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Cortes-Santiago N, Deutsch G, Patel KR, Silva-Carmona M, Henderson C, Sartain SE, Bhar S, Pogoriler J. The Pathology of Pulmonary Disease After Pediatric Hematopoietic Stem Cell Transplantation. Am J Surg Pathol 2024; 48:1201-1214. [PMID: 39072367 DOI: 10.1097/pas.0000000000002267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Pulmonary complications continue to cause significant morbidity and mortality in posthematopoietic stem cell transplantation (HSCT) settings. The histopathology of pulmonary diseases in the post-HSCT context is poorly characterized, especially in the pediatric population. We sought to characterize the pathologic spectrum of pulmonary disease post-HSCT in a pediatric cohort. Fifty-six specimens, including 53 biopsy specimens, corresponding to 53 patients, were identified. Biopsy slides were reviewed and assigned to diagnostic categories (infectious, graft-versus-host disease, vasculopathy, indeterminate, and others) by consensus among 3 pediatric pulmonary pathologists, taking into consideration pathologic, clinical, radiologic, and laboratory findings. The most common diagnostic category was infection (n=20). Vasculopathy, mostly in the form of fibromyxoid intimal expansion, was very common in the entire cohort (n=26) and was the sole finding in a small subset of patients (n=5), with particularly poor outcomes. A subset of biopsies remained indeterminate (n=10), and the findings in this cohort were dominated by acute lung injury. The latter group had a poor prognosis, with a short biopsy-to-death interval. The overall clinicopathologic concordance was 40%, most commonly agreeing in the infectious category. Finally, wedge biopsies led to a change in management in 69% of cases versus 23% of limited procedures (i.e., core needle biopsies). Our results suggest that while infectious complications continue to be common post-HSCT, other findings such as vasculopathy and acute lung injury portend a particularly poor prognosis and should be actively sought and reported.
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Affiliation(s)
- Nahir Cortes-Santiago
- Department of Pediatrics, Section of Hematology, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Gail Deutsch
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine; Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Kalyani R Patel
- Department of Pediatrics, Section of Hematology, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Manuel Silva-Carmona
- Department of Pediatrics, Division of Pulmonary Medicine, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Carolyn Henderson
- Department of Pediatric Pulmonology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sarah E Sartain
- Department of Pediatrics, Section of Hematology, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Saleh Bhar
- Department of Pediatrics, Divisions of Hematology-Oncology and Critical Care Medicine, Pediatric Bone Marrow Transplantation and Cellular Therapy, Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | - Jennifer Pogoriler
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Higham CS, Shimano KA, Kharbanda S, Chu J, Cisneros GS, Winestone LE, Dara J, Huang JN, Hermiston ML, Long-Boyle JR, Dvorak CC. Cyclophosphamide and Thiotepa Increases Risk of Transplant-Associated Thrombotic Microangiopathy. Transplant Cell Ther 2024; 30:931.e1-931.e10. [PMID: 38944154 DOI: 10.1016/j.jtct.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/12/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024]
Abstract
Transplant associated thrombotic microangiopathy (TA-TMA) is a complication of hematopoietic cell transplant (HCT) associated with endothelial injury resulting in severe end organ damage, acute and long-term morbidity, and mortality. Myeloablative conditioning is a known risk factor, though specific causative agents have not been identified. We hypothesized that the combination of cyclophosphamide and thiotepa (CY + TT) is particularly toxic to the endothelium, placing patients at elevated risk for TA-TMA. We conducted a retrospective review of pediatric and young adult patients who received conditioned autologous and allogeneic HCT between 2012 and August 2023 at UCSF Benioff Children's Hospital, San Francisco. We excluded patients undergoing gene therapy or triple tandem transplants for brain tumors. Neuroblastoma tandem transplants were classified a single transplant occurrence. High dose N-acetylcysteine (NAC) prophylaxis was incorporated into the institutional standard of care from December 2016-May 2019 and May 2022-August 2023. Defibrotide was given prophylactically to patients deemed high-risk for sinusoidal obstruction syndrome (SOS) per institutional guidelines or on clinical trial NCT#02851407 for SOS prophylaxis or NCT#03384693 for TA-TMA prophylaxis. Kaplan-Meier analysis was used to estimate the 1-year cumulative incidence of TA-TMA. Univariate analysis was performed for each of the potential risk factors of interest using log-rank tests and bivariate analysis with Cox regression models using backward selection and hazard ratios were built using all covariates with a univariate P-value < .2 for allogeneic HCT. SPSS (v29) was used to estimate all summary statistics, cumulative incidences, and uni- and bi-variate analyses. A total of 558 transplants were performed with 43 patients developing TA-TMA, for a 1-year cumulative incidence of 8.6% (95% CI, 5.9-11.3) and 7.2% (95% CI, 2.9-11.5) in allogeneic and autologous HCTs, respectively (P = .62). In allogeneic recipients (n = 417), the 1-year cumulative incidence of TA-TMA with CY + TT as part of conditioning was 35.7% (95% CI, 15.7-55.7) compared to 11.7% (95% CI, 7.2-16.2) with either CY or TT alone, and 1.2% (95% CI, 0-2.8) if neither agent was included in the conditioning regimen (P < .001). Use of either CY or TT (HR = 10.14; P = .002) or CY + TT (HR = 35.93; P < .001), viral infections (HR = 4.3; P = .017) and fungal infections (HR = 2.98; P = 0.027) were significant factors resulting in increased risk for developing TA-TMA. In subjects undergoing autologous HCT (n = 141), the 1-year cumulative incidence of TA-TMA with CY + TT was 19.6% (95% CI, 8.8-30.6) while TA-TMA did not occur in patients receiving either CY or TT alone or when neither were included (P < .001). TA-TMA occurred only in patients with neuroblastoma receiving CY + TT as part of their conditioning. For autologous patients who received CY + TT, those who were CMV seronegative at the time of HCT had an incidence of TA-TMA of 6.7% (95% CI, 0.1-15.7) compared to 38.1% (95% CI, 35-41.2) for those CMV seropositive (P = .007). These data show that CY or TT alone or in combination as part of pre-transplant conditioning prior to HCT increase the incidence of TA-TMA. Alternative conditioning excluding the combination of CY + TT should be considered whenever possible to limit the development of TA-TMA.
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Affiliation(s)
- Christine S Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California.
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California; Division of Pediatric Hematology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California
| | - Julia Chu
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California
| | - Gabriel Salinas Cisneros
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California
| | - James N Huang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California; Division of Pediatric Hematology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Michelle L Hermiston
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California; Division of Pediatric Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Janel R Long-Boyle
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California; Department of Clinical Pharmacy, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California
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Davitt M, Offenbacher R, Lee MA, Loeb DM, Manwani D, Mitchell W, Weiser DA. Atypical hemolytic uremic syndrome during induction chemotherapy in neuroblastoma, a rare phenomenon or common congenital predisposition? Pediatr Blood Cancer 2024; 71:e31175. [PMID: 38961591 DOI: 10.1002/pbc.31175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a complement-mediated thrombotic microangiopathy sometimes associated with germline variants in genes of the complement system. Clinical findings of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury arise due to aberrant complement protein activation in the circulation. A 13-month-old boy with metastatic neuroblastoma (NB) developed aHUS during his first cycle of induction chemotherapy with germline testing revealing a complement factor H (CFH) gene mutation, currently classified as a variant of uncertain significance (VUS). Now he is in disease remission after successful complement blockade therapy, thus highlighting a unique presentation of aHUS in a patient with newly diagnosed NB.
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Affiliation(s)
- Meghan Davitt
- Lisa Dean Mosely Foundation Institute for Cancer and Blood Disorders, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Rachel Offenbacher
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michelle A Lee
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David M Loeb
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Deepa Manwani
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - William Mitchell
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel A Weiser
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
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Zhou X, Ye Y, Jin A, Pan Z, Xu Z, Ding S, Yan J, Cheng Y, Huang Y, Cao K, Xie W, Zhang J, Xu L, Zhou W, Huang L. Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study. BMC Nurs 2024; 23:535. [PMID: 39113009 PMCID: PMC11304727 DOI: 10.1186/s12912-024-02093-7] [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: 12/19/2023] [Accepted: 06/13/2024] [Indexed: 08/11/2024] Open
Abstract
OBJECTIVE The early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project. METHODS This study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement. RESULTS A total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001). CONCLUSION The evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.
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Affiliation(s)
- Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhengwen Pan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Zhe Xu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Shuyi Ding
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jiali Yan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yin Cheng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Yixuan Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Kai Cao
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Wei Xie
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Jianli Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Liwei Xu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Weiwei Zhou
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Lihua Huang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medical, Hangzhou, China.
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Kafa K, Hoell JI. Transplant-associated thrombotic microangiopathy in pediatrics: incidence, risk factors, therapeutic options, and outcome based on data from a single center. Front Oncol 2024; 14:1399696. [PMID: 39050576 PMCID: PMC11266128 DOI: 10.3389/fonc.2024.1399696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a critical complication of hematopoietic stem cell transplantation. Awareness about TA-TMA has increased in recent years, resulting in the implementation of TA-TMA screening in most centers. Methods Retrospective analysis of children who underwent autologous or allogeneic hematopoietic stem cell transplantation at our center between January 2018 and December 2022 was conducted to evaluate the incidence, clinical features, and outcomes of TA-TMA following the administration of different therapeutic options. Results A total of 45 patients comprised the study cohort, of whom 10 developed TA-TMA with a cumulative incidence of 22% by 100 days after transplantation. Patients with and without TA-TMA in our cohort displayed an overall survival of 80% and 88%, respectively (p = 0.48), and a non-relapse mortality of 0% and 5.7%, respectively (p = 0.12), at 1 year after transplantation. Risk factors for TA-TMA development included allogeneic transplantation and total body irradiation-based conditioning regime. Among the 10 patients with TA-TMA, 7 did not meet the high-risk criteria described by Jodele and colleagues. Of these seven patients, two responded to calcineurin-inhibitor withdrawal without further therapy and five developed multiorgan dysfunction syndrome and were treated with anti-inflammatory steroids (prednisone), and all responded to therapy. The three patients with high-risk TA-TMA were treated with complement blockade or prednisone, and all responded to therapy. Conclusion TA-TMA is a multifactorial complication with high morbidity rates. Patients with high-risk TA-TMA may benefit from complement blockade using eculizumab. No consensus has been reached regarding therapy for patients who do not meet high-risk criteria. Our analysis showed that these patients may respond to anti-inflammatory treatment with prednisone.
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Affiliation(s)
- Kinan Kafa
- Department of Pediatric Hematology and Oncology, University Hospital Halle (Saale), Halle, Germany
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Schoettler ML, Westbrook A, Watkins B, Stenger E, Qayed M, Chonat S, Williams KM. Age, GVHD prophylaxis, and timing matter in thrombotic microangiopathy after haematopoietic cell transplantation-A secondary CIBMTR analysis. Br J Haematol 2024; 205:243-255. [PMID: 38817006 DOI: 10.1111/bjh.19506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/23/2024] [Indexed: 06/01/2024]
Abstract
Most reports of risk factors (RF) for developing transplant-associated thrombotic microangiopathy (TA-TMA) and death are derived from paediatric and young adult cohorts, with minimal data on differences in RF and outcomes by age. In this secondary CIBMTR analysis, we used a previously prepared dataset that included all first allogenic haematopoietic cell transplantation (HCT) recipients with malignant or non-malignant diseases between 2008 and 2016. The incidence of TA-TMA 6 months post HCT was similar in children and adults 2.1% and 2.0% respectively. Grade 2-4 acute graft-versus-host disease (aGVHD) was a significant adjusted RF for developing TA-TMA in both children and adults. In adults, additional adjusted RFs for TA-TMA included female sex and black race, and in children an unrelated donor. Compared to a calcineurin inhibitor and sirolimus, other forms of GVHD prophylaxis had an adjusted decreased risk of developing TA-TMA in adults. Adjusted RF for death in those with TA-TMA (n = 652) included age ≥18 years old, early onset of TA-TMA diagnosis (<100 days post HCT), grade 3-4 aGVHD and a performance score of <90 prior to HCT. In this cohort, the incidence of TA-TMA was similar in children and adults, and TA-TMA timing was a newly identified RF for death.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Children's Hospital, New Orleans, Tulane Pediatric Hematology/Oncology, New Orleans, Louisiana, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
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Evangelidis P, Evangelidis N, Kalmoukos P, Kourti M, Tragiannidis A, Gavriilaki E. Genetic Susceptibility in Endothelial Injury Syndromes after Hematopoietic Cell Transplantation and Other Cellular Therapies: Climbing a Steep Hill. Curr Issues Mol Biol 2024; 46:4787-4802. [PMID: 38785556 PMCID: PMC11119915 DOI: 10.3390/cimb46050288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) remains a cornerstone in the management of patients with hematological malignancies. Endothelial injury syndromes, such as HSCT-associated thrombotic microangiopathy (HSCT-TMA), veno-occlusive disease/sinusoidal obstruction syndrome (SOS/VOD), and capillary leak syndrome (CLS), constitute complications after HSCT. Moreover, endothelial damage is prevalent after immunotherapy with chimeric antigen receptor-T (CAR-T) and can be manifested with cytokine release syndrome (CRS) or immune effector cell-associated neurotoxicity syndrome (ICANS). Our literature review aims to investigate the genetic susceptibility in endothelial injury syndromes after HSCT and CAR-T cell therapy. Variations in complement pathway- and endothelial function-related genes have been associated with the development of HSCT-TMA. In these genes, CFHR5, CFHR1, CFHR3, CFI, ADAMTS13, CFB, C3, C4, C5, and MASP1 are included. Thus, patients with these variations might have a predisposition to complement activation, which is also exaggerated by other factors (such as acute graft-versus-host disease, infections, and calcineurin inhibitors). Few studies have examined the genetic susceptibility to SOS/VOD syndrome, and the implicated genes include CFH, methylenetetrahydrofolate reductase, and heparinase. Finally, specific mutations have been associated with the onset of CRS (PFKFB4, CX3CR1) and ICANS (PPM1D, DNMT3A, TE2, ASXL1). More research is essential in this field to achieve better outcomes for our patients.
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Affiliation(s)
- Paschalis Evangelidis
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Nikolaos Evangelidis
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Panagiotis Kalmoukos
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
| | - Maria Kourti
- 3rd Department of Pediatrics, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (P.E.); (N.E.); (P.K.)
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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [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: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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Sabulski A, Abdullah S, Luebbering N, Aunins B, Castillo C, Lake K, Duell A, Strecker L, Langenberg L, Broomhead W, DiMeo S, Odegard EA, Blackard JT, Ziady AG, Seif AE, Dandoy CE, Laskin BL, Jodele S, Davies SM. Mechanisms of endothelial injury and transplant-associated thrombotic microangiopathy in tandem autologous hematopoietic stem cell transplant for neuroblastoma. Haematologica 2023; 108:3449-3453. [PMID: 37317894 PMCID: PMC10690916 DOI: 10.3324/haematol.2023.283351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Affiliation(s)
- Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Sheyar Abdullah
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nathan Luebbering
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin Aunins
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Caitlin Castillo
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kelly Lake
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Alexandra Duell
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lauren Strecker
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lucille Langenberg
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - William Broomhead
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Scott DiMeo
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Elizabeth A Odegard
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jason T Blackard
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Assem G Ziady
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alix E Seif
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Benjamin L Laskin
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Doering J, Perl M, Weber D, Banas B, Schulz C, Hamer OW, Angstwurm K, Holler E, Herr W, Edinger M, Wolff D, Fante MA. Incidence and Outcome of Atypical Manifestations of Chronic Graft-versus-Host Disease: Results From a Retrospective Single-Center Analysis. Transplant Cell Ther 2023; 29:772.e1-772.e10. [PMID: 37777112 DOI: 10.1016/j.jtct.2023.09.016] [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: 08/25/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Abstract
Chronic graft-versus-host disease (cGVHD) is the leading cause of late nonrelapse mortality (NRM) after allogeneic hematopoietic stem cell transplantation (alloHSCT) and defined by 8 diagnostic target organs. Recently, provisional criteria for atypical manifestations of cGVHD that include manifestations in nonclassic organs as well as atypical manifestations in National Institutes of Health (NIH)-defined organs, were proposed by a NIH task force. Little is known about the incidence, risk factors, and impact on survival of atypical cGVHD, however. The aim of the present study was to analyze these parameters in a sequential patient population. We retrospectively screened 623 patients who underwent alloHSCT at the University Medical Center Regensburg between January 2008 and December 2020 for atypical cGVHD manifestations, applying the provisional NIH taskforce criteria. A total of 102 patients (16.4%) met the criteria, representing 25% of all cGVHD cases, and 14 patients (2.2%) had only atypical cGVHD. The most frequent manifestations were immune-mediated cytopenias (24.5%), renal cGVHD (13.7%) and (poly)serositis (13.7%). Multivariate analysis identified prior acute GVHD (odds ratio [OR], 2.28 and 2.93) and infusion of donor lymphocytes (OR, 1.77 for both) as risk factors for classic cGVHD and atypical cGVHD, whereas total body irradiation was an independent risk factor for atypical cGVHD manifestations only (OR, 1.76). Compared to patients without cGVHD, those with atypical and NIH-defined cGVHD showed similarly better overall survival (P = .034 and < .001) and low relapse-related mortality (P < .001 for both). NRM was significantly increased by atypical GVHD, but not by NIH-defined cGVHD (P = .019 and .10), which was driven only by a few atypical organ manifestations (eg, renal, restrictive lung disease, peripheral neuropathy), whereas others did not contribute to NRM (eg, thyroid gland, musculoskeletal, pancreas). In summary, atypical cGVHD is more common than previously estimated and has both similarities with and differences from NIH-defined cGVHD. In particular, the increased NRM and a subset of patients with only atypical cGVHD point to the urgent need to capture these manifestations in cGVHD cohorts, including analysis of treatment outcomes.
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Affiliation(s)
- Jana Doering
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Perl
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Bernhard Banas
- Department of Nephrology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Schulz
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Okka W Hamer
- Department of Diagnostic Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany; Leibniz Institute for Immunotherapy (LIT), Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias A Fante
- Department of Internal Medicine III, University Medical Center Regensburg, Regensburg, Germany.
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12
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Knight TE, Ahn KW, Hebert KM, Atshan R, Wall DA, Chiengthong K, Lund TC, Prestidge T, Rangarajan HG, Dvorak CC, Auletta JJ, Kent M, Hashem H, Talano JA, Rotz SJ, Fraint E, Myers KC, Leung W, Sharma A, Bhatt NS, Driscoll TA, Yu LC, Schultz KR, Qayed M, Broglie L, Eapen M, Yanik GA. No impact of CD34 + cell dose on outcome among children undergoing autologous hematopoietic stem cell transplant for high-risk neuroblastoma. Bone Marrow Transplant 2023; 58:1390-1393. [PMID: 37666957 PMCID: PMC11221560 DOI: 10.1038/s41409-023-02092-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Tristan E Knight
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kyle M Hebert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rasha Atshan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Donna A Wall
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Troy C Lund
- Division of Pediatric Blood and Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Jeffery J Auletta
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - Michael Kent
- Atrium Health Levine Children's, Charlotte, NC, USA
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Ellen Fraint
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, The Children's Hospital at Montefiore, Bronx, NY, USA
| | - Kasiani C Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wing Leung
- Duke-NUS Medical School, Singapore, Singapore
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Neel S Bhatt
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Timothy A Driscoll
- Duke University Pediatric Transplantation and Cellular Therapy, Durham, NC, USA
| | - Lolie C Yu
- Division of Hematology/Oncology & HSCT, The Center for Cancer and Blood Disorders, Children's Hospital, Louisiana State University Medical Center, New Orleans, LA, USA
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Mary Eapen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gregory A Yanik
- Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor, MI, USA
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13
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Leimi L, Koski JR, Kilpivaara O, Vettenranta K, Lokki AI, Meri S. Rare variants in complement system genes associate with endothelial damage after pediatric allogeneic hematopoietic stem cell transplantation. Front Immunol 2023; 14:1249958. [PMID: 37771589 PMCID: PMC10525714 DOI: 10.3389/fimmu.2023.1249958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Complement system has a postulated role in endothelial problems after hematopoietic stem cell transplantation (HSCT). In this retrospective, singlecenter study we studied genetic complement system variants in patients with documented endotheliopathy. In our previous study among pediatric patients with an allogeneic HSCT (2001-2013) at the Helsinki University Children´s Hospital, Finland, we identified a total of 19/122 (15.6%) patients with vascular complications, fulfilling the criteria of capillary leak syndrome (CLS), venoocclusive disease/sinusoidal obstruction syndrome (VOD/SOS) or thrombotic microangiopathy (TMA). Methods We performed whole exome sequencing (WES) on 109 patients having an adequate pre-transplantation DNA for the analysis to define possible variations and mutations potentially predisposing to functional abnormalities of the complement system. In our data analysis, we focused on 41 genes coding for complement components. Results 50 patients (45.9%) had one or several, nonsynonymous, rare germline variants in complement genes. 21/66 (31.8%) of the variants were in the terminal pathway. Patients with endotheliopathy had variants in different complement genes: in the terminal pathway (C6 and C9), lectin pathway (MASP1) and receptor ITGAM (CD11b, part of CR3). Four had the same rare missense variant (rs183125896; Thr279Ala) in the C9 gene. Two of these patients were diagnosed with endotheliopathy and one with capillary leak syndrome-like problems. The C9 variant Thr279Ala has no previously known disease associations and is classified by the ACMG guidelines as a variant of uncertain significance (VUS). We conducted a gene burden test with gnomAD Finnish (fin) as the reference population. Complement gene variants seen in our patient population were investigated and Total Frequency Testing (TFT) was used for execution of burden tests. The gene variants seen in our patients with endotheliopathy were all significantly (FDR < 0.05) enriched compared to gnomAD. Overall, 14/25 genes coding for components of the complement system had an increased burden of missense variants among the patients when compared to the gnomAD Finnish population (N=10 816). Discussion Injury to the vascular endothelium is relatively common after HSCT with different phenotypic appearances suggesting yet unidentified underlying mechanisms. Variants in complement components may be related to endotheliopathy and poor prognosis in these patients.
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Affiliation(s)
- Lilli Leimi
- Pediatric Research Center, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jessica R. Koski
- Applied Tumor Genomics Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Medical and Clinical Genetics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Medicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Kilpivaara
- Applied Tumor Genomics Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Medical and Clinical Genetics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Medicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Kim Vettenranta
- Pediatric Research Center, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - A. Inkeri Lokki
- Department of Bacteriology and Immunology and Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Seppo Meri
- Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Department of Bacteriology and Immunology and Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
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14
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Cao XY, Zhang JP, Zhao YL, Xiong M, Zhou JR, Lu Y, Sun RJ, Wei ZJ, Liu DY, Zhang X, Yang JF, Lu P. Analysis benefits of a second Allo-HSCT after CAR-T cell therapy in patients with relapsed/refractory B-cell acute lymphoblastic leukemia who relapsed after transplant. Front Immunol 2023; 14:1191382. [PMID: 37469510 PMCID: PMC10352576 DOI: 10.3389/fimmu.2023.1191382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023] Open
Abstract
Background Chimeric antigen receptor (CAR) T-cell therapy has demonstrated high initial complete remission (CR) rates in B-cell acute lymphoblastic leukemia (B-ALL) patients, including those who relapsed after transplant. However, the duration of remission requires improvements. Whether bridging to a second allogeneic hematopoietic stem cell transplant (allo-HSCT) after CAR-T therapy can improve long-term survival remains controversial. We retrospectively analyzed long-term follow-up data of B-ALL patients who relapsed post-transplant and received CAR-T therapy followed by consolidation second allo-HSCT to investigate whether such a treatment sequence could improve long-term survival. Methods A single-center, retrospective study was performed between October 2017 and March 2022, involving 95 patients who received a consolidation second transplant after achieving CR from CAR-T therapy. Results The median age of patients was 22.8 years (range: 3.3-52.8) at the second transplant. After the first transplant, 71 patients (74.7%) experienced bone marrow relapse, 16 patients (16.8%) had extramedullary relapse, 5 patients (5.3%) had both bone marrow and extramedullary relapse and 3/95 patients (3.2%) had positive minimal residual disease (MRD) only. Patients received autologous (n=57, 60.0%) or allogeneic (n=28, 29.5%) CAR-T cells, while 10 patients (10.5%) were unknown. All patients achieved CR after CAR-T therapy. Before second HSCT, 86 patients (90.5%) were MRD-negative, and 9 (9.5%) were MRD-positive. All second transplant donors were different from the first transplant donors. The median follow-up time was 623 days (range: 33-1901) after the second HSCT. The 3-year overall survival (OS) and leukemia-free survival (LFS) were 55.3% (95%CI, 44.3-66.1%) and 49.8% (95%CI, 38.7-60.9%), respectively. The 3-year relapse incidence (RI) and non-relapse mortality (NRM) were 10.5% (95%CI, 5.6-19.6%) and 43.6% (95%CI, 33.9-56.2%), respectively. In multivariate analysis, the interval from CAR-T to second HSCT ≤90 days was associated with superior LFS(HR, 4.10, 95%CI,1.64-10.24; p=0.003) and OS(HR, 2.67, 95%CI, 1.24-5.74, p=0.012), as well as reduced NRM (HR, 2.45, 95%CI, 1.14-5.24, p=0.021). Conclusions Our study indicated that CAR-T therapy followed by consolidation second transplant could significantly improve long-term survival in B-ALL patients who relapsed post-transplant. The second transplant should be considered in suitable patients and is recommended to be performed within 90 days after CAR-T treatment.
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Affiliation(s)
- Xing-yu Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jian-ping Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yan-li Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Min Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jia-rui Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Yue Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Rui-juan Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Zhi-jie Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - De-yan Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xian Zhang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Jun-fang Yang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Peihua Lu
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang, China
- Beijing Lu Daopei Institute of Hematology, Beijing, China
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15
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Knight TE, Ahn KW, Hebert KM, Atshan R, Wall DA, Chiengthong K, Rotz SJ, Fraint E, Rangarajan HG, Auletta JJ, Sharma A, Kitko CL, Hashem H, Williams KM, Wirk B, Dvorak CC, Myers KC, Pulsipher MA, Warwick AB, Lalefar NR, Schultz KR, Qayed M, Broglie L, Eapen M, Yanik GA. Effect of Autograft CD34 + Dose on Outcome in Pediatric Patients Undergoing Autologous Hematopoietic Stem Cell Transplant for Central Nervous System Tumors. Transplant Cell Ther 2023; 29:380.e1-380.e9. [PMID: 36990222 PMCID: PMC10247464 DOI: 10.1016/j.jtct.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Consolidation with autologous hematopoietic stem cell transplantation (HSCT) has improved survival for patients with central nervous system tumors (CNSTs). The impact of the autologous graft CD34+ dose on patient outcomes is unknown. We wanted to analyze the relationship between CD34+ dose, total nucleated cell (TNC) dose, and clinical outcomes, including overall survival (OS), progression-free survival (PFS), relapse, non-relapse mortality (NRM), endothelial-injury complications (EIC), and time to neutrophil engraftment in children undergoing autologous HSCT for CNSTs. A retrospective analysis of the CIBMTR database was performed. Children aged <10 years who underwent autologous HSCT between 2008 to 2018 for an indication of CNST were included. An optimal cut point was identified for patient age, CD34+ cell dose, and TNC, using the maximum likelihood method and PFS as an endpoint. Univariable analysis for PFS, OS, and relapse was described using the Kaplan-Meier estimator. Cox models were fitted for PFS and OS outcomes. Cause-specific hazards models were fitted for relapse and NRM. One hundred fifteen patients met the inclusion criteria. A statistically significant association was identified between autograft CD34+ content and clinical outcomes. Children receiving >3.6×106/kg CD34+ cells experienced superior PFS (p = .04) and OS (p = .04) compared to children receiving ≤3.6 × 106/kg. Relapse rates were lower in patients receiving >3.6 × 106/kg CD34+ cells (p = .05). Higher CD34+ doses were not associated with increased NRM (p = .59). Stratification of CD34+ dose by quartile did not reveal any statistically significant differences between quartiles for 3-year PFS (p = .66), OS (p = .29), risk of relapse (p = .57), or EIC (p = .87). There were no significant differences in patient outcomes based on TNC, and those receiving a TNC >4.4 × 108/kg did not experience superior PFS (p = .26), superior OS (p = .14), reduced risk of relapse (p = .37), or reduced NRM (p = .25). Children with medulloblastoma had superior PFS (p < .001), OS (p = .01), and relapse rates (p = .001) compared to those with other CNS tumor types. Median time to neutrophil engraftment was 10 days versus 12 days in the highest and lowest infused CD34+ quartiles, respectively. For children undergoing autologous HSCT for CNSTs, increasing CD34+ cell dose was associated with significantly improved OS and PFS, and lower relapse rates, without increased NRM or EICs.
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Affiliation(s)
- Tristan E Knight
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington; Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kyle M Hebert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rasha Atshan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Donna A Wall
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Ellen Fraint
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, The Children's Hospital at Montefiore, Bronx, New York
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffery J Auletta
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Carrie L Kitko
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Kasiani C Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital Division of Hematology and Oncology, Huntsman Cancer Institute at the Spencer Eccles Fox School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Anne B Warwick
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Nahal Rose Lalefar
- Division of Pediatric Hematology, UCSF Benioff Children's Hospital, Oakland, California
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Mary Eapen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gregory A Yanik
- Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor, Michigan
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Mahmoudjafari Z, Alencar MC, Alexander MD, Johnson DJ, Yeh J, Evans MD. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy and the role of advanced practice providers and pharmacists. Bone Marrow Transplant 2023:10.1038/s41409-023-01951-3. [PMID: 37059738 DOI: 10.1038/s41409-023-01951-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a severe and potentially life-threatening complication. HSCT-TMA is often underdiagnosed due to multifactorial pathophysiology and a historic lack of standard diagnostic criteria. Identification of the multi-hit hypothesis and the key role of the complement system, particularly the lectin pathway of complement, has led to development of treatments targeting the underlying pathogenesis of HSCT-TMA. Additional research is ongoing to investigate the efficacy and safety of these targeted therapies in patients with HSCT-TMA. Advanced practice providers (APPs; nurse practitioners and physician assistants) and pharmacists are critical members of the multidisciplinary HSCT team and ensure management of patients throughout the continuum of care. Additionally, pharmacists and APPs can improve patient care through medication management of complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives to improve outcomes. Understanding the presentation, prognosis, pathophysiology, and treatment options for HSCT-TMA can improve each of these efforts. Collaborative practice model for monitoring and care of HSCT-TMA. Advanced practice providers and pharmacists contribute to many aspects of patient care in transplant centers, including medication management for complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives. HSCT-TMA is a severe and potentially life-threatening complication that is often underdiagnosed. The collaboration of a multidisciplinary team of advanced practice providers, pharmacists, and physicians can optimize recognition, diagnosis, management, and monitoring of patients with HSCT-TMA, thereby improving outcomes for these patients.
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Affiliation(s)
- Zahra Mahmoudjafari
- Department of Pharmacy, University of Kansas Cancer Center, Kansas City, KS, USA.
| | - Maritza C Alencar
- Oncology Service Line, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Darren J Johnson
- Pediatric Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jason Yeh
- Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | - Misty D Evans
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- Sarah Cannon Pediatric Hematology/Oncology & Cellular Therapy at TriStar Centennial, Nashville, TN, USA
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17
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Luo L, Xiong H, Chen Z, Yang L, Sun M, Lu W, Tao F, Wang Z, Li J, Li Z, Tang S. Clinical characteristics of pediatric allogeneic hematopoietic stem cell transplantation-associated thrombotic microangiopathy (TA-TMA): a retrospective single-center analysis. Clin Transl Oncol 2023:10.1007/s12094-023-03129-1. [PMID: 36973479 DOI: 10.1007/s12094-023-03129-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To investigate the clinical features of thrombotic microangiopathy associated with allogeneic hematopoietic stem cell transplantation in children. METHODS A retrospective analysis of continuous clinical data from HSCT received in the Department of Hematology and Oncology of Wuhan Children's Hospital from August 1, 2016 to December 31, 2021. RESULTS During this period, 209 patients received allo-HSCT in our department, 20 (9.6%) of whom developed TA-TMA. TA-TMA was diagnosed at a median of 94 (7-289) days post-HSCT. Eleven (55%) patients had early TA-TMA within 100 days post-HSCT, while the other 9 (45%) patients had TA-TMA thereafter. The most common symptom of TA-TMA was ecchymosis (55%), while the main signs were refractory hypertension (90%) and multi-cavity effusion (35%). Five (25%) patients had central nervous system symptoms (convulsions and lethargy). All 20 patients had progressive thrombocytopenia, with 16 patients receiving transfusion of platelets that was ineffective. Ruptured red blood cells were visible in only two patients with peripheral blood smears. Cyclosporine A or Tacrolimus (CNI) dose was reduced once TA-TMA was diagnosed. Nineteen cases were treated with low-molecular-weight heparin, 17 patients received plasma exchange, and 12 patients were treated with rituximab. TA-TMA-related mortality percentage in this study was 45% (9/20). CONCLUSION Platelet decline and/or ineffective transfusion post-HSCT should be considered an early indicator of TA-TMA in pediatric patients. TA-TMA in pediatric patients may occur without evidence of peripheral blood schistocytes. Aggressive treatment is required once diagnosis is confirmed, but the long-term prognosis is poor.
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Affiliation(s)
- Linlin Luo
- Medical College of Jianghan University, Wuhan, 430056, Hubei Province, China
| | - Hao Xiong
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China.
| | - Zhi Chen
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Li Yang
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Ming Sun
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Wenjie Lu
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Fang Tao
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Zhuo Wang
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Jianxin Li
- Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Wuhan, 430016, Hubei Province, China
| | - Zuofeng Li
- Medical College of Wuhan University of Science and Technology, Wuhan, 430065, Hubei Province, China
| | - Sujie Tang
- Medical College of Jianghan University, Wuhan, 430056, Hubei Province, China
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18
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Schoettler ML, Carreras E, Cho B, Dandoy CE, Ho VT, Jodele S, Moissev I, Sanchez-Ortega I, Srivastava A, Atsuta Y, Carpenter P, Koreth J, Kroger N, Ljungman P, Page K, Popat U, Shaw BE, Sureda A, Soiffer R, Vasu S. Harmonizing Definitions for Diagnostic Criteria and Prognostic Assessment of Transplantation-Associated Thrombotic Microangiopathy: A Report on Behalf of the European Society for Blood and Marrow Transplantation, American Society for Transplantation and Cellular Therapy, Asia-Pacific Blood and Marrow Transplantation Group, and Center for International Blood and Marrow Transplant Research. Transplant Cell Ther 2023; 29:151-163. [PMID: 36442770 PMCID: PMC10119629 DOI: 10.1016/j.jtct.2022.11.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic cell transplantation (HCT) associated with significant morbidity and mortality. However, TA-TMA is a clinical diagnosis, and multiple criteria have been proposed without universal application. Although some patients have a self-resolving disease, others progress to multiorgan failure and/or death. Poor prognostic features also are not uniformly accepted. The lack of harmonization of diagnostic and prognostic markers has precluded multi-institutional studies to better understand incidence and outcomes. Even current interventional trials use different criteria, making it challenging to interpret the data. To address this urgent need, the American Society for Transplantation and Cellular Therapy, Center for International Bone Marrow Transplant Research, Asia-Pacific Blood and Marrow Transplantation, and European Society for Blood and Marrow Transplantation nominated representatives for an expert panel tasked with reaching consensus on diagnostic and prognostic criteria. The panel reviewed literature, generated consensus statements regarding diagnostic and prognostic features of TA-TMA using the Delphi method, and identified future directions of investigation. Consensus was reached on 4 key concepts: (1) TA-TMA can be diagnosed using clinical and laboratory criteria or tissue biopsy of kidney or gastrointestinal tissue; however, biopsy is not required; (2) consensus diagnostic criteria are proposed using the modified Jodele criteria with additional definitions of anemia and thrombocytopenia. TA-TMA is diagnosed when ≥4 of the following 7 features occur twice within 14 days: anemia, defined as failure to achieve transfusion independence despite neutrophil engraftment; hemoglobin decline by ≥1 g/dL or new-onset transfusion dependence; thrombocytopenia, defined as failure to achieve platelet engraftment, higher-than-expected transfusion needs, refractory to platelet transfusions, or ≥50% reduction in baseline platelet count after full platelet engraftment; lactate dehydrogenase (LDH) exceeding the upper limit of normal (ULN); schistocytes; hypertension; soluble C5b-9 (sC5b-9) exceeding the ULN; and proteinuria (≥1 mg/mg random urine protein-to-creatinine ratio [rUPCR]); (3) patients with any of the following features are at increased risk of nonrelapse mortality and should be stratified as high-risk TA-TMA: elevated sC5b-9, LDH ≥2 times the ULN, rUPCR ≥1 mg/mg, multiorgan dysfunction, concurrent grade II-IV acute graft-versus-host disease (GVHD), or infection (bacterial or viral); and (4) all allogeneic and pediatric autologous HCT recipients with neuroblastoma should be screened weekly for TA-TMA during the first 100 days post-HCT. Patients diagnosed with TA-TMA should be risk-stratified, and those with high-risk disease should be offered participation in a clinical trial for TA-TMA-directed therapy if available. We propose that these criteria and risk stratification features be used in data registries, prospective studies, and clinical practice across international settings. This harmonization will facilitate the investigation of TA-TMA across populations diverse in race, ethnicity, age, disease indications, and transplantation characteristics. As these criteria are widely used, we expect continued refinement as necessary. Efforts to identify more specific diagnostic and prognostic biomarkers are a top priority of the field. Finally, an investigation of the impact of TA-TMA-directed treatment, particularly in the setting of concurrent highly morbid complications, such as steroid-refractory GVHD and infection, is critically needed.
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Affiliation(s)
- M L Schoettler
- Department Blood and Marrow Transplantation, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Atlanta, Georgia
| | - E Carreras
- Spanish Bone Marrow Donor Registry, Josep Carreras Foundation and Leukemia Research Institute, Barcelona, Catalunya, Spain
| | - B Cho
- Department of Internal Medicine, Catholic Blood and Marrow Transplantation Center, Seoul, Korea
| | - C E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - V T Ho
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - S Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - I Moissev
- RM Gorbacheva Research Institute, Pavlov University, Saint-Petersburg, Russian Federation
| | | | - A Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Y Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
| | - P Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - J Koreth
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - N Kroger
- Division of Hematology, Ohio State University, Columbus, Ohio
| | - P Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - K Page
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - U Popat
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - B E Shaw
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A Sureda
- Clinical Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - R Soiffer
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - S Vasu
- Division of Hematology, Ohio State University, Columbus, Ohio.
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19
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Sabulski A, Jodele S. Peering into the darkness of drug-induced thrombotic microangiopathy: complement, are you in there? J Gastrointest Oncol 2023; 14:468-471. [PMID: 36915433 PMCID: PMC10007918 DOI: 10.21037/jgo-2022-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/20/2022] [Indexed: 03/03/2023] Open
Affiliation(s)
- Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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20
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Use of eculizumab in children with allogeneic haematopoietic stem cell transplantation associated thrombotic microangiopathy - a multicentre retrospective PDWP and IEWP EBMT study. Bone Marrow Transplant 2023; 58:129-141. [PMID: 36333550 DOI: 10.1038/s41409-022-01852-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 09/24/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Terminal complement blockade by humanised monoclonal antibody eculizumab has been used to treat transplantation-associated thrombotic microangiopathy (TA-TMA) in recent years. This retrospective international study conducted by the Paediatric Diseases (PDWP) and Inborn Error Working Party (IEWP) of the European Society for Blood and Marrow Transplantation (EBMT) describes outcome and response of 82 paediatric patients from 29 centres who developed TA-TMA and were treated with eculizumab between January 2014 and May 2019. The median time from hematopoietic stem cell transplantation (HSCT) to TA-TMA manifestation was 92 days (range: 7-606) and from TA-TMA diagnosis to the start of eculizumab treatment 6 days (range: 0-135). Most patients received eculizumab weekly (72%, n = 55) with a standard weight (kg)-based dose (78%, n = 64). Six months from beginning of eculizumab therapy, the cumulative incidence of TA-TMA resolution was 36.6% (95% CI: 26.2-47) and the overall survival (OS) was 47.1% (95% CI: 35.9-57.5). All 43 patients with unresolved TA-TMA died. The cause of death was HSCT-related in 41 patients. This study also documents poor outcome of patients without aGvHD and their frequent concomitant viral infections. Considering recent publications, intensified eculizumab dosing and complement monitoring could potentially improve upon outcomes observed in this study.
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21
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Genest DS, Patriquin CJ, Licht C, John R, Reich HN. Renal Thrombotic Microangiopathy: A Review. Am J Kidney Dis 2022; 81:591-605. [PMID: 36509342 DOI: 10.1053/j.ajkd.2022.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA), a pathological lesion observed in a wide spectrum of diseases, is triggered by endothelial injury and/or dysfunction. Although TMA lesions are often accompanied by clinical features of microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury, renal-limited forms of TMA are not infrequently encountered in clinical practice. The presence of renal-limited manifestations can be diagnostically challenging, often delaying the initiation of targeted therapy. Prompt investigation and empirical treatment of TMA is warranted to reduce associated morbidity and mortality. Major advances have been made with respect to the pathophysiology of primary TMA entities, with the subsequent development of novel diagnostic tools and lifesaving therapies for diseases like thrombotic thrombocytopenic purpura and complement-mediated TMA. This article will review the clinical presentation and pathologic hallmarks of TMA involving the kidney, and the disease-specific mechanisms that contribute to the endothelial injury that characterizes TMA lesions. Diagnostic approach and both empirical and disease-specific treatment strategies will be discussed, along with the potential role for emerging targeted disease-specific therapies.
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Affiliation(s)
- Dominique Suzanne Genest
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rohan John
- Division of Laboratory Medicine and Pathology, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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22
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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23
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Chan WYK, Ma ALT, Chan EYH, Kan ANC, Ng WF, Lee PPW, Cheuk DKL, Chiang AKS, Leung W, Chan GCF. Epidemiology and outcomes of pediatric transplant-associated thrombotic microangiopathy in Hong Kong. Pediatr Transplant 2022; 26:e14366. [PMID: 35860972 DOI: 10.1111/petr.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/13/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is an under-recognized yet potentially devastating complication of hematopoietic stem cell transplantation (HSCT) which had increased awareness in recent years. This report summarizes the demographics and outcomes of pediatric TA-TMA in Hong Kong. METHODS All patients aged below 18 years who underwent HSCT in the Hong Kong Children's Hospital and were diagnosed to have TA-TMA during the 2-year period from April 1, 2019 to March 31, 2021 were included. RESULTS A total of 73 transplants (51 allogeneic and 22 autologous) in 63 patients had been performed. Six patients (four males and two females) developed TA-TMA at a median duration of 2.5 months post-HSCT. The incidence rate was 9.52%. Of the six TA-TMA patients, five underwent allogenic one underwent autologous HSCT, respectively. Three of them were histologically proven. All four patients with cyclosporine had stopped the drug once TA-TMA was suspected. Median six doses of eculizumab were administered to five out of six patients. Three patients died (two due to fungal infection and one due to acute-on-chronic renal failure) within 3 months upon diagnosis of TA-TMA. Among three survivors, two stabilized with mild stage 2 chronic kidney disease (CKD) while the other suffered from stage 5 end-stage CKD requiring lifelong dialysis. CONCLUSION In conclusion, recognition and diagnosis of TA-TMA are challenging. Early recognition and prompt administration of complement blockage with eculizumab may be beneficial in selected cases. Further prospective research studies are recommended to improve the management and outcomes of TA-TMA.
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Affiliation(s)
- Wilson Yau Ki Chan
- Paediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Alison Lap Tak Ma
- Pediatric Nephrology team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Eugene Yu Hin Chan
- Pediatric Nephrology team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Amanda Nim Chi Kan
- Department of Pathology, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Wai Fu Ng
- Department of Pathology, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Pamela Pui Wah Lee
- Paediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Daniel Ka Leung Cheuk
- Paediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Alan Kwok Shing Chiang
- Paediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Wing Leung
- Paediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Godfrey Chi Fung Chan
- Paediatric Hematology, Oncology and Hematopoietic Stem Cell Transplantation Team, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
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24
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Sabulski A, Jodele S. What complements complement in transplant-associated thrombotic microangiopathy? Br J Haematol 2022; 199:477-479. [PMID: 35942659 DOI: 10.1111/bjh.18402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
Transplant-associated thrombotic microangiopathy remains a lethal complication of haematopoietic stem cell transplant and not all patients respond to terminal complement inhibitors. Qi et al. show that hypoxia-inducible factor-1α (HIF-1α) may be a previously unrecognized driver of this endothelial injury syndrome. Commentary on Qi et al. Upregulation of HIF-1α contributes to complement activation in transplantation-associated thrombotic microangiopathy. Br J Haematol. 2022 (Online ahead of print). doi: 10.1111/bjh.18377.
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Affiliation(s)
- Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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25
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Cerebral vascular injury in transplant-associated thrombotic microangiopathy. Blood Adv 2022; 6:4310-4319. [PMID: 35877136 PMCID: PMC9327538 DOI: 10.1182/bloodadvances.2022007453] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) and atypical hemolytic uremic syndrome (aHUS) are complement-mediated TMAs. The central nervous system (CNS) is the most common extrarenal organ affected by aHUS, and, despite mechanistic overlap between aHUS and TA-TMA, CNS involvement is rarely reported in TA-TMA, suggesting that CNS involvement in TA-TMA may be underdiagnosed and that these patients may benefit from complement blockers. In addition, there are no widely used histologic or radiologic criteria for the diagnosis of TMA in the brain. Thirteen recipients of pediatric hematopoietic cell transplants (HCTs) who had TA-TMA and who underwent autopsy were studied. Seven of 13 brains had vascular injury, and 2 had severe vascular injury. Neurologic symptoms correlated with severe vascular injury. Classic TMA histology was present and most often observed in the cerebellum, brainstem, and cerebral white matter. Abnormalities in similar anatomic regions were seen on imaging. Brain imaging findings related to TMA included hemorrhages, siderosis, and posterior reversible encephalopathy syndrome. We then studied 100 consecutive HCT recipients to identify differences in neurologic complications between patients with and those without TA-TMA. Patients with TA-TMA were significantly more likely to have a clinical concern for seizure, have an electroencephalogram performed, and develop altered mental status. In summary, our study confirms that TA-TMA involves the brains of recipients of HCT and is associated with an increased incidence of neurologic symptoms. Based on these findings, we propose that patients with low- or moderate-risk TA-TMA who develop neurologic complications should be considered for TA-TMA-directed therapy.
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26
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The Role of Complement in HSCT-TMA: Basic Science to Clinical Practice. Adv Ther 2022; 39:3896-3915. [PMID: 35781192 PMCID: PMC9402756 DOI: 10.1007/s12325-022-02184-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/06/2022] [Indexed: 12/05/2022]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a common complication occurring post-HSCT and is associated with substantial morbidity and mortality if not promptly identified and treated. Emerging evidence suggests a central role for the complement system in the pathogenesis of HSCT-TMA. The complement system has also been shown to interact with other pathways and processes including coagulation and inflammation, all of which are activated following HSCT. Three endothelial cell-damaging “hits” are required for HSCT-TMA genesis: a genetic predisposition or existing damage, an endothelial cell-damaging conditioning regimen, and additional damaging insults. Numerous risk factors for the development of HSCT-TMA have been identified (including primary diagnosis, graft type, and conditioning regimen) and validated lists of relatively simple diagnostic signs and symptoms exist, many utilizing routine clinical and laboratory assessments. Despite the relative ease with which HSCT-TMA can be screened for, it is often overlooked or masked by other common post-transplant conditions. Recent evidence that patients with HSCT-TMA may also concurrently present with these differential diagnoses only serve to further confound its identification and treatment. HSCT-TMA may be treated, or even prevented, by removing or ameliorating triggering “hits”, and recent studies have also shown substantial utility of complement-targeted therapies in this patient population. Further investigation into optimal management and treatment strategies is needed. Greater awareness of TMA post-HSCT is urgently needed to improve patient outcomes; the objective of this article is to clarify current understanding, explain underlying complement biology and provide simple tools to aid the early recognition, management, and monitoring of HSCT-TMA.
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Stallworth JY, Horton JC. Massive periorbital edema following hematopoietic stem cell transplantation. Am J Ophthalmol Case Rep 2022; 26:101559. [PMID: 35540706 PMCID: PMC9079772 DOI: 10.1016/j.ajoc.2022.101559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose To describe a case of severe, bilateral periorbital edema after hematopoietic stem cell transplantation. Observations A three-year old girl with metastatic neuroblastoma underwent the second of two tandem autologous peripheral blood stem cell transplants, complicated by engraftment syndrome. On post-engraftment day 11, she developed acute onset of severe periorbital edema. She was soon thereafter diagnosed with transplant-associated thrombotic microangiopathy with significant volume overload requiring treatment with eculizumab and etanercept. Periorbital edema resolved after four days with concurrent treatment of her underlying condition. Conclusions and Importance We report an ocular manifestation related to complications of hematopoietic stem cell transplantation. This highlights a non-infectious etiology of eyelid swelling in the post-transplant, immunocompromised population.
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Affiliation(s)
- Jeannette Y. Stallworth
- University of California San Francisco, Department of Ophthalmology, San Francisco, CA, 94158 USA
| | - Jonathan C. Horton
- University of California San Francisco, Department of Ophthalmology, San Francisco, CA, 94158 USA
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Blasco M, Guillén-Olmos E, Diaz-Ricart M, Palomo M. Complement Mediated Endothelial Damage in Thrombotic Microangiopathies. Front Med (Lausanne) 2022; 9:811504. [PMID: 35547236 PMCID: PMC9082680 DOI: 10.3389/fmed.2022.811504] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
Thrombotic microangiopathies (TMA) constitute a group of different disorders that have a common underlying mechanism: the endothelial damage. These disorders may exhibit different mechanisms of endothelial injury depending on the pathological trigger. However, over the last decades, the potential role of the complement system (CS) has gained prominence in their pathogenesis. This is partly due to the great efficacy of complement-inhibitors in atypical hemolytic syndrome (aHUS), a TMA form where the primary defect is an alternative complement pathway dysregulation over endothelial cells (genetic and/or adquired). Complement involvement has also been demonstrated in other forms of TMA, such as thrombotic thrombocytopenic purpura (TTP) and in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (STEC-HUS), as well as in secondary TMAs, in which complement activation occurs in the context of other diseases. However, at present, there is scarce evidence about the efficacy of complement-targeted therapies in these entities. The relationship between complement dysregulation and endothelial damage as the main causes of TMA will be reviewed here. Moreover, the different clinical trials evaluating the use of complement-inhibitors for the treatment of patients suffering from different TMA-associated disorders are summarized, as a clear example of the entry into a new era of personalized medicine in its management.
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Affiliation(s)
- Miquel Blasco
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Elena Guillén-Olmos
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Marta Palomo
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain.,Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
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29
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Prognostic role of serum cytokines and soluble HLA-G levels in children with leukemia who undergo allogeneic stem cell transplantation. Cytokine 2022; 153:155869. [DOI: 10.1016/j.cyto.2022.155869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022]
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Higham CS, Shimano KA, Melton A, Kharbanda S, Chu J, Dara J, Winestone LE, Hermiston ML, Huang JN, Dvorak CC. A pilot trial of prophylactic defibrotide to prevent serious thrombotic microangiopathy in high-risk pediatric patients. Pediatr Blood Cancer 2022; 69:e29641. [PMID: 35253361 DOI: 10.1002/pbc.29641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial injury complication of hematopoietic stem cell transplant (HSCT) leading to end-organ damage and high morbidity and mortality. Defibrotide is an anti-inflammatory and antithrombotic agent that may protect the endothelium during conditioning. PROCEDURE We hypothesized that prophylactic use of defibrotide during HSCT conditioning and acute recovery could prevent TA-TMA. A pilot single-arm phase II trial (NCT#03384693) evaluated the safety and feasibility of administering prophylactic defibrotide to high-risk pediatric patients during HSCT and assessed if prophylactic defibrotide prevented TA-TMA compared to historic controls. Patients received defibrotide 6.25 mg/kg IV q6h the day prior to the start of conditioning through day +21. Patients were prospectively monitored for TA-TMA from admission through week 24 post transplant. Potential biomarkers of endothelial injury (suppression of tumorigenicity 2 [ST2], angiopoietin-2 [ANG-2], plasminogen activator inhibitor-1 [PAI-1], and free hemoglobin) were analyzed. RESULTS Twenty-five patients were enrolled, 14 undergoing tandem autologous HSCT for neuroblastoma and 11 undergoing allogeneic HSCT. Defibrotide was discontinued early due to possibly related clinically significant bleeding in 12% (3/25) of patients; no other severe adverse events occurred due to the study intervention. The other 22 patients missed a median of 0.7% of doses (0%-5.2%). One patient developed nonsevere TA-TMA 12 days post HSCT. This observed TA-TMA incidence of 4% was below the historic rate of 18%-40% in a similar population of allogeneic and autologous patients. CONCLUSIONS Our study provides evidence that defibrotide prophylaxis is feasible in pediatric patients undergoing HSCT at high risk for TA-TMA and preliminary data indicating that defibrotide may reduce the risk of TA-TMA.
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Affiliation(s)
- Christine S Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Julia Chu
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
| | - Michelle L Hermiston
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - James N Huang
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA.,Division of Pediatric Hematology and Oncology, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospitals, San Francisco, California, USA
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31
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Abou‐Ismail MY, Kapoor S, Citla Sridhar D, Nayak L, Ahuja S. Thrombotic microangiopathies: An illustrated review. Res Pract Thromb Haemost 2022; 6:e12708. [PMID: 35615754 PMCID: PMC9027164 DOI: 10.1002/rth2.12708] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 11/11/2022] Open
Abstract
The thrombotic microangiopathies (TMAs) are a heterogenous group of disorders with distinct pathophysiologies that cause occlusive microvascular or macrovascular thrombosis, and are characterized by microangiopathic hemolytic anemia, thrombocytopenia, and/or end-organ ischemia. TMAs are associated with significant morbidity and mortality, and data on the management of certain TMAs are often lacking. The nomenclature, classification, and management of various TMAs is constantly evolving as we learn more about these rare syndromes. Thorough clinical and laboratory evaluation is essential to distinguish various TMAs and arrive at an accurate diagnosis, which is key for appropriate management. In this illustrated review, we focus on thrombotic thrombocytopenic purpura (TTP), Shiga toxin-associated hemolytic uremic syndrome, complement-mediated hemolytic uremic syndrome, hematopoietic cell transplant-associated TMA, and drug-induced TMA, and describe their incidence, pathophysiology, diagnosis, and management. We also highlight emerging complement-directed therapies under investigation for the management of complement-mediated TMAs.
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Affiliation(s)
- Mouhamed Yazan Abou‐Ismail
- Division of Hematology and Hematologic Malignancies Department of Internal Medicine University of Utah Health Sciences Center Salt Lake City Utah USA
| | - Sargam Kapoor
- Department of Hematology & Oncology Alaska Native Medical Center Anchorage Alaska USA
| | - Divyaswathi Citla Sridhar
- Department of Pediatric Hematology & Oncology University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Lalitha Nayak
- Department of Hematology & Oncology University Hospitals Cleveland Medical Center Cleveland Ohio USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology University Hospitals Rainbow Babies and Children’s Hospital Cleveland Ohio USA
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32
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Betzmann D, Döring M, Blumenstock G, Erdmann F, Grabow D, Lang P, Binder G. Impact of serum insulin-like growth factor-1 on HSCT outcome in pediatric cancer patients. Transplant Cell Ther 2022; 28:355.e1-355.e9. [PMID: 35405367 DOI: 10.1016/j.jtct.2022.03.027] [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: 10/13/2021] [Revised: 12/20/2021] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is associated with severe medical complications and variable outcome depending on the recipient's disease stage and health condition. Biomarkers predicting outcome may have therapeutic relevance in pediatric cancer care. Insulin like growth factor 1 (IGF 1) is a mitogenic and anabolic peptide hormone that is expressed in almost all tissues. This hormone is the major growth factor in childhood. As IGF 1 is decreased in conditions that cause catabolic metabolism, it may reflect the degree of physical robustness of the patient and serve as predictive biomarker for transplant outcome. OBJECTIVES AND STUDY DESIGN We evaluated the impact of pre-transplant serum-IGF 1 on both survival and adverse events in 587 pediatric cancer patients, who underwent autologous or allogeneic HSCT between 1987 and 2014 at the University Children's Hospital Tübingen, Germany. Survival probabilities of the entire cohort and of defined subgroups according to pre-transplant serum-IGF-1 were estimated using the Kaplan-Meier method. RESULTS Mean pre-transplant IGF 1 (n = 498) was low: -1.67 SDS (SD, 1.54). Completeness of follow-up three and ten years post HSCT was 96 % and 83 %, respectively. The ten-year overall survival was 44.8 % (95 % confidence interval [CI], 40.6-48.9). With decreasing IGF-1 SDS, there was a significant increase of transplant-related mortality (p = 0.027), sinusoidal obstruction syndrome (quartiles 4 to 1: 3; 1; 12; 12%; p < 0.001) and thrombotic microangiopathy (quartiles 4 to 1: 0: 0: 2; 5%; p = 0.004). IGF 1 decile 1 showed a significantly poorer outcome (p=0.042) with lower median (12 versus 68 months) and ten-year overall survival (37 % versus 52 %) when compared to decile 2-10. CONCLUSIONS This retrospective study suggests pre-transplant serum-IGF 1 as a predictor of survival and selected vascular adverse events that may have diagnostic and therapeutic relevance in pediatric cancer care.
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Affiliation(s)
- Deborah Betzmann
- University Children's Hospital Tübingen, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Michaela Döring
- University Children's Hospital Tübingen, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Silcherstraße 5, 72076 Tübingen, Germany
| | - Friederike Erdmann
- Division of Childhood Cancer Epidemiology, German Childhood Cancer Registry, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI) University Medical Center of the Johannes Gutenberg University Mainz, Mainz
| | - Desiree Grabow
- Division of Childhood Cancer Epidemiology, German Childhood Cancer Registry, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI) University Medical Center of the Johannes Gutenberg University Mainz, Mainz
| | - Peter Lang
- University Children's Hospital Tübingen, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Gerhard Binder
- University Children's Hospital Tübingen, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany.
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Jodele S, Dandoy CE, Sabulski A, Koo J, Lane A, Myers KC, Wallace G, Chima RS, Teusink-Cross A, Hirsch R, Ryan TD, Benoit S, Davies SM. TA-TMA risk stratification: is there a window of opportunity to improve outcomes? Transplant Cell Ther 2022; 28:392.e1-392.e9. [DOI: 10.1016/j.jtct.2022.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
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34
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Prabahran A, Koldej R, Chee L, Ritchie D. Clinical features, pathophysiology, and therapy of poor graft function post-allogeneic stem cell transplantation. Blood Adv 2022; 6:1947-1959. [PMID: 34492685 PMCID: PMC8941468 DOI: 10.1182/bloodadvances.2021004537] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/07/2021] [Indexed: 01/05/2023] Open
Abstract
Poor graft function (PGF), defined by the presence of multilineage cytopenias in the presence of 100% donor chimerism, is a serious complication of allogeneic stem cell transplant (alloSCT). Inducers or potentiators of alloimmunity such as cytomegalovirus reactivation and graft-versus-host disease are associated with the development of PGF, however, more clinical studies are required to establish further risk factors and describe outcomes of PGF. The pathophysiology of PGF can be conceptualized as dysfunction related to the number or productivity of the stem cell compartment, defects in bone marrow microenvironment components such as mesenchymal stromal cells and endothelial cells, or immunological suppression of post-alloSCT hematopoiesis. Treatment strategies focused on improving stem cell number and function and microenvironment support of hematopoiesis have been attempted with variable success. There has been limited use of immune manipulation as a therapeutic strategy, but emerging therapies hold promise. This review details the current understanding of the causes of PGF and methods of treatment to provide a framework for clinicians managing this complex problem.
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Affiliation(s)
- Ashvind Prabahran
- Department of Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Parkville, VIC, Australia
- Australian Cancer Research Fund Translational Research Laboratory, Royal Melbourne Hospital, Parkville, VIC, Australia; and
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Rachel Koldej
- Department of Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Parkville, VIC, Australia
- Australian Cancer Research Fund Translational Research Laboratory, Royal Melbourne Hospital, Parkville, VIC, Australia; and
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Lynette Chee
- Department of Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Parkville, VIC, Australia
- Australian Cancer Research Fund Translational Research Laboratory, Royal Melbourne Hospital, Parkville, VIC, Australia; and
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - David Ritchie
- Department of Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Parkville, VIC, Australia
- Australian Cancer Research Fund Translational Research Laboratory, Royal Melbourne Hospital, Parkville, VIC, Australia; and
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
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35
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Schoettler ML, Bhatt H, Vasu S. A systematic review of diagnostic, prognostic, and risk blood and urine biomarkers of transplant-associated thrombotic microangiopathy. Front Immunol 2022; 13:1064203. [PMID: 36818475 PMCID: PMC9933706 DOI: 10.3389/fimmu.2022.1064203] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/28/2022] [Indexed: 02/05/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of allogeneic and autologous hematopoietic cellular therapy (HCT), associated with significant morbidity and mortality. Although the central drivers of the disease are thought to be endothelial damage and complement activation, no specific diagnostic biomarkers have been identified. TA-TMA is typically diagnosed using criteria comprised of non-specific clinical and laboratory features. Some patients will have a self-remitting course, but more than half develop multi-organ dysfunction or die, making prognostic biomarkers critical. Prevention of TA-TMA, an approach central to other HCT complications such as graft-versus-host disease, is largely untested in part due to a lack of identified early high-risk biomarkers. We conducted a systematic review to summarize the diagnostic, early risk, and prognostic biomarkers of TA-TMA. We screened the titles and abstracts of 1524 citations. After screening out duplications, we read the abstracts of 979 papers and fully reviewed 132 full-text publications. Thirty-one publications fulfilled the inclusion criteria of more than five patients with TA-TMA and a reported measure of association with diagnosis, prognosis, or risk of later development of the disease. Fourteen studies (45%) were with adults, 12 (39%) were with children <18 years old, three included both children and adults, and two did not report age. There were 53 biomarker or biomarker signature entries, and a total of 27 unique biomarkers. Only four biomarkers reported sensitivity and specificity. The single biomarker with the most robust data was sC5b-9, which conferred diagnostic, prognostic, and risk implications. Studies of combinations of biomarkers were rare. No meta-analyses were performed because of significant heterogeneity between studies. The limitations of studies included small sample size, study designs with a high risk of bias (i.e., case-control), the timing of sample collection, and the selection of controls. Furthermore, only two (6%) studies included a training and validation cohort. Cut-off points are needed to stratify groups, as most biomarkers do not have normal values, or normal values cannot be assumed in the HCT setting. In the future, multi-institutional, collaborative efforts are needed to perform rigorously designed, prospective studies with serially enrolled patients, with samples collected at the time of TA-TMA diagnosis, careful selection of controls, and validation of selected biomarkers and cut-off points in a separate cohort.
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Affiliation(s)
- Michelle L Schoettler
- Children's Healthcare of Atlanta/Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA, United States.,Department of Pediatrics, Emory School of Medicine, Columbus, OH, United States
| | - Harshil Bhatt
- Hematopoietic Cell Transplantation, Ohio State University, Columbus, OH, United States
| | - Sumithira Vasu
- Hematopoietic Cell Transplantation, Ohio State University, Columbus, OH, United States
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Shimizu S, Morohashi T, Kanezawa K, Yagasaki H, Takahashi S, Morioka I. Case Report: Successful Treatment With Anti-C5 Monoclonal Antibody in a Japanese Adolescent Who Developed Thrombotic Microangiopathy After Autologous Bone Marrow Transplantation for Malignant Lymphoma. Front Pediatr 2022; 10:908183. [PMID: 35859949 PMCID: PMC9289264 DOI: 10.3389/fped.2022.908183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Transplant-associated thrombotic microangiopathy (TA-TMA) is a serious complication of bone marrow transplantation (BMT). Recently, abnormalities in the complement system have been identified in the pathogenesis of TA-TMA, and there are series of reports stating that anti-C5 monoclonal antibody (eculizumab) is effective in patients with high levels of the membrane attack complex (C5b-9). CASE PRESENTATION A 12-year-old boy underwent autologous BMT after receiving high-dose chemotherapy for malignant lymphoma. The patient was engrafted on day 19 after transplantation; however, hemolytic anemia and non-immune thrombocytopenia persisted, and haptoglobin decreased on day 46. Moreover, on day 83, the patient developed pulmonary hemorrhage, hypertension, severe proteinuria, hematuria, and acute kidney injury (AKI). Pulmonary bleeding stopped with daily platelet transfusion and hemostatic agents, but reappeared on day 100. Based on the presence of destruction of red blood cells, elevated lactate dehydrogenase levels, negative direct and indirect Coombs tests, normal ADAMTS13 levels, hemolytic anemia, non-immune thrombocytopenia, and AKI, the patient was diagnosed with systemic TA-TMA and we initiated plasma exchange (PE) and continuous hemodialysis for AKI. High C5b-9 levels were identified at the start of the series of PE, therefore we decided to administer eculizumab. After three courses of eculizumab, no pulmonary hemorrhage was observed, and anemia, thrombocytopenia, renal dysfunction, hematuria, and proteinuria all tended to improve. Three years after transplantation, the patient is alive and does not require eculizumab. DISCUSSION Eculizumab is a humanized monoclonal antibody that binds complement protein C5, preventing cleavage C5 and the formation of C5b-9. In this case, TA-TMA could not be controlled with PE alone. We therefore decided to use eculizumab relatively early based on the high C5b-9 level and could resolve the momentum of TA-TMA. CONCLUSION In previous reports, TA-TMA typically occurred in early post-allogeneic BMT of patients with lymphoma or in post-autologous BMT of patients with neuroblastoma and was treated with eculizumab. We here reported that eculizumab could be successful treatment for TA-TMA in post-autologous BMT of patient with lymphoma.
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Affiliation(s)
- Shoichi Shimizu
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Tamaki Morohashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Koji Kanezawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagasaki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | | | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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37
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Gavriilaki E, Ho VT, Schwaeble W, Dudler T, Daha M, Fujita T, Jodele S. Role of the lectin pathway of complement in hematopoietic stem cell transplantation-associated endothelial injury and thrombotic microangiopathy. Exp Hematol Oncol 2021; 10:57. [PMID: 34924021 PMCID: PMC8684592 DOI: 10.1186/s40164-021-00249-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/27/2021] [Indexed: 12/30/2022] Open
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a life-threatening syndrome that occurs in adult and pediatric patients after hematopoietic stem cell transplantation. Nonspecific symptoms, heterogeneity within study populations, and variability among current diagnostic criteria contribute to misdiagnosis and underdiagnosis of this syndrome. Hematopoietic stem cell transplantation and associated risk factors precipitate endothelial injury, leading to HSCT-TMA and other endothelial injury syndromes such as hepatic veno-occlusive disease/sinusoidal obstruction syndrome, idiopathic pneumonia syndrome, diffuse alveolar hemorrhage, capillary leak syndrome, and graft-versus-host disease. Endothelial injury can trigger activation of the complement system, promoting inflammation and the development of endothelial injury syndromes, ultimately leading to organ damage and failure. In particular, the lectin pathway of complement is activated by damage-associated molecular patterns (DAMPs) on the surface of injured endothelial cells. Pattern-recognition molecules such as mannose-binding lectin (MBL), collectins, and ficolins—collectively termed lectins—bind to DAMPs on injured host cells, forming activation complexes with MBL-associated serine proteases 1, 2, and 3 (MASP-1, MASP-2, and MASP-3). Activation of the lectin pathway may also trigger the coagulation cascade via MASP-2 cleavage of prothrombin to thrombin. Together, activation of complement and the coagulation cascade lead to a procoagulant state that may result in development of HSCT-TMA. Several complement inhibitors targeting various complement pathways are in clinical trials for the treatment of HSCT-TMA. In this article, we review the role of the complement system in HSCT-TMA pathogenesis, with a focus on the lectin pathway.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Leof. Papanikolaou, Pilea Chortiatis 570 10, Thessaloniki, Greece.
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Wilhelm Schwaeble
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB3 0ES, UK
| | - Thomas Dudler
- Discovery and Development, Omeros Corporation, 201 Elliott Ave W, Seattle, WA, 98119, USA
| | - Mohamed Daha
- Department of Nephrology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Netherlands
| | - Teizo Fujita
- Department Fukushima Prefectural General Hygiene Institute, 61-Watari-Nakakado, Fukushima, Fukushima, 960-8141, Japan
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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38
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Proteomic profiling of MIS-C patients indicates heterogeneity relating to interferon gamma dysregulation and vascular endothelial dysfunction. Nat Commun 2021; 12:7222. [PMID: 34893640 PMCID: PMC8664884 DOI: 10.1038/s41467-021-27544-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 11/25/2021] [Indexed: 01/19/2023] Open
Abstract
Multi-system Inflammatory Syndrome in Children (MIS-C) is a major complication of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in pediatric patients. Weeks after an often mild or asymptomatic initial infection with SARS-CoV-2 children may present with a severe shock-like picture and marked inflammation. Children with MIS-C present with varying degrees of cardiovascular and hyperinflammatory symptoms. Here we perform a comprehensive analysis of the plasma proteome of more than 1400 proteins in children with SARS-CoV-2. We hypothesize that the proteome would reflect heterogeneity in hyperinflammation and vascular injury, and further identify pathogenic mediators of disease. We show that protein signatures demonstrate overlap between MIS-C, and the inflammatory syndromes macrophage activation syndrome (MAS) and thrombotic microangiopathy (TMA). We demonstrate that PLA2G2A is an important marker of MIS-C that associates with TMA. We find that IFNγ responses are dysregulated in MIS-C patients, and that IFNγ levels delineate clinical heterogeneity.
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39
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Schoettler M, Chonat S, Williams K, Lehmann L. Emerging therapeutic and preventive approaches to transplant-associated thrombotic microangiopathy. Curr Opin Hematol 2021; 28:408-416. [PMID: 34534983 PMCID: PMC9908033 DOI: 10.1097/moh.0000000000000687] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW Transplant-associated thrombotic microangiopathy (TA-TMA) is a complication that can occur in both allogeneic and autologous haematopoietic cellular therapy (HCT) recipients and is associated with significant morbidity and mortality. Although TA-TMA is a complex disease, there is emerging evidence that complement activation and endothelial dysfunction play a key role in the pathophysiology of the disease. The use of eculizumab has improved survival in patients with high risk and severe disease, but mortality rates in treated patients still exceed 30%, highlighting the need for novel approaches. RECENT FINDINGS There are multiple ongoing and planned clinical trials investigating novel complement agents in TA-TMA and other TMAs. Drugs vary by targets of the complement system, mechanism, and form of administration. Clinical trial designs include single arm studies that span across multiple age groups including children, and double-blind, randomized, placebo-controlled studies. These studies will provide robust data to inform the care of patients with TA-TMA in the future. In addition to multiple promising therapeutic agents, preventing TA-TMA is an emerging strategy. Agents known to protect the endothelium from damage and augment endothelial function by promoting anti-inflammatory and antithrombotic effects may have a role in preventing TA-TMA or ameliorating the severity, though additional studies are needed. SUMMARY Novel therapeutic agents for TA-TMA inhibition of the complement system are under investigation and prophylactic strategies of endothelial protection are emerging. Further understanding of the pathophysiology of the disease may identify additional therapeutic targets. Multiinstitutional, collaborative clinical trials are needed to determine the safety and efficacy of these agents going forward.
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Affiliation(s)
- Michelle Schoettler
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Pediatric Hematopoietic Cellular Therapy, Atlanta, GA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Department of Pediatrics, Pediatric Hematology, Emory University, Atlanta, GA
| | - Kirsten Williams
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Pediatric Hematopoietic Cellular Therapy, Atlanta, GA
| | - Leslie Lehmann
- Boston Children’s/Dana Farber Cancer and Blood Disorders Center, Pediatric Hematopoietic Cellular Therapies
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Jodele S, Sabulski A. Transplant-associated thrombotic microangiopathy: elucidating prevention strategies and identifying high-risk patients. Expert Rev Hematol 2021; 14:751-763. [PMID: 34301169 DOI: 10.1080/17474086.2021.1960816] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (TA-TMA) is a severe complication of transplant. TA-TMA is a multifactorial disease where generalized endothelial dysfunction leads to microangiopathic hemolytic anemia, intravascular platelet activation, and formation of microthrombi leading to end-organ injury. It is essential to identify patients at risk for this complication and to implement early interventions to improve TA-TMA associated transplant outcomes. AREAS COVERED Recognition of TA-TMA and associated multi-organ injury, risk predictors, contributing factors, differential diagnosis and targeting complement pathway in TA-TMA by summarizing peer reviewed manuscripts. EXPERT OPINION TA-TMA is an important transplant complication. Diagnostic and risk criteria are established in children and young adults and risk-based targeted therapies have been proposed using complement blockers. The immediate goal is to extend this work into adult stem cell transplant recipients by implementing universal TA-TMA screening practices. This will facilitate early TA-TMA diagnosis and targeted interventions, which will further improve survival. While complement blocking therapy is effective, about one third of patients are refractory to treatment and those patients commonly die. The next hurdle for the field is identifying reasons for failure, optimizing strategies for complement modifying therapy and searching for additional targetable pathways of endothelial injury.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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41
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Saha BK. A Deadly Thrombotic Microangiopathy Syndrome without Schistocytosis. South Med J 2021; 114:416-418. [PMID: 34215894 DOI: 10.14423/smj.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Biplab K Saha
- From the Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri
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42
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Transplant-associated thrombotic microangiopathy in pediatric patients: pre-HSCT risk stratification and prophylaxis. Blood Adv 2021; 5:2106-2114. [PMID: 33877298 DOI: 10.1182/bloodadvances.2020003988] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/08/2021] [Indexed: 12/19/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial injury syndrome that complicates hematopoietic stem cell transplant (HSCT). Morbidity and mortality from TA-TMA remain high, making prevention critical. We describe our retrospective single-center experience of TA-TMA after pediatric allogeneic HSCT and present a novel pre-HSCT risk-stratification system and prophylaxis regimen. From January 2012 through October 2019, 257 patients underwent 292 allogeneic HSCTs. Prospective risk stratification was introduced in December 2016. High-risk (HR) patients were treated with combination prophylaxis with eicosapentaenoic acid and N-acetylcysteine. The 1-year cumulative incidence of TA-TMA was 6.3% (95% confidence interval [CI], 3.2-9.4). Age ≥10 years, myeloablative conditioning with total body irradiation, HLA mismatch, diagnosis of severe aplastic anemia or malignancy, prior calcineurin inhibitor exposure, and recipient cytomegalovirus seropositivity were found to be pre-HSCT risk factors for development of TA-TMA. Before routine prophylaxis, TA-TMA rates were significantly different between the HR and standard-risk groups, at 28.2% (95% CI, 0-12.7) vs 3.2% (0.1-6.3), respectively (P < .001). After introduction of prophylaxis, the 1-year cumulative incidence of TA-TMA in the HR group decreased to 4.5% (95% CI, 0-13.1; P = .062, compared with the incidence before prophylaxis). Multicenter pediatric studies are needed to validate these risk criteria and to confirm the efficacy of the prophylactic regimen.
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Thrombotic Microangiopathy: Multi-Institutional Review of Pediatric Patients Who Underwent HSCT. J Pers Med 2021; 11:jpm11060467. [PMID: 34070379 PMCID: PMC8226470 DOI: 10.3390/jpm11060467] [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: 04/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 12/03/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but serious complication of hematopoietic stem cell transplantation (HSCT). The purpose of our study is to estimate the incidence, prevalence, and analyze the risk factors and outcome of TMA in children receiving HSCT. Patients under the age of 21 who underwent HSCT at one of the 42 Pediatric Health Information System (PHIS) hospitals from 2000–2012 were analyzed, including demographics, hospitalizations, TMA, and other HSCT-related complications. From 2000 to 2012, a total of 12,369 unique pediatric patients who received HSCT were identified. Among these, 93 (0.8%) children were identified to have the diagnosis of TMA. TMA was significantly associated with allogeneic HSCT, peripheral blood stem cell trasnplants (PBSCT), cytomegalovirus (CMV), human herpes virus 6 (HHV6), fungal infection, graft-versus-host disease (GVHD), and veno-occlusive disease (VOD) (p = 0.01). Multivariate logistic regression analysis of mortality showed only HHV6 was an independent risk factor associated with increased mortality in patients with TMA (hazard ratio: 2.86 [1.01, 8.39], p = 0.05). The prevalence of TMA in our study is 0.8% with a mortality in our pediatric TMA cohort of 30%, which is in contrast to the higher mortality reported in previously published, small-case series. HHV6 emerged as not only a risk factor for TMA but also as associated with increased mortality in these patients.
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44
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Lia G, Giaccone L, Leone S, Bruno B. Biomarkers for Early Complications of Endothelial Origin After Allogeneic Hematopoietic Stem Cell Transplantation: Do They Have a Potential Clinical Role? Front Immunol 2021; 12:641427. [PMID: 34093530 PMCID: PMC8170404 DOI: 10.3389/fimmu.2021.641427] [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: 12/22/2020] [Accepted: 05/04/2021] [Indexed: 12/17/2022] Open
Abstract
Endothelial cell (EC) dysfunction causes a number of early and life-threatening post hematopoietic stem cell transplant (HCT) complications that result in a rapid clinical decline. The main early complications are graft-vs.-host disease (GVHD), transplant associated thrombotic microangiopathy (TA-TMA), and sinusoidal obstruction syndrome (SOS). Post-HCT endothelial dysfunction occurs as a result of chemotherapy, infections, and allogeneic reactivity. Despite major advances in transplant immunology and improvements in supportive care medicine, these complications represent a major obstacle for successful HCT. In recent years, different biomarkers have been investigated for early detection of post-transplant endothelial cell dysfunction, but few have been validated. In this review we will define GVHD, TA-TMA and SOS, summarize the current data available in HCT biomarker research and identify promising biomarkers for detection and diagnosis of early HCT complications.
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Affiliation(s)
- Giuseppe Lia
- Stem Cell Transplant Program, Department of Oncology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Luisa Giaccone
- Stem Cell Transplant Program, Department of Oncology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Sarah Leone
- Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
- Division of Hematology and Medical Oncology, New York University Grossman School of Medicine, Perlmutter Cancer Center, New York University Langone Health, New York, NY, United States
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A pragmatic multi-institutional approach to understanding transplant-associated thrombotic microangiopathy after stem cell transplant. Blood Adv 2021; 5:1-11. [PMID: 33570619 DOI: 10.1182/bloodadvances.2020003455] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/22/2020] [Indexed: 12/26/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication of hematopoietic stem cell transplantation (HSCT). A single-center prospective screening study has shown that the incidence of TA-TMA is much higher than prior retrospective studies that did not systematically screen. These data have not been replicated in a multicenter study. Our objective was to determine the incidence and risk factors for TA-TMA and compare outcomes of pediatric HSCT patients with and without TA-TMA. Patients were prospectively screened for TA-TMA at participating centers using a simple to implement and inexpensive strategy from the start of the preparative regimen through day +100. TA-TMA was diagnosed if ≥4 of 7 laboratory/clinical markers diagnostic for TA-TMA were present concurrently or if tissue histology showed TA-TMA. A total of 614 patients (359 males; 58%) received prospective TA-TMA screening at 13 pediatric centers. TA-TMA was diagnosed in 98 patients (16%) at a median of 22 days (interquartile range, 14-44) posttransplant. Patients with TA-TMA had significantly increased bloodstream infections (38% [37/98] vs 21% [107/51], P ≤ .001), mean total hospitalization days (68; 95% confidence interval [CI], 63-74 vs 43; 95% CI, 41-45; P ≤ .001), and number of days spent in the intensive care unit (10.1; 95% CI, 6.4-14; vs 1.6; 95% CI, 1.1-2.2; P ≤ .001) in the first 100 days after HSCT compared with patients without TA-TMA. Overall survival was significantly higher in patients without TA-TMA (93%; 490/516) compared with patients with TA-TMA (78%; 76/98) (P ≤ .001). These data support the need for systematic screening for TA-TMA and demonstrate the feasibility and efficacy of an easy to implement strategy to do so.
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Cao XY, Qiu LY, Zhang JP, Xiong M, Zhao YL, Lu Y, Zhou JR, Wei ZJ, Sun RJ, Liu DY, Zhang X, Yang JF, Lu PH. [CART therapy followed by allo-HSCT for patients with B-cell acute lymphoblastic leukemia relapsing after the first hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:318-323. [PMID: 33979977 PMCID: PMC8120115 DOI: 10.3760/cma.j.issn.0253-2727.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
目的 观察嵌合抗原受体T细胞(CART)序贯二次异基因造血干细胞移植(allo-HSCT)治疗移植后复发急性B淋巴细胞白血病(B-ALL)的疗效。 方法 回顾性分析2015年10月至2020年6月在河北燕达陆道培医院接受二次allo-HSCT的41例B-ALL患者的临床资料,入选患者均为移植后骨髓形态学或髓外复发且二次移植前接受CART治疗。 结果 全部41例患者中男21例、女20例,二次移植时中位年龄为16(3~46)岁。移植后骨髓复发31例(75.6%)、髓外复发5例(12.2%)、骨髓和髓外复发5例(12.2%)。复发后接受CD19-CART治疗35例(85.4%)、CD22-CART治疗2例(4.9%)、CD19-CART联合CD22-CART治疗4例(9.8%)。二次移植后预期3年总生存(OS)率为48.9%(95% CI 23.0%~70.6%)、无白血病生存(LFS)率为41.8%(95% CI 17.3%~64.9%),累积复发率(RI)为8.8%(95% CI 2.9%~26.4%),非复发相关死亡率(NRM)为51.1%(95% CI 31.2%~83.6%)。首次移植后复发时间≤6个月组(10例)二次移植后1年OS率低于复发时间>6个月组(31例)[45.0%(95% CI 12.7%~73.5%)对75.0%(95% CI 51.4%~88.8%),P=0.017]。 结论 CART序贯二次allo-HSCT可使部分造血干细胞移植后复发B-ALL患者获得长生存,但NRM较高,移植方案有待进一步改进。
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Affiliation(s)
- X Y Cao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - L Y Qiu
- Cryopreservation Department, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - J P Zhang
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - M Xiong
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Y L Zhao
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Y Lu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - J R Zhou
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - Z J Wei
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - R J Sun
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - D Y Liu
- Department of Bone Marrow Transplantation, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - X Zhang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - J F Yang
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
| | - P H Lu
- Department of Hematology, Hebei Yanda Lu Daopei Hospital, Langfang 065201, China
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Diorio C, Shraim R, Vella LA, Giles JR, Baxter AE, Oldridge DA, Canna SW, Henrickson SE, McNerney KO, Balamuth F, Burudpakdee C, Lee J, Leng T, Farrell A, Lambert MP, Sullivan KE, John Wherry E, Teachey DT, Bassiri H, Behrens EM. Proteomic Profiling of MIS-C Patients Reveals Heterogeneity Relating to Interferon Gamma Dysregulation and Vascular Endothelial Dysfunction. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.04.13.21255439. [PMID: 33907759 PMCID: PMC8077582 DOI: 10.1101/2021.04.13.21255439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Multi-system Inflammatory Syndrome in Children (MIS-C) is a major complication of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic in pediatric patients. Weeks after an often mild or asymptomatic initial infection with SARS-CoV-2 children may present with a severe shock-like picture and marked inflammation. Children with MIS-C present with varying degrees of cardiovascular and hyperinflammatory symptoms. We performed a comprehensive analysis of the plasma proteome of more than 1400 proteins in children with SARS-CoV-2. We hypothesized that the proteome would reflect heterogeneity in hyperinflammation and vascular injury, and further identify pathogenic mediators of disease. Protein signatures demonstrated overlap between MIS-C, and the inflammatory syndromes macrophage activation syndrome (MAS) and thrombotic microangiopathy (TMA). We demonstrate that PLA2G2A is a key marker of MIS-C that associates with TMA. We found that IFNγ responses are dysregulated in MIS-C patients, and that IFNγ levels delineate clinical heterogeneity.
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48
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Transplant-associated thrombotic microangiopathy: theoretical considerations and a practical approach to an unrefined diagnosis. Bone Marrow Transplant 2021; 56:1805-1817. [PMID: 33875812 PMCID: PMC8338557 DOI: 10.1038/s41409-021-01283-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 02/07/2023]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic stem cell transplant (HSCT) with high morbidity and mortality. The triad of endothelial cell activation, complement dysregulation, and microvascular hemolytic anemia has the potential to cause end organ dysfunction, multiple organ dysfunction syndrome and death, but clinical features mimic other disorders following HSCT, delaying diagnosis. Recent advances have implicated complement as a major contributor and the therapeutic potential of complement inhibition has been explored. Eculizumab has emerged as an effective therapy and narsoplimab (OMS721) has been granted priority review by the FDA. Large studies performed mostly in pediatric patients suggest that earlier recognition and treatment may lead to improved outcomes. Here we present a clinically focused summary of recently published literature and propose a diagnostic and treatment algorithm.
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49
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Kirkpatrick EC. Pulmonary Hypertension as a Complication of Pediatric Cancer. Glob Pediatr Health 2021; 8:2333794X211009094. [PMID: 33889681 PMCID: PMC8040614 DOI: 10.1177/2333794x211009094] [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: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
Pediatric cancer is a life threatening disease known to create multi-organ complications that further compromise medical management affecting patient morbidity and mortality. Pulmonary hypertension (PH) is becoming more recognized as a complication of cancer and its therapies but has not been well characterized in pediatrics. Cancer pathophysiology can be uniquely set up to promote pulmonary vascular injury and remodeling that is similar to PH patients without cancer. This highlights the need to evaluate for PH clinically and with routine testing such as echocardiography during the course of a patient's care even into adulthood. This review article will discuss the direct, indirect and therapy related aspects of cancer which can promote PH in these patients. This understanding is essential to target effective treatment options in a potentially fatal complication. Diagnostic and treatment algorithms are presented in relation to the most recent pediatric PH management guidelines.
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50
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Wang X, Sahu KK, Cerny J. Coagulopathy, endothelial dysfunction, thrombotic microangiopathy and complement activation: potential role of complement system inhibition in COVID-19. J Thromb Thrombolysis 2021; 51:657-662. [PMID: 33063256 PMCID: PMC7561230 DOI: 10.1007/s11239-020-02297-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2020] [Indexed: 12/18/2022]
Abstract
Coronavirus disease-2019 (COVID-19) is a rapidly evolving health crisis caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 is a novel disease entity and we are in a learning phase with regards to the pathogenesis, disease manifestations, and therapeutics. In addition to the primary lung injury, many patients especially the ones with moderate to severe COVID-19 display evidence of endothelial damage, complement activation, which leads to a pro-coagulable state. While there are still missing links in our understanding, the interplay of endothelium, complement system activation, and immune response to the SARS-CoV-2 virus is a surprisingly major factor in COVID-19 pathogenesis. One could envision COVID-19 becoming a novel hematological syndrome. This review is to discuss the available literature with regards to the involvement of the complement system, and coagulation cascade and their interaction with endothelium.
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Affiliation(s)
- Xin Wang
- Department of Medicine, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA USA
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608 USA
| | - Jan Cerny
- Department of Medicine - Hematology, and Oncology, UMass Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA USA
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