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Warlo EM, Kalstad AA, Myhre PL, Solheim S, Arnesen H, Tveit A, Holme PA, Seljeflot I, Bratseth V. von Willebrand factor, ADAMTS-13, and thrombospondin 1 in relation to clinical outcomes in elderly patients with a recent myocardial infarction. Res Pract Thromb Haemost 2023; 7:100164. [PMID: 37255854 PMCID: PMC10225923 DOI: 10.1016/j.rpth.2023.100164] [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: 02/14/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 06/01/2023] Open
Abstract
Background von Willebrand factor (VWF) multimers are cleaved by A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS-13) into less active fragments. Thrombospondin 1 (TSP-1) competes with VWF's cleavage site, protecting it from degradation. Low ADAMTS-13 and high VWF have been associated with cardiovascular disease and atrial fibrillation (AF). Objectives We aimed to investigate whether VWF, ADAMTS-13, and TSP-1 are associated with clinical outcome. Methods Elderly patients with a recent myocardial infarction (MI) (n = 1027) were followed for 2 years. Blood was collected 2 to 8 weeks after the MI for ADAMTS-13, VWF, and TSP-1 measures. The primary endpoints (major adverse cardiovascular events; n = 210) included the first event of MI, stroke, heart failure hospitalization, coronary revascularization, and all-cause death. Total mortality was also registered (n = 56). The secondary endpoint was new-onset AF (n = 43). Results Concentrations of VWF, ADAMTS-13, and TSP-1 did not intercorrelate. The risk of major adverse cardiovascular events was altered in patients with VWF ≥ median (hazard ratio [HR], 1.4; 95% CI, 1.0-1.8; P = .03) and ADAMTS-13 ≥ median (HR, 0.7; 95% CI, 0.5-0.9; P = .02); however, it was not significant in adjusted models. VWF and ADAMTS-13 were significantly associated with total mortality, with a HR of 2.7 (95% CI, 1.6-4.6; P < .001) for VWF (Q4 vs. Q1-Q3) and HR of 0.3 (95% CI, 0.2-0.5; P < .001) for ADAMTS-13 (Q2-4 vs. Q1). The associations persisted in multivariable analysis, but the significance disappeared for VWF after correcting for high-sensitivity C-reactive protein. The risk of new-onset AF was lower in patients with VWF ≥ median (HR, 0.5; 95% CI, 0.3-1.0; P = .04]), and this was still significant after adjustments. Conclusion Although low ADAMTS-13 predicted death, the cardiovascular risk associated with VWF and ADAMTS-13 was weaker than previously reported. Low VWF is associated with new-onset AF and needs further research.
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Affiliation(s)
- Ellen M.K. Warlo
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Are A. Kalstad
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Peder L. Myhre
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Svein Solheim
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Arnljot Tveit
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medical Research, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway
| | - Pål Andre Holme
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Vibeke Bratseth
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway
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Bains S, Patel K, Bath T, Singh P, Kaur R, Patel P, Jamali M, Ghaffari MAZ. A Case of Thrombotic Thrombocytopenic Purpura Possibly Induced by Graves' Disease. Cureus 2022; 14:e29961. [PMID: 36381849 PMCID: PMC9635859 DOI: 10.7759/cureus.29961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 06/16/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) has historically been diagnosed with a pentad of features, i.e., thrombocytopenia, micro-angiopathic hemolytic anemia (MAHA), fever, neurological abnormalities, and kidney failure. Traditionally, TTP cases have been described in healthy adults. However, their association with autoimmune diseases is now well documented in the literature. There is limited availability of literature on the association between TTP and Graves' disease (GD). Here, we report a case of an adult female, a known case of Graves' disease, who has now been diagnosed with an acquired case of TTP. The presence of MAHA associated with thrombocytopenia was considered a clinical diagnosis of TTP and the patient immediately underwent plasma exchange (PEX), which led to the resolution of complaints. Hyperthyroidism cases should be adequately followed up as clinical severity could lead to the emergence of TTP.
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Affiliation(s)
- Shifali Bains
- Internal Medicine, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Kriyesha Patel
- Medicine, M.P. Shah Government Medical College, Jamnagar, IND
| | - Taranjit Bath
- General Medicine, Punjab Institute of Medical Sciences, Calgary, CAN
| | - Pawanpreet Singh
- Internal Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, IND
| | - Ravanjit Kaur
- Medicine, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Parth Patel
- Medicine, Shri M.P. Shah Medical College, Jamnagar, IND
| | - Momal Jamali
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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Chiruvolu NV, Scott J, Yeh SS. An Imperfect Marker: SLE and TTP-Like MAHA Without Low ADAMTS13. J Investig Med High Impact Case Rep 2021; 9:23247096211029746. [PMID: 34229453 PMCID: PMC8267025 DOI: 10.1177/23247096211029746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a potentially fatal condition that can be challenging for clinicians to identify in the setting of autoimmune diseases such as systemic lupus erythematosus (SLE). This difficulty is compounded when a patient presents with all of the clinical signs of a TTP-like microangiopathy, however, with near normal ADAMTS13. This case report describes a 44-year-old female with a history of SLE who was hospitalized with acute on chronic anemia, thrombocytopenia, and altered mental status. The patient's ADAMTS13 was mildly low; hence, she was initially treated for SLE-associated immune thrombocytopenic purpura without any clinical response. The patient then underwent plasmapheresis (plasma exchange [PLEX]) for treatment of a suspected TTP-like microangiopathy. She responded to PLEX with improvement in her platelet count and mental status. This case illustrates the importance of considering TTP-like microangiopathic hemolytic anemia in the differential for patients with a history of SLE presenting with clinical signs of TTP even in the setting of near-normal ADAMTS13, thus warranting prompt treatment with PLEX.
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Affiliation(s)
| | | | - Sam S Yeh
- Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
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4
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Bitsadze VO, Khizroeva JK, Makatsariya A, Slukhanchuk EV, Tretyakova MV, Rizzo G, Gris JCR, Elalamy I, Serov VN, Shkoda AS, Samburova NV. COVID-19, septic shock and syndrome of disseminated intravascular coagulation syndrome. Part 1. ANNALS OF THE RUSSIAN ACADEMY OF MEDICAL SCIENCES 2020. [DOI: 10.15690/vramn1335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pandemic of a new coronavirus infection (Coronavirus Disease 2019, COVID-19) caused by SARS-CoV-2 became a real challenge to humanity and the medical community in 2020 and raised a number of medical, social and even philosophical questions. An almost avalanche-like increase in the number of infected people in a short time, due to the high contagiousness of viral infection, allowed us to identify groups of patients with mild, moderate and severe forms of the disease. Doctors around the world are faced with an acute problem of treating a large number of patients in critical conditions caused by COVID-19.
From the currently available information on clinical cases of COVID-19, it follows that COVID-19 patients in critical condition have a clinical picture of disseminated intravascular coagulation (DIC), septic shock with the development of multiple organ failure.
The first part of the article discusses the pathogenesis of non-specific universal biological responses of the body in critical condition - from the Sanarelli-Schwartzman phenomenon to the DIC, septic shock, systemic inflammatory response syndrome and the so-called neutrophil extracellular traps (NETs). The questions of cytokine storm in severe forms of systemic inflammatory response syndrome (SIRS), the role of inflammation in the activation of coagulation, and the relationship between inflammation and thrombosis are discussed. Modern ideas about the mechanisms of so-called NETosis, their role in the occurrence of immunothrombosis and inflammation-induced thrombosis in autoimmune diseases - vasculitis, antiphospholipid syndrome, and systemic lupus erythematosus is highlighted. The article discusses the possibility of participation of ADAMTS-13 metalloproteinase in the pathogenesis of multiple organ failure in severe endotheliopathy in patients with viral septic shock.
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5
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Upadhyay VA, Geisler BP, Sun L, Uhl L, Kaufman RM, Stowell C, Makar RS, Bendapudi PK. Utilizing a PLASMIC score-based approach in the management of suspected immune thrombotic thrombocytopenic purpura: a cost minimization analysis within the Harvard TMA Research Collaborative. Br J Haematol 2019; 186:490-498. [PMID: 31131442 DOI: 10.1111/bjh.15932] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/03/2019] [Indexed: 01/19/2023]
Abstract
The PLASMIC score is a recently described clinical scoring algorithm that rapidly assesses the probability of severe ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) deficiency among patients presenting with microangiopathic haemolytic anaemia. Using a large multi-institutional cohort, we explored whether an approach utilizing the PLASMIC score to risk-stratify patients with suspected immune thrombotic thrombocytopenic purpura (iTTP) could lead to significant cost savings. Our consortium consists of institutions with an unrestricted approach to ADAMTS13 testing (Group A) and those that require pre-approval by the transfusion medicine service (Group B). Institutions in Group A tested more patients than those in Group B (P < 0·001) but did not identify more cases of iTTP (P = 0·29) or have lower iTTP-related mortality (P = 0·84). Decision tree cost analysis showed that applying a PLASMIC score-based strategy to screen patients for ADAMTS13 testing in Group A would have reduced costs by approximately 27% over the 12-year period of our study compared to the current approach. Savings were primarily driven by a reduction in unnecessary therapeutic plasma exchanges, but lower utilization of ADAMTS13 testing and subspecialty consultations also contributed. Our data indicate that using the PLASMIC score to guide ADAMTS13 testing and the management of patients with suspected iTTP could be associated with significant cost savings.
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Affiliation(s)
- Vivek A Upadhyay
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Benjamin P Geisler
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lova Sun
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lynne Uhl
- Harvard Medical School, Boston, MA, USA.,Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Richard M Kaufman
- Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Christopher Stowell
- Harvard Medical School, Boston, MA, USA.,Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert S Makar
- Harvard Medical School, Boston, MA, USA.,Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Pavan K Bendapudi
- Harvard Medical School, Boston, MA, USA.,Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA.,Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, USA
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6
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Das A, Dean A, Clay T. Gemcitabine-induced haemolytic uraemic syndrome in pancreatic adenocarcinoma. BMJ Case Rep 2019; 12:12/4/e228363. [PMID: 30962211 DOI: 10.1136/bcr-2018-228363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A woman in her mid-70s with metastatic pancreatic adenocarcinoma presented with fatigue, nausea and bilateral leg swelling, 4 days after an intravenous gemcitabine infusion. Additional examination and laboratory tests showed mild hypertension, low haemoglobin, high lactate dehydrogenase, low platelet count and high serum creatinine. The patient was subsequently diagnosed with haemolytic uraemic syndrome (HUS), and gemcitabine administration was immediately ceased. The patient received a 5-day course of methylprednisolone, with a full recovery being made 10 days after diagnosis. Clinicians should be aware of the rare but serious complication of gemcitabine-induced HUS (GiHUS), as early diagnosis and management, which includes prompt discontinuation of gemcitabine, are crucial in promptly resolving this condition. This case report describes one treatment that can be used for the treatment of GiHUS, while briefly covering some other novel treatments that have been described in other studies.
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Affiliation(s)
- Adarsh Das
- Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Dean
- Department of Medical Oncology, Saint John of God Hospital Subiaco, Subiaco, Western Australia, Australia
| | - Tim Clay
- Department of Medical Oncology, Saint John of God Hospital Subiaco, Subiaco, Western Australia, Australia
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7
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Chitnis SD, Mene-Afejuku TO, Aujla A, Shady A, Gil GS, Cativo EH, Popescu-Martinez A. Thrombotic thrombocytopenic purpura possibly triggered by Graves' disease. Oxf Med Case Reports 2017; 2017:omx057. [PMID: 29744115 PMCID: PMC5934682 DOI: 10.1093/omcr/omx057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 07/26/2017] [Indexed: 12/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a part of a spectrum of thrombotic microangiopathy syndromes which are mainly characterized by platelet aggregation causing microangiopathic hemolytic anemia, thrombocytopenia and microvascular occlusion. In literature, very few cases expressing a direct association between pre-existing Grave’s disease and TTP have been described. A 37-year-old African–American woman with past medical history of Grave’s disease and polysubstance abuse who presented with complaints of dyspnoea at rest and chest pain was diagnosed to have TTP on further evaluation. Patient also showed severely elevated thyroid hormones and suppressed thyroid stimulating hormone levels indicating severe thyrotoxicosis. Initiation of prompt management of TTP and thyrotoxicosis led to a favorable patient outcome. In conclusion, patients presenting with thyrotoxicosis, thrombocytopenia and microangioapthic hemolytic anemia without an alternative cause should be treated and screened for TTP due to the high fatality associated with untreated or untimely detection of this disease.
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Affiliation(s)
- Saurabh D Chitnis
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Tuoyo O Mene-Afejuku
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Amandeep Aujla
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Ahmed Shady
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Gaby S Gil
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Eder Hans Cativo
- Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
| | - Andrea Popescu-Martinez
- Division of Hematology and Oncology, Department of Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, NY, USA
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8
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Thrombotic Thrombocytopenic Purpura in Black People: Impact of Ethnicity on Survival and Genetic Risk Factors. PLoS One 2016; 11:e0156679. [PMID: 27383202 PMCID: PMC4934773 DOI: 10.1371/journal.pone.0156679] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
Black people are at increased risk of thrombotic thrombocytopenic purpura (TTP). Whether clinical presentation of TTP in Black patients has specific features is unknown. We assessed here differences in TTP presentation and outcome between Black and White patients. Clinical presentation was comparable between both ethnic groups. However, prognosis differed with a lower death rate in Black patients than in White patients (2.7% versus 11.6%, respectively, P = .04). Ethnicity, increasing age and neurologic involvement were retained as risk factors for death in a multivariable model (P < .05 all). Sixty-day overall survival estimated by the Kaplan-Meier curves and compared with the Log-Rank test confirmed that Black patients had a better survival than White patients (P = .03). Salvage therapies were similarly performed between both groups, suggesting that disease severity was comparable. The comparison of HLA-DRB1*11, -DRB1*04 and -DQB1*03 allele frequencies between Black patients and healthy Black individuals revealed no significant difference. However, the protective allele against TTP, HLA-DRB1*04, was dramatically decreased in Black individuals in comparison with White individuals. Black people with TTP may have a better survival than White patients despite a comparable disease severity. A low natural frequency of HLA-DRB1*04 in Black ethnicity may account for the greater risk of TTP in this population.
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9
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Radhi M, Carpenter SL. Thrombotic microangiopathies. ISRN HEMATOLOGY 2012; 2012:310596. [PMID: 22888446 PMCID: PMC3410315 DOI: 10.5402/2012/310596] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/10/2012] [Indexed: 01/13/2023]
Abstract
Thrombotic microangiopathy results from thrombotic occlusion of the microvasculature leading to fragmentation of red blood cells, profound thrombocytopenia, and a microangiopathic hemolytic anemia with elevation of lactate dehydrogenase and negative direct Coomb's test. This constellation of clinical and laboratory findings is not due to one disease entity; rather, it represents a variety of underlying diagnoses. Among the major disease entities are TTP/HUS, which can be congenital or acquired, bacterial infections, medications, vascular or endothelial pathology like Kasabach-Merritt phenomenon, and stem cell transplantation. In this paper, we offer a review of some of the major causes of thrombotic microangiopathy.
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Affiliation(s)
- Mohamed Radhi
- Pediatric Hematology/Oncology/Stem Cell Transplant, Children's Mercy Hospital, Kansas City, MO 64108, USA
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10
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Edwards NC, Hing ZA, Perry A, Blaisdell A, Kopelman DB, Fathke R, Plum W, Newell J, Allen CE, S. G, Shapiro A, Okunji C, Kosti I, Shomron N, Grigoryan V, Przytycka TM, Sauna ZE, Salari R, Mandel-Gutfreund Y, Komar AA, Kimchi-Sarfaty C. Characterization of coding synonymous and non-synonymous variants in ADAMTS13 using ex vivo and in silico approaches. PLoS One 2012; 7:e38864. [PMID: 22768050 PMCID: PMC3387200 DOI: 10.1371/journal.pone.0038864] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 05/13/2012] [Indexed: 12/20/2022] Open
Abstract
Synonymous variations, which are defined as codon substitutions that do not change the encoded amino acid, were previously thought to have no effect on the properties of the synthesized protein(s). However, mounting evidence shows that these “silent” variations can have a significant impact on protein expression and function and should no longer be considered “silent”. Here, the effects of six synonymous and six non-synonymous variations, previously found in the gene of ADAMTS13, the von Willebrand Factor (VWF) cleaving hemostatic protease, have been investigated using a variety of approaches. The ADAMTS13 mRNA and protein expression levels, as well as the conformation and activity of the variants have been compared to that of wild-type ADAMTS13. Interestingly, not only the non-synonymous variants but also the synonymous variants have been found to change the protein expression levels, conformation and function. Bioinformatic analysis of ADAMTS13 mRNA structure, amino acid conservation and codon usage allowed us to establish correlations between mRNA stability, RSCU, and intracellular protein expression. This study demonstrates that variants and more specifically, synonymous variants can have a substantial and definite effect on ADAMTS13 function and that bioinformatic analysis may allow development of predictive tools to identify variants that will have significant effects on the encoded protein.
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Affiliation(s)
- Nathan C. Edwards
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Zachary A. Hing
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Avital Perry
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Adam Blaisdell
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - David B. Kopelman
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Robert Fathke
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - William Plum
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Jordan Newell
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Courtni E. Allen
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Geetha S.
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Aaron Shapiro
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Chinyere Okunji
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Idit Kosti
- Department of Biology, Technion-Israel Institute of Technology, Haifa, Israel
| | - Noam Shomron
- Department of Cell and Developmental Biology, Tel Aviv University, Tel Aviv, Israel
| | - Vahan Grigoryan
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Teresa M. Przytycka
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Zuben E. Sauna
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
| | - Raheleh Salari
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Anton A. Komar
- Center for Gene Regulation in Health and Disease, Department of Biological, Geological and Environmental Sciences, Cleveland State University, Cleveland, Ohio, United States of America
- * E-mail: (CKS); (AAK)
| | - Chava Kimchi-Sarfaty
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland, United States of America
- * E-mail: (CKS); (AAK)
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Benhamou Y, Assié C, Boelle PY, Buffet M, Grillberger R, Malot S, Wynckel A, Presne C, Choukroun G, Poullin P, Provôt F, Gruson D, Hamidou M, Bordessoule D, Pourrat J, Mira JP, Le Guern V, Pouteil-Noble C, Daubin C, Vanhille P, Rondeau E, Palcoux JB, Mousson C, Vigneau C, Bonmarchand G, Guidet B, Galicier L, Azoulay E, Rottensteiner H, Veyradier A, Coppo P. Development and validation of a predictive model for death in acquired severe ADAMTS13 deficiency-associated idiopathic thrombotic thrombocytopenic purpura: the French TMA Reference Center experience. Haematologica 2012; 97:1181-6. [PMID: 22580997 DOI: 10.3324/haematol.2011.049676] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acquired thrombotic thrombocytopenic purpura is still associated with a 10-20% death rate. It has still not been possible to clearly identify early prognostic factors of death. This study involved thrombotic thrombocytopenic purpura patients with acquired severe (<10% of normal activity) ADAMTS13 deficiency and aimed to identify prognostic factors associated with 30-day death. DESIGN AND METHODS The study involved a prospective cohort of patients and was carried out between October 2000 and August 2010. A validation cohort of patients was set up from September 2010 to August 2011. Altogether, 281 (analysis cohort) and 66 (validation cohort) consecutive adult thrombotic thrombocytopenic purpura patients with acquired severe ADAMTS13 deficiency were enrolled. The study evaluated 30-day mortality after treatment initiation according to characteristics at inclusion. RESULTS Non-survivors (11%) were older (P=10(-6)) and more frequently presented arterial hypertension (P=5.10(-4)) and ischemic heart disease (P=0.013). Prognosis was increasingly poor with age (P=0.004). On presentation, cerebral manifestations were more frequent in non-survivors (P=0.018) and serum creatinine level was higher (P=0.008). The most significant independent variables determining death were age, severe cerebral involvement and LDH level 10 N or over. A 3-level risk score for early death was defined and confirmed in the validation cohort using these variables, with higher values corresponding to increased risk of early death. CONCLUSIONS A risk score for early death was defined in patients with thrombotic thrombocytopenic purpura and validated on an independent cohort. This score should help to stratify early treatment and identify patients with a worse prognosis.
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Affiliation(s)
- Ygal Benhamou
- Service de Médecine Interne, Hôpital Charles Nicolle, Rouen, France
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Coppo P, Schwarzinger M, Buffet M, Wynckel A, Clabault K, Presne C, Poullin P, Malot S, Vanhille P, Azoulay E, Galicier L, Lemiale V, Mira JP, Ridel C, Rondeau E, Pourrat J, Girault S, Bordessoule D, Saheb S, Ramakers M, Hamidou M, Vernant JP, Guidet B, Wolf M, Veyradier A. Predictive features of severe acquired ADAMTS13 deficiency in idiopathic thrombotic microangiopathies: the French TMA reference center experience. PLoS One 2010; 5:e10208. [PMID: 20436664 PMCID: PMC2859048 DOI: 10.1371/journal.pone.0010208] [Citation(s) in RCA: 241] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 03/12/2010] [Indexed: 11/19/2022] Open
Abstract
Severe ADAMTS13 deficiency occurs in 13% to 75% of thrombotic microangiopathies (TMA). In this context, the early identification of a severe, antibody-mediated, ADAMTS13 deficiency may allow to start targeted therapies such as B-lymphocytes-depleting monoclonal antibodies. To date, assays exploring ADAMTS13 activity require skill and are limited to only some specialized reference laboratories, given the very low incidence of the disease. To identify clinical features which may allow to predict rapidly an acquired ADAMTS13 deficiency, we performed a cross-sectional analysis of our national registry from 2000 to 2007. The clinical presentation of 160 patients with TMA and acquired ADAMTS13 deficiency was compared with that of 54 patients with detectable ADAMTS13 activity. ADAMTS13 deficiency was associated with more relapses during treatment and with a good renal prognosis. Patients with acquired ADAMTS13 deficiency had platelet count <30×109/L (adjusted odds ratio [OR] 9.1, 95% confidence interval [CI] 3.4–24.2, P<.001), serum creatinine level ≤200 µmol/L (OR 23.4, 95% CI 8.8–62.5, P<.001), and detectable antinuclear antibodies (OR 2.8, 95% CI 1.0–8.0, P<.05). When at least 1 criteria was met, patients with a severe acquired ADAMTS13 deficiency were identified with positive predictive value of 85%, negative predictive value of 93.3%, sensitivity of 98.8%, and specificity of 48.1%. Our criteria should be useful to identify rapidly newly diagnosed patients with an acquired ADAMTS13 deficiency to better tailor treatment for different pathophysiological groups.
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Affiliation(s)
- Paul Coppo
- Service d'Hématologie et de Thérapie Cellulaire, AP-HP, Hôpital Saint-Antoine, Paris, France.
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