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Imanifard Z, Liguori L, Remuzzi G. TMA in Kidney Transplantation. Transplantation 2023; 107:2329-2340. [PMID: 36944606 DOI: 10.1097/tp.0000000000004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Thrombotic microangiopathy (TMA) is a rare and devastating complication of kidney transplantation, which often leads to graft failure. Posttransplant TMA (PT-TMA) may occur either de novo or as a recurrence of the disease. De novo TMA can be triggered by immunosuppressant drugs, antibody-mediated rejection, viral infections, and ischemia/reperfusion injury in patients with no evidence of the disease before transplantation. Recurrent TMA may occur in the kidney grafts of patients with a history of atypical hemolytic uremic syndrome (aHUS) in the native kidneys. Studies have shown that some patients with aHUS carry genetic abnormalities that affect genes that code for complement regulators (CFH, MCP, CFI) and components (C3 and CFB), whereas in 10% of patients (mostly children), anti-FH autoantibodies have been reported. The incidence of aHUS recurrence is determined by the underlying genetic or acquired complement abnormality. Although treatment of the causative agents is usually the first line of treatment for de novo PT-TMA, this approach might be insufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve kidney function. Targeted complement inhibition is an effective treatment for recurrent TMA and may be effective in de novo PT-TMA as well, but it is necessary to establish which patients can benefit from different therapeutic options and when and how these can be applied.
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Affiliation(s)
- Zahra Imanifard
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
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Yang W, Zhu G, Qin M, Li Z, Wang B, Yang J, Wang T. The Effectiveness of Ruxolitinib for Acute/Chronic Graft-versus-Host Disease in Children: A Retrospective Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:743-752. [PMID: 33654380 PMCID: PMC7910527 DOI: 10.2147/dddt.s287218] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/22/2020] [Indexed: 01/23/2023]
Abstract
Objective This study aimed to evaluate the effectiveness of Ruxolitinib for acute/chronic graft-versus-host disease in children. Methods This study was a retrospective trial. We analyzed the clinical characteristics of children who responded poorly to previous treatment for graft-versus-host disease (GVHD) and received ruxolitinib treatment after allogeneic hematopoietic stem cell transplantation (allo-HSCT) as an additional or replacement therapy. Results A total of 53 patients were analyzed: aGVHD and cGVHD. The overall response rate (ORR) to ruxolitinib was 75.5%. The ORR was 64.7% (11/17) in the aGVHD group including 6, 5, and 6 patients with partial responses (PRs), complete responses (CRs), and treatment failure, respectively. The ORR was 80.6% (29/36) in the cGVHD group including 10 with CRs and 19 with PRs. Five and 2 patients showed no response and treatment failure, respectively. Four and 14 patients were GVHD recurrence in aGVHD and cGVHD respectively. A total of 14 patients (39%) discontinued steroids and 8 patients (22.2%) reduced steroids. The incidence of obvious adverse events was 94.1% (16/17) in the aGVHD group, which was higher than that in the cGVHD group. Meanwhile, the prognosis of children with cGVHD was superior to that of children with aGVHD after treatment with ruxolitinib. During the ruxolitinib treatment, only 1 patient suffered a relapse of the primary tumor. Eleven patients also suffered transplantation-associated thrombotic microangiopathy (TA-TMA) after allo-HSCT. Conclusion Pediatric patients with GVHD (especially cGVHD) responded well to ruxolitinib treatment. Ruxolitinib can also be used as an alternative treatment for patients with TMA.
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Affiliation(s)
- Wenli Yang
- Department of Clinical Nutrition, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Guanghua Zhu
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Maoquan Qin
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Zhigang Li
- Hematology and Oncology Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Bin Wang
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Jun Yang
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
| | - Tianyou Wang
- Department of Hematology and Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics, Beijing, People's Republic of China
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Xu Z, Luo C, Lai P, Ling W, Wu S, Huang X, Huang L, Zhang G, Du X, Weng J. von Willebrand Factor as a Predictor for Transplant-Associated Thrombotic Microangiopathy. Clin Appl Thromb Hemost 2020; 26:1076029619892684. [PMID: 32088973 PMCID: PMC7256332 DOI: 10.1177/1076029619892684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/04/2019] [Accepted: 11/13/2019] [Indexed: 12/29/2022] Open
Abstract
CONCLUSION von Willebrand factor is a useful predictor and prognostic measure for TA-TMA, which may help clinicians identify and manage this life-threatening disease earlier.
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Affiliation(s)
- Zhenzhen Xu
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Chengwei Luo
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Peilong Lai
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Wei Ling
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Suijing Wu
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Xin Huang
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Lisi Huang
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Guanrong Zhang
- Information and Statistics Center, Guangdong Provincial People’s Hospital,
Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of
China
| | - Xin Du
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
| | - Jianyu Weng
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong
Academy of Medical Sciences, Guangzhou, Guangdong, People’s Republic of China
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Complement-mediated thrombotic microangiopathy as a link between endothelial damage and steroid-refractory GVHD. Blood Adv 2019; 2:2619-2628. [PMID: 30327370 DOI: 10.1182/bloodadvances.2018020321] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/07/2018] [Indexed: 12/19/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA), a complication of hematopoietic cell transplant (HCT), is associated with significant morbidity and mortality. The pathophysiology and overlap of TA-TMA with other posttransplant complications such as graft-versus-host disease (GVHD) is poorly understood. We retrospectively identified cases of TA-TMA among patients with grade 3/4 gastrointestinal (GI) GVHD, reviewed intestinal biopsy specimens, and performed correlative testing of biomarkers associated with TA-TMA. TA-TMA was more common in patients with steroid-refractory GVHD compared with steroid-responsive GVHD (79.3% vs 42.1%; P = .001). Among patients surviving 100 days post-HCT, 1-year survival from day 100 was significantly better for patients who had not developed TA-TMA in the first 100 days (69.5% vs 36.7%; P < .001). Only 1 of 7 proposed TA-TMA histology criteria (mucosal hemorrhage) differed significantly based on GVHD steroid response. In multivariable modeling, steroid-refractory GVHD was a risk factor for development of TA-TMA (hazard ratio, 3.09; 95% confidence interval, 1.68-5.67; P < .001). There were no differences in complement activation at GVHD onset; however, 2 to 6 weeks later, patients with TA-TMA had higher levels of BBPlus and C5b-9, markers of alternative and terminal pathway activation (BBPlus: median, 600 vs 209.3 ng/mL; P = .0045) (C5b-9: median, 425.9 vs 258.4 ng/mL; P = .029). TA-TMA is associated with poor overall survival (OS) following HCT and may be detected early by histologic findings and may be differentiated from GVHD by measurement of alternative and terminal complement pathway activation. It is unknown whether treatment of TA-TMA will improve survival in steroid-refractory GVHD.
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A Heterozygous CFHR3-CFHR1 Gene Deletion in a Pediatric Patient With Transplant-associated Thrombotic Microangiopathy Who was Treated With Eculizumab. J Pediatr Hematol Oncol 2018; 40:e544-e546. [PMID: 28991129 DOI: 10.1097/mph.0000000000000986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Complement system dysregulation, such as complement Factor H (CFH) autoantibodies and deletions in CFH-related (CFHR) genes 3 and 1, might cause transplant-associated thrombotic microangiopathy (TA-TMA). The use of eculizumab, a terminal complement inhibitor, could be a targeted therapy for TA-TMA. We report a 1-year-old girl who developed TA-TMA, just after autologous peripheral blood stem cell transplantation in neuroblastoma therapy. Eculizumab improved TA-TMA. Investigation for the complement alternative pathway showed a heterozygous CFHR3-CFHR1 gene deletion, which is involved in complement activation. The patient might develop TA-TMA as a result of complement regulatory gene mutation.
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Eculizumab and thrombotic microangiopathy after hematopoietic stem cell transplantation: A report on its efficacy and safety in two pediatric patients. Arch Pediatr 2018; 25:485-488. [PMID: 30340942 DOI: 10.1016/j.arcped.2018.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/30/2018] [Accepted: 09/23/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a severe complication after hematopoietic stem cell transplantation (HSCT), with the reported mortality rate in such cases usually reaching 90%. CASES We report on two pediatric cases of patients successfully treated by eculizumab for severe HSCT-TMA, occurring in two girls (8.4 and 3.6 years). The first patient developed TMA with hematologic abnormalities and renal/pulmonary lesions after allogeneic HSCT for Philadelphia-positive acute lymphoblastic leukemia; she received eculizumab 7 months after HSCT, with a dramatic improvement of renal function. The second patient developed severe TMA (cardiac tamponade, renal failure requiring dialysis, gastritis) after autologous HSCT for metastatic neuroblastoma. She received eculizumab for 7 months, with a dramatic improvement of renal function. No side effects were observed. CONCLUSION The use of eculizumab as first-line therapy in pediatric patients with severe HSCT-TMA with multisystemic lesions appears promising. Larger international studies are required to confirm its benefit and safety for this specific indication.
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Klaihmon P, Lertthammakiat S, Anurathapan U, Pakakasama S, Sirachainan N, Hongeng S, Pattanapanyasat K. Activated platelets and leukocyte activations in young patients with β-thalassemia/HbE following bone marrow transplantation. Thromb Res 2018; 169:8-14. [DOI: 10.1016/j.thromres.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/23/2022]
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Rudoni J, Jan A, Hosing C, Aung F, Yeh J. Eculizumab for transplant-associated thrombotic microangiopathy in adult allogeneic stem cell transplant recipients. Eur J Haematol 2018; 101:389-398. [PMID: 29920784 DOI: 10.1111/ejh.13127] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate response rates and survival in adults with transplant-associated thrombotic microangiopathy (TA-TMA) after allogeneic hematopoietic stem cell transplantation (HSCT) who were treated with eculizumab (ECU). METHODS Patients were identified retrospectively and data collected through HSCT and pharmacy databases. RESULTS Ten patients with TA-TMA after allogeneic HSCT were treated with ECU between 2013 and 2016. TA-TMA was diagnosed at a median of 93 days post-HSCT. Organ-specific injury was documented in all ten patients at time of TA-TMA diagnosis, the most common being renal dysfunction (90%). Acute GVHD (70%) and active infection (80%) were common at time of diagnosis. The median time to ECU initiation from TA-TMA diagnosis was 4 days. Seven patients received ECU as first-line therapy in combination with other treatment modalities, while three patients were treated with ECU as second-line therapy. ECU was well tolerated with the exception of one case of severe skin rash leading to discontinuation. ECU achieved an overall hematologic response rate of 70% and an overall survival rate of 60%. One patient achieved a complete response with corresponding organ recovery. CONCLUSION Early initiation of ECU may not alter the disease process enough to restore organ function, but it may prolong survival.
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Affiliation(s)
- Joslyn Rudoni
- Department of Pharmacy, Cleveland Clinic Health System, Cleveland, Ohio
| | - Anna Jan
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Division of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fleur Aung
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Yeh
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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9
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Seaby EG, Gilbert RD. Thrombotic microangiopathy following haematopoietic stem cell transplant. Pediatr Nephrol 2018; 33:1489-1500. [PMID: 28993886 PMCID: PMC6061668 DOI: 10.1007/s00467-017-3803-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 08/23/2017] [Accepted: 09/01/2017] [Indexed: 12/19/2022]
Abstract
Thrombotic microangiopathy is a potentially lethal complication of haematopoietic stem cell (bone marrow) transplantation. The pathophysiology is incompletely understood, although endothelial damage appears to be central. Platelet activation, neutrophil extracellular traps and complement activation appear to play key roles. Diagnosis may be difficult and universally accepted diagnostic criteria are not available. Treatment remains controversial. In some cases, withdrawal of calcineurin inhibitors is adequate. Rituximab and defibrotide also appear to have been used successfully. In severe cases, complement inhibitors such as eculizumab may play a valuable role. Further research is required to define the pathophysiology and determine both robust diagnostic criteria and the optimal treatment.
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Affiliation(s)
- Eleanor G. Seaby
- Human Genetics and Genomics Department, University of Southampton, Southampton, UK
| | - Rodney D. Gilbert
- Southampton Children’s Hospital and Faculty of Medicine, University of Southampton, Tremona Road, Southampton, SO16 6YD UK
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Raina R, Herrera N, Krishnappa V, Sethi SK, Deep A, Kao WM, Bunchman T, Abu-Arja R. Hematopoietic stem cell transplantation and acute kidney injury in children: A comprehensive review. Pediatr Transplant 2017; 21. [PMID: 28485097 DOI: 10.1111/petr.12935] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 12/27/2022]
Abstract
AKI in the setting of HSCT is commonly investigated among adult patients. In the same way, malignancies requiring treatment with HSCT are not limited to the adult patient population, AKI following HSCT is frequently encountered within pediatric patient populations. However, inadequate information regarding epidemiology and pathophysiology specific to pediatric patients prevents development of appropriate and successful therapeutic strategies for those afflicted. Addressing AKI in the context of sinusoidal obstruction syndrome, chemotherapy, thrombotic microangiopathy and hypertension post chemotherapy, glomerulonephritis, and graft versus host disease provides greater insight into renal impairment associated with these HSCT-related ailments. To obtain a better understanding of AKI among pediatric patients receiving HSCT, we investigated the current literature specifically addressing these areas of concern.
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Affiliation(s)
- Rupesh Raina
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nicholas Herrera
- Department of Pediatrics-Nephrology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA
| | - Sidharth Kumar Sethi
- Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Akash Deep
- Department of Paediatric Intensive Care, King's College Hospital, London, UK
| | - Wei-Ming Kao
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy Bunchman
- Children's Hospital of Richmond, VCU School of Medicine, Richmond, VA, USA
| | - Rolla Abu-Arja
- Department of Pediatric Hematology & Oncology Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, OH, USA
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Ghimire S, Weber D, Mavin E, Wang XN, Dickinson AM, Holler E. Pathophysiology of GvHD and Other HSCT-Related Major Complications. Front Immunol 2017; 8:79. [PMID: 28373870 PMCID: PMC5357769 DOI: 10.3389/fimmu.2017.00079] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
For over 60 years, hematopoietic stem cell transplantation has been the major curative therapy for several hematological and genetic disorders, but its efficacy is limited by the secondary disease called graft versus host disease (GvHD). Huge advances have been made in successful transplantation in order to improve patient quality of life, and yet, complete success is hard to achieve. This review assimilates recent updates on pathophysiology of GvHD, prophylaxis and treatment of GvHD-related complications, and advances in the potential treatment of GvHD.
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Affiliation(s)
- Sakhila Ghimire
- Department of Internal Medicine III, University Medical Centre , Regensburg , Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Medical Centre , Regensburg , Germany
| | - Emily Mavin
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle , UK
| | - Xiao Nong Wang
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle , UK
| | - Anne Mary Dickinson
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle , UK
| | - Ernst Holler
- Department of Internal Medicine III, University Medical Centre , Regensburg , Germany
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Ye Y, Zheng W, Wang J, Hu Y, Luo Y, Tan Y, Shi J, Zhang M, Huang H. Risk and prognostic factors of transplantation-associated thrombotic microangiopathy in allogeneic haematopoietic stem cell transplantation: a nested case control study. Hematol Oncol 2016; 35:821-827. [PMID: 27245857 DOI: 10.1002/hon.2310] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/29/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Yishan Ye
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Weiyan Zheng
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Jiasheng Wang
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Yongxian Hu
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Yi Luo
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Yamin Tan
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Jimin Shi
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - Mingming Zhang
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
| | - He Huang
- Bone Marrow Transplantation Center; The First Affiliated Hospital, School of Medicine, Zhejiang University; Hangzhou China
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Obut F, Kasinath V, Abdi R. Post-bone marrow transplant thrombotic microangiopathy. Bone Marrow Transplant 2016; 51:891-7. [DOI: 10.1038/bmt.2016.61] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 12/15/2022]
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García-Martín P, Alarcón-Payer C, López-Fernández E, Moratalla L, Romero A, Sainz J, Ríos R, Jurado M. Transplantation-Associated Thrombotic Microangiopathy in Patients Treated With Sirolimus and Cyclosporine as Salvage Therapy for Graft-Versus-Host Disease. Ann Pharmacother 2015; 49:986-94. [DOI: 10.1177/1060028015593369] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Transplantation-associated thrombotic microangiopathy (TA-TMA) is a rare complication of hematopoietic stem cell transplantation. Because sirolimus (SIR) and calcineurin inhibitor—either cyclosporine (CsA) or tacrolimus—have become more common as graft-versus-host disease (GVHD) prophylaxis, we are witnessing a higher frequency of this complication. Objective: To analyze the incidence, timing, and management of TA-TMA in patients who received the combination of CsA and SIR as therapy for uncontrolled GVHD in one single center. Methods: This was a retrospective analysis from February 2002 to June 2014 of the combination of SIR and CsA as salvage therapy in 61 patients with treatment-refractory or relapsed acute GVHD (n = 24) or chronic GVHD (n = 37) in a tertiary hospital. Results: A total of 61 patients received CsA and SIR as salvage therapy for acute (n = 16), late acute (n = 8), overlap syndrome (n = 22), or classic chronic (n = 15) GVHD. We identified 13 patients with TA-TMA (21.3%), and the status of GVHD was active in 11 of 13 patients. Only 1 patient showed high CsA levels, and 6 of 13 patients had very high concentrations of SIR in blood. We used an enzyme inducer in 6 patients, which proved effective in 3. Overall survival for TA-TMA patients was inferior compared to that for non TA-TMA patients at 12 months (42.9% vs 51.9%) and 24 months (34.3% vs 49.1%), although this difference was not significant. Conclusion: Prompt identification and good management of TA-TMA, with better control of GVHD, may contribute to a decrease in patient mortality that would result from this complication.
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Affiliation(s)
- Paloma García-Martín
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Elisa López-Fernández
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Lucía Moratalla
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Antonio Romero
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Juan Sainz
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Rafael Ríos
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Manuel Jurado
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
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15
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The potential role of HLA-DRB1*11 in the development and outcome of haematopoietic stem cell transplantation-associated thrombotic microangiopathy. Bone Marrow Transplant 2015; 50:1321-5. [PMID: 26146809 DOI: 10.1038/bmt.2015.161] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/11/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a serious complication of allogeneic haematopoietic stem cell transplantation (allo-HSCT) with high mortality rate. We retrospectively studied the frequency, clinical and genetic associations and prognostic effect of TA-TMA, in a total of 425 consecutive adult patients, who underwent allo-HSCT for a malignant haematological condition between 2007 and 2013 at our single centre. TA-TMA developed in 19% of the patients. Unrelated donor type (P<0.001), acute GvHD grades II-IV (P<0.001), myeloablative conditioning regimens (P=0.003), tacrolimus-based GvHD prophylaxis (P=0.003), CMV infection (P=0.003) and carriership for HLA-DRB1*11 (P=0.034) were associated with the development of TA-TMA. Survival was adversely affected by the presence of TA-TMA (P<0.001). Among patients with TA-TMA, the outcome of HLA-DRB1*11 carriers was significantly better compared with non-carriers (P=0.003). As a new finding, our observations suggest that the presence of HLA-DRB1*11 antigen contributes to the development of TA-TMA and affects the outcome.
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Reduced IL-35 levels are associated with increased platelet aggregation and activation in patients with acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Ann Hematol 2014; 94:837-45. [PMID: 25512184 DOI: 10.1007/s00277-014-2278-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/07/2014] [Indexed: 01/30/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a major complication associated with allogeneic hematopoietic stem cell transplantation (allo-HSCT). Interleukin (IL)-35 is a novel anti-inflammatory cytokine that suppresses the immune response. This prospective study explored IL-35 plasma levels in 65 patients after HSCT. The results revealed that the peripheral blood of patients with grades III-IV aGVHD (23.46 ng/ml) had reduced IL-35 compared to transplanted patients with grades I-II aGVHD (40.26 ng/ml, p < 0.01) or patients without aGVHD (41.40 ng/ml, p < 0.05). Allografts, including granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood progenitor cell (PBPC) and G-CSF-primed bone marrow (GBM), from 38 patients were analyzed for IL-35 levels with respect to aGVHD. The patients who received lower levels of IL-35 cells in the GBM (28.0 ng/ml, p = 0.551) or lower levels of IL-35 in PBPC (53.46 ng/ml, p = 0.03) exhibited a higher incidence of aGVHD. Patients with aGVHD have increased platelet aggregation. IL-35 was added to patient blood in vitro, and platelet aggregation was inhibited by IL-35 in a dose-dependent manner. The markers of platelet activation (CD62P/PAC-1) can also be inhibited by IL-35. The results indicate that IL-35 may affect the development of aGVHD by inhibiting platelet activation and aggregation. Our data suggests that IL-35 represents a potentially effective therapeutic agent against aGVHD after allo-HSCT.
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Remission of microangiopathy in transplanted thalassemic child. Indian J Hematol Blood Transfus 2014; 30:356-8. [PMID: 25332618 DOI: 10.1007/s12288-014-0404-2] [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: 01/23/2014] [Accepted: 05/11/2014] [Indexed: 10/25/2022] Open
Abstract
Transplant associated thrombotic microangiopathy is a severe complication of Hematopoeitic stem cell transplantation. Although there is agreement in terms of diagnostic criteria, treatment options are not clarified yet. We present a patient aged 2.6 years who developed transplant associated thrombotic microangiopathy after allogeneic bone marrow transplantation and to discuss both risk factors and possible spontaneous remission of transplant associated thrombotic microangiopathy.
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Diagnostic and risk criteria for HSCT-associated thrombotic microangiopathy: a study in children and young adults. Blood 2014; 124:645-53. [PMID: 24876561 DOI: 10.1182/blood-2014-03-564997] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TMA) leads to generalized endothelial dysfunction that can progress to multiorgan injury, and severe cases are associated with poor outcomes after hematopoietic stem cell transplantation (HSCT). Identifying patients at highest risk for severe disease is challenging. We prospectively evaluated 100 consecutive HSCT recipients to determine the incidence of moderate and severe TMA and factors associated with poor overall outcomes. Thirty-nine subjects (39%) met previously published criteria for TMA. Subjects with TMA had a significantly higher nonrelapse mortality (43.6% vs 7.8%, P < .0001) at 1 year post-HSCT compared with those without TMA. Elevated lactate dehydrogenase, proteinuria on routine urinalysis, and hypertension were the earliest markers of TMA. Proteinuria (>30 mg/dL) and evidence of terminal complement activation (elevated sC5b-9) in the blood at the time of TMA diagnosis were associated with very poor survival (<20% at 1 year), whereas all TMA subjects without proteinuria and a normal sC5b-9 serum concentration survived (P < .01). Based on these prospective observations, we conclude that severe TMA occurred in 18% of HSCT recipients in our cohort and propose an algorithm to identify the highest-risk patients who might benefit from prompt clinical interventions.
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González-Vicent M, Herrero B, Guillén M, Sevilla J, Díaz MÁ. Using Rheopheresis for stem cell Transplantation-Associated Thrombotic Microangiopathy (TA-TMA). Transfus Apher Sci 2013; 49:234-7. [DOI: 10.1016/j.transci.2013.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 02/25/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
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Renal arteriolar C4d deposition: a novel characteristic of hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Transplantation 2013; 96:217-23. [PMID: 23698598 DOI: 10.1097/tp.0b013e31829807aa] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The mechanism of kidney injury in hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is not completely understood. Renal C4d staining is a marker of classic complement activation and endothelial injury and has been described in preliminary reports of HSCT recipients with TA-TMA. Our objective was to evaluate complement in the pathogenesis of small vessel injury in children receiving HSCT. We hypothesized that kidney tissue from children with TA-TMA would more frequently show C4d deposition compared with HSCT recipients without histologic TA-TMA. METHODS We reviewed kidney specimens (biopsy or autopsy) from children who had undergone HSCT at a single center. Using histologic criteria alone, subjects were divided into TA-TMA (n = 8) and non-TA-TMA (control) groups (n = 12). C4d staining was performed by immunohistochemistry and evaluated on arterioles, peritubular capillaries, glomeruli, and tubular basement membranes. RESULTS Diffuse or focal renal arteriolar C4d staining was more common in subjects with histologic TA-TMA (75%) compared with controls (8%). Rare peritubular capillary C4d staining was present in 50% of TA-TMA samples and was absent in controls. Glomerular C4d staining was seen at a similar frequency in cases and controls, whereas tubular basement membrane staining was less frequently observed and only in subjects with TA-TMA. CONCLUSIONS Arteriolar C4d deposition may be a pathologic marker of TA-TMA, implicating localized complement fixation in HSCT recipients with kidney disease secondary to small vessel injury. Further studies to better characterize the preferential arteriolar C4d staining may identify a renal compartment of injury, possibly explaining the dramatic hypertension seen in TA-TMA.
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Defibrotide: properties and clinical use of an old/new drug. Vascul Pharmacol 2013; 59:1-10. [PMID: 23680861 DOI: 10.1016/j.vph.2013.05.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 04/29/2013] [Accepted: 05/03/2013] [Indexed: 12/30/2022]
Abstract
The drug named defibrotide (DFT) has been studied for many years. It has been shown to possess many activities: profibrinolytic, antithrombotic-thrombolytic, antiischemic (heart, liver, kidney, skin, brain), antishock, antiatherosclerotic, antirejection and anti-angiogenic. The previously displayed activities, as antithrombotic, profibrinolytic and anti-inflammatory, suggested its use in vascular disorders, as in the treatment of peripheral obliterative arterial disease and in thrombophlebitis. Some years after, the use of DFT in hepatic veno-occlusive disease has been also proposed. Even if DFT was considered for long time a multi-target drug, now it could be considered on the whole as a drug able to protect endothelium against activation. The present work reviews the more important experimental and clinical studies performed to detect DFT effects.
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Rizzo C, Rizzo S, Scirè E, Di Bona D, Ingrassia C, Franco G, Bono R, Quintini G, Caruso C. Thrombotic thrombocytopenic purpura: a review of the literature in the light of our experience with plasma exchange. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 10:521-32. [PMID: 22790258 PMCID: PMC3496241 DOI: 10.2450/2012.0122-11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 12/05/2011] [Indexed: 12/18/2022]
Affiliation(s)
- Claudia Rizzo
- Unit of Immunohaematology and Transfusion Medicine, “Paolo Giaccone” University Hospital, Department of Biopathology and Medical and Forensic Biotechnologies (DIBIMEF), University of Palermo, Palermo
| | - Sergio Rizzo
- Unit of Immunohaematology and Transfusion Medicine, “Paolo Giaccone” University Hospital, Palermo
| | - Elisabetta Scirè
- Unit of Immunohaematology and Transfusion Medicine, “Paolo Giaccone” University Hospital, Palermo
| | - Danilo Di Bona
- Unit of Immunohaematology and Transfusion Medicine, “Paolo Giaccone” University Hospital, Palermo
| | - Carlo Ingrassia
- Unit of Immunohaematology and Transfusion Medicine, “Paolo Giaccone” University Hospital, Palermo
| | - Giovanni Franco
- Haematology and BMT Unit, “Paolo Giaccone” University Hospital, Department of Internal and Specialist Medicine (DIMIS), University of Palermo, Palermo, Italy
| | - Roberto Bono
- Haematology and BMT Unit, “Paolo Giaccone” University Hospital, Department of Internal and Specialist Medicine (DIMIS), University of Palermo, Palermo, Italy
| | - Gerlando Quintini
- Haematology and BMT Unit, “Paolo Giaccone” University Hospital, Palermo
| | - Calogero Caruso
- Unit of Immunohaematology and Transfusion Medicine, “Paolo Giaccone” University Hospital, Department of Biopathology and Medical and Forensic Biotechnologies (DIBIMEF), University of Palermo, Palermo
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