacizumab, an anti-VWF A1 domain nanobody, has a novel mechanism of action, involving direct inhibition of platelet glycoprotein Ib-VWF binding. The recommended first-line treatments of iTTP in Japan are plasma exchange and corticosteroids, as well as caplacizumab.
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Affiliation(s)
- Masanori Matsumoto
- Department of Blood Transfusion Medicine and Department of Hematology, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara, 634-8521, Japan.
| | | | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hideo Wada
- Department of General Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo Medical University, Nishinomiya, Japan
| | - Hideo Yagi
- Department of Hematology and Oncology, Nara Prefecture General Medical Center, Nara, Japan
| | | | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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19
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Neuman L, Joseph A, Bouzid R, Lescroart M, Mariotte E, Ederhy S, Tuffet S, Baudel JL, Benhamou Y, Galicier L, Grangé S, Provôt F, Neel A, Pène F, Delmas Y, Presne C, Poullin P, Wynckel A, Perez P, Barbet C, Halimi JM, Chatelet V, Rebibou JM, Ojeda-Uribe M, Vigneau C, Mesnard L, Veyradier A, Azoulay E, Coppo P, Chabriat H. Predictors of acute ischemic cerebral lesions in immune-mediated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. J Neurol 2023; 270:5023-5033. [PMID: 37392208 DOI: 10.1007/s00415-023-11830-y] [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: 05/19/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND The immune form of thrombotic thrombocytopenic purpura (iTTP) and the hemolytic and uremic syndrome (HUS) are two major forms of thrombotic microangiopathy (TMA). Their treatment has been recently greatly improved. In this new era, both the prevalence and predictors of cerebral lesions occurring during the acute phase of these severe conditions remain poorly known. AIM The prevalence and predictors of cerebral lesions appearing during the acute phase of iTTP and Shiga toxin-producing Escherichia coli-HUS or atypical HUS were evaluated in a prospective multicenter study. METHODS Univariate analysis was performed to report the main differences between patients with iTTP and those with HUS or between patients with acute cerebral lesions and the others. Multivariable logistic regression analysis was used to identify the potential predictors of these lesions. RESULTS Among 73 TMA cases (mean age 46.9 ± 16 years (range 21-87 years) with iTTP (n = 57) or HUS (n = 16), one-third presented with acute ischemic cerebral lesions on magnetic resonance imagery (MRI); two individuals also had hemorrhagic lesions. One in ten patients had acute ischemic lesions without any neurological symptom. The neurological manifestations did not differ between iTTP and HUS. In multivariable analysis, three factors predicted the occurrence of acute ischemic lesions on cerebral MRI: (1) the presence of old infarcts on cerebral MRI, (2) the level of blood pulse pressure, (3) the diagnosis of iTTP. CONCLUSION At the acute phase of iTTP or HUS, both symptomatic and covert ischemic lesions are detected in one third of cases on MRI. Diagnosis of iTTP and the presence of old infarcts on MRI are associated with the occurrence of such acute lesions as well as increased blood pulse pressure, that may represent a potential target to further improve the therapeutic management of these conditions.
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Affiliation(s)
- Lisa Neuman
- Centre NeuroVasculaire Translationnel, Centre de Référence CERVCO, Département de Neurologie, Hôpital Lariboisière, GHU AP-HP Nord, Université de Paris, Paris, France
| | - Adrien Joseph
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Raïda Bouzid
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
| | - Mickael Lescroart
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Eric Mariotte
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Stéphane Ederhy
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Department of Cardiology, Saint-Antoine Hospital, GRC N° 27, Sorbonne Université, AP-HP, 75012, Paris, France
| | - Sophie Tuffet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Department of Clinical Pharmacology, Clinical Research Platform of East of Paris (Unité de Recherche Clinique (URCEST), Centre de Recherche Clinique (CRCEST), Centre de Ressources Biologiques (CRB.APHP-SU), Hôpital Saint Antoine, AP-HP, Paris, France
| | - Jean-Luc Baudel
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Département de Médecine Interne, Hôpital Universitaire de Rouen, Université de Normandie, Rouen, France
- Service de Réanimation Médicale, CHU Charles Nicolle, Rouen, France
| | - Lionel Galicier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service d'Immunologie Clinique, CHU Saint-Louis, Université de Paris, Paris, France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Réanimation Médicale, CHU Charles Nicolle, Rouen, France
| | - François Provôt
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, Hôpital Albert-Calmette, Lille, France
| | - Antoine Neel
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Réanimation Médicale, CHU Hôtel-Dieu, Nantes, France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de médecine intensive-réanimationHôpital Cochin, APHP Centre &, Université de Paris, Paris, France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, Hôpital Nord, Amiens, France
| | - Pascale Poullin
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service d'hémaphérèse et d'autotransfusion, Hôpital la Conception, Marseille, France
| | - Alain Wynckel
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, Hôpital Maison Blanche, Reims, France
| | - Pierre Perez
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Réanimation Polyvalente, CHU de Nancy, Nancy, France
| | - Christelle Barbet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Hôpitaux Bretonneau et Clocheville, Tours, France
| | - Jean-Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Hôpitaux Bretonneau et Clocheville, Tours, France
| | - Valérie Chatelet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Centre Universitaire des Maladies Rénales, UNICAEN, CHU de Caen Normandie, Normandie Université, Caen, France
| | - Jean-Michel Rebibou
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, CHU de Dijon, Dijon, France
| | - Mario Ojeda-Uribe
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service d'Hématologie et de Thérapie Cellulaire, Groupe Hospitalier Region Mulhouse-Sud-Alsace (GHRMSA), Mulhouse, France
| | - Cécile Vigneau
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Inserm, EHESP, Irset (Institut de Recherche en SantéEnvironnement et Travail)-UMR_S 1085, Université de Rennes, CHU Rennes, 35000, Rennes, France
| | - Laurent Mesnard
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Biochimie, Hôpital Saint-Antoine, 75571, Paris Cedex 12, France
| | - Elie Azoulay
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France.
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France.
- Service d'Hématologie, Centre National de Référence des Microangiopathies Thrombotiques, AP-HP.6 and Sorbonne-Université, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.
- Centre de Recherche Des Cordeliers, INSERM UMRS 1138, Paris, France.
| | - Hugues Chabriat
- Centre NeuroVasculaire Translationnel, Centre de Référence CERVCO, Département de Neurologie, Hôpital Lariboisière, GHU AP-HP Nord, Université de Paris, Paris, France
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20
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Orhan B, Özkocaman V, Akdemir Ç, Ersal T, Pınar İE, Yalçın C, Candar Ö, Çubukçu S, Koca TG, Ambarcıoğlu P, Ali R, Özkalemkaş F. Potential modifications of the PLASMIC scoring system for predicting thrombotic thrombocytopenic purpura: Sometimes, less is more. Int J Lab Hematol 2023; 45:751-757. [PMID: 37309683 DOI: 10.1111/ijlh.14115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/27/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening occlusive disease of the microcirculation characterized by systemic platelet plugs, organ ischemia, deep thrombocytopenia, and fragmentation of erythrocytes. One of the widely used scoring system to determine the clinical probability of TTP is the PLASMIC scoring system. This study aimed to evaluate the contribution of PLASMIC score modifications to sensitivity and specificity in patients with microangiopathic hemolytic anemia (MAHA) undergoing plasma exchange with a prediagnosis of TTP at our center. MATERIALS AND METHODS The data of patients who were hospitalized with a previous diagnosis of MAHA and TTP and underwent plasma exchange at Bursa Uludag University, Faculty of Medicine, Department of Hematology between January 2000 and January 2022 were retrospectively analyzed. RESULTS Overall, 33 patients (including 15 and 18 with and without TTP, respectively) were included in this study. Receiver operating characteristic (ROC) analysis revealed that the area under the curve (AUC) for the original PLASMIC score was 0.985 (95% confidence interval [95% CI]: 0.955-1.000), and AUC for the PLASMIC score without mean corpuscular volume (MCV) was 0.967 (95% CI: 0.910-1.000), which is close to the original AUC. With the removal of MCV from the scoring system, the sensitivity decreased from 100% to 93%, whereas the specificity increased from 33% to 78%. CONCLUSIONS Based on the results of this validation study, removing MCV from the PLASMIC score led to the categorization of eight non-TTP cases in the low-risk category, and this could avoid unnecessary plasma exchange. However, in our study increasing the specificity was at the expense of the sensitivity by missing one patient with this new scoring system without MCV. Further multicenter studies with large sample sizes are required owing to the fact that different parameters may be effective in TTP prediction among different populations.
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Affiliation(s)
- Bedrettin Orhan
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Vildan Özkocaman
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Çiğdem Akdemir
- Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Tuba Ersal
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - İbrahim Ethem Pınar
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Cumali Yalçın
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Ömer Candar
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Sinem Çubukçu
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Tuba Güllü Koca
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Pınar Ambarcıoğlu
- Department of Biostatistics, Faculty of Veterinary Medicine, Mustafa Kemal University, Hatay, Turkey
| | - Rıdvan Ali
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Fahir Özkalemkaş
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
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21
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Radhwi O, Badawi MA, Almarzouki A, Al-Ayoubi F, ElGohary G, Asfina KN, Basendwah AM, Alhazmi IA, Almahasnah EA, AlBahrani A, Raizah AA, Yahya A, Alshahrani K, Hindawi S. A Saudi multicenter experience on therapeutic plasma exchange for patients with thrombotic thrombocytopenic purpura: A call for national registry. J Clin Apher 2023; 38:573-581. [PMID: 37317696 DOI: 10.1002/jca.22067] [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: 12/21/2022] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The improvement in the clinical care for patients with thrombotic thrombocytopenic purpura (TTP) is evolving, and many efforts are being put to standardize it. Here, we aimed to assess the provided care at a national level and identify deficiencies. METHODS A national Saudi retrospective descriptive study was carried out at six tertiary referral centers and included all patients who underwent therapeutic plasma exchange (TPE) for the diagnosis of TTP between May 2005, and July 2022. Collected information included demographic data, clinical features on presentation, and the results of laboratory investigations at admission and discharge. In addition, the number of TPE sessions, days till the first session of TPE, usage of immunological agents, and clinical outcomes were all collected. RESULTS One hundred patients were enrolled, predominantly female (56%). The mean age was 36.8 years. At diagnosis, 53% of patients showed neurological involvement. The mean platelet count at presentation was 21 × 109 /L. All patients had anemia (mean hematocrit 24.2%). Schistocytes were present in the peripheral blood film of all patients. The mean number of TPE rounds was 13 ± 9.3, and the mean days to start TPE since admission for the first episode was 2.5 days. ADAMTS13 level was measured in 48% of patients and was significantly low in 77% of them. Assessing for clinical TTP scores, 83%, 1000%, 64% of eligible patients had an intermediate/high PLASMIC, FRENCH, and Bentley scores, respectively. Caplacizumab was used on only one patient, and rituximab was administered to 37% of patients. A complete response for the first episode was achieved in 78% of patients. The overall mortality rate was 25%. Neither time to TPE, the use of rituximab or steroid affected survival. CONCLUSIONS Our study shows an excellent response to TPE with a survival rate approximate to the reported international literature. We observed a deficiency in using validated scoring systems in addition to confirming the disease by ADAMTS13 testing. This emphasizes the need for a national registry to facilitate proper diagnosis and management of this rare disorder.
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Affiliation(s)
- Osman Radhwi
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
- Hematology Research Unit, King Fahd Medical Research Centre, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maha A Badawi
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
- Hematology Research Unit, King Fahd Medical Research Centre, King Abdulaziz University, Jeddah, Saudi Arabia
- Blood Transfusion Services Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Adel Almarzouki
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
- Hematology Research Unit, King Fahd Medical Research Centre, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fakhr Al-Ayoubi
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ghada ElGohary
- Department of Adult Hematology/Oncology, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Kazi Nur Asfina
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Iman Ayed Alhazmi
- Hematology and Oncology Division, Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Eiman A Almahasnah
- Adult Hematology Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed AlBahrani
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Abdulrahman Al Raizah
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Saudi Society for Bone Marrow Transplant, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Hematology Department, King Saud bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Ayel Yahya
- Division of Adult Hematology, Department of Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Internal Medicine Department, King Khalid University, Abha, Saudi Arabia
| | - Khadeja Alshahrani
- Internal Medicine Department, Asser Central Hospital, Abha, Saudi Arabia
| | - Salwa Hindawi
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
- Hematology Research Unit, King Fahd Medical Research Centre, King Abdulaziz University, Jeddah, Saudi Arabia
- Blood Transfusion Services Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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22
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Lee JA, Lin MH, Kang CM, Chuang MK, Fung CKB, Lo SC. A validation and modification of PLASMIC score by adjusting the criteria of mean corpuscular volume and international normalized ratio. J Clin Apher 2023; 38:582-589. [PMID: 37325919 DOI: 10.1002/jca.22068] [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: 02/03/2023] [Revised: 05/21/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The PLASMIC score was developed for distinguishing thrombotic thrombocytopenic purpura (TTP) from other types of thrombotic microangiopathy. However, two components of the PLASMIC score, mean corpuscular volume (MCV) and international normalized ratio (INR), showed non-significant differences between TTP and non-TTP patients in previous validations. Here, we validate the PLASMIC score and aim to modify it by adjusting the criteria of MCV and INR. MATERIALS AND METHODS A retrospective validation of suspected TTP patients was performed by reviewing electronic medical records from two medical centers in Taiwan. The performance of different modified types of the PLASMIC score was carried out. RESULTS Among 50 patients included in the final analysis, 12 were diagnosed with TTP based on deficiency of ADAMTS13 activity and clinical judgement. When stratified by high (score ≥ 6) and low-intermediate risk (score < 6), the positive predictive value (PPV) of the PLASMIC score to predict TTP was 0.45 (95% confidence interval [CI]: 0.29-0.61). The area under curve (AUC) was 0.70 (95% CI: 0.56-0.82). When adjusting the criteria of the PLASMIC score from MCV < 90 fL to MCV ≥ 90 fL, the PPV increased to 0.57 (95% CI: 0.37-0.75). The AUC was 0.75 (95% CI: 0.61-0.87). When adjusting the INR from >1.5 to >1.1, the PPV increased to 0.56 (95% CI: 0.39-0.71). The AUC was 0.81 (95% CI: 0.68-0.90). CONCLUSION MCV ≥ 90 fL and/or INR > 1.1 might be suitable modifications for PLASMIC score but should be validated in a larger sample size.
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Affiliation(s)
- Jia-Arng Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mei-Hwa Lin
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Min Kang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Kai Chuang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi Kwan Boris Fung
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
- Department of Anesthesiology, China Medical University College of Medicine, Taichung, Taiwan
| | - Shyh-Chyi Lo
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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23
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Xu HB, Ye Y, Xue F, Wu J, Suo Z, Zhang H. Association Between Endothelial Activation and Stress Index and 28-Day Mortality in Septic ICU patients: a Retrospective Cohort Study. Int J Med Sci 2023; 20:1165-1173. [PMID: 37575274 PMCID: PMC10416722 DOI: 10.7150/ijms.85870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Background: Endothelial Activation and Stress Index (EASIX) is a reliable alternative biomarker of endothelial dysfunction. Because endothelial activation is involved in sepsis pathophysiology, we aimed to investigate the association between EASIX and prognosis in septic patients. Methods: Data were extracted from the Medical Information Mart for Intensive Care (MIMIC) IV database. EASIX scores were calculated using the formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelet count (109/L). Patients were grouped into tertiles according to log2 transformed EASIX. The primary and secondary outcomes were 28-day and 90-day mortality. Cox proportional hazards models, Kaplan-Meier curves, restricted cubic spline curves, and subgroup analyses were conducted to evaluate the association between EASIX and prognosis in septic patients. Results: A total of 7504 patients were included. Multivariable Cox proportional hazards analyses showed that higher log2-EASIX was associated with increased risk of 28-day mortality (HR, 1.10; 95% CI, 1.07-1.13; P < 0.001). Compared with tertile 1, the tertile 2 and 3 groups had higher risk of 28-day mortality [HR (95% CI) 1.24 (1.09-1.41); HR (95% CI) 1.51 (1.31-1.74)]; P for trend < 0.001). Similar results were found for 90-day mortality. Kaplan-Meier curves showed that patients with higher EASIX had lower 28-day and 90-day survival rates. A linear relationship was found between log2-EASIX and 28-day and 90-day mortality. Conclusion: High EASIX was significantly associated with an increased risk of 28-day and 90-day all-cause mortality in patients with sepsis.
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Affiliation(s)
- Hong-Bo Xu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518033, China
- Department of Critical Care Medicine, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518033, China
| | - Yuan Ye
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518033, China
- Department of Critical Care Medicine, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518033, China
| | - Fang Xue
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518033, China
- Department of Critical Care Medicine, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518033, China
| | - Jinglan Wu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518033, China
- Department of Critical Care Medicine, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518033, China
| | - Zhijun Suo
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518033, China
- Department of Critical Care Medicine, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518033, China
| | - Haigang Zhang
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518033, China
- Department of Critical Care Medicine, The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518033, China
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24
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Chase ML, Drews R, Zumberg MS, Ellis LR, Reid EG, Gerds AT, Lee AI, Hobbs GS, Berry J, Freed JA. Consensus recommendations on peripheral blood smear review: defining curricular standards and fellow competency. Blood Adv 2023; 7:3244-3252. [PMID: 36930800 PMCID: PMC10336252 DOI: 10.1182/bloodadvances.2023009843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/19/2023] Open
Abstract
Graduate medical education training in hematology in North America is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees routinely review peripheral blood smears (PBS) in providing clinical care. Competency in PBS review at graduation is required by the ACGME. However, there are no consensus guidelines on best practices surrounding PBS review, education, or competency. We describe the generation of proposed theory and the consensus recommendations developed through a multi-institutional focus group, developed using constructivist grounded theory and a modified nominal group technique. Eight academic hematologists, spanning classical and malignant hematology, enrolled and participated in 2 one-hour focus groups. All routinely worked with fellows and half had formally instructed trainees on PBS interpretation. Focus group data were analyzed using mixed-methods techniques. Tenets of emerging theory were identified through inductive coding. Consensus recommendations (CR) were generated. Participants reviewed CR in an iterative fashion until consensus was reached. Strong consensus was reached on multiple aspects of PBS education. All agreed that trainees should learn PBS review through a systematic approach. Group discussion focused on disorders of red and white blood cells. The diagnoses of acute leukemia and thrombotic microangiopathies were most commonly discussed, with specific emphasis on disorders in which prompt recognition was required to avert significant patient morbidity. These CR offer external validity to future research and curricular development for both PBS review and other visuospatial tasks in medical education.
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Affiliation(s)
- Matthew L. Chase
- Division of Hematology and Hematologic Malignancies and Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Reed Drews
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc S. Zumberg
- Division of Hematology/Oncology, University of Florida, Gainesville, FL
| | - Leslie R. Ellis
- Section on Hematology and Oncology, Comprehensive Cancer Center of Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Erin G. Reid
- Division of Hematology/Oncology, Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Aaron T. Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Alfred I. Lee
- Division of Hematology, Yale University School of Medicine, New Haven, CT
| | - Gabriela S. Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jonathan Berry
- Division of Hematology and Hematologic Malignancies and Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jason A. Freed
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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25
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Siniard RC, Gangaraju R, May JE, Marques MB. Challenges in the diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:861-869. [PMID: 37767808 DOI: 10.1080/17474086.2023.2265058] [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: 11/02/2022] [Accepted: 09/26/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Immune-mediated TTP (iTTP) is a rare condition without pathognomonic signs and symptoms. For this reason, the diagnosis of iTTP may be delayed or even missed, with potentially catastrophic consequences. AREAS COVERED The authors performed an extensive literature review on the diagnosis of iTTP and its challenges combined with their own experience in a referral center for patients with iTTP. EXPERT OPINION Although a definitive diagnosis of iTTP depends on the ADAMTS13 activity result, timely testing is rarely available at many centers to which patients present. If less complex tests were to become available, they would decrease the chances of late and/or missed diagnoses of iTTP throughout the world. While clinical scores to estimate the likelihood of iTTP exist, they are not well known, and can be misleading if used in the wrong context. Furthermore, the three scoring systems (PLASMIC, Bentley, and French) only moderately correlate with each other, which further complicates the landscape. The existence of these scores and how they should be used in practice is but one opportunity that can be seized through more robust programs to educate nonspecialist clinicians on how to recognize and treat patients with iTTP.
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Affiliation(s)
- Rance C Siniard
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Radhika Gangaraju
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jori E May
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marisa B Marques
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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26
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Okoli S, Jenkins KA, Bojanowski CM. Current Intensive Care Management of Thrombotic Thrombocytopenic Purpura: A Case Report and Updated Literature Review. J Intensive Care Med 2023:8850666231171907. [PMID: 37331965 DOI: 10.1177/08850666231171907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP), caused by severely reduced activity of the von Willebrand factor-cleaving protease ADAMTS13, is a medical emergency with life-threatening complications and a 90% mortality rate if left untreated. It presents a diagnostic challenge given the multiorgan involvement of the cardiovascular, gastrointestinal, and central nervous systems. Furthermore, the well-known full pentad of fever, hemolytic anemia, bleeding associated with thrombocytopenia, neurological signs, and renal disease is often absent in patients with TTP. We present a 51-year-old male adult with TTP. We utilized the PLASMIC scoring system, which predicts the likelihood of ADAMST13 activity in adults with features of thrombotic microangiopathy and thrombocytopenia with high sensitivity and specificity. We further review the literature supporting the expert statement on ICU management of patients with TTP that plasma exchange (PEX) should be initiated within 6 hours of diagnosis with adjunctive glucocorticoids, rituximab, and caplacizumab. If PEX is unavailable, plasma infusion can be started while the patient awaits transfer to a center with PEX capabilities.
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Affiliation(s)
- Sandra Okoli
- Section of Pulmonary Diseases, Critical Care and Environmental Medicine, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kathleen A Jenkins
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christine M Bojanowski
- Section of Pulmonary Diseases, Critical Care and Environmental Medicine, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
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27
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David S, Russell L, Castro P, van de Louw A, Zafrani L, Pirani T, Nielsen ND, Mariotte E, Ferreyro BL, Kielstein JT, Montini L, Brignier AC, Kochanek M, Cid J, Robba C, Martin-Loeches I, Ostermann M, Juffermans NP. Research priorities for therapeutic plasma exchange in critically ill patients. Intensive Care Med Exp 2023; 11:26. [PMID: 37150798 PMCID: PMC10164453 DOI: 10.1186/s40635-023-00510-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Therapeutic plasma exchange (TPE) is a therapeutic intervention that separates plasma from blood cells to remove pathological factors or to replenish deficient factors. The use of TPE is increasing over the last decades. However, despite a good theoretical rationale and biological plausibility for TPE as a therapy for numerous diseases or syndromes associated with critical illness, TPE in the intensive care unit (ICU) setting has not been studied extensively. A group of eighteen experts around the globe from different clinical backgrounds used a modified Delphi method to phrase key research questions related to "TPE in the critically ill patient". These questions focused on: (1) the pathophysiological role of the removal and replacement process, (2) optimal timing of treatment, (3) dosing and treatment regimes, (4) risk-benefit assumptions and (5) novel indications in need of exploration. For all five topics, the current understanding as well as gaps in knowledge and future directions were assessed. The content should stimulate future research in the field and novel clinical applications.
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Affiliation(s)
- Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Andry van de Louw
- Medical Intensive Care Unit, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Tasneem Pirani
- King's College Hospital, General and Liver Intensive Care, London, UK
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Brunswick, Germany
| | - Luca Montini
- Department of Intensive Care Medicine and Anesthesiology, "Fondazione Policlinico Universitario Agostino Gemelli IRCCS" Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anne C Brignier
- Apheresis Unit, Saint-Louis Hospital, AP-HP, University of Paris Cite, Paris, France
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO), University of Cologne, Cologne, Germany
| | - Joan Cid
- Apheresis and Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- IRCCS per Oncologia e Neuroscienze, Genoa, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Universita' di Genova, Genoa, Italy
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, D08 NHY1, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, D02 PN91, Ireland
- Institut D'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' Hospital, King's College London, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, Rotterdam, The Netherlands
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Sanchez-Escamilla M, Flynn J, Devlin S, Maloy M, Fatmi SA, Tomas AA, Escribano-Serrat S, Ponce D, Sauter CS, Giralt SA, Scordo M, Perales MA. EASIX score predicts inferior survival after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2023; 58:498-505. [PMID: 36721042 PMCID: PMC10513445 DOI: 10.1038/s41409-023-01922-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 02/02/2023]
Abstract
The Endothelial Activation and Stress Index (EASIX) is a prognostic tool that uses common clinical laboratory values and has been shown to predict non-relapse mortality (NRM) and overall survival (OS) at the onset of acute graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT). We hypothesized that EASIX calculated at different time points pre- and post- HCT may predict NRM and OS, and that EASIX calculated at onset of GVHD may predict response to steroids. We evaluated the EASIX score pre- and post-HCT in 152 patients with lymphoid malignancies undergoing unmodified reduced intensity conditioning (RIC) alloHCT with uniform GVHD prophylaxis. In multivariate analysis, EASIX calculated pre-HCT was significantly associated with higher NRM (HR = 1.64, p = 0.009) and lower OS (HR = 1.33, p = 0.046). Furthermore, EASIX calculated at day 30 and at day 100 was associated with increased NRM (HR = 1.65, p < 0.001; and HR = 1.65, p < 0.001) and decreased OS (HR = 1.27, p = 0.018; and HR = 1.49, p < 0.001), independent of HCT-CI, disease and conditioning regimen. Our study shows that high EASIX scores at various time points pre- and post-HCT are significantly associated with poorer overall outcomes. EASIX provides an independent and easily accessible tool to predict outcomes that can be complementary to other measures of risk stratification for patients undergoing HCT.
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Affiliation(s)
- Miriam Sanchez-Escamilla
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Hematological Malignancies and Stem Cell Transplantation, Research Institute of Marques de Valdecilla (IDIVAL), Santander, Spain.
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sean Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Samira A Fatmi
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Ana Alarcon Tomas
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Silvia Escribano-Serrat
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Doris Ponce
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Craig S Sauter
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Michael Scordo
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA.
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Joseph A, Joly BS, Picod A, Veyradier A, Coppo P. The Specificities of Thrombotic Thrombocytopenic Purpura at Extreme Ages: A Narrative Review. J Clin Med 2023; 12:jcm12093068. [PMID: 37176509 PMCID: PMC10179719 DOI: 10.3390/jcm12093068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy (TMA) related to a severe ADAMTS13 deficiency, the specific von Willebrand factor (VWF)-cleaving protease. This deficiency is often immune-mediated (iTTP) and related to the presence of anti-ADAMTS13 autoantibodies that enhance its clearance or inhibit its VWF processing activity. iTTP management may be challenging at extreme ages of life. International cohorts of people with TTP report delayed diagnoses and misdiagnoses in children and elderly people. Child-onset iTTP shares many features with adult-onset iTTP: a female predominance, an idiopathic presentation, and the presence of neurological disorders and therapeutic strategies. Long-term follow-ups and a transition from childhood to adulthood are crucial to preventing iTTP relapses, in order to identify the occurrence of other autoimmune disorders and psychosocial sequelae. In contrast, older iTTP patients have an atypical clinical presentation, with delirium, an atypical neurological presentation, and severe renal and cardiac damages. They also have a poorer response to treatment and prognosis. Long-term sequelae are highly prevalent in older patients. Prediction scores for iTTP diagnoses are not used for children and have a lower sensitivity and specificity in patients over 60 years old. ADAMTS13 remains the unique biological marker that is able to definitely confirm or rule out the diagnosis of iTTP and predict relapses during follow-ups.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Bérangère S Joly
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Adrien Picod
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Department, Saint-Antoine hospital, Public Assistance Hospitals of Paris, 75571 Paris, France
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30
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Woods AI, Paiva J, Dos Santos C, Alberto MF, Sánchez-Luceros A. From the Discovery of ADAMTS13 to Current Understanding of Its Role in Health and Disease. Semin Thromb Hemost 2023; 49:284-294. [PMID: 36368692 DOI: 10.1055/s-0042-1758059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ADAMTS13 (a disintegrin-like metalloprotease domain with thrombospondin type 1 motif, member 13) is a protease of crucial importance in the regulation of the size of von Willebrand factor multimers. Very low ADAMTS13 activity levels result in thrombotic thrombocytopenic purpura, a rare and life-threatening disease. The mechanisms involved can either be acquired (immune-mediated thrombotic thrombocytopenic purpura [iTTP]) or congenital (cTTP, Upshaw-Schulman syndrome) caused by the autosomal recessive inheritance of disease-causing variants (DCVs) located along the ADAMTS13 gene, which is located in chromosome 9q34. Apart from its role in TTP, and as a regulator of microthrombosis, ADAMTS13 has begun to be identified as a prognostic and/or diagnostic marker of other diseases, such as those related to inflammatory processes, liver damage, metastasis of malignancies, sepsis, and different disorders related to angiogenesis. Since its first description almost 100 years ago, the improvement of laboratory tests and the description of novel DCVs along the ADAMTS13 gene have contributed to a better and faster diagnosis of patients under critical conditions. The ability of ADAMTS13 to dissolve platelet aggregates in vitro and its antithrombotic properties makes recombinant human ADAMTS13 treatment a potential therapeutic approach targeting not only patients with cTTP but also other medical conditions.
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Affiliation(s)
- Adriana Inés Woods
- Laboratorio de Hemostasia y Trombosis, IMEX-CONICET-Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - Juvenal Paiva
- Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - Celia Dos Santos
- Laboratorio de Hemostasia y Trombosis, IMEX-CONICET-Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - María Fabiana Alberto
- Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
| | - Analía Sánchez-Luceros
- Laboratorio de Hemostasia y Trombosis, IMEX-CONICET-Academia Nacional de Medicina de Buenos Aires, CABA, Argentina.,Departamento de Hemostasia y Trombosis, Instituto de Investigaciones Hematológicas, Academia Nacional de Medicina de Buenos Aires, CABA, Argentina
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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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32
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Frontiers in pathophysiology and management of thrombotic thrombocytopenic purpura. Int J Hematol 2023; 117:331-340. [PMID: 36757521 DOI: 10.1007/s12185-023-03552-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a fatal disease in which platelet-rich microthrombi cause end-organ ischemia and damage. TTP is caused by markedly reduced ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity. Hereditary or congenital TTP (cTTP) is caused by ADAMTS13 gene mutations. In acquired or immune TTP (iTTP), ADAMTS13 activity is reduced by anti-ADAMTS13 autoantibodies. TTP is characterized by thrombocytopenia, hemolytic anemia, fever, renal dysfunction, and neuropsychiatric symptoms. Therapeutic plasma exchange (TPE) and immunosuppressive therapy are the mainstays of treatment. As untreated TTP has a high mortality rate, immediate initiation of TPE is recommended when TTP is suspected. Conventionally, corticosteroids have been used for immunosuppressive therapy. Current drug therapies include rituximab, an anti-CD20 antibody that is effective in newly diagnosed cases and refractory cases, as well as for relapse prevention, and caplacizumab, an anti- von Willebrand factor (VWF) nanobody that inhibits the binding of platelets to VWF and prevents microthrombi formation. Recombinant human ADAMTS13 is a promising treatment for cTTP. Although these therapeutic advances have improved the outcomes of TTP, early diagnosis and prompt initiation of appropriate therapy are necessary to achieve these outcomes.
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Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol 2023; 141:85-108. [PMID: 36455925 DOI: 10.1097/aog.0000000000005024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 12/05/2022]
Abstract
The most common thrombotic microangiopathy (TMA) of pregnancy is the well-recognized syndrome of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, rare TMAs, including thrombotic thrombocytopenic purpura, complement-mediated hemolytic-uremic syndrome, and catastrophic antiphospholipid syndrome, may occur during pregnancy or postpartum and present with features similar to those of preeclampsia with severe features. Early recognition and treatment of these infrequently encountered conditions are key for avoiding serious maternal morbidities with long-term sequelae and possible maternal or fetal death. Differentiating between preeclampsia with severe features and these rare TMAs is diagnostically challenging as there is significant overlap in their clinical and laboratory presentation. Given the rarity of these TMAs, high-quality evidence-based recommendations on diagnosis and management during pregnancy are lacking. Using current objective information and recommendations from working groups, this report provides practical clinical approaches to diagnose and manage these rare TMAs. This report also discusses how to manage individuals with a history of these rare TMAs who are planning to conceive. To optimize favorable outcomes, a multidisciplinary approach including obstetricians, maternal-fetal medicine specialists, hematologists, and nephrologists alongside close clinical and laboratory monitoring is vital.
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34
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Gómez-Seguí I, Pascual Izquierdo C, Mingot Castellano ME, de la Rubia Comos J. An update on the pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:17-32. [PMID: 36537217 DOI: 10.1080/17474086.2023.2159803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Severe ADAMTS13 deficiency defines thrombotic thrombocytopenic purpura (TTP). ADAMTS13 is responsible for VWF cleavage. In the absence of this enzyme, widespread thrombi formation occurs, causing microangiopathic anemia and thrombocytopenia and leading to ischemic organ injury. Understanding ADAMTS13 function is crucial to diagnose and manage TTP, both in the immune and hereditary forms. AREAS COVERED The role of ADAMTS13 in coagulation homeostasis and the consequences of its deficiency are detailed. Other factors that modulate the consequences of ADAMTS13 deficiency are explained, such as complement system activation, genetic predisposition, or the presence of an inflammatory status. Clinical suspicion of TTP is crucial to start prompt treatment and avoid mortality and sequelae. Available techniques to diagnose this deficiency and detect autoantibodies or gene mutations are presented, as they have become faster and more available in recent years. EXPERT OPINION A better knowledge of TTP pathophysiology is leading to an improvement in diagnosis and follow-up, as well as a customized treatment in patients with TTP. This scenario is necessary to define the role of new targeted therapies already available or coming soon and the need to better diagnose and monitor at the molecular level the evolution of the disease.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio de Hematología y Hemoterapia, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón, Calle Dr. Esquerdo 46, 28007, Madrid, Spain
| | - María Eva Mingot Castellano
- Servicio de Hematología, Área de Banco de Sangre y Establecimiento de Tejidos, Hospital Universitario Virgen del Rocío, Calle Manuel Siurot s/n, 41013, Sevilla, Spain
| | - Javier de la Rubia Comos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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Lin Y, Huang L, Tu Y, Huang B, Zhang S, Chen Y, Li W. Case report of Salmonella derby septicemia complicated with co-occurrence of disseminated intravascular coagulation and thrombotic microangiopathy. BMC Infect Dis 2022; 22:914. [PMID: 36476209 PMCID: PMC9730593 DOI: 10.1186/s12879-022-07913-2] [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: 07/13/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Both disseminated intravascular coagulation and thrombotic microangiopathy are complications of sepsis as Salmonella septicemia, respectively. They are related and have similar clinical characteristics as thrombopenia and organ dysfunctions. They rarely co-occur in some specific cases, which requires a clear distinction. CASE PRESENTATION A 22-year-old woman had just undergone intracranial surgery and suffered from Salmonella derby septicemia with multiorgan involvement in the hospital. Laboratory workup demonstrated coagulation disorder, hemolytic anemia, thrombocytopenia, and acute kidney injury, leading to the co-occurrence of disseminated intravascular coagulation and secondary thrombotic microangiopathy. She received antibiotics, plasma exchange therapy, dialysis, mechanical ventilation, fluids, and vasopressors and gained full recovery without complications. CONCLUSION Disseminated intravascular coagulation and secondary thrombotic microangiopathy can co-occur in Salmonella derby septicemia. They should be treated cautiously in diagnosis and differential diagnosis. Thrombotic microangiopathy should not be missed just because of the diagnosis of disseminated intravascular coagulation. Proper and timely identification of thrombotic microangiopathy with a diagnostic algorithm is essential for appropriate treatment and better outcomes.
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Affiliation(s)
- Yingxin Lin
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lei Huang
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yunliang Tu
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Bin Huang
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Sheng Zhang
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yingqun Chen
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Weijia Li
- grid.440601.70000 0004 1798 0578Department of Intensive Care, Peking University Shenzhen Hospital, Shenzhen, China
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Tsitsikas DA, Mihalca D, Hall J, May JE, Gangaraju R, Marques MB, Scully M. Pitfalls in Diagnosing Thrombotic Thrombocytopenic Purpura in Sickle Cell Disease. J Clin Med 2022; 11:jcm11226676. [PMID: 36431152 PMCID: PMC9696110 DOI: 10.3390/jcm11226676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenia purpura is characterised by microangiopathic haemolytic anaemia and red cell fragmentation on the peripheral smear, neurological involvement and thrombocytopenia. Diagnosis in the context of sickle cell disease can be challenging due to the inherent haemolytic state and the multitude of other associated complications of the latter. Specifically, fat embolism syndrome characterised by respiratory failure, neurological impairment and thrombocytopenia can be misdiagnosed this way. Confirmation of a diagnosis of thrombotic thrombocytopenic purpura requires demonstration of very low levels (<10%) of the metalloproteinase ADAMTS13 which in fat embolism syndrome is normal. Existing scoring systems used to estimate the pre-test probability for thrombotic thrombocytopenic purpura cannot be applied in patients with sickle cell disease due to the chronic underlying haemolysis. Here, we analyse the diagnostic approach in published cases of thrombotic thrombocytopenic purpura affecting patients with sickle-cell disease. The vast majority of cases were characterised by severe respiratory failure before any other manifestation, a feature of fat embolism syndrome but not of thrombotic thrombocytopenic purpura, and all received red cell transfusion prior to receiving therapeutic plasma exchange. Despite the potential overestimation of the pre-test probability using the existing scoring systems, a large number of cases still scored low. There were no cases with documented low ADAMTS13. In the majority this was not tested, while in the 3 cases that ADAMTS13 was tested, levels were normal. Our review suggests that due to many overlapping clinical and laboratory features thrombotic thrombocytopenic purpura may be erroneously diagnosed in sickle cell disease instead of other complications such as fat embolism syndrome and confirmation with ADAMTS13 testing is essential.
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Affiliation(s)
| | - Diana Mihalca
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
| | - John Hall
- Homerton Healthcare NHS Foundation Trust, London E9 6SR, UK
| | - Jori E. May
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Radhika Gangaraju
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Marisa B. Marques
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Marie Scully
- University College Hospital, 235 Euston Road, Fitzrovia, London NW1 2BU, UK
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Lipsyc-Sharf M, Connell NT, Ostrominski JW, Levy BD, Loscalzo J. A Shear Decline. N Engl J Med 2022; 387:1700-1706. [PMID: 36322848 DOI: 10.1056/nejmcps2115778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Nathan T Connell
- From the Department of Medicine, Brigham and Women's Hospital, Boston
| | | | - Bruce D Levy
- From the Department of Medicine, Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Department of Medicine, Brigham and Women's Hospital, Boston
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38
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Joseph A, Brilland B, Burguet L, Eloit M, Fage N, Augusto JF, Delmas Y, Veyradier A, Halimi JM, Coppo P. Predictive scores for early identification of immune-mediated thrombotic thrombocytopenic purpura: room for improvement? Kidney Int Rep 2022; 7:2541-2542. [DOI: 10.1016/j.ekir.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 10/14/2022] Open
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39
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Park S, Go SI, Lee GW. The Endothelial Activation and Stress Index (EASIX) score is an independent prognostic factor in patients with diffuse large B-cell lymphoma. BMC Cancer 2022; 22:816. [PMID: 35879680 PMCID: PMC9312320 DOI: 10.1186/s12885-022-09915-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The endothelial activation and stress index (EASIX) score has been reported to predict overall survival (OS) in hematological cancers. However, it has not been validated as a prognostic marker for diffuse large B-cell lymphoma (DLBCL) to date. METHODS The records of 265 patients who presented with DLBCL in the Republic of Korea between January 07, 2004, and March 05, 2020 were retrospectively reviewed. For all included patients, EASIX scores were calculated using serum lactate dehydrogenase (LDH) and creatinine levels and the platelet count measured at diagnosis as follows: LDH (U/L) × creatinine (mg/dL)/platelet count (109/L). RESULTS The median age of the patients was 64 years. The optimal cutoff value of EASIX according to the receiver operating characteristic analysis for OS was 1.33. All the patients were treated with cyclophosphamide, doxorubicin, vincristine, and prednisone combined with rituximab. The 1-year OS and progression-free survival (PFS) rates were lower in the high-EASIX group than in the low EASIX group (63.8% vs. 84.4%, p < 0.001 and 54.0% vs. 79.6%, p < 0.001, respectively). A high EASIX was an independent poor prognostic factor for OS and PFS (hazard ratio, 1.606; 95% CI, 1.077-2.395; p = 0.020 and hazard ratio, 1.621; 95% CI, 1.066-2.464; p = 0.024, respectively). CONCLUSIONS EASIX is a readily available and cheaply obtainable parameter in clinical studies and shows considerable potential as a new prognostic marker for patients with newly diagnosed DLBCL.
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Affiliation(s)
- Sungwoo Park
- Division of Hematology and Oncology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Se-Il Go
- Division of Hematology and Oncology, Department of Internal Medicine, Institute of Health Sciences, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, South Korea
| | - Gyeong-Won Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, South Korea.
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Mingot Castellano ME, Pascual Izquierdo C, González A, Viejo Llorente A, Valcarcel Ferreiras D, Sebastián E, García Candel F, Sarmiento Palao H, Gómez Seguí I, de la Rubia J, Cid J, Martínez Nieto J, Hernández Mateo L, Goterris Viciedo R, Fidalgo T, Salinas R, Del Rio-Garma J. Recommendations for the diagnosis and treatment of patients with thrombotic thrombocytopenic purpura. Med Clin (Barc) 2022; 158:630.e1-630.e14. [PMID: 34266669 DOI: 10.1016/j.medcli.2021.03.040] [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: 02/06/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/09/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by the development of microangiopathic haemolytic anaemia, thrombocytopenia, and ischaemic organ dysfunction associated with ADAMTS13 levels lower than 10% in most cases. Recently there have been numerous advances in the field of PTT, new, rapid and accessible techniques capable of quantifying ADAMTS13 activity and inhibitors. The massive sequencing systems facilitate the identification of polymorphisms in the ADAMTS13 gene. In addition, new drugs such as caplacizumab have appeared and relapse prevention strategies are being proposed with the use of rituximab. The existence of TTP patient registries allow a deeper understanding of this disease but the great variability in the diagnosis and treatment makes it necessary to elaborate guidelines that homogenize terminology and clinical practice. The recommendations set out in this document were prepared following the AGREE methodology. The research questions were formulated according to the PICO format. A search of the literature published during the last 10 years was carried out. The recommendations were established by consensus among the entire group, specifying the existing strengths and limitations according to the level of evidence obtained. In conclusion, this document contains recommendations on the management, diagnosis, and treatment of TTP with the ultimate objective of developing guidelines based on the evidence published to date that allow healthcare professionals to optimize TTP treatment.
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Affiliation(s)
| | | | - Ataulfo González
- Servicio de Hematología y Hemoterapia, Hospital Universitario de San Carlos, Madrid, España
| | - Aurora Viejo Llorente
- Servicio de Hematología, Área de Hemoterapia, Hospital Universitario La Paz, Madrid, España
| | - David Valcarcel Ferreiras
- Unidad de Hematología Intensiva y Terapia Celular, Departamento de Hematología, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Faustino García Candel
- Sección de Hemostasia y Trombosis, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Inés Gómez Seguí
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Joan Cid
- Unidad de Aféresis y Terapia Celular, Servicio de Hemoterapia y Hemostasia, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Martínez Nieto
- Servicio de Hematología y Hemostasia, Hospital Universitario Clínico San Carlos. Instituto de Investigación Sanitaria San Carlos (IdissC), Madrid, España
| | - Luis Hernández Mateo
- Servicio de Hematología y Hemoterapia, Hospital General de Alicante, Valencia, España
| | - Rosa Goterris Viciedo
- Servicio de Hematología y Hemoterapia, Hospital Clínico Valencia. INCLIVA, Valencia, España
| | - Teresa Fidalgo
- Departamento de Hematología Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ramon Salinas
- Banc de Sang i Teixits de Catalunya, Barcelona, España
| | - Julio Del Rio-Garma
- Servicio de Transfusión. Servicio de Hematología. Complexo Hospitalario Universitario de Ourense, Galicia, España.
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41
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Mancini I, Agosti P, Boscarino M, Ferrari B, Artoni A, Palla R, Spreafico M, Crovetti G, Volpato E, Rossini S, Novelli C, Gattillo S, Barcella L, Salmoiraghi M, Falanga A, Peyvandi F. Lombardy diagnostic and therapeutic network of thrombotic microangiopathy. Orphanet J Rare Dis 2022; 17:246. [PMID: 35739601 PMCID: PMC9229100 DOI: 10.1186/s13023-022-02400-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/12/2022] [Indexed: 11/14/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening thrombotic microangiopathy (TMA) requiring urgent treatment. Standardization of its diagnosis and optimal management is challenging. This study aimed to evaluate the role of centralized, rapid testing of ADAMTS13 in patients experiencing acute TMAs requiring plasma-exchange (PEX) and to estimate the incidence of TTP in a large Italian Region. Methods We perfomed a cohort study in the frame of the project “Set-up of a Lombardy network for the study and treatment of patients undergoing apheresis”, including 11 transfusion centers in the Region. Consecutive patients referred from 2014 to 2016 with acute TMAs requiring PEX were enrolled. Centralized ADAMTS13 activity testing was performed at the Milan Hemophilia and Thrombosis Center within 24 h. Results Forty-three TMA patients (44 events) were enrolled, of whom 35 (81%) had severe ADAMTS13 deficiency. Patients with severe ADAMTS13 deficiency were younger, mainly women, with a higher prevalence of autoimmune disorders and a lower prevalence of cancer. Clinical and laboratory characteristics of patients with and without severe ADAMTS13 deficiency largely overlapped, with a lower platelet count being the only baseline marker that significantly differed between the two patient groups (ADAMTS13 activity < 10% vs ≥ 10%: median difference of -27 × 109/l, 95% CI − 37 to − 3). PEX treatment was initiated in all patients, but soon discontinued in cases without severe ADAMTS13 deficiency. In this group, the mortality rate was higher and no episode exacerbations or relapses within 6 months occured. The estimated average annual incidence of acute acquired TTP events was 1.17 [0.78–1.55] per million people. Conclusions Severe ADAMTS13 deficiency distinguished two groups of patients with largely overlapping clinical features but different treatment and disease course. This study provides a feasible model implemented in a large Italian region for the practical clinical approach to TMAs and underlines the importance of urgent ADAMTS13 activity testing for an accurate differential diagnosis and therapeutic approach. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02400-y.
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Affiliation(s)
- I Mancini
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, and Fondazione Luigi Villa, Via Pace 9, 20122, Milan, Italy
| | - P Agosti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, and Fondazione Luigi Villa, Via Pace 9, 20122, Milan, Italy
| | - M Boscarino
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, and Fondazione Luigi Villa, Via Pace 9, 20122, Milan, Italy
| | - B Ferrari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - A Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - R Palla
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, and Fondazione Luigi Villa, Via Pace 9, 20122, Milan, Italy
| | - M Spreafico
- Transfusion Medicine and Haematology Department, "A. Manzoni" Hospital, ASST-Lecco, Lecco, Italy
| | - G Crovetti
- SIMT, ASST Valle Olona, Busto Arsizio, Italy
| | - E Volpato
- Division of Immunohaematology and Transfusion Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - S Rossini
- Division of Immunohaematology and Transfusion Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - C Novelli
- Transfusion Center and Haematology Laboratory, Legnano Hospital, ASST Ovest Milanese, Legnano, Italy
| | - S Gattillo
- Immuno-Hematology and Transfusion Medicine Unit, San Raffaele Hospital, Milan, Italy
| | - L Barcella
- Immunohematology Division, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - M Salmoiraghi
- Unità Organizzativa Programmazione Della DG Welfare, Unità Organizzativa Programmazione Della DG Welfare Regione Lombardia, Regione Lombardia, Milan, Italy
| | - A Falanga
- Immunohematology Division, Hospital Papa Giovanni XXIII, Bergamo, Italy.,Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - F Peyvandi
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, and Fondazione Luigi Villa, Via Pace 9, 20122, Milan, Italy. .,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
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Buetler VA, Agbariah N, Schild DP, Liechti FD, Wieland A, Andina N, Hammann F, Kremer Hovinga JA. Immune-Mediated Thrombotic Thrombocytopenic Purpura Following mRNA-Based COVID-19 Vaccine BNT162b2: Case Report and Mini-Review of the Literature. Front Med (Lausanne) 2022; 9:890661. [PMID: 35655852 PMCID: PMC9152022 DOI: 10.3389/fmed.2022.890661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/29/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction An increasing number of case reports have associated vaccinations against coronavirus disease 2019 (COVID-19) with immune-mediated thrombotic thrombocytopenic purpura (iTTP), a very rare but potentially life-threatening thrombotic microangiopathy, which leads to ischemic organ dysfunction. Thrombus formation in iTTP is related to a severe deficiency of the specific von Willebrand-factor-cleaving protease ADAMTS13 due to ADAMTS13 autoantibodies. Methods We present a case of iTTP following exposure to the mRNA-based COVID-19 vaccine BNT162b2 (Comirnaty®, Pfizer-BioNTech). In addition, we review previously reported cases in the literature and assess current evidence. Results Apart from our case, twenty cases of iTTP occurring after COVID-19 vaccination had been published until the end of November 2021. There were 11 male and 10 female cases; their median age at diagnosis was 50 years (range 14–84 years). Five patients (24%) had a preexisting history of iTTP. Recombinant adenoviral vector-based vaccines were involved in 19%, mRNA-based vaccines in 81%. The median onset of symptoms after vaccination was 12 days (range 5–37), with 20 cases presenting within 30 days. Treatment included therapeutic plasma exchange in all patients. Additional rituximab, caplacizumab, or both these treatments were given in 43% (9/21), 14% (3/21), and 24% (5/21) of cases, respectively. One patient died, despite a prolonged clinical course in one patient, all surviving patients were in clinical remission at the end of the observational period. Conclusion Clinical features of iTTP following COVID-19 vaccination were in line with those of pre-pandemic iTTP. When timely initiated, an excellent response to standard treatment was seen in all cases. ADAMTS13 activity should be determined pre-vaccination in patients with a history of a previous iTTP episode. None of the reported cases met the WHO criteria for assessing an adverse event following immunization (AEFI) as a consistent causal association to immunization. Further surveillance of safety data and additional case-based assessment are needed.
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Affiliation(s)
- Vanessa Alexandra Buetler
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nada Agbariah
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Deborah Pia Schild
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian D Liechti
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Wieland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicola Andina
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Felix Hammann
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Kovala M, Seppälä M, Kaartinen K, Meri S, Honkanen E, Räisänen-Sokolowski A. Vascular Occlusion in Kidney Biopsy Is Characteristic of Clinically Manifesting Thrombotic Microangiopathy. J Clin Med 2022; 11:jcm11113124. [PMID: 35683519 PMCID: PMC9181253 DOI: 10.3390/jcm11113124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) can sometimes manifest only histologically. Our aim was to retrospectively compare biopsy-proven adult TMA patients showing only histological (h-TMA) or both histological and clinical (c-TMA) TMA in 2006–2017. All native kidney biopsies with TMA were included. Biopsies were re-evaluated by light and electron microscopy, and immunofluorescence. Clinical characteristics, laboratory variables, and treatments were recorded from the electronic medical database. Patients were categorized into h-TMA and c-TMA and these groups were compared. In total, 30 biopsy-proven cases among 7943 kidney biopsies were identified and, of these, 15 had h-TMA and 15 c-TMA. Mean follow-up was 6.3 y, and 73.3% had secondary hemolytic uremic syndrome (HUS) and the rest were atypical HUS. Patient characteristics, treatments, and kidney, and patient survival in the groups were similar. Statistically significant differences were found in histological variables. Vascular myxoid swelling and vascular onion-skinning were almost exclusively detected in c-TMA and, thus, vascular occlusive changes indicate clinically apparent rather than merely histological TMA. In addition, regardless of clinical presentation, kidney and patient survival times were similar in the patient groups highlighting the importance of a kidney biopsy in the case of any kidney-related symptoms.
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Affiliation(s)
- Marja Kovala
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
- Correspondence:
| | - Minna Seppälä
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Kati Kaartinen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Seppo Meri
- Department of Bacteriology and Immunology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
| | - Eero Honkanen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Anne Räisänen-Sokolowski
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
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Joseph A, Eloit M, Azoulay E, Kaplanski G, Provot F, Presne C, Wynckel A, Grangé S, Rondeau É, Pène F, Delmas Y, Lautrette A, Barbet C, Mousson C, Coindre J, Perez P, Jamme M, Augusto J, Poullin P, Jacobs F, El Karoui K, Vigneau C, Ulrich M, Kanouni T, Le Quintrec M, Hamidou M, Ville S, Charvet‐Rumpler A, Ojeda‐Uribe M, Godmer P, Fremeaux‐Bacchi V, Veyradier A, Halimi J, Coppo P. Immune‐mediated thrombotic thrombocytopenic purpura prognosis is affected by blood pressure. Res Pract Thromb Haemost 2022; 6:e12702. [PMID: 35599703 PMCID: PMC9115975 DOI: 10.1002/rth2.12702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 12/28/2022] Open
Abstract
Background The prevalence, prognostic role, and diagnostic value of blood pressure in immune-mediated thrombotic thrombocytopenic purpura (iTTP) and other thrombotic microangiopathies (TMAs) remain unclear. Methods Using a national cohort of iTTP (n = 368), Shigatoxin-induced hemolytic uremic syndrome (n = 86), atypical hemolytic uremic syndrome (n = 84), and hypertension-related thrombotic microangiopathy (n = 25), we sought to compare the cohort's blood pressure profile to assess its impact on prognosis and diagnostic performances. Results Patients with iTTP had lower blood pressure than patients with other TMAs, systolic (130 [interquartile range (IQR) 118-143] vs 161 [IQR 142-180] mmHg) and diastolic (76 [IQR 69-83] vs 92 [IQR 79-105] mmHg, both p < 0.001). The best threshold for iTTP diagnosis corresponded to a systolic blood pressure <150 mmHg. iTTP patients presenting with hypertension had a significantly poorer survival (hazard ratio 1.80, 95% confidence interval 1.07-3.04), and this effect remained significant after multivariable adjustment (hazard ratio = 1.14, 95% confidence interval 1.00-1.30). Addition of a blood pressure criterion modestly improved the French clinical score to predict a severe A disintegrin and metalloprotease with thrombospondin type 1 deficiency in patients with an intermediate score (i.e., either platelet count <30 × 109/L or serum creatinine <200 µM). Conclusions Elevated blood pressure at admission affects the prognosis of iTTP patients and may help discriminate them from other TMA patients. Particular attention should be paid to blood pressure and its management in these patients.
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Affiliation(s)
- Adrien Joseph
- INSERM, U1138, INSERM, Équipe 11 labellisée Ligue Nationale Contre le Cancer, Centre de Recherche des Cordeliers Paris France
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Martin Eloit
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et Thérapie Cellulaire CHRU de Tours Tours France
| | - Elie Azoulay
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Gilles Kaplanski
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Hôpital la Conception Marseille France
| | - François Provot
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Albert‐Calmette Lille France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Nord Amiens France
| | - Alain Wynckel
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Maison Blanche Reims France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale CHU Charles Nicolle Rouen France
| | - Éric Rondeau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Urgences Néphrologiques et Transplantation Rénale Hôpital Tenon Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Intensive–Réanimation Hôpital Cochin APHP Centre & Université de Paris Paris France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Bordeaux Bordeaux France
| | - Alexandre Lautrette
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Gabriel Montpied Clermont‐Ferrand France
| | - Christelle Barbet
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Christiane Mousson
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Dijon Dijon France
| | - Jean‐Philippe Coindre
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CH Le Mans Le Mans France
| | - Pierre Perez
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Polyvalente CHU de Nancy Nancy France
| | - Matthieu Jamme
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Centre Hospitalier Intercommunal Poissy Saint‐Germain Poissy France
| | - Jean‐François Augusto
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Dialyse et Transplantation CHU Larrey Angers France
| | - Pascale Poullin
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’hémaphérèse et d’autotransfusion Hôpital la Conception Marseille France
| | - Frédéric Jacobs
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Antoine Béclère Clamart France
| | - Khalil El Karoui
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie et Transplantation rénale Groupe Hospitalier Henri‐Mondor Créteil France
| | - Cécile Vigneau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)–UMR_S 1085 Rennes France
| | - Marc Ulrich
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Jean Bernard Valenciennes France
| | - Tarik Kanouni
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Unité d’Hémaphérèse Service d’Hématologie CHU de Montpellier Montpellier France
| | - Moglie Le Quintrec
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Montpellier Montpellier France
| | - Mohamed Hamidou
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne CHU de Nantes Nantes France
| | - Simon Ville
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Nantes Nantes France
| | - Anne Charvet‐Rumpler
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Centre Hospitalier Régional Universitaire Hôpital Jean Minjoz Besançon France
| | - Mario Ojeda‐Uribe
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et de Thérapie Cellulaire Groupe Hospitalier Region Mulhouse‐Sud‐Alsace (GHRMSA) Mulhouse France
| | - Pascal Godmer
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Centre Hospitalier Bretagne Atlantique de Vannes Vannes France
| | - Véronique Fremeaux‐Bacchi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Immunologie Biologique Hôpital Européen Georges Pompidou, AP‐HP Paris France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Biologique Hôpital Lariboisière, AP‐HP Paris France
| | - Jean‐Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Hôpital Saint‐Antoine AP‐HP Paris France
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Lee CH, Huang YC, Li SS, Hsu YT, Chen YP, Chen TY. Application of PLASMIC Score in Risk Prediction of Thrombotic Thrombocytopenic Purpura: Real-World Experience From a Tertiary Medical Center in Taiwan. Front Med (Lausanne) 2022; 9:893273. [PMID: 35615090 PMCID: PMC9124890 DOI: 10.3389/fmed.2022.893273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) deficiency (activity <10%). Urgent intervention based on the timely evaluation of ADAMTS13 level is crucial to guide optimal therapy. The recently developed PLASMIC score based on seven items allows the rapid identification of patients at high risk for TTP due to severe ADAMTS13 deficiency. This retrospective study included 31 hospitalized patients with suspicious thrombotic microangiopathy in National Cheng Kung University Hospital from December 2016 to July 2021. Data on ADAMTS13 activity and medical and laboratory information were retrieved from medical records. The PLASMIC score could be calculated in 24 of the 31 patients with available data, and the final cohort was stratified according to the 7-point PLASMIC score. All patients with high PLASMIC score (6-7) exhibited severe ADAMTS13 deficiency (activity ≤10%). One patient with a brain tumor and a PLASMIC score of 6 did not have severe ADAMTS13 activity of ≤10%. The patients in the intermediate- and low risk groups (PLASMIC scores of 5 and 0-4, respectively) exhibited ADAMTS13 activities of above 10%. Given the role of prompt diagnosis in the timely delivery of appropriate therapy, these findings confirm and strengthen the predictive value of the PLASMIC score in patients at high risk for TTP due to severe ADAMTS13 deficiency.
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Affiliation(s)
- Chun-Hui Lee
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ching Huang
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sin-Syue Li
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ting Hsu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ping Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsai-Yun Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Bae SH, Kim SH, Bang SM. Recent advances in the management of immune-mediated thrombotic thrombocytopenic purpura. Blood Res 2022; 57:37-43. [PMID: 35483924 PMCID: PMC9057674 DOI: 10.5045/br.2022.2022005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially life-threatening thrombotic microangiopathy caused by autoantibody-mediated severe ADAMTS13 deficiency. TTP should be suspected in patients with microangiopathic hemolytic anemia and thrombocytopenia without a definite cause. Early detection of iTTP and prompt treatment with plasma exchange and corticosteroids are essential. Rituximab administration should be considered for refractory or relapsed iTTP, and can be used as a first-line adjuvant or preemptive therapy. Treatment with caplacizumab, a novel anti-von Willebrand factor nanobody, resulted in a faster time to platelet count response, significant reduction in iTTP-related deaths, and reduced incidence of refractory iTTP. TTP survivors showed a higher rate of chronic morbidities, including cardiovascular disease and neurocognitive impairment, which can lead to a poor quality of life and higher mortality rate. Meticulous long-term follow-up of TTP survivors is crucial.
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Affiliation(s)
- Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Karsenty CL, Kirk SE, Helber HL, Esquilin JM, Despotovic JM, Grimes AB. Molecular Diagnosis Is Vital to the Accurate Classification and Management of Thrombotic Thrombocytopenic Purpura in Children. Front Immunol 2022; 13:836960. [PMID: 35479064 PMCID: PMC9038040 DOI: 10.3389/fimmu.2022.836960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening hematologic disease, presenting a myriad of diagnostic and management challenges in children. Here, we provide a review of this disorder and discuss 2 exemplary cases of TTP occurring in adolescents, emphasizing the need for consideration of late-onset congenital TTP (cTTP). We demonstrate the importance of early confirmation of ADAMTS13 enzyme deficiency and the presence or absence of ADAMTS13 inhibitor in order to rapidly initiate the appropriate life-saving therapies. Ultimately, molecular testing is paramount to distinguishing between congenital and acquired immune-mediated TTP.
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Affiliation(s)
- Cecile L. Karsenty
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
- *Correspondence: Cecile L. Karsenty,
| | - Susan E. Kirk
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Hannah L. Helber
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Jose M. Esquilin
- Methodist Children’s Hospital, San Antonio, TX, United States
- Methodist Physicians Pediatric Specialists of Texas, San Antonio, TX, United States
| | - Jenny M. Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Amanda B. Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
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48
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Graça NAG, Joly BS, Voorberg J, Vanhoorelbeke K, Béranger N, Veyradier A, Coppo P. TTP: From empiricism for an enigmatic disease to targeted molecular therapies. Br J Haematol 2022; 197:156-170. [PMID: 35146746 PMCID: PMC9304236 DOI: 10.1111/bjh.18040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022]
Abstract
The 100th anniversary of the first description of Thrombotic Thrombocytopenic Purpura (TTP) as a disease by Dr. Eli Moschcowitz approaches. For many decades, TTP remained mostly a mysterious fatal condition, where diagnosis was often post-mortem. Initially a pentad of symptoms was identified, a pattern that later revealed to be fallible. Sporadic observations led to empiric interventions that allowed for the first impactful breakthrough in TTP treatment, almost 70 years after its first description: the introduction of plasma exchange and infusions as treatments. The main body of knowledge within the field was gathered in the latest three decades: patient registries were set and proved crucial for advancements; the general mechanisms of disease have been described; the diagnosis was refined; new treatments and biomarkers with improvements on prognosis and management were introduced. Further changes and improvements are expected in the upcoming decades. In this review, we provide a brief historic overview of TTP, as an illustrative example of the success of translational medicine enabling to rapidly shift from a management largely based on empiricism to targeted therapies and personalized medicine, for the benefit of patients. Current management options and present and future perspectives in this still evolving field are summarized.
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Affiliation(s)
- Nuno A. G. Graça
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
| | - Bérangère S. Joly
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin‐Academic Medical CenterLandsteiner LaboratoryAmsterdamThe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Nicolas Béranger
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Agnès Veyradier
- Service d'hématologie biologique and EA3518‐ Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐Lariboisière, AP‐HP, Université Paris DiderotParisFrance
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
| | - Paul Coppo
- Centre de Référence des Microangiopathies ThrombotiquesHôpital Saint‐Antoine, AP‐HPParisFrance
- Service d'HématologieHôpital Saint‐Antoine, AP‐HPParisFrance
- Sorbonne UniversitéUPMC Univ ParisParisFrance
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Milon V, Fage N, Guibert F, Frémeaux-Bacchi V, Augusto JF, Brilland B. Thrombotic microangiopathy with mild renal involvement and profound thrombocytopenia: not all roads lead to thrombotic thrombocytopenic purpura. J Nephrol 2022; 35:1271-1273. [PMID: 35318588 DOI: 10.1007/s40620-022-01289-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/16/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Victor Milon
- Service de Néphrologie-Dialyse-Transplantation, Université d'AngersCHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France
| | - Nicolas Fage
- Service de Néphrologie-Dialyse-Transplantation, Université d'AngersCHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France
| | - Fanny Guibert
- Service de Néphrologie-Dialyse-Transplantation, Université d'AngersCHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France
- Service de Néphrologie-Dialyse, CH de Cholet, Cholet, France
| | | | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, Université d'AngersCHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France.
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, Université d'AngersCHU Angers, 4 rue Larrey, 49033, Angers CEDEX 09, France
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Asano T, Mori H. Thrombotic Microangiopathy Due to Malignant Hypertension Treated Exclusively With Antihypertensive Therapy. Cureus 2022; 14:e21835. [PMID: 35291517 PMCID: PMC8895853 DOI: 10.7759/cureus.21835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/10/2022] Open
Abstract
Plasma exchange is the commonly considered therapy for the treatment of thrombotic microangiopathy (TMA); however, it is not always mandatory. We treated a patient who presented with malignant hypertension (MH) complicated by TMA using antihypertensive therapy that was not accompanied by plasma exchange. A 38-year-old woman with photophobia, diarrhea, fever, and severely elevated blood pressure was referred to our hospital. Blood test results revealed thrombocytopenia and hemolytic anemia, and ascites were observed on the computed tomography images. Although TMA was suspected, plasma exchange was not performed because the platelet count was not markedly low. Her blood cell counts improved after antihypertensive treatment, and she was discharged. The patient is currently under therapy and remains stable. Thus, TMA secondary to MH may improve using antihypertensive therapy, without the need for invasive plasma exchange. Considering the platelet count may be helpful in deciding whether plasma exchange is required.
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Affiliation(s)
- Taro Asano
- Emergency Medicine, National Organization Nagasaki Medical Center, Omura, JPN
| | - Hideki Mori
- General Internal Medicine, National Organization Nagasaki Medical Center, Omura, JPN
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