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Godeau B. Is splenectomy a good strategy for refractory immune thrombocytopenia in adults? Br J Haematol 2023; 203:86-95. [PMID: 37735555 DOI: 10.1111/bjh.19077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
Rituximab and thrombopoietin receptor agonists (TPO-RAs) have profoundly changed the management of immune thrombocytopenia (ITP) over the last 20 years. Even if most current guidelines put splenectomy, rituximab and TPO-RAs on the same treatment level, most clinicians and patients clearly prefer to postpone splenectomy and to multiply the lines of medical treatment before considering surgery. The management of ITP refractory to rituximab and TPO-RAs is challenging. Splenectomy is currently performed much less frequently because of a better knowledge of its complications, particularly severe late infections and deep vein thrombosis, and the inability to reliably predict its effectiveness. Furthermore, there is a reluctance to propose splenectomy when other treatments have been ineffective, based on the not well-documented risk that splenectomy could not be effective in such a case. The objective of this update was to review the most recent published data on the long-term tolerability and side effects of splenectomy and the predictors of response and efficacy, especially for patients exposed to multiple medical lines. This update can help physicians and patients with failure of multiple lines of therapy make an informed decision on the indication for splenectomy with the help of up-to-date data.
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Affiliation(s)
- Bertrand Godeau
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
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2
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Chen HY, Lee WK, Chang R, Hung YM, Hsu CY, Shih YH, Chen JS. Immune thrombocytopenia and risk of stroke: Evidence from a nationwide population-based cohort study. Int J Stroke 2023; 18:408-415. [PMID: 36073612 DOI: 10.1177/17474930221125556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Research investigating differences in the overall stroke risk between individuals with and without immune thrombocytopenia (ITP) is lacking. METHODS This real-world study used the National Health Insurance Research Database (NHIRD). Risk of stroke was compared between 13,085 individuals with ITP enrolled between 1 January 2000 and 31 December 2015 and a control cohort of 52,340 individuals without ITP (1:4 ratio propensity score-matched by age, sex, index year, relevant comorbidities, and medications). Sub-distribution hazards models were used to estimate adjusted sub-distribution hazard ratio (SHR) and 95% confidence intervals (CIs), with the non-ITP group as the control group. RESULTS Of the 65,425 participants, 13,085 had ITP, 63.3% were women, and the mean age was 52.59 years. The risk of both ischemic and hemorrhagic stroke was 1.14 times (adjusted SHR 1.14, 95% CI, 1.07-1.22) and 1.93 times (adjusted SHR 1.93, 95% CI, 1.70-2.20) higher in the ITP group than in controls. Patients with ITP in the 20- to 29-year subgroup had a higher risk of new-onset stroke (adjusted SHR, 4.06 (95% CI, 2.72-6.07), p value for interaction <0.01) than those aged 20-29 years without ITP. Individuals with severe ITP with splenectomy had a 1.79 times higher overall stroke risk than those without. CONCLUSIONS ITP is associated with increased risk of both ischemic and hemorrhagic stroke.
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Affiliation(s)
- Hsin-Yu Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wei-Kai Lee
- Department of Emergency Medicine, Sinying Hospital, Ministry of Health and Welfare, Tainan
- Min-Hwei Junior College of Health Care Management, Tainan
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Yao-Min Hung
- Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung
- College of Health and Nursing, Meiho University, Pingtung
- Institute of Medicine, Chung Shan Medical University, Taichung
| | - Chung Y Hsu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung
| | - Ying-Hsiu Shih
- Management Office for Health Data (DryLab), Clinical Trial Research Center (CTC), China Medical University Hospital, Taichung
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung
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3
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Goshua G, Sinha P, Kunst N, Pischel L, Lee AI, Cuker A. Cost-effectiveness of second-line therapies in adults with chronic immune thrombocytopenia. Am J Hematol 2023; 98:122-130. [PMID: 35147241 PMCID: PMC9365880 DOI: 10.1002/ajh.26497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023]
Abstract
Major options for second-line therapy in adults with chronic immune thrombocytopenia (ITP) include splenectomy, rituximab, and thrombopoietin receptor agonists (TRAs). The American Society of Hematology guidelines recommend rituximab over splenectomy, TRAs over rituximab, and splenectomy or TRAs while noting a lack of evidence on the cost-effectiveness of these therapies. Using prospective, observational, and meta-analytic data, we performed the first cost-effectiveness analysis of second-line therapies in chronic ITP, from the perspective of the U.S. health system. Over a 20-year time-horizon, our six-strategy Markov model shows that a strategy incorporating early splenectomy, an approach at odds with current guidelines and clinical practice, is the cost-effective strategy. All four strategies utilizing TRAs in the first or second position cost over $1 million per quality-adjusted life-year, as compared to strategies involving early use of splenectomy and rituximab. In a probabilistic sensitivity analysis, early use of splenectomy and rituximab in either order was favored in 100% of 10 000 iterations. The annual cost of TRAs would have to decrease over 80% to begin to become cost-effective in any early TRA strategy. Our data indicate that effectiveness of early TRA and late TRA strategies is similar with the cost significantly greater with early TRA strategies. Contrary to current practice trends and guidelines, early use of splenectomy and rituximab, rather than TRAs, constitutes cost-effective treatment in adults with chronic ITP.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Pranay Sinha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Natalia Kunst
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Lauren Pischel
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Alfred Ian Lee
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Interaction of aging with lipoxygenase deficiency initiates hypersplenism, cardiac dysfunction, and profound leukocyte directed non-resolving inflammation. GeroScience 2021; 44:1689-1702. [PMID: 34932185 DOI: 10.1007/s11357-021-00496-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/08/2021] [Indexed: 10/19/2022] Open
Abstract
In the process of physiological cardiac repair, splenic leukocyte-activated lipoxygenases (LOXs) are essential for the biosynthesis of specialized pro-resolving lipid mediators as a segment of an active process of acute inflammation in splenocardiac manner. In contrast, young 12/15LOX-/- mice use a compensatory mechanism that amplifies epoxyeicosatrienoic acid mediators after myocardial infarction, improving cardiac repair, function, and survival. Next, we tested whether deletion of 12/15LOX impacted the genesis of chronic inflammation in progressive aging. To test the risk factor of aging, we used the inter-organ hypothesis and assessed heart and spleen leukocyte population along with the number of inflammation markers in age-related 12/15LOX-/- aging mice (2 months, 6 months, 13 months) and compared with C57BL/6 J (WT; wild type) as controls (2 months). The 12/15LOX-/- aging mice showed an age-related increase in spleen mass (hypersplenism) and decreased marginal zone area. Results suggest increased interstitial fibrosis in the heart marked with the inflammatory mediator (PGD2) level in 12/15LOX-/- aging mice than WT controls. From a cellular perspective, the quantitative measurement of immune cells indicates that heart and spleen leukocytes (CD11b+ and F4/80+ population) were reduced in 12/15LOX-/- aging mice than WT controls. At the molecular level, analyses of cytokines in the heart and spleen suggest amplified IFN-γ, with reduced COX-1, COX-2, and ALOX5 expression in the absence of 12/15LOX-derived mediators in the spleen. Thus, aging of 12/15LOX-/- mice increased spleen mass and altered spleen and heart structure with activation of multiple molecular and cellular pathways contributing to age-related integrative and inter-organ inflammation.
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Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. Hemasphere 2021; 5:e574. [PMID: 34095758 PMCID: PMC8171374 DOI: 10.1097/hs9.0000000000000574] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to both a peripheral destruction of platelets and an inappropriate bone marrow production. Although the primary triggering factors of ITP remain unknown, a loss of immune tolerance-mostly represented by a regulatory T-cell defect-allows T follicular helper cells to stimulate autoreactive splenic B cells that differentiate into antiplatelet antibody-producing plasma cells. Glycoprotein IIb/IIIa is the main target of antiplatelet antibodies leading to platelet phagocytosis by splenic macrophages, through interactions with Fc gamma receptors (FcγRs) and complement receptors. This allows macrophages to activate autoreactive T cells by their antigen-presenting functions. Moreover, the activation of the classical complement pathway participates to platelet opsonization and also to their destruction by complement-dependent cytotoxicity. Platelet destruction is also mediated by a FcγR-independent pathway, involving platelet desialylation that favors their binding to the Ashwell-Morell receptor and their clearance in the liver. Cytotoxic T cells also contribute to ITP pathogenesis by mediating cytotoxicity against megakaryocytes and peripheral platelets. The deficient megakaryopoiesis resulting from both the humoral and the cytotoxic immune responses is sustained by inappropriate levels of thrombopoietin, the major growth factor of megakaryocytes. The better understanding of ITP pathogenesis has provided important therapeutic advances. B cell-targeting therapies and thrombopoietin-receptor agonists (TPO-RAs) have been used for years. New emerging therapeutic strategies that inhibit FcγR signaling, the neonatal Fc receptor or the classical complement pathway, will deeply modify the management of ITP in the near future.
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Cooper N, Altomare I, Thomas MR, Nicolson PLR, Watson SP, Markovtsov V, Todd LK, Masuda E, Bussel JB. Assessment of thrombotic risk during long-term treatment of immune thrombocytopenia with fostamatinib. Ther Adv Hematol 2021; 12:20406207211010875. [PMID: 33995988 PMCID: PMC8111531 DOI: 10.1177/20406207211010875] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with immune thrombocytopenia (ITP) are at risk of bleeding and, paradoxically, thromboembolic events (TEEs), irrespective of thrombocytopenia. The risk of thrombosis is increased by advanced age, obesity, and prothrombotic comorbidities: cancer, hyperlipidemia, diabetes, hypertension, coronary artery disease, and chronic kidney disease, among others. Certain ITP treatments further increase the risk of TEE, especially splenectomy and thrombopoietin receptor agonists. Spleen tyrosine kinase (SYK) is a key signaling molecule common to thromboembolic and hemostatic (in addition to inflammatory) pathways. Fostamatinib is an orally administered SYK inhibitor approved in the USA and Europe for treatment of chronic ITP in adults. Methods: The phase III and extension studies included heavily pretreated patients with long-standing ITP, many of whom had risk factors for thrombosis prior to initiating fostamatinib. This report describes long-term safety and efficacy of fostamatinib in 146 patients with up to 5 years of treatment, a total of 229 patient-years, and assesses the incidence of thromboembolic events (by standardized MedDRA query). Results: Platelet counts ⩾50,000/µL were achieved in 54% of patients and the safety profile was as described in the phase III clinical studies with no new toxicities observed over the 5 years of follow-up. The only TEE occurred in one patient (0.7%, or 0.44/100 patient-years), who experienced a mild transient ischemic attack. This is a much lower rate than might be expected in ITP patients. Conclusion: This report demonstrates durable efficacy and a very low incidence of TEE in patients receiving long-term treatment of ITP with the SYK inhibitor fostamatinib. ClinicalTrials.gov identifiers: NCT02076399, NCT02076412, and NCT02077192.
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Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, UK
| | - Ivy Altomare
- Duke University School of Medicine, Durham, NC, USA
| | - Mark R Thomas
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Steve P Watson
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Vadim Markovtsov
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - Leslie K Todd
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - Esteban Masuda
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Medical College of Cornell University, 115 East 67th Street, New York, NY 10065, USA
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Swan D, Newland A, Rodegheiro F, Thachil J. Thrombosis in immune thrombocytopenia - current status and future perspectives. Br J Haematol 2021; 194:822-834. [PMID: 33822358 DOI: 10.1111/bjh.17390] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder in which a combination of defective platelet production and enhanced clearance leads to thrombocytopenia. The primary aim for therapy in patients with this condition is the prevention of bleeding. However, more recently, increased rates of venous and arterial thrombotic events have been reported in ITP, even in the context of marked thrombocytopenia. In this review we discuss the epidemiology, aetiology and management of thrombotic events in these patients. We consider the impact of ITP therapies on the increased thrombotic risk, in particular the use of thrombopoietin-receptor agonists (TPO-RAs), as well as factors inherent to ITP itself. We also discuss the limited evidence available to guide clinicians in the treatment of these complex cases.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Republic of Ireland
| | - Adrian Newland
- Department of Haematology, The Royal London Hospital, London, UK
| | | | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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8
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Emerging Therapies in Immune Thrombocytopenia. J Clin Med 2021; 10:jcm10051004. [PMID: 33801294 PMCID: PMC7958340 DOI: 10.3390/jcm10051004] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder caused by peripheral platelet destruction and inappropriate bone marrow production. The management of ITP is based on the utilization of steroids, intravenous immunoglobulins, rituximab, thrombopoietin receptor agonists (TPO-RAs), immunosuppressants and splenectomy. Recent advances in the understanding of its pathogenesis have opened new fields of therapeutic interventions. The phagocytosis of platelets by splenic macrophages could be inhibited by spleen tyrosine kinase (Syk) or Bruton tyrosine kinase (BTK) inhibitors. The clearance of antiplatelet antibodies could be accelerated by blocking the neonatal Fc receptor (FcRn), while new strategies targeting B cells and/or plasma cells could improve the reduction of pathogenic autoantibodies. The inhibition of the classical complement pathway that participates in platelet destruction also represents a new target. Platelet desialylation has emerged as a new mechanism of platelet destruction in ITP, and the inhibition of neuraminidase could dampen this phenomenon. T cells that support the autoimmune B cell response also represent an interesting target. Beyond the inhibition of the autoimmune response, new TPO-RAs that stimulate platelet production have been developed. The upcoming challenges will be the determination of predictive factors of response to treatments at a patient scale to optimize their management.
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10
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Dragomir MP, Tudor S, Okubo K, Shimizu M, Chen M, Giza DE, He WR, Ivan C, Calin GA, Vasilescu C. The non-coding RNome after splenectomy. J Cell Mol Med 2019; 23:7844-7858. [PMID: 31496026 PMCID: PMC6815812 DOI: 10.1111/jcmm.14664] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/26/2022] Open
Abstract
Splenectomy is a common surgical procedure performed in millions of people worldwide. Epidemiologic data show that splenectomy is followed by infectious (sepsis) and non-infectious complications, with unknown mechanisms. In order to explore the role of the non-coding transcripts involved in these complications, we analysed a panel of circulating microRNAs (miRNAs), which were previously reported to be deregulated in sepsis, in the plasma of splenectomized patients. MiR-223 was overexpressed immediately and late after splenectomy, while miR-146a was overexpressed immediately after splenectomy, returning latter to basal levels; and miR-16, miR-93, miR-26a and miR-26b were overexpressed only late after splenectomy, suggesting similarities with sepsis. We also explored the non-coding (nc)RNome of circulating peripheral blood leucocytes by performing a ncRNA full genome profiling. We observed a reorganization of the ncRNoma after splenectomy, characterized by up-regulation of miRNAs and down-regulation of transcribed pyknons (T-PYKs). Pathway analysis revealed that deregulated miRNAs control pathways involved in immunity, cancer and endothelial growth. We checked the expression of the ncRNAs in 15 immune cell types from healthy donors and observed that plasma miRNAs, cellular miRNAs and T-PYKs have a cell-specific expression pattern and are abundant in different types of immune cells. These findings suggest that the ncRNAs potentially regulate the immune changes observed after splenectomy.
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Affiliation(s)
- Mihnea P. Dragomir
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
- Department of SurgeryFundeni Clinical HospitalCarol Davila University of Medicine and PharmacyBucharestRomania
| | - Stefan Tudor
- Department of SurgeryFundeni Clinical HospitalCarol Davila University of Medicine and PharmacyBucharestRomania
| | - Keishi Okubo
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - Masayoshi Shimizu
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - Meng Chen
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - Dana Elena Giza
- Department of Family and Community MedicineMcGovern Medical School at The University of Texas Health Science Center at HoustonHoustonTXUSA
| | - William Ruixian He
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - Cristina Ivan
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
- Center for RNA Interference and Non‐coding RNAsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - George A. Calin
- Department of Experimental TherapeuticsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
- Center for RNA Interference and Non‐coding RNAsThe University of Texas MD Anderson Cancer CenterHoustonTXUSA
| | - Catalin Vasilescu
- Department of SurgeryFundeni Clinical HospitalCarol Davila University of Medicine and PharmacyBucharestRomania
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Affiliation(s)
- Nichola Cooper
- From the Department of Medicine, Hammersmith Hospital, Imperial College, London (N.C.); and the Departments of Medicine, Hematology-Oncology, and Research, Østfold Hospital Trust, Kalnes, and the Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo (W.G.) - both in Norway
| | - Waleed Ghanima
- From the Department of Medicine, Hammersmith Hospital, Imperial College, London (N.C.); and the Departments of Medicine, Hematology-Oncology, and Research, Østfold Hospital Trust, Kalnes, and the Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo (W.G.) - both in Norway
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12
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Bussel J, Miltiadous O. Immune Thrombocytopenia: Are We Stuck in the Mud or Is There Light at the End of the Tunnel? Clin Hematol Int 2019; 1:173-179. [PMID: 34595428 PMCID: PMC8432374 DOI: 10.2991/chi.d.190805.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 11/17/2022] Open
Abstract
The differences in diagnosis and management between immune thrombocytopenia (ITP) and leukemia are striking. Leukemia diagnosis and management have evolved substantially over the past 30 years and are now relatively precise. The tendency for leukemic cells to be the overwhelming majority of circulating and/or bone marrow cells certainly continues to facilitate developments, as does improved molecular assessment. Furthermore, randomized controlled clinical trials of competing regimens in well-defined populations have advanced treatment as well. Currently, ITP diagnosis and management depend very much on the experience and preferences of the hematologist. There are no unequivocally useful molecular tests, no agreement on which testing needs to be performed, and no consensus on treatment. Future studies using advanced techniques would ideally change this over time but, thus far, progress in ITP has been slow. However, the increasing ability to do single-cell DNA and RNA studies and flow cytometric dissection of small populations of cells could radically change the approach to ITP if critical distinctions were uncovered.
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Affiliation(s)
- James Bussel
- Pediatrics, Division of Hematology-Oncology, Weill Cornell Medicine, New York, NY
| | - Oriana Miltiadous
- Pediatrics, Division of Hematology-Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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13
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Impact of risk factors on the occurrence of arterial thrombosis and venous thromboembolism in adults with primary immune thrombocytopenia – Results from two nationwide cohorts. Thromb Res 2019; 178:124-131. [DOI: 10.1016/j.thromres.2019.04.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/07/2019] [Accepted: 04/15/2019] [Indexed: 01/27/2023]
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Yi T, Ma W, Qiu J, Ding W. Pulmonary hypertension with massive megalosplenia: A case report. Medicine (Baltimore) 2019; 98:e14594. [PMID: 30896614 PMCID: PMC6708804 DOI: 10.1097/md.0000000000014594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 01/20/2019] [Accepted: 01/28/2019] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Pulmonary hypertension (PH) is a complicated disease which has complex causes and poor outcome. Many factors are involved in the increase of pulmonary artery pressure. It is often difficult to identify the specific cause of a particular patient. However, identifying the etiology is of great importance for specifying treatment strategies and improving the prognosis of patients. PATIENT CONCERNS A 58-year-old male was admitted because of fatigue, breath shortness for 6 months, which got worse in the last 3 months. The ultrasound cardiogram (UCG) indicated a remarkably elevated pulmonary artery systolic pressure (PASP = 82 mm Hg). He had hypertension for 15 years. Besides, his spleen was found to be enlarged since 15 years ago. Bone marrow biopsy of the patient revealed myeloproliferative neoplasm (MPN) with severe myelofibrosis (MF). DIAGNOSIS Myeloproliferative neoplasm (MPN) with severe myelofibrosis (MF) which in turn caused PH and portal vein hypertension (PVH). INTERVENTIONS We treated the patient with diuretics and fosinopril, and also steroids and thalidomide for his MPN/MF. OUTCOMES Two weeks later, the pulmonary artery pressure (PAP) was remarkably decreased (PASP = 53.1 mm Hg by UCG, mean PAP = 21 mm Hg by right cardiac catheterization). Within 2 years' follow-up, his circulatory state and hematological state remained stable. LESSONS It is often difficult to define the cause of PH, but it is important for making the appropriate treatment at the same time.
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Affiliation(s)
| | | | - Jianxing Qiu
- Medical Imaging Department, Peking University First Hospital, Beijing, China
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15
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Ruggiero SA, Huber JS, Murrant CL, Brunt KR, Simpson JA. Splenic blood-flow response following myocardial infarction in rat. Can J Physiol Pharmacol 2018; 96:1060-1068. [PMID: 30102865 DOI: 10.1139/cjpp-2018-0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During physiological stress (e.g., exercise, hypoxia), blood flow is shunted to specific anatomical regions to protect critical organs; yet, splenic blood flow in these circumstances remains to be investigated. Despite being classically viewed as a non-critical organ, recent experimental and epidemiological evidence suggests the spleen plays a significant role in cardiovascular pathophysiology. We hypothesized that splenic blood flow is prioritized in the development of heart failure (i.e., chronic state of reduced cardiac output). Five-week-old male Wistar rats were randomized for either myocardial infarction (MI; n = 58) or sham (n = 56) surgery. At 2, 5, and 9 weeks post-surgery, Doppler ultrasound measurements of the splenic, left renal, left common carotid, and left femoral arteries were performed. Cardiac function was assessed at all time points using echocardiography and at 9 weeks post-surgery using invasive hemodynamic analysis. Splenic and cerebral blood flow was preferentially maintained at 9 weeks post-MI, whereas blood flow to the lower limb and kidney were reduced. Spleen size increased by 5 weeks post-MI and remained elevated. Splenic blood flow was maintained in conditions of decreased cardiac output, when other tissues showed decreased blood flow. The maintenance of blood flow in the face of decreased cardiac output indicates that splenic function is being prioritized during heart failure.
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Affiliation(s)
- Sara A Ruggiero
- a Department of Human Health and Nutritional Science, College of Biological Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada
| | - Jason S Huber
- a Department of Human Health and Nutritional Science, College of Biological Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada.,b IMPART team Canada Investigator Network
| | - Coral L Murrant
- a Department of Human Health and Nutritional Science, College of Biological Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada
| | - Keith R Brunt
- b IMPART team Canada Investigator Network.,c Department of Pharmacology, Dalhousie Medicine New Brunswick, Dalhousie University, Saint John, NB E2K 5E2, Canada
| | - Jeremy A Simpson
- a Department of Human Health and Nutritional Science, College of Biological Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada.,b IMPART team Canada Investigator Network
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Florentin J, Coppin E, Vasamsetti SB, Zhao J, Tai YY, Tang Y, Zhang Y, Watson A, Sembrat J, Rojas M, Vargas SO, Chan SY, Dutta P. Inflammatory Macrophage Expansion in Pulmonary Hypertension Depends upon Mobilization of Blood-Borne Monocytes. THE JOURNAL OF IMMUNOLOGY 2018; 200:3612-3625. [PMID: 29632145 DOI: 10.4049/jimmunol.1701287] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 03/17/2018] [Indexed: 12/22/2022]
Abstract
Pulmonary inflammation, which is characterized by the presence of perivascular macrophages, has been proposed as a key pathogenic driver of pulmonary hypertension (PH), a vascular disease with increasing global significance. However, the mechanisms of expansion of lung macrophages and the role of blood-borne monocytes in PH are poorly understood. Using multicolor flow cytometric analysis of blood in mouse and rat models of PH and patients with PH, an increase in blood monocytes was observed. In parallel, lung tissue displayed increased chemokine transcript expression, including those responsible for monocyte recruitment, such as Ccl2 and Cx3cl1, accompanied by an expansion of interstitial lung macrophages. These data indicate that blood monocytes are recruited to lung perivascular spaces and differentiate into inflammatory macrophages. Correspondingly, parabiosis between congenically different hypoxic mice demonstrated that most interstitial macrophages originated from blood monocytes. To define the actions of these cells in PH in vivo, we reduced blood monocyte numbers via genetic deficiency of cx3cr1 or ccr2 in chronically hypoxic male mice and by pharmacologic inhibition of Cx3cl1 in monocrotaline-exposed rats. Both models exhibited decreased inflammatory blood monocytes, as well as interstitial macrophages, leading to a substantial decrease in arteriolar remodeling but with a less robust hemodynamic effect. This study defines a direct mechanism by which interstitial macrophages expand in PH. It also demonstrates a pathway for pulmonary vascular remodeling in PH that depends upon interstitial macrophage-dependent inflammation yet is dissociated, at least in part, from hemodynamic consequences, thus offering guidance on future anti-inflammatory therapeutic strategies in this disease.
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Affiliation(s)
- Jonathan Florentin
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Emilie Coppin
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Sathish Babu Vasamsetti
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Jingsi Zhao
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Yi-Yin Tai
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Ying Tang
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Yingze Zhang
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Annie Watson
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - John Sembrat
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213.,Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | - Mauricio Rojas
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213.,Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | - Sara O Vargas
- Department of Pathology, Boston Children's Hospital, Boston, MA 02115; and
| | - Stephen Y Chan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213;
| | - Partha Dutta
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213; .,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
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17
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Wang WT, Li YY, Lin WC, Chen JY, Lan KM, Sun CK, Hung KC. Bilateral visual loss and cerebral infarction after spleen embolization in a trauma patient with idiopathic thrombocytopenic purpura: A case report. Medicine (Baltimore) 2018; 97:e0332. [PMID: 29668582 PMCID: PMC5916660 DOI: 10.1097/md.0000000000010332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE Splenic artery embolization (SAE) is a common procedure in trauma patients with blunt splenic injuries. We report a case of acute ischemic stroke following orthopedic surgery in a patient with post-SAE reactive thrombocytosis. PATIENT CONCERNS A 37-year-old woman with idiopathic thrombocytopenic purpura (ITP) suffered from multiple trauma scheduled for open reduction and internal fixation for right tibial and left radius fracture five days after SAE. The patient did not have any thromboembolic complications, although the platelet counts increased from 43 × 10/L to 568 × 10/L within two days after SAE. Surgery was completed under general anesthesia with tracheal intubation without complications. The patient complained of visual loss followed by limb weakness on the fourth and eighth hour postoperatively. DIAGNOSES Magnetic resonance imaging (MRI) of head demonstrated ischemic change over bilateral basal ganglia, and occipital areas, suggesting the diagnosis of cortical blindness. INTERVENTIONS To suppress platelet count and avoid platelet hyper-aggregation, anti-platelet drug (i.e., oral aspirin 100 mg daily), hydration, and hydroxyurea (i.e., 20 mg/kg daily) were used for the treatment of reactive thrombocytosis. OUTCOMES Although right-sided hemiparesis persisted, the patient reported mild visual recovery. She was discharged four months after SAE with active rehabilitation. LESSONS Our report highlights an increased risk of acute arterial thromboembolic events in patients with reactive thrombocytosis, especially those undergoing surgery.
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Affiliation(s)
- Wei-Ting Wang
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung
| | - Yu-Yu Li
- Department of Anesthesiology, Chi Mei Medical Center, Tainan
| | - Wan-Ching Lin
- Department of Neuroradiology, E-Da Hospital, I-Shou University, Kaohsiung
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan
- Department of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan R.O.C
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan
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Rodeghiero F. A critical appraisal of the evidence for the role of splenectomy in adults and children with ITP. Br J Haematol 2018; 181:183-195. [DOI: 10.1111/bjh.15090] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Francesco Rodeghiero
- Haematology Project Foundation; Affiliated to the Department of Cell Therapy and Haematology; S. Bortolo Hospital; Vicenza Italy
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Abstract
There are numerous congenital and acquired causes of thrombocytopenia. Thrombocytopenia could be a result of decreased bone marrow production, increased consumption, increased destruction, splenic sequestration or a combination of these causes. In this review, we have focused on some of the serious acquired causes of thrombocytopenia. There have been some significant advances in our understanding of the pathophysiology, diagnostic testing, and treatment of immune thrombocytopenia, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome over the past five years. These advances have resulted in a significant decrease in mortality and morbidity of patients with these disorders. Despite these advances, we are still faced with numerous unanswered questions in the pathophysiology and management of these complex thrombocytopenic disorders.
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Affiliation(s)
- Srikanth Nagalla
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ravindra Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
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20
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Splenectomy for immune thrombocytopenia: down but not out. Blood 2018; 131:1172-1182. [PMID: 29295846 DOI: 10.1182/blood-2017-09-742353] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/29/2017] [Indexed: 01/19/2023] Open
Abstract
Splenectomy is an effective therapy for steroid-refractory or dependent immune thrombocytopenia (ITP). With the advent of medical alternatives such as rituximab and thrombopoietin receptor antagonists, the use of splenectomy has declined and is generally reserved for patients that fail multiple medical therapies. Splenectomy removes the primary site of platelet clearance and autoantibody production and offers the highest rate of durable response (50% to 70%) compared with other ITP therapies. However, there are no reliable predictors of splenectomy response, and long-term risks of infection and cardiovascular complications must be considered. Because the long-term efficacy of different second-line medical therapies for ITP have not been directly compared, treatment decisions must be made without supportive evidence. Splenectomy continues to be a reasonable treatment option for many patients, including those with an active lifestyle who desire freedom from medication and monitoring, and patients with fulminant ITP that does not respond well to medical therapy. We try to avoid splenectomy within the first 12 months after ITP diagnosis for most patients to allow for spontaneous or therapy-induced remissions, particularly in older patients who have increased surgical morbidity and lower rates of response, and in young children. Treatment decisions must be individualized based on patients' comorbidities, lifestyles, and preferences. Future research should focus on comparing long-term outcomes of patients treated with different second-line therapies and on developing personalized medicine approaches to identify subsets of patients most likely to respond to splenectomy or other therapeutic approaches.
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