1
|
Loriamini M, Cserti-Gazdewich C, Branch DR. Autoimmune Hemolytic Anemias: Classifications, Pathophysiology, Diagnoses and Management. Int J Mol Sci 2024; 25:4296. [PMID: 38673882 PMCID: PMC11049952 DOI: 10.3390/ijms25084296] [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: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Autoimmune hemolytic anemias (AIHAs) are conditions involving the production of antibodies against one's own red blood cells (RBCs). These can be primary with unknown cause or secondary (by association with diseases or infections). There are several different categories of AIHAs recognized according to their features in the direct antiglobulin test (DAT). (1) Warm-antibody AIHA (wAIHA) exhibits a pan-reactive IgG autoantibody recognizing a portion of band 3 (wherein the DAT may be positive with IgG, C3d or both). Treatment involves glucocorticoids and steroid-sparing agents and may consider IVIG or monoclonal antibodies to CD20, CD38 or C1q. (2) Cold-antibody AIHA due to IgMs range from cold agglutinin syndrome (CAS) to cold agglutin disease (CAD). These are typically specific to the Ii blood group system, with the former (CAS) being polyclonal and the latter (CAD) being a more severe and monoclonal entity. The DAT in either case is positive only with C3d. Foundationally, the patient is kept warm, though treatment for significant complement-related outcomes may, therefore, capitalize on monoclonal options against C1q or C5. (3) Mixed AIHA, also called combined cold and warm AIHA, has a DAT positive for both IgG and C3d, with treatment approaches inclusive of those appropriate for wAIHA and cold AIHA. (4) Paroxysmal cold hemoglobinuria (PCH), also termed Donath-Landsteiner test-positive AIHA, has a DAT positive only for C3d, driven upstream by a biphasic cold-reactive IgG antibody recruiting complement. Although usually self-remitting, management may consider monoclonal antibodies to C1q or C5. (5) Direct antiglobulin test-negative AIHA (DAT-neg AIHA), due to IgG antibody below detection thresholds in the DAT, or by non-detected IgM or IgA antibodies, is managed as wAIHA. (6) Drug-induced immune hemolytic anemia (DIIHA) appears as wAIHA with DAT IgG and/or C3d. Some cases may resolve after ceasing the instigating drug. (7) Passenger lymphocyte syndrome, found after transplantation, is caused by B-cells transferred from an antigen-negative donor whose antibodies react with a recipient who produces antigen-positive RBCs. This comprehensive review will discuss in detail each of these AIHAs and provide information on diagnosis, pathophysiology and treatment modalities.
Collapse
Affiliation(s)
- Melika Loriamini
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Laboratory Medicine Program, Blood Transfusion Laboratory, University Health Network, Toronto, ON M5G 2C4, Canada
- Blood Disorders Program, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Donald R. Branch
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5B 1W8, Canada
| |
Collapse
|
2
|
Murakhovskaya I, Crivera C, Leon A, Alemao E, Anupindi VR, DeKoven M, Divino V, Lin I, Shu C, Ebrahim T. Healthcare resource utilization of patients with warm autoimmune hemolytic anemia initiating first line therapy of oral corticosteroids with or without rituximab. Ann Hematol 2024; 103:1139-1147. [PMID: 38296903 DOI: 10.1007/s00277-023-05613-8] [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: 05/19/2023] [Accepted: 12/27/2023] [Indexed: 02/02/2024]
Abstract
This retrospective cohort study described real-world treatment patterns and healthcare resource utilization (HCRU) of patients with warm autoimmune hemolytic anemia (wAIHA) initiating treatment with first-line (1L) oral corticosteroids (OCS) + rituximab (R) compared to 1L OCS. Patients with a wAIHA diagnosis code (D59.11) between 8/2020-3/2022 were identified using US pharmacy and medical claims databases. Patients initiating 1L OCS ± R were identified (date of initiation = 'index date') with a 1-year pre-index period and a variable (minimum 1-year) follow-up period. The final sample comprised 77 1L OCS + R patients and 400 1L OCS patients (~ 60% female, mean age > 64 years). Over the 1-year follow-up, HCRU was higher in the OCS + R cohort with higher mean number of physician office visits (22.9 and 14.4; p < 0.01), including hematology/oncology office visits, and higher utilization of rescue therapy (59.7% and 33.3%; p < 0.01), driven by higher use of injectable corticosteroids. Patients in OCS + R and OCS groups completed 1L therapy after a similar mean duration of 103.5 and 134.6 days, respectively (p = 0.24). In the majority of patients, second-line (2L) therapy was initiated at a similar timepoint: 66.2% OCS + R and 72.0% OCS cohorts (p = 0.31) initiated 2L in a mean of 218.3 and 203.2 days (p = 0.76) after the end of 1L treatment, respectively. The addition of rituximab in 1L did not extend the remission period, with most patients in both cohorts initiating 2L therapy within less than 1 year of completing 1L treatment. 1L OCS + R patients also had substantial HCRU burden. More effective novel therapies are needed to address the high unmet need in wAIHA.
Collapse
Affiliation(s)
- Irina Murakhovskaya
- Department of Hematology and Oncology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.
| | - Concetta Crivera
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| | - Ann Leon
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| | - Evo Alemao
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| | | | | | | | - Iris Lin
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| | - Cathye Shu
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| | - Tarek Ebrahim
- Janssen Pharmaceutical Companies of Johnson & Johnson, Horsham, PA, USA
| |
Collapse
|
3
|
Hansen DL, Maquet J, Lafaurie M, Möller S, Berentsen S, Frederiksen H, Moulis G, Gaist D. Primary autoimmune haemolytic anaemia is associated with increased risk of ischaemic stroke: A binational cohort study from Denmark and France. Br J Haematol 2024; 204:1072-1081. [PMID: 38098244 DOI: 10.1111/bjh.19242] [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: 08/28/2023] [Revised: 11/09/2023] [Accepted: 11/22/2023] [Indexed: 03/14/2024]
Abstract
Primary autoimmune haemolytic anaemia (AIHA) causes the destruction of red blood cells and a subsequent pro-thrombotic state, potentially increasing the risk of ischaemic stroke. We investigated the risk of ischaemic stroke in patients with AIHA in a binational study. We used prospectively collected data from nationwide registers in Denmark and France to identify cohorts of patients with primary AIHA and age- and sex-matched general population comparators. We followed the patient and comparison cohorts for up to 5 years, with the first hospitalization of a stroke during follow-up as the main outcome. We estimated cumulative incidence, cause-specific hazard ratios (csHR) and adjusted for comorbidity and exposure to selected medications. The combined AIHA cohorts from both countries comprised 5994 patients and the 81 525 comparators. There were 130 ischaemic strokes in the AIHA cohort and 1821 among the comparators. Country-specific estimates were comparable, and the overall adjusted csHR was 1.36 [95% CI: 1.13-1.65], p = 0.001; the higher rate was limited to the first year after AIHA diagnosis (csHR 2.29 [95% CI: 1.77-2.97], p < 10-9 ) and decreased thereafter (csHR 0.89 [95% CI: 0.66-1.20], p = 0.45) (p-interaction < 10-5 ). The findings indicate that patients diagnosed with primary AIHA are at higher risk of ischaemic stroke in the first year after diagnosis.
Collapse
Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Julien Maquet
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Odense University Hospital, Odense, Denmark
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| |
Collapse
|
4
|
Mulder FVM, Evers D, de Haas M, Cruijsen MJ, Bernelot Moens SJ, Barcellini W, Fattizzo B, Vos JMI. Severe autoimmune hemolytic anemia; epidemiology, clinical management, outcomes and knowledge gaps. Front Immunol 2023; 14:1228142. [PMID: 37795092 PMCID: PMC10545865 DOI: 10.3389/fimmu.2023.1228142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired hemolytic disorder, mediated by auto-antibodies, and has a variable clinical course ranging from fully compensated low grade hemolysis to severe life-threatening cases. The rarity, heterogeneity and incomplete understanding of severe AIHA complicate the recognition and management of severe cases. In this review, we describe how severe AIHA can be defined and what is currently known of the severity and outcome of AIHA. There are no validated predictors for severe clinical course, but certain risk factors for poor outcomes (hospitalisation, transfusion need and mortality) can aid in recognizing severe cases. Some serological subtypes of AIHA (warm AIHA with complement positive DAT, mixed, atypical) are associated with lower hemoglobin levels, higher transfusion need and mortality. Currently, there is no evidence-based therapeutic approach for severe AIHA. We provide a general approach for the management of severe AIHA patients, incorporating monitoring, supportive measures and therapeutic options based on expert opinion. In cases where steroids fail, there is a lack of rapidly effective therapeutic options. In this era, numerous novel therapies are emerging for AIHA, including novel complement inhibitors, such as sutimlimab. Their potential in severe AIHA is discussed. Future research efforts are needed to gain a clearer picture of severe AIHA and develop prediction models for severe disease course. It is crucial to incorporate not only clinical characteristics but also biomarkers that are associated with pathophysiological differences and severity, to enhance the accuracy of prediction models and facilitate the selection of the optimal therapeutic approach. Future clinical trials should prioritize the inclusion of severe AIHA patients, particularly in the quest for rapidly acting novel agents.
Collapse
Affiliation(s)
- Femke V. M. Mulder
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Dorothea Evers
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Masja de Haas
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | | | - Sophie J. Bernelot Moens
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wilma Barcellini
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Josephine M. I. Vos
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
5
|
Chinnadurai A, Strum S, Ghassemian A, Fortin D, Foster C, Breadner D. A Rare Association of Mixed Autoimmune Hemolytic Anemia with Gastric Carcinoma. Case Rep Oncol 2023; 16:1209-1216. [PMID: 37900792 PMCID: PMC10601801 DOI: 10.1159/000534278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
This case report outlines a 70-year-old female patient who presented with a concurrent mixed autoimmune hemolytic anemia (AIHA) and a gastric adenocarcinoma. Her treatment course of these two diseases is summarized, which included supportive care, neoadjuvant chemotherapy for her gastric adenocarcinoma, steroids, rituximab, and surgical resection of the tumor. This approach ultimately led to the stabilization of her AIHA and primary cure for her solid malignancy. We briefly review both AIHA and gastric adenocarcinoma as clinical entities, propose working causes of hemolytic anemia including gastric adenocarcinoma, and outline a successful treatment pathway for these two concurrent conditions.
Collapse
Affiliation(s)
- Anu Chinnadurai
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Scott Strum
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - Artin Ghassemian
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - Dalilah Fortin
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Cheryl Foster
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - Daniel Breadner
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Regional Cancer Program, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| |
Collapse
|
6
|
Kuter DJ. Warm autoimmune hemolytic anemia and the best treatment strategies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:105-113. [PMID: 36485114 PMCID: PMC9821065 DOI: 10.1182/hematology.2022000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is characterized by evidence of red blood cell (RBC) hemolysis and a direct antiglobulin test positive for IgG and sometimes complement. While varying with the extent of the compensatory increase in RBC production, symptoms of anemia predominate, as does jaundice, the latter often exacerbated by concurrent Gilbert's syndrome. Initial treatment with corticosteroids is highly effective, with over 85% of patients responding but with less than one-third maintaining that response upon weaning. Subsequent rituximab administration in those failing corticosteroids provides complete remission in over 75% of patients and may be long-lasting. Over 50% of patients failing rituximab respond to erythropoiesis-stimulating agents or immunosuppressive agents. Splenectomy is best deferred if possible but does offer long-term remission in over two-thirds of patients. A number of new treatments for wAIHA (fostamatinib, rilzabrutinib, and FcRn inhibitors) show promise. A treatment algorithm for wAIHA is proposed to avoid the excessive use of corticosteroids.
Collapse
Affiliation(s)
- David J. Kuter
- Correspondence David J. Kuter, Hematology Division, Massachusetts General Hospital, Ste 118, Rm 110, Zero Emerson Pl, Boston, MA 02114; e-mail:
| |
Collapse
|
7
|
Barcellini W, Fattizzo B. Diagnosis and Management of Autoimmune Hemolytic Anemias. J Clin Med 2022; 11:6029. [PMID: 36294350 PMCID: PMC9604556 DOI: 10.3390/jcm11206029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 10/29/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is usually categorized, as other immune-mediated cytopenias, in so-called benign hematology, and it is consequently managed in various settings, namely, internal medicine, transfusion centers, hematology and, more rarely, onco-hematology departments [...].
Collapse
Affiliation(s)
- Wilma Barcellini
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20100 Milan, Italy
| | - Bruno Fattizzo
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20100 Milan, Italy
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
| |
Collapse
|
8
|
Hansen DL, Möller S, Frederiksen H. Survival in autoimmune hemolytic anemia remains poor, results from a nationwide cohort with 37 years of follow-up. Eur J Haematol 2022; 109:10-20. [PMID: 35276014 PMCID: PMC9314695 DOI: 10.1111/ejh.13764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023]
Abstract
Introduction Autoimmune hemolytic anemia (AIHA) is considered a chronic disease, with an overall good prognosis. However, recent reports indicate pre‐mature mortality. Causes of death have not been evaluated previously. Methods In a nationwide setting, we identified all patients with warm type AIHA or cold agglutinin disease (CAD), and age–sex‐matched comparators from Denmark, 1980–2016. We estimated overall survival and cause‐specific mortality from anemia, infection, cardiovascular causes, hematological or solid cancer, bleeding, or other causes, using cumulative incidence proportions. Results We identified 1460 patients with primary AIHA, 1078 with secondary AIHA, 112 with CAD, and 130 801 comparators. One‐year survival and median survival were, 82.7% and 9.8 years for primary AIHA, 69.1% and 3.3 years for secondary AIHA, and 85.5% and 8.8 years for CAD. Prognosis was comparable to the general population only in patients with primary AIHA below 30 years. In all other age and subgroups, the difference was considerable. Cumulated cause‐specific mortality at 1 year was increased among patients versus comparators. Discussion All groups of autoimmune hemolytic anemia are associated with increased overall and cause‐specific mortality compared to the general population. This probably reflects unmet needs in both treatment and follow‐up programs.
Collapse
Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN, Odense University Hospital, Odense, Denmark
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
9
|
Shi L, Lin CL, Su CH, Lin KC, Leong KH, Wang YTT, Kuo CF, Tsai SY. The Risk of Developing Osteoporosis in Hemolytic Anemia-What Aggravates the Bone Loss? J Clin Med 2021; 10:jcm10153364. [PMID: 34362147 PMCID: PMC8348015 DOI: 10.3390/jcm10153364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 01/05/2023] Open
Abstract
Hemolytic anemia (HA) renders erythropoietic stress on the bone marrow and has been linked to osteoporosis. In this nationwide retrospective cohort study, we examined this correlation by utilizing the Taiwan National Health Insurance Research Database (NHIRD). We identified two cohorts, matching population with and without HA in a 1:4 ratio. A total of 2242 HA patients and 8968 non-HA patients were enrolled. Patients with HA had a significantly higher cumulative incidence (log-rank test p = 0.0073), higher incidence density (5.11 vs. 3.76 per 1000 persons-years), and a 1.31-fold risk of developing osteoporosis than non-HA patients (aHR = 1.31, 95% C.I. 1.04-1.63, p = 0.01). After adjusting for age, sex, and comorbidities, patients with factors including female (aHR = 2.57, 95% C.I. 2.05-3.22, p < 0.001), age > 65 (aHR = 9.25, 95% C.I. 7.46-11.50, p < 0.001), diagnosis of cholelithiasis (aHR = 1.76, 95% C.I. 1.20-2.58, p = 0.003) and peptic ulcer disease (aHR = 1.87, 95% C.I. 1.52-2.29, p < 0.001) had significantly higher risk of osteoporosis. We propose that this correlation may be related to increased hematopoietic stress, increased consumption of nitric oxide (NO) by hemolysis, and the inhibitory effects of iron supplements on osteogenesis through the receptor activator of nuclear factor κB ligand (RANKL)/Osteoprotegerin pathway and the Runt-related transcription factor 2 (RUNX2) factor. Our findings suggest that patients with hemolytic anemia are at a higher risk of developing osteoporosis, and it would be in the patient's best interest for physicians to be aware of this potential complication and offer preventative measures.
Collapse
Affiliation(s)
- Leiyu Shi
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Cheng-Li Lin
- College of Medicine, China Medical University, Taichung City 404, Taiwan;
| | - Ching-Huang Su
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan; (C.-H.S.); (K.-C.L.); (K.-H.L.); (Y.-T.T.W.)
| | - Keng-Chian Lin
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan; (C.-H.S.); (K.-C.L.); (K.-H.L.); (Y.-T.T.W.)
| | - Kam-Hang Leong
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan; (C.-H.S.); (K.-C.L.); (K.-H.L.); (Y.-T.T.W.)
| | - Yu-Ting Tina Wang
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan; (C.-H.S.); (K.-C.L.); (K.-H.L.); (Y.-T.T.W.)
| | - Chien-Feng Kuo
- Division of Infectious Diseases, Department of Internal Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan;
- Department of Medicine, Mackay Medical College, New Taipei City 25245, Taiwan
- Department of Cosmetic Applications and Management, MacKay Junior College of Medicine, Nursing and Management, New Taipei City 25245, Taiwan
| | - Shin-Yi Tsai
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA;
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan; (C.-H.S.); (K.-C.L.); (K.-H.L.); (Y.-T.T.W.)
- Department of Medicine, Mackay Medical College, New Taipei City 25245, Taiwan
- Graduate Institute of Long-Term Care, Mackay Medical College, New Taipei City 25245, Taiwan
- Graduate Institute of Biomedical Sciences, Mackay Medical College, New Taipei City 25245, Taiwan
- Correspondence: ; Tel.: +886-975-835-797 or +886-915-309-666
| |
Collapse
|