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Goh YT, Yap ES, Tan CW, Tan D, Loh YSM, Lee YS, Chong LL, Lim ZY, Than H. Consensus recommendations for optimising the diagnosis and treatment of paroxysmal nocturnal haemoglobinuria in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:371-385. [PMID: 38979993 DOI: 10.47102/annals-acadmedsg.202475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Introduction Paroxysmal nocturnal haemoglobinuria (PNH) is a rare haematologic disease characterised by intravascular haemolysis, thrombophilia and bone marrow failure. There is a lack of established clinical guidance on the screening, diagnosis and manage-ment of PNH in Singapore. A relatively low level of awareness among healthcare professionals regarding PNH manifestations further contributes to diagnostic delays. Additionally, limited access to complement inhibitors, like eculizumab, may delay treatment and impact patient outcomes. Method Nine haematologists from different institu-tions in Singapore convened to formulate evidence-based consensus recommendations for optimising the diagnosis and management of patients with PNH and improving access to novel treatments. The experts reviewed the existing literature and international guidelines published from January 2010 to July 2023, focusing on 7 clinical questions spanning PNH screening, diagnostic criteria, investigations, treatment and monitoring of subclinical and classic disease, PNH with underlying bone marrow disorders, and PNH in pregnancy. A total of 181 papers were reviewed to formulate the statements. All experts voted on the statements via 2 rounds of Delphi and convened for an expert panel discussion to finetune the recommendations. Results Sixteen statements have been formulated for optimising the screening, diagnosis and management of PNH. Upon confirmation of PNH diagnosis, individuals with active haemolysis and/or thrombosis should be considered for anti-complement therapy, with eculizumab being the only approved drug in Singapore. Conclusion The current recommendations aim to guide the clinicians in optimising the screening, diagnosis and management of PNH in Singapore.
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Affiliation(s)
- Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Eng Soo Yap
- Department of Laboratory Medicine, National University of Singapore, Singapore
| | - Chuen Wen Tan
- Department of Haematology, Singapore General Hospital, Singapore
| | - Daryl Tan
- Department of Haematology, Mount Elizabeth Novena Specialist Centre, Singapore
| | | | - Yuh Shan Lee
- Department of Haematology, Mount Elizabeth Novena Specialist Centre and Gleneagles Hospital, Singapore
| | - Lip Leong Chong
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Zi Yi Lim
- Centre for Clinical Haematology, Mount Elizabeth Novena Specialist Centre, Singapore
| | - Hein Than
- Department of Haematology, Singapore General Hospital, Singapore
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2
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Du W, Mei L. A case report of pegcetacoplan use for a pregnant woman with paroxysmal nocturnal hemoglobinuria. Res Pract Thromb Haemost 2024; 8:102435. [PMID: 38846741 PMCID: PMC11153911 DOI: 10.1016/j.rpth.2024.102435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/09/2024] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH), a rare hematologic disease, is associated with high maternal and fetal mortality rates. Only 1 medication approved for PNH, the complement component 5 inhibitor eculizumab, has published evidence of use during pregnancy. Key Clinical Question What were the circumstances and outcomes of the first use of pegcetacoplan, a complement component 3 inhibitor, by a pregnant woman with PNH? Clinical Approach The patient, with a history of 2 miscarriages and a suboptimal response to eculizumab, had hematologic improvement after switching to pegcetacoplan. She continued pegcetacoplan throughout her pregnancy. At gestational week 30, she developed abruptio placentae and breakthrough hemolysis. She delivered a normal-appearing male infant via emergency cesarean section. The breakthrough hemolysis resolved quickly with short-term intensive pegcetacoplan dosing and add-on eculizumab. To date, her laboratory values remain normal, and she has had no thromboembolic events; her son has not demonstrated growth defects. Conclusion This is the first report of pegcetacoplan treatment for PNH throughout pregnancy. The mother recovered promptly from breakthrough hemolysis that prompted an emergency delivery. Her son, who was born prematurely but healthy, has developed normally.
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Affiliation(s)
- Wei Du
- Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lin Mei
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ilic J, Pujic B, Jakovljevic B, Sekulic B, Agic D, El Farra A, Micanovic B, Vejnovic T, Urosevic I, Savic A. Eculizumab for paroxysmal nocturnal hemoglobinuria: Two cases of successful pregnancy outcomes. Clin Case Rep 2024; 12:e8900. [PMID: 38725930 PMCID: PMC11079538 DOI: 10.1002/ccr3.8900] [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: 02/13/2024] [Revised: 04/10/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
Paroxysmal nocturnal hemoglobinuria is a rare disease with the incidence ranging from 0.08 to 0.57 per 100,000 person-years. Up to 25% of cases in women are detected during pregnancy. We report two cases of successful pregnancy outcomes in patients treated with eculizumab, pointing out the importance of interdisciplinary approach in these high-risk pregnancies.
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Affiliation(s)
- Jovanka Ilic
- Clinic оf HematologyClinical Center оf VojvodinaNovi SadSerbia
| | - Borislava Pujic
- Clinic of AnesthesiaIntensive Care and Pain Therapy, Clinical Center оf VojvodinaNovi SadSerbia
| | | | - Borivoj Sekulic
- Clinic оf HematologyClinical Center оf VojvodinaNovi SadSerbia
- Department of Internal Medicine, Faculty оf MedicineUniversity оf Novi SadNovi SadSerbia
| | - Danijela Agic
- Clinic оf HematologyClinical Center оf VojvodinaNovi SadSerbia
- Department of Internal Medicine, Faculty оf MedicineUniversity оf Novi SadNovi SadSerbia
| | - Amir El Farra
- Clinic оf HematologyClinical Center оf VojvodinaNovi SadSerbia
- Department of Internal Medicine, Faculty оf MedicineUniversity оf Novi SadNovi SadSerbia
| | | | - Tihomir Vejnovic
- Clinic of Gynecology and ObstetricsClinical Center оf VojvodinaNovi SadSerbia
- Department of Gynecology and Obstetrics, Faculty оf MedicineUniversity оf Novi SadNovi SadSerbia
| | - Ivana Urosevic
- Clinic оf HematologyClinical Center оf VojvodinaNovi SadSerbia
- Department of Internal Medicine, Faculty оf MedicineUniversity оf Novi SadNovi SadSerbia
| | - Aleksandar Savic
- Clinic оf HematologyClinical Center оf VojvodinaNovi SadSerbia
- Department of Internal Medicine, Faculty оf MedicineUniversity оf Novi SadNovi SadSerbia
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4
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Szer J. C5 inhibition in PNH: still effective and safe. Blood 2024; 143:1064-1065. [PMID: 38512266 DOI: 10.1182/blood.2023023626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
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5
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Zhang B, Chu R, Huang C, Song X, Wang J, Li L, Xu Y, Ma Y. Progress in the Management of Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Review. J Womens Health (Larchmt) 2024; 33:98-104. [PMID: 37917919 DOI: 10.1089/jwh.2023.0164] [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] [Indexed: 11/04/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired complement-mediated hemolytic disease characterized by intravascular hemolysis, thrombosis, smooth muscle dystonia, and so on. Thrombosis is the principal cause of death in PNH patients. During the perinatal period, pregnant PNH patients have increased morbidity and mortality with a heightened risk of complications, including significant preterm birth. The management of pregnancy complicated by PNH is difficult. Therefore, early diagnosis, standardized treatment protocols, and improving perinatal outcomes are crucial. However, there is a lack of consensus on treating patients with PNH during pregnancy. This article reviews 32 studies of pregnancy affected by PNH, focusing on the clinical presentation, diagnosis, and treatment strategies of PNH, to provide guidance for obstetricians on how to handle pregnant patients with PNH, and to offer academic support for the management of PNH patients. We found that Eculizumab has become the primary choice for treating PNH, effectively controlling intravascular hemolysis and reducing the frequency of blood transfusions necessary to stabilize the condition, with no severe threat to the safety of the mother and fetus.
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Affiliation(s)
- Bei Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, P.R. China
| | - Changzhen Huang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Xiao Song
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, P.R. China
| | - Jianye Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Liang Li
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, P.R. China
| | - Yintao Xu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, P.R. China
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Vinogradova MA, Kulagin AD, Shmakov RG. Pregnancy in paroxysmal nocturnal hemoglobinuria: from survival to life. TERAPEVT ARKH 2022; 94:859-864. [DOI: 10.26442/00403660.2022.07.201714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/22/2022]
Abstract
Background. Pregnancy in paroxysmal nocturnal hemoglobinuria (PNH) patients has historically been a high-risk situation. The combination of chronic complement-mediated hemolysis caused by the disease and physiological activation of the complement system during pregnancy, significantly worsened the prognosis for the life. For a long time, there were no effective methods for the PNH treatment, and pregnancy in patients seemed to be extremely risky, as it significantly increased the risk of life-threatening complications. The advent of targeted therapy with eculizumab turned the prognosis of this disease upside down: patients began not only to survive, but also to live comparable to healthy people. A comparative analysis of the course and outcomes of pregnancy in patients with PNH treated with eculizumab and in patients without targeted therapy was carried out.
Aim. The study was to evaluate the course and outcomes of pregnancy in patients with PNH, depending on the therapeutic approach.
Materials and methods. We analyzed data from 57 pregnancies in 49 women (31 used eculizumab, 26 with supportive care only) observed at the Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology or with remote consultation (23 clinics from 19 cities of Russia).
Results. The high probability of pregnancy complications and its adverse outcomes outside of targeted therapy indicates the vital need for its use: all observations were accompanied by complications of varying severity. The course of pregnancy with the eculizumab is generally more favorable: an apparently higher rate of live births and a lower likelihood of complications are registered. Without increasing the incidence of complications, eculizumab significantly improves pregnancy outcomes for both mother and fetus, and does not adversely affect the health of newborns.
Conclusion. Thus, eculizumab allows not only to increase the survival rate of patients with PNH, but also to comprehensively improve their quality of life, including the possibility of safe childbirth.
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7
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Manning JE, Anderson RM, Hill A, Zeidan D, Ciantar E. Pregnancy outcomes in women receiving eculizumab for the management of paroxysmal nocturnal haemoglobinuria. Obstet Med 2022; 15:45-49. [PMID: 35444730 PMCID: PMC9014543 DOI: 10.1177/1753495x211019899] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 11/15/2022] Open
Abstract
Aims To report pregnancy outcomes and complications in women receiving eculizumab for the management of paroxysmal nocturnal haemoglobinuria. Methods A service evaluation of routinely collected medical records across 49 pregnancies in 21 women. Results Eculizumab was used in 37 pregnancies, 31 of which (83.8%) ended in live birth. Eight infants (25.8%) were born prematurely. Over half (54%) of women required increases in their dose of eculizumab to control their haemolysis. There were no reported cases of maternal thrombosis. Major ante/postpartum bleeding necessitating urgent intervention was reported in 10.8% of pregnancies. There were two cases of intrauterine death and three miscarriages. There were no maternal or neonatal deaths. Three newborns required prolonged hospital stays. Conclusions Eculizumab appears to benefit pregnant women with paroxysmal nocturnal haemoglobinuria and pregnancy outcomes following its use are largely good.
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Affiliation(s)
| | | | - Anita Hill
- Department of Haematology, Leeds
Teaching Hospitals NHS Trust, Leeds, UK
| | - Doaa Zeidan
- Department of Obstetrics &
Gynaecology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Etienne Ciantar
- Department of Obstetrics &
Gynaecology, Leeds Teaching Hospitals NHS Trust, Leeds, UK,Etienne Ciantar, Division of Women's and
Children's Health, Leeds Teaching Hospitals NHS Trust, Room 9.88, Worsley
Building, Leeds LS29NL, UK.
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8
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de Latour RP, Hosokawa K, Risitano AM. Hemolytic paroxysmal nocturnal hemoglobinuria: 20 years of medical progress. Semin Hematol 2022; 59:38-46. [DOI: 10.1053/j.seminhematol.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/06/2022] [Indexed: 12/15/2022]
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9
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Risitano AM, Peffault de Latour R. How we('ll) treat paroxysmal nocturnal haemoglobinuria: diving into the future. Br J Haematol 2021; 196:288-303. [PMID: 34355382 PMCID: PMC9291300 DOI: 10.1111/bjh.17753] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by complement-mediated intravascular haemolysis, severe thrombophilia and bone marrow failure. While for patients with bone marrow failure the treatment follows that of immune-mediated aplastic anaemia, that of classic, haemolytic PNH is based on anti-complement medication. The anti-C5 monoclonal antibody eculizumab has revolutionized treatment, resulting in control of intravascular haemolysis and thromboembolic risk, with improved long-term survival. Novel strategies of complement inhibition are emerging. New anti-C5 agents reproduce the safety and efficacy of eculizumab, with improved patient convenience. Proximal complement inhibitors have been developed to address C3-mediated extra-vascular haemolysis and seem to improve haematological response.
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Affiliation(s)
- Antonio Maria Risitano
- Department of Onco-Hematology, AORN San Giuseppe Moscati Avellino, Avellino, Italy.,Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.,Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands
| | - Régis Peffault de Latour
- Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands.,French Reference Centre for Aplastic Anaemia and Paroxysmal Nocturnal Haemoglobinuria, Assistance Publique - Hôpitaux de Paris, Saint-Louis Hospital, Paris, France.,Bone Marrow Transplant Unit, Université de Paris, Denis Diderot, Paris, France
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10
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Al-Dosari YM, Al-Zahrani H, Al-Mohareb F, Hashmi S. Pregnancy with Paroxysmal Nocturnal Hemoglobinuria: A Case Series with Review of the Literature. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2021; 9:178-189. [PMID: 34084110 PMCID: PMC8152383 DOI: 10.4103/sjmms.sjmms_4_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 12/31/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematopoietic stem cell disorder, and eculizumab and ravulizumab are its two approved therapies. Only few case series/reports have reported the outcomes of pregnancies in patients with PNH despite the increased risk of thrombosis. Similarly, there is limited knowledge regarding the effect of the approved treatments on conception and pregnancy outcomes. Here, we report the first series of pregnancies in PNH patients from the Middle Eastern region from our tertiary care hospital. Ten pregnancies in four females after diagnosis with PNH were identified. In terms of PNH management, only eculizumab was used, as the safety of ravulizumab use in pregnancies has not yet been established. In the antepartum period, the patients had variable symptoms that ranged from mild symptoms including epistaxis, tea-colored urine and vaginal bleeding to life-threatening vessel thrombosis. Further, red blood cell and platelet transfusions were required because of bleeding and hemolysis in four pregnancies. The pregnancy outcomes varied, but based on these, the safety of eculizumab use during pregnancy remained inconclusive. The postpartum period was complicated in one case by portal vein thrombosis and was managed accordingly. In conclusion, pregnant females with PNH are at an increased risk for complications due to PNH, and thus experienced hematologists and obstetricians should be involved jointly in their care.
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Affiliation(s)
- Yara Mohammad Al-Dosari
- Internal Medicine Department, Bahrain Defence Force Hospital and Royal Medical Services, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hazza Al-Zahrani
- Adult Hematology/Bone Marrow Transplantation Section, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahad Al-Mohareb
- Adult Hematology, HSCT Section, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shahrukh Hashmi
- Adult Hematology/Bone Marrow Transplantation Section, Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Magnani HN. Rationale for the Role of Heparin and Related GAG Antithrombotics in COVID-19 Infection. Clin Appl Thromb Hemost 2021; 27:1076029620977702. [PMID: 33539214 PMCID: PMC7868468 DOI: 10.1177/1076029620977702] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
The SARS-CoV-2 pandemic has focused attention on prevention, restriction and treatment methods that are acceptable worldwide. This means that they should be simple and inexpensive. This review examines the possible role of glycosaminoglycan (GAG) antithrombotics in the treatment of COVID-19. The pathophysiology of this disease reveals a complex interplay between the hemostatic and immune systems that can be readily disrupted by SARS-CoV-2. Some of the GAG antithrombotics also possess immune-modulatory actions and since they are relatively inexpensive they could play an important role in the management of COVID-19 and its complications.
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12
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Alashkar F, Saner FH, Vance C, Schmücker U, Herich-Terhürne D, Dührsen U, Köninger A, Röth A. Pregnancy in Classical Paroxysmal Nocturnal Hemoglobinuria and Aplastic Anemia-Paroxysmal Nocturnal Hemoglobinuria: A High-Risk Constellation. Front Med (Lausanne) 2020; 7:543372. [PMID: 33102497 PMCID: PMC7546795 DOI: 10.3389/fmed.2020.543372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 08/20/2020] [Indexed: 11/13/2022] Open
Abstract
Pregnancies in paroxysmal nocturnal hemoglobinuria (PNH) are associated with increased morbidity and mortality. Retrospective studies suggest that outcome has improved with the advent of the complement inhibitor eculizumab. To substantiate this assumption we analyzed the data from patients treated in our department since 2009. All patients were included in the International PNH registry and followed prospectively. We identified 16 pregnancies in 9 patients with classical PNH, and two pregnancies in two patients with aplastic anemia (AA)-PNH. In classical PNH, 13 pregnancies were supported by eculizumab. Breakthrough hemolysis occurred in six pregnancies, necessitating an increase in the biweekly eculizumab dose from 900 mg to 1,200–1,800 mg. Red blood cell transfusions were given in six and platelet transfusions in two pregnancies. A Budd-Chiari syndrome and cholecystitis complicated the course of two pregnancies. Four of 13 pregnancies supported by eculizumab ended in spontaneous abortion or stillbirth, and one was prematurely terminated because of fetal trisomy 21. None of the three pregnancies not supported by eculizumab had a successful outcome. Half the deliveries were preterm. None of the patients died, and, in all but one patient, the post-partum period was uneventful. Both pregnancies in patients with AA-PNH took a favorable course. Our results confirm low maternal mortality and frequent breakthrough hemolysis in pregnant PNH patients receiving eculizumab. Fetal mortality and the rate of preterm delivery were higher than reported previously, possibly related to the use of registry data that are likely to reduce the risk of publication and recall biases.
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Affiliation(s)
- Ferras Alashkar
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, University Hospital, University Duisburg Essen, Essen, Germany
| | - Colin Vance
- Rheinisch-Westfälisches Institut für Wirtschaftsforschung, Essen, Germany
| | - Ute Schmücker
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dörte Herich-Terhürne
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Dührsen
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Angela Köninger
- Department of Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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13
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Rodríguez-Ferreras A, Velasco-Roces L. Eculizumab-Related Abortion in a Woman with Paroxysmal Nocturnal Hemoglobinuria: A Case Report. J Reprod Infertil 2019; 20:252-255. [PMID: 31897393 PMCID: PMC6928406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The use of eculizumab during pregnancy has generally been discouraged. Published data on related studies provides conflicting information and establishing a benefit-risk relationship proves to be a complicated task. Miscarriage rates, concomitant medications, and the stages of pregnancy when eculizumab treatment was initiated varied among the patients included in the case series. The aim of this report is to discuss eculizumab use during pregnancy. CASE PRESENTATION A case of a woman diagnosed with Paroxysmal Nocturnal Hemoglobinuria (PNH) and treated with eculizumab, who expressed desire for pregnancy is presented. Six months after her eculizumab treatment, the patient experienced spontaneous abortion in her first trimester. The direct relation between eculizumab and the miscarriage is not clear. Other factors may have influenced this case, thus demonstrating the difficulty of managing pregnancy in women with PNH. CONCLUSION Controversy on eculizumab risk during pregnancy encourages further review on its use, highlighting the importance to assess each case individually.
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Affiliation(s)
- Adrián Rodríguez-Ferreras
- Corresponding Author: Adrián Rodríguez-Ferreras, Pharmacy Department, Hospital Universitario Central de Asturias, Oviedo, Spain, E-mail:
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Patriquin CJ, Kiss T, Caplan S, Chin-Yee I, Grewal K, Grossman J, Larratt L, Marceau D, Nevill T, Sutherland DR, Wells RA, Leber B. How we treat paroxysmal nocturnal hemoglobinuria: A consensus statement of the Canadian PNH Network and review of the national registry. Eur J Haematol 2018; 102:36-52. [PMID: 30242915 DOI: 10.1111/ejh.13176] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 12/27/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disease characterized by intravascular hemolysis, thrombophilia, and marrow failure. Its phenotype is due to absent or reduced expression of GPI-linked complement regulators and subsequent sensitivity of hematopoietic cells to complement-mediated damage and lysis. Introduction of the terminal complement inhibitor eculizumab drastically improved outcomes in PNH patients; however, despite this improvement, there remain several challenges faced by PNH patients and physicians who care for them. One of the most important is increasing awareness of the heterogeneity with which patients can present, which can lead to significant delays in recognition. Data from the Canadian PNH Registry are presented to demonstrate the variety of presenting symptoms. In Canada, geography precludes consolidation of care to just a few centers, so management is distributed across academic hospitals, linked together as the Canadian PNH Network. The Network over the last several years has developed educational programs and clinical checklists and has worked to standardize access to diagnostics across the country. Herein, we address some of the common diagnostic and therapeutic challenges faced by PNH physicians and give our recommendations. Gaps in knowledge are also addressed, and where appropriate, consensus opinion is provided.
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Affiliation(s)
| | - Thomas Kiss
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Stephen Caplan
- Transfusion Services, Jewish General Hospital, Montreal, Quebec, Canada
| | - Ian Chin-Yee
- Divisions of Hematology and Pathology & Laboratory Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Kuljit Grewal
- Department of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Jennifer Grossman
- Division of Hematology and Hematological Malignancies, University of Calgary, Calgary, Alberta, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, Alberta, Canada
| | - Daniele Marceau
- Division of Hematology and Oncology, Laval University, Quebec City, Quebec, Canada
| | - Tom Nevill
- Leukemia/BMT Program of British Columbia, BC Cancer Agency, Vancouver, British Columbia, Canada
| | | | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences, Toronto, Ontario, Canada
| | - Brian Leber
- Division of Hematology & Thromboembolism, McMaster University, Hamilton, Ontario, Canada
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15
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Devos T, Meers S, Boeckx N, Gothot A, Deeren D, Chatelain B, Chatelain C, Devalet B. Diagnosis and management of PNH: Review and recommendations from a Belgian expert panel. Eur J Haematol 2018; 101:737-749. [PMID: 30171728 DOI: 10.1111/ejh.13166] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 12/17/2022]
Abstract
Despite its considerable morbidity and mortality, paroxysmal nocturnal haemoglobinuria (PNH) is still underdiagnosed. Patients with PNH can suffer from cardiovascular, gastrointestinal, neurological or haematological symptoms and refer to several specialists. The aim of this paper is to review the diagnosis and the management of PNH patients, with the primary focus on identifying high-risk groups. Additionally, the implementation and prognostic value of the defined high-risk groups will be commented on and the management of PNH patients is discussed from a Belgian perspective. Finally, based on the available data, recommendations are provided. Eculizumab is a potent C5 complement inhibitor and reduces intravascular haemolysis and thrombosis in PNH patients and improves their quality of life. As thrombosis is the main cause of death in PNH patients, identifying high-risk PNH patients in need of therapy is essential. Currently, novel complement inhibitors are in development and the first data seem promising. Another challenge in PNH is to identify new markers to assess the thrombotic risk to achieve a better risk-based prophylactic anti-thrombotic management. Finally, because of the low prevalence of the disease, PNH patients should be included in the prospective PNH registry, which will offer new insights on the natural course of the disease and the impact of treatment of PNH.
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Affiliation(s)
- Timothy Devos
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Experimental Transplantation, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Stef Meers
- Department of Haematology, AZ KLINA, Brasschaat, Belgium
| | - Nancy Boeckx
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | - Andre Gothot
- Department of Laboratory Haematology and Immuno-Haematology, CHU Liège, Liège, Belgium
| | - Dries Deeren
- Department of Haematology, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Bernard Chatelain
- Laboratory of Haematology, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Christian Chatelain
- Department of Haematology, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Bérangère Devalet
- Department of Haematology, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
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16
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Abstract
Pregnancy can be a dangerous trigger for patients with paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), or hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome. Due to the possibility of several serious complications, pregnancy is somewhat discouraged in the presence of the above diseases. Eculizumab is a humanized antibody that may dramatically change the clinical course of PNH, aHUS and HELLP syndrome. However, data on the safety of eculizumab in pregnancy are scarce. In this narrative overview, we summarize current evidence on the use of eculizumab during pregnancy in women with PNH, aHUS and HELLP syndrome. Eculizumab is not present in breast milk, and the levels observed in umbilical cord blood samples are not sufficient to affect the concentrations of complement in newborns. Therefore, eculizumab may be regarded as safe in pregnancy. Nonetheless, given that data on eculizumab in pregnancy are limited, it is not possible to completely exclude risks for both mother and fetus in treating PNH, aHUS and HELLP syndrome.
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17
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Lauritsch‐Hernandez LS, Kraehenmann F, Balabanov S, Kimmich N. Eculizumab application during pregnancy in a patient with paroxysmal nocturnal hemoglobinuria: A case report with review of the literature. Clin Case Rep 2018; 6:1582-1587. [PMID: 30147909 PMCID: PMC6099006 DOI: 10.1002/ccr3.1634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/19/2018] [Accepted: 05/19/2018] [Indexed: 01/20/2023] Open
Abstract
Eculizumab is highly effective in inhibiting complement activation and has successfully shown to prevent complications and to improve quality of life in patients with paroxysmal nocturnal hemoglobinuria (PNH). Its application during pregnancy showed favorable fetal and maternal outcome in the presented case and has proven to be effective without raising safety concerns.
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Affiliation(s)
| | | | - Stefan Balabanov
- Department of HematologyUniversity Hospital of ZurichZurichSwitzerland
| | - Nina Kimmich
- Department of ObstetricsUniversity Hospital of ZurichZurichSwitzerland
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18
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Sicre de Fontbrune F, Peffault de Latour R. Ten Years of Clinical Experience With Eculizumab in Patients With Paroxysmal Nocturnal Hemoglobinuria. Semin Hematol 2018; 55:124-129. [DOI: 10.1053/j.seminhematol.2018.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/03/2018] [Indexed: 12/12/2022]
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19
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Vasbien M, Minon JM. Paroxysmal nocturnal haemoglobinuria diagnosis in a woman after foetal loss. Int J Lab Hematol 2017; 39:e86-e89. [PMID: 28333408 DOI: 10.1111/ijlh.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Vasbien
- Thrombosis and Haemostasis Unit, Department of Laboratory Medicine, Centre Hospitalier Régional de Liège, Liege, Belgium
| | - J M Minon
- Thrombosis and Haemostasis Unit, Department of Laboratory Medicine, Centre Hospitalier Régional de Liège, Liege, Belgium
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20
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Griffin M, Munir T. Management of thrombosis in paroxysmal nocturnal hemoglobinuria: a clinician's guide. Ther Adv Hematol 2016; 8:119-126. [PMID: 28246555 DOI: 10.1177/2040620716681748] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH), an ultra-orphan disease with a prevalence of 15.9 per million in Europe, is a life-threatening disorder, characterized by haemolysis, bone marrow failure and thrombosis. Patients with PNH prior to the availability of eculizumab had a median survival of between 10 and 22 years, with thrombosis accounting for 22-67% of deaths. 29-44% of patients had at least one thrombosis. This paper provides a clinician's guide to the diagnosis, management and complications of PNH, with an emphasis on thrombosis.
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Affiliation(s)
- Morag Griffin
- Leeds Teaching Hospitals NHS Trust, St James Hospital, Beckett Street, Leeds LS1 3EX, UK
| | - Talha Munir
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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21
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Two consecutive pregnancies in a patient with paroxysmal nocturnal haemoglobinuria treated with anticoagulant therapy at different doses. Blood Coagul Fibrinolysis 2016; 27:109-12. [PMID: 26258669 DOI: 10.1097/mbc.0000000000000386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is a rare acquired disorder of haematopoietic stem cells characterized by intravascular haemolysis, cytopenias and thrombophilia. Thrombophilia is the leading cause of mortality in patients with PNH. As the risk of thrombogenesis further increases during pregnancy and the postpartum period, an anticoagulant therapy is generally recommended for pregnant women with PNH. However, there are no standardized criteria for determining the appropriate dose of anticoagulant therapy. We describe the case of a PNH patient with who was managed with anticoagulant therapy at different doses during two consecutive pregnancies. A prophylactic dose of heparin was administered during her first pregnancy and a therapeutic dose, during her second pregnancy. Both pregnancies resulted in uncomplicated vaginal deliveries without thrombosis. Interestingly, not only D-dimer (as a thrombotic marker) but also lactate dehydrogenase (as a haemolytic marker) levels were lower during her second pregnancy when a therapeutic dose of heparin was used.
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22
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Al-Ani F, Chin-Yee I, Lazo-Langner A. Eculizumab in the management of paroxysmal nocturnal hemoglobinuria: patient selection and special considerations. Ther Clin Risk Manag 2016; 12:1161-70. [PMID: 27536121 PMCID: PMC4975135 DOI: 10.2147/tcrm.s96720] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a nonmalignant clonal disorder resulting from somatic mutation in the PIG-A gene leading to a deficiency of the membrane-anchoring molecule glycosylphosphatidylinositol. The lack of expression of two glycosylphosphatidylinositol-anchored proteins involved in the regulation of the complement system renders PNH erythrocytes susceptible to complement-mediated lysis. Clinical manifestations include thromboembolic disease, chronic kidney injury, pulmonary hypertension, smooth muscle dysfunction, and chronic hemolysis. Until recently, treatment was mainly supportive with most patients suffering from significant morbidity and shortened survival compared to age-matched controls. The development of eculizumab, a humanized monoclonal antibody directed against the terminal complement protein C5, has resulted in dramatic improvements of survival and reduction in complications. In this paper, we review some special considerations pertaining to the use of eculizumab for PNH.
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Affiliation(s)
| | | | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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23
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Consenso español para el diagnóstico y tratamiento de la hemoglobinuria paroxística nocturna. Med Clin (Barc) 2016; 146:278.e1-7. [DOI: 10.1016/j.medcli.2015.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/26/2015] [Accepted: 12/01/2015] [Indexed: 11/22/2022]
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24
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Miyasaka N, Miura O, Kawaguchi T, Arima N, Morishita E, Usuki K, Morita Y, Nishiwaki K, Ninomiya H, Gotoh A, Imashuku S, Urabe A, Shichishima T, Nishimura JI, Kanakura Y. Pregnancy outcomes of patients with paroxysmal nocturnal hemoglobinuria treated with eculizumab: a Japanese experience and updated review. Int J Hematol 2016; 103:703-12. [PMID: 26857155 DOI: 10.1007/s12185-016-1946-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 12/16/2022]
Abstract
Pregnancy with paroxysmal nocturnal hemoglobinuria (PNH) is associated with significant risk of complications, such as life-threatening thrombosis. Recently, eculizumab has come into clinical use and revolutionized the treatment of PNH. However, clinical information regarding eculizumab use for PNH during pregnancy is limited. The present report describes pregnancies with PNH treated with eculizumab that were registered with the Japan PNH study group and reviews the literature. In case 1, the patient received eculizumab throughout pregnancy and delivered a healthy neonate at term, although breakthrough hemolysis occurred at 20 weeks of gestation. In case 2, the patient discontinued eculizumab before pregnancy and developed preeclampsia at 27 weeks of gestation. She received eculizumab and delivered a preterm, but healthy, neonate by cesarean section. In case 3, the patient received eculizumab from 18 weeks of gestation and delivered a healthy neonate at term without any complications. Reports of 11 pregnant women treated with eculizumab were identified in the literature. Of 14 pregnancies, including our own cases, breakthrough hemolysis and preeclampsia occurred in five and two cases, respectively. There were no thrombotic complications, maternal or neonatal deaths, or fetal structural abnormalities. Thus, eculizumab appears to be safe and effective for managing PNH during pregnancy.
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Affiliation(s)
- Naoyuki Miyasaka
- Department of Pediatrics, Perinatal and Maternal Medicine, Graduate School of Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan.
| | - Osamu Miura
- Department of Hematology, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Tatsuya Kawaguchi
- Departments of Hematology and Infectious Diseases, Kumamoto University Hospital, Kumamoto, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Nobuyoshi Arima
- Department of Hematology, Medical Research Institute Kitano Hospital, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Yasuyoshi Morita
- Division of Hematology and Rheumatology, Department of Internal Medicine, Kinki University Faculty of Medicine, Osaka-Sayama, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Kaichi Nishiwaki
- Department of Oncology and Haematology, Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Haruhiko Ninomiya
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Akihiko Gotoh
- Division of Hematology, First Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Shinsaku Imashuku
- Division of Hematology, Takasago-Seibu Hospital, Takasago, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Akio Urabe
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Tsutomu Shichishima
- Department of Cardiology and Hematology, Fukushima Medical University, Fukushima, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan.,Working Group for Pregnancy in PNH, The Japan PNH Study Group, Tokyo, Japan
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25
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Postpartum thrombotic complication in a patient with paroxysmal nocturnal hemoglobinuria. Blood Coagul Fibrinolysis 2016; 26:458-63. [PMID: 25688459 DOI: 10.1097/mbc.0000000000000250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal nonneoplastic hematopoietic stem cell disease characterized by an acquired mutation of the PIG-A gene with reduction or absence of CD55 and CD59. The absence of these proteins renders PNH erythrocytes susceptible to complement-mediated hemolysis. We report the case of a PNH patient before and during pregnancy until delivery. We observed and treated some postpartum thrombotic complications. Eculizumab should be used with caution in pregnancy. There are several reports supporting its use in these patients. This case should be considered paradigmatic of a series of clinical situations that may occur in the course of a pregnancy in patients with PNH: increased need for transfusion, need to increase the dose of Eculizumab, and insurgence of fetal sufferance. Moreover, after delivery, the patient, despite adequate prophylaxis with low-molecular-weight heparins, presented severe complications: development of pleural and peritoneal effusion, pulmonary embolism, bilateral upper limbs thrombophlebitis, and a possible abdominal angina with a transient paralytic ileus. All these complications were overcome and now the baby is healthy and the mother has returned to the usual therapeutic regimen.
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26
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Kelly RJ, Höchsmann B, Szer J, Kulasekararaj A, de Guibert S, Röth A, Weitz IC, Armstrong E, Risitano AM, Patriquin CJ, Terriou L, Muus P, Hill A, Turner MP, Schrezenmeier H, Peffault de Latour R. Eculizumab in Pregnant Patients with Paroxysmal Nocturnal Hemoglobinuria. N Engl J Med 2015; 373:1032-9. [PMID: 26352814 DOI: 10.1056/nejmoa1502950] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Eculizumab, a humanized monoclonal antibody against complement protein C5 that inhibits terminal complement activation, has been shown to prevent complications of paroxysmal nocturnal hemoglobinuria (PNH) and improve quality of life and overall survival, but data on the use of eculizumab in women during pregnancy are scarce. METHODS We designed a questionnaire to solicit data on pregnancies in women with PNH and sent it to the members of the International PNH Interest Group and to the physicians participating in the International PNH Registry. We assessed the safety and efficacy of eculizumab in pregnant patients with PNH by examining the birth and developmental records of the children born and adverse events in the mothers. RESULTS Of the 94 questionnaires that were sent out, 75 were returned, representing a response rate of 80%. Data on 75 pregnancies in 61 women with PNH were evaluated. There were no maternal deaths and three fetal deaths (4%). Six miscarriages (8%) occurred during the first trimester. Requirements for transfusion of red cells increased during pregnancy, from a mean of 0.14 units per month in the 6 months before pregnancy to 0.92 units per month during pregnancy. Platelet transfusions were given in 16 pregnancies. In 54% of pregnancies that progressed past the first trimester, the dose or the frequency of use of eculizumab had to be increased. Low-molecular-weight heparin was used in 88% of the pregnancies. Ten hemorrhagic events and 2 thrombotic events were documented; both thrombotic events occurred during the postpartum period. A total of 22 births (29%) were premature. Twenty cord-blood samples were examined for the presence of eculizumab; the drug was detected in 7 of the samples. A total of 25 babies were breast-fed, and in 10 of these cases, breast milk was examined for the presence of eculizumab; the drug was not detected in any of the 10 breast-milk samples. CONCLUSIONS Eculizumab provided benefit for women with PNH during pregnancy, as evidenced by a high rate of fetal survival and a low rate of maternal complications. (ClinicalTrials.gov number, NCT01374360.).
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Affiliation(s)
- Richard J Kelly
- From Department of Haematology, St. James's University Hospital, Leeds (R.J.K., A.H.), and Haematological Medicine, Kings College Hospital, London (A.K.) - both in the United Kingdom; University of Ulm and German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen, Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, Ulm (B.H., H.S.), and Department of Hematology, University Hospital of Essen, Essen (A.R.) - both in Germany; PNH Subcommittee of the Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden (B.H., A.K., A.M.R., L.T., H.S., R.P.L.), and Radboud University Medical Center, Nijmegen (P.M.) - both in the Netherlands; Department of Clinical Haematology, the Royal Melbourne Hospital and University of Melbourne, Parkville, VIC, Australia (J.S.); Department of Hematology, University Hospital, Rennes (S.G.), Clinical Immunology, Department of Internal Medicine, University Hospital of Lille, Lille (L.T.), and Assistance Publique-Hôpitaux de Paris, Service d'Hématologie-Greffe, Hôpital Saint-Louis, University Paris Diderot, Sorbonne Paris Cité, Centre de Référence Aplasie Médullaire-HPN, and Filière de Santé Maladie Rare Immuno-Hématologique (MARIH), Paris (R.P.L.) - all in France; Jane Anne Nohl Division of Hematology, Keck School of Medicine of University of Southern California, Los Angeles (I.C.W.); Department of Hematology, Helsinki University Central Hospital, Helsinki (E.A.); Hematology, Department of Clinical Medicine and Surgery, Federico II, University of Naples, Naples, Italy (A.M.R.); Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada (C.J.P.); and ICON Clinical Research, San Francisco (M.P.T.)
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27
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Eculizumab treatment during pregnancy does not affect the complement system activity of the newborn. Immunobiology 2015; 220:452-9. [DOI: 10.1016/j.imbio.2014.11.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 11/18/2022]
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28
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Meppiel E, Crassard I, Latour RPD, de Guibert S, Terriou L, Chabriat H, Socié G, Bousser MG. Cerebral venous thrombosis in paroxysmal nocturnal hemoglobinuria: a series of 15 cases and review of the literature. Medicine (Baltimore) 2015; 94:e362. [PMID: 25569655 PMCID: PMC4602837 DOI: 10.1097/md.0000000000000362] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of hematopoietic stem cells characterized by hemolytic anemia, marrow failure, and a high incidence of life-threatening venous thrombosis. Cerebral venous system is the second most frequent location of thrombosis after hepatic veins. However, data about PNH-related cerebral venous thrombosis (CVT) are very scarce because of the rarity of both the disorders.We report a French study about PNH patients with CVT. Patients were recruited retrospectively, from the Société Française d'Hématologie (SFH) registry of 465 patients with PNH; the Lariboisière registry of 399 patients with CVT; and a direct contact with 26 French Hematology Units. We review cases reported since 1938 in the English and French language literature. We then compared patients of our series with cases from the literature, with non-PNH-related CVT cases from Lariboisière registry, and with PNH patients without CVT from SFH registry.Fifteen patients were included between 1990 and 2012. Most patients were women (12/15) and half of them presented associated hormonal venous thrombosis risk factors. Three patients had concomitant hepatic vein thrombosis. CVT was the first manifestation of PNH in 4 patients. No major difference in CVT characteristics was found compared with non-PNH-related CVT cases, except for a younger age at diagnosis in PNH patients (P < 0.001). All patients were treated with anticoagulation therapy. One death occurred in acute stage. All surviving patients were independent 1 year after. Median survival time was 9 years. Recurrent thrombosis rate was 50% at 6 years, occurring in patients that did not have bone marrow transplantation or eculizumab therapy. Cases of death were mainly related to hepatic vein thrombosis.Prognosis of CVT was good in our series. However, these patients have a poor long-term prognosis due to PNH disease by itself. PNH treatment should be proposed as soon as possible to avoid recurrent thrombosis. Besides, inaugural CVT events encourage investigating PNH in case of cytopenia, hemolysis, abdominal veins thrombosis, or aplastic anemia history associated with the neurological complication.
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Affiliation(s)
- Elodie Meppiel
- From the AP-HP, Hôpital Lariboisière (EM, IC, HC, M-GB), Service de Neurologie; AP-HP, Hôpital Saint Louis (RPL, GS), Service d'Hématologie Greffe, Paris; Centre Hospitalier Pontchaillou (SG), Service d'Hématologie Clinique, Rennes; Hôpital Claude Huriez (LT), Service des Maladies du Sang, Lille; and INSERM 728 (GS), Université Paris 7 Denis Diderot, Paris, France
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29
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Patriquin C, Leber B. Increased eculizumab requirements during pregnancy in a patient with paroxysmal nocturnal hemoglobinuria: case report and review of the literature. Clin Case Rep 2014; 3:88-91. [PMID: 25767703 PMCID: PMC4352359 DOI: 10.1002/ccr3.161] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/24/2014] [Indexed: 11/21/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) results from reduced complement regulatory proteins on hematopoietic cells, predisposing patients to intravascular hemolysis, thrombophilia, and cytopenias. Women diagnosed in pregnancy can experience significant maternofetal complications. Trials of eculizumab in PNH excluded pregnant women. Here, we report the first Canadian patient taken through pregnancy on eculizumab.
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Affiliation(s)
- Christopher Patriquin
- Division of Hematology & Thromboembolism, Department of Medicine, Juravinski Hospital and Cancer Centre 711 Concession Street, Hamilton, Ontario, Canada, L8V1C3
| | - Brian Leber
- Division of Hematology & Thromboembolism, Department of Medicine, Juravinski Hospital and Cancer Centre 711 Concession Street, Hamilton, Ontario, Canada, L8V1C3
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30
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Morita Y, Nishimura JI, Shimada T, Tanaka H, Serizawa K, Taniguchi Y, Tsuritani M, Kanakura Y, Matsumura I. Successful anticoagulant therapy for two pregnant PNH patients, and prospects for the eculizumab era. Int J Hematol 2013; 97:491-7. [DOI: 10.1007/s12185-013-1302-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
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31
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Michieli M, Peccatori FA, Lleshi A, Del Pup L, Valente D, Rupolo M, Tirelli U, Berretta M. Antiblastic treatment of haematological malignancies during pregnancy: a crucial decision. Int J Immunopathol Pharmacol 2013; 25:21S-32S. [PMID: 23092517 DOI: 10.1177/03946320120250s202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Antiblastic treatment of hematological malignancies during pregnancy poses a number of issues related to the curability of the maternal disease, the need of a prompt treatment and the potential toxicity of chemotherapy for the fetus. Here we report the results of a systematic literature search about the management of the most frequent hematological malignancies that may occur during pregnancy, focusing on specific issues related to gestational age at diagnosis, fetal toxicity and efficacy on the maternal side. The standard approach in non-pregnant women is illustrated as reference.
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Affiliation(s)
- M Michieli
- Department of Medical Oncology, National Cancer Institute, Aviano (PN), Italy.
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