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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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Richardson E, García-Bernal D, Calabretta E, Jara R, Palomo M, Baron RM, Yanik G, Fareed J, Vlodavsky I, Iacobelli M, Díaz-Ricart M, Richardson PG, Carlo-Stella C, Moraleda JM. Defibrotide: potential for treating endothelial dysfunction related to viral and post-infectious syndromes. Expert Opin Ther Targets 2021; 25:423-433. [PMID: 34167431 DOI: 10.1080/14728222.2021.1944101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Defibrotide (DF) is a polyribonucleotide with antithrombotic, pro-fibrinolytic, and anti-inflammatory effects on endothelium. These effects and the established safety of DF present DF as a strong candidate to treat viral and post-infectious syndromes involving endothelial dysfunction. AREAS COVERED We discuss DF and other therapeutic agents that have the potential to target endothelial components of pathogenesis in viral and post-infectious syndromes. We introduce defibrotide (DF), describe its mechanisms of action, and explore its established pleiotropic effects on the endothelium. We describe the established pathophysiology of Coronavirus Disease 2019 (COVID-19) and highlight the processes specific to COVID-19 potentially modulated by DF. We also present influenza A and viral hemorrhagic fevers, especially those caused by hantavirus, Ebola virus, and dengue virus, as viral syndromes in which DF might serve therapeutic benefit. Finally, we offer our opinion on novel treatment strategies targeting endothelial dysfunction in viral infections and their severe manifestations. EXPERT OPINION Given the critical role of endothelial dysfunction in numerous infectious syndromes, in particular COVID-19, therapeutic pharmacology for these conditions should increasingly prioritize endothelial stabilization. Several agents with endothelial protective properties should be further studied as treatments for severe viral infections and vasculitides, especially where other therapeutic modalities have failed.
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Affiliation(s)
- Edward Richardson
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut, USA.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David García-Bernal
- Department of Medicine, Stem Cell Transplant and Cell Therapy Unit, IMIB-Arrixaca, Virgen De La Arrixaca University Hospital, University of Murcia, Murcia, Spain
| | - Eleonora Calabretta
- Department of Biomedical Sciences, Humanitas University, Rozzano-Milano, Italy.,Department of Oncology and Hematology, IRCCS - Humanitas Research Hospital, Rozzano-Milano, Italy
| | - Rubén Jara
- Intensive Care Unit, Virgen De La Arrixaca University Hospital, University of Murcia, Murcia, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Yanik
- Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Jawed Fareed
- Department of Molecular Pharmacology and Therapeutics, Hemostasis and Thrombosis Research Laboratories, Loyola University Medical Center, Chicago, Illinois, USA
| | - Israel Vlodavsky
- Technion Integrated Cancer Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - Maribel Díaz-Ricart
- Barcelona Endothelium Team, Barcelona, Spain.,Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain.,IDIBAPS, Barcelona, Spain
| | - Paul G Richardson
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Hematologic Malignancy, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Carmelo Carlo-Stella
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut, USA.,Department of Biomedical Sciences, Humanitas University, Rozzano-Milano, Italy.,Department of Oncology and Hematology, IRCCS - Humanitas Research Hospital, Rozzano-Milano, Italy.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose M Moraleda
- Department of Medicine, Stem Cell Transplant and Cell Therapy Unit, IMIB-Arrixaca, Virgen De La Arrixaca University Hospital, University of Murcia, Murcia, Spain
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