1
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Labrosse R, Chu JI, Armant MA, Everett JK, Pellin D, Kareddy N, Frelinger AL, Henderson LA, O’Connell AE, Biswas A, Coenen-van der Spek J, Miggelbrink A, Fiorini C, Adhikari H, Berry CC, Cantu VA, Fong J, Jaroslavsky J, Karadeniz DF, Li QZ, Reddy S, Roche AM, Zhu C, Whangbo JS, Dansereau C, Mackinnon B, Morris E, Koo SM, London WB, Baris S, Ozen A, Karakoc-Aydiner E, Despotovic JM, Forbes Satter LR, Saitoh A, Aizawa Y, King A, Nguyen MAT, Vu VDU, Snapper SB, Galy A, Notarangelo LD, Bushman FD, Williams DA, Pai SY. Outcomes of hematopoietic stem cell gene therapy for Wiskott-Aldrich syndrome. Blood 2023; 142:1281-1296. [PMID: 37478401 PMCID: PMC10731922 DOI: 10.1182/blood.2022019117] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/16/2023] [Accepted: 06/17/2023] [Indexed: 07/23/2023] Open
Abstract
Wiskott-Aldrich syndrome (WAS) is a rare X-linked disorder characterized by combined immunodeficiency, eczema, microthrombocytopenia, autoimmunity, and lymphoid malignancies. Gene therapy (GT) to modify autologous CD34+ cells is an emerging alternative treatment with advantages over standard allogeneic hematopoietic stem cell transplantation for patients who lack well-matched donors, avoiding graft-versus-host-disease. We report the outcomes of a phase 1/2 clinical trial in which 5 patients with severe WAS underwent GT using a self-inactivating lentiviral vector expressing the human WAS complementary DNA under the control of a 1.6-kB fragment of the autologous promoter after busulfan and fludarabine conditioning. All patients were alive and well with sustained multilineage vector gene marking (median follow-up: 7.6 years). Clinical improvement of eczema, infections, and bleeding diathesis was universal. Immune function was consistently improved despite subphysiologic levels of transgenic WAS protein expression. Improvements in platelet count and cytoskeletal function in myeloid cells were most prominent in patients with high vector copy number in the transduced product. Two patients with a history of autoimmunity had flares of autoimmunity after GT, despite similar percentages of WAS protein-expressing cells and gene marking to those without autoimmunity. Patients with flares of autoimmunity demonstrated poor numerical recovery of T cells and regulatory T cells (Tregs), interleukin-10-producing regulatory B cells (Bregs), and transitional B cells. Thus, recovery of the Breg compartment, along with Tregs appears to be protective against development of autoimmunity after GT. These results indicate that clinical and laboratory manifestations of WAS are improved with GT with an acceptable safety profile. This trial is registered at clinicaltrials.gov as #NCT01410825.
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Affiliation(s)
- Roxane Labrosse
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Immune Deficiency-Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Division of Allergy and Immunology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Julia I. Chu
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pediatric Allergy, Immunology and Bone Marrow Transplantation, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA
| | - Myriam A. Armant
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - John K. Everett
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danilo Pellin
- Gene Therapy Program, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Niharika Kareddy
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Andrew L. Frelinger
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Amy E. O’Connell
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA
| | - Amlan Biswas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Jet Coenen-van der Spek
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Alexandra Miggelbrink
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Claudia Fiorini
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Hriju Adhikari
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Charles C. Berry
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, UC San Diego, La Jolla, CA
| | - Vito Adrian Cantu
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Johnson Fong
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jason Jaroslavsky
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Derin F. Karadeniz
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Quan-Zhen Li
- Department of Immunology, Microarray and Immune Phenotyping Core Facility, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shantan Reddy
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Aoife M. Roche
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chengsong Zhu
- Department of Immunology, Microarray and Immune Phenotyping Core Facility, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jennifer S. Whangbo
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Colleen Dansereau
- Gene Therapy Program, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Brenda Mackinnon
- Gene Therapy Program, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Emily Morris
- Gene Therapy Program, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Stephanie M. Koo
- Gene Therapy Program, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Wendy B. London
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Safa Baris
- Department of Pediatrics, Division of Allergy and Immunology, Marmara University, Istanbul, Turkey
- The Işıl Berat Barlan Center for Translational Medicine, Marmara University, Istanbul, Turkey
| | - Ahmet Ozen
- Department of Pediatrics, Division of Allergy and Immunology, Marmara University, Istanbul, Turkey
- The Işıl Berat Barlan Center for Translational Medicine, Marmara University, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Department of Pediatrics, Division of Allergy and Immunology, Marmara University, Istanbul, Turkey
- The Işıl Berat Barlan Center for Translational Medicine, Marmara University, Istanbul, Turkey
| | - Jenny M. Despotovic
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Lisa R. Forbes Satter
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Akihiko Saitoh
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuta Aizawa
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Alejandra King
- Hospital Luis Calvo Mackenna, Clínica Alemana De Santiago Universidad del Desarrollo, Santiago, Chile
| | - Mai Anh Thi Nguyen
- Department of Pediatrics, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Vy Do Uyen Vu
- Department of Pediatrics, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Scott B. Snapper
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Anne Galy
- Genethon, Évry, France
- University of Paris-Saclay, University of Évry, INSERM, Genethon, Integrare Research Unit UMR_S951, Évry, France
| | - Luigi D. Notarangelo
- Division of Immunology, Boston Children’s Hospital, Boston, MA
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Frederic D. Bushman
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David A. Williams
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sung-Yun Pai
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Immune Deficiency-Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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2
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Kim TO, Curry CV, Wiszniewska J, Elghetany MT, Satter LRF, Grimes AB, Despotovic JM. Pediatric autoimmune myelofibrosis: Experience from a large pediatric tertiary care center. Pediatr Blood Cancer 2023; 70:e30144. [PMID: 36661251 DOI: 10.1002/pbc.30144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/17/2022] [Accepted: 10/28/2022] [Indexed: 01/21/2023]
Abstract
Autoimmune myelofibrosis (AIMF) is a rare disorder characterized by cytopenias and autoimmunity, with characteristic bone marrow findings that include lymphocytic infiltration and fibrosis. AIMF is described predominantly in adult populations who have systemic lupus erythematosis (SLE), with scant pediatric cases described mainly in older adolescents with SLE. Here, we described the largest single-center pediatric experience of pediatric autoimmune myelofibrosis (PAIMF) series, demonstrating both similarities and distinctions from the adult experience. Patients overall respond well to steroid therapy, but these patients were significantly younger, infrequently carried a diagnosis of SLE, and causative genetic lesions were identified in many cases.
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Affiliation(s)
- Taylor Olmsted Kim
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA.,Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Choladda V Curry
- Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Hospital, Department of Pathology, Houston, Texas, USA
| | - Joanna Wiszniewska
- Departments of Pathology and Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
| | - M Tarek Elghetany
- Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Hospital, Department of Pathology, Houston, Texas, USA
| | - Lisa R Forbes Satter
- Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Immunology Allergy and Retrovirology and William T. Shearer Texas Children's Hospital Center for Human Immunobiology, Houston, Texas, USA
| | - Amanda B Grimes
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA.,Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Jenny M Despotovic
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA.,Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
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3
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Johnson S, Grace RF, Despotovic JM. Diagnosis, monitoring, and management of pyruvate kinase deficiency in children. Pediatr Blood Cancer 2022; 69:e29696. [PMID: 35452178 DOI: 10.1002/pbc.29696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase (PK) deficiency is a rare, congenital red blood cell disorder caused by a single gene defect. The spectrum of genotypes, variants, and phenotypes are broad, commonly requiring a multimodal approach including enzyme and genetic testing for accurate and reliable diagnosis. Similarly, management of primary and secondary sequelae of PK deficiency varies, mainly including supportive care with transfusions and surgical interventions to improve symptoms and quality of life. Given the risk of acute and long-term complications of PK deficiency and its treatment, regular monitoring and management of iron burden and organ dysfunction is critical. Therefore, all children and adolescents with PK deficiency should receive regular hematology care with visits at least every 6 months regardless of transfusion status. We continue to learn more about the spectrum of symptoms and complications of PK deficiency and best practice for monitoring and management through registry efforts (NCT03481738). The treatment of PK deficiency has made strides over the last few years with newer disease-modifying therapies being developed and studied, with the potential to change the course of disease in childhood and beyond.
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Affiliation(s)
- Shaniqua Johnson
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, USA.,Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
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4
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Vorster L, Kirk SE, Muscal E, Despotovic JM, Cohen CT, Sartain SE. COVID-19 vaccine (mRNA BNT162b2) and COVID-19 infection-induced thrombotic thrombocytopenic purpura in adolescents. Pediatr Blood Cancer 2022; 69:e29681. [PMID: 35373880 PMCID: PMC9088367 DOI: 10.1002/pbc.29681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/08/2022] [Accepted: 03/04/2022] [Indexed: 12/13/2022]
Abstract
The mRNA COVID-19 vaccine and COVID-19 infection caused by the SARS-CoV-2 virus may be immunologic triggers for the development of thrombotic thrombocytopenic purpura (TTP). There is not yet literature that discusses TTP induced by COVID-19 vaccination or infection in pediatric or adolescent patients. We describe three adolescents presenting with TTP (both de novo and relapsed disease) following administration of the Pfizer COVID-19 vaccine or after COVID-19 infection. Our observations demonstrate that the Pfizer-BioNTech mRNA vaccine and COVID-19 infection can act as triggers for the development/relapse of both congenital and acquired TTP.
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Affiliation(s)
- Luna Vorster
- Department of Pediatrics, Baylor College of MedicineTexas Children's HospitalHoustonTexasUSA
| | - Susan E. Kirk
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Eyal Muscal
- Department of Pediatrics, Section of Rheumatology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
- Department of Pediatrics, Section of Neurology/Developmental Neuroscience, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Jenny M. Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Clay T. Cohen
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Sarah E. Sartain
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
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5
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Karsenty CL, Kirk SE, Helber HL, Esquilin JM, Despotovic JM, Grimes AB. Molecular Diagnosis Is Vital to the Accurate Classification and Management of Thrombotic Thrombocytopenic Purpura in Children. Front Immunol 2022; 13:836960. [PMID: 35479064 PMCID: PMC9038040 DOI: 10.3389/fimmu.2022.836960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening hematologic disease, presenting a myriad of diagnostic and management challenges in children. Here, we provide a review of this disorder and discuss 2 exemplary cases of TTP occurring in adolescents, emphasizing the need for consideration of late-onset congenital TTP (cTTP). We demonstrate the importance of early confirmation of ADAMTS13 enzyme deficiency and the presence or absence of ADAMTS13 inhibitor in order to rapidly initiate the appropriate life-saving therapies. Ultimately, molecular testing is paramount to distinguishing between congenital and acquired immune-mediated TTP.
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Affiliation(s)
- Cecile L. Karsenty
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
- *Correspondence: Cecile L. Karsenty,
| | - Susan E. Kirk
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Hannah L. Helber
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Jose M. Esquilin
- Methodist Children’s Hospital, San Antonio, TX, United States
- Methodist Physicians Pediatric Specialists of Texas, San Antonio, TX, United States
| | - Jenny M. Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Amanda B. Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
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Lee-Sundlov MM, Burns RT, Kim TO, Grozovsky R, Giannini S, Rivadeneyra L, Zheng Y, Glabere SH, Kahr WHA, Abdi R, Despotovic JM, Wang D, Hoffmeister KM. Immune cells surveil aberrantly sialylated O-glycans on megakaryocytes to regulate platelet count. Blood 2021; 138:2408-2424. [PMID: 34324649 PMCID: PMC8662070 DOI: 10.1182/blood.2020008238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 06/09/2021] [Indexed: 11/20/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a platelet disorder. Pediatric and adult ITP have been associated with sialic acid alterations, but the pathophysiology of ITP remains elusive, and ITP is often a diagnosis of exclusion. Our analysis of pediatric ITP plasma samples showed increased anti-Thomsen-Friedenreich antigen (TF antigen) antibody representation, suggesting increased exposure of the typically sialylated and cryptic TF antigen in these patients. The O-glycan sialyltransferase St3gal1 adds sialic acid specifically on the TF antigen. To understand if TF antigen exposure associates with thrombocytopenia, we generated a mouse model with targeted deletion of St3gal1 in megakaryocytes (MK) (St3gal1MK-/-). TF antigen exposure was restricted to MKs and resulted in thrombocytopenia. Deletion of Jak3 in St3gal1MK-/- mice normalized platelet counts implicating involvement of immune cells. Interferon-producing Siglec H-positive bone marrow (BM) immune cells engaged with O-glycan sialic acid moieties to regulate type I interferon secretion and platelet release (thrombopoiesis), as evidenced by partially normalized platelet count following inhibition of interferon and Siglec H receptors. Single-cell RNA-sequencing determined that TF antigen exposure by MKs primed St3gal1MK-/- BM immune cells to release type I interferon. Single-cell RNA-sequencing further revealed a new population of immune cells with a plasmacytoid dendritic cell-like signature and concomitant upregulation of the immunoglobulin rearrangement gene transcripts Igkc and Ighm, suggesting additional immune regulatory mechanisms. Thus, aberrant TF antigen moieties, often found in pathological conditions, regulate immune cells and thrombopoiesis in the BM, leading to reduced platelet count.
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Affiliation(s)
| | - Robert T Burns
- Translational Glycomics Center, Versiti Blood Research Institute, Milwaukee, WI
| | - Taylor O Kim
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Texas Children's Cancer and Hematology Centers, Houston, TX
| | - Renata Grozovsky
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Silvia Giannini
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Yongwei Zheng
- Translational Glycomics Center, Versiti Blood Research Institute, Milwaukee, WI
| | - Simon H Glabere
- Translational Glycomics Center, Versiti Blood Research Institute, Milwaukee, WI
| | - Walter H A Kahr
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, and
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Reza Abdi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
| | - Jenny M Despotovic
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Texas Children's Cancer and Hematology Centers, Houston, TX
| | - Demin Wang
- Translational Glycomics Center, Versiti Blood Research Institute, Milwaukee, WI
| | - Karin M Hoffmeister
- Translational Glycomics Center, Versiti Blood Research Institute, Milwaukee, WI
- Department of Biochemistry and
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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7
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Shimano KA, Grace RF, Despotovic JM, Neufeld EJ, Klaassen RJ, Bennett CM, Ma C, London WB, Neunert C. Phase 3 randomised trial of eltrombopag versus standard first-line pharmacological management for newly diagnosed immune thrombocytopaenia (ITP) in children: study protocol. BMJ Open 2021; 11:e044885. [PMID: 34452956 PMCID: PMC8404450 DOI: 10.1136/bmjopen-2020-044885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopaenia (ITP) is an acquired disorder of low platelets and risk of bleeding. Although many children can be observed until spontaneous remission, others require treatment due to bleeding or impact on health-related quality of life. Standard first-line therapies for those who need intervention include corticosteroids, intravenous immunoglobulin and anti-D globulin, though response to these agents may be only transient. Eltrombopag is an oral thrombopoietin receptor agonist approved for children with chronic ITP who have had an insufficient response to corticosteroids, intravenous immunoglobulin or splenectomy. This protocol paper describes an ongoing open-label, randomised trial comparing eltrombopag to standard first-line management in children with newly diagnosed ITP. METHODS AND ANALYSIS Randomised treatment assignment is 2:1 for eltrombopag versus standard first-line management and is stratified by age and by prior treatment. The primary endpoint of the study is platelet response, defined as ≥3 of 4 weeks with platelets >50×109/L during weeks 6-12 of therapy. Secondary outcomes include number of rescue therapies needed during the first 12 weeks, proportion of patients who do not need ongoing treatment at 12 weeks and 6 months, proportion of patients with a treatment response at 1 year, and number of second-line therapies used in weeks 13-52, as well as changes in regulatory T cells, iron studies, bleeding, health-related quality of life and fatigue. A planned sample size of up to 162 randomised paediatric patients will be enrolled over 2 years at 20 sites. ETHICS AND DISSEMINATION The study has been approved by the centralised Baylor University Institutional Review Board. The results are expected to be published in 2023. TRIAL REGISTRATION NUMBER NCT03939637.
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Affiliation(s)
- Kristin A Shimano
- UCSF Benioff Children's Hospital, San Francisco, California, USA
- Pediatrics, UCSF, San Francisco, California, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carolyn M Bennett
- Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Biostatistics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Neunert
- Pediatrics, Columbia University Medical School, New York, New York, USA
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8
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Shimano KA, Neunert C, Bussel JB, Klaassen RJ, Bhat R, Pastore YD, Lambert MP, Bennett CM, Despotovic JM, Forbes P, Grace RF. Quality of life is an important indication for second-line treatment in children with immune thrombocytopenia. Pediatr Blood Cancer 2021; 68:e29023. [PMID: 33764667 DOI: 10.1002/pbc.29023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The decision to initiate second-line treatment in children with immune thrombocytopenia (ITP) is complex and involves many different factors. METHODS In this prospective, observational, longitudinal cohort study of 120 children from 21 centers, the factors contributing to the decision to start second-line treatments for ITP were captured. At study entry, clinicians were given a curated list of 12 potential reasons the patient required a second-line treatment. Clinicians selected all that applied and ranked the top three reasons. RESULTS Quality of life (QOL) was the most frequently cited reason for starting a second-line therapy. Clinicians chose it as a reason to treat in 88/120 (73%) patients, as among the top three reasons in 68/120 (57%), and as the top reason in 32/120 (27%). Additional factors ranked as the top reason to start second-line treatment included severity of bleeding (22/120, 18%), frequency of bleeding (19/120, 16%), and severity of thrombocytopenia (18/120, 15%). Patients for whom QOL (p = .006) or sports participation (p = .02) were ranked reasons were more likely to have chronic ITP, whereas those for whom severity (p = .003) or frequency (p = .005) of bleeding were ranked reasons were more likely to have newly diagnosed or persistent ITP. Parental anxiety, though rarely the primary impetus for treatment, was frequently cited (70/120, 58%) as a contributing factor. CONCLUSION Perceived QOL is the most frequently selected reason pediatric patients start second-line therapies for ITP. It is critical that studies of treatments for childhood ITP include assessments of their effects on QOL.
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Affiliation(s)
| | - Cindy Neunert
- Columbia University Medical Center, New York, New York, USA
| | | | | | - Rukhmi Bhat
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carolyn M Bennett
- Emory University School of Medicine, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Atlanta, Georgia, USA
| | - Jenny M Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
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9
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Grimes AB, Kim TO, Kirk SE, Flanagan J, Lambert MP, Grace RF, Despotovic JM. Refractory autoimmune cytopenias in pediatric Evans syndrome with underlying systemic immune dysregulation. Eur J Haematol 2021; 106:783-787. [PMID: 33570766 DOI: 10.1111/ejh.13600] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023]
Abstract
Evans syndrome is a rare but challenging disorder in children; and despite rapidly growing evidence for targetable systemic immune dysregulation driving these "idiopathic" autoimmune cytopenias, precision diagnosis and management remains sub-optimal among these patients. We analyzed retrospective clinical data for 60 pediatric ES patients followed at 3 large tertiary referral centers in the United States over a recent 6-year period and found that definable underlying systemic immune dysregulation was identified in only 42% of these patients throughout the course of clinical care. Median time from ES diagnosis to identification of the underlying systemic immune dysregulation disorder was 1.3 years (<1 month for rheumatologic disease, 2.3 years for CVID, 3.4 years for ALPS, and 7.4 years for monogenic disorders of immune regulation). Notably, a significantly higher percentage of patients in whom a definitive immune dysregulation disorder was ultimately identified required ≥3 cytopenia-directed therapies (92%) and also second- and third-line immunomodulatory agents (84%), vs those in whom no unifying immune dysregulation was diagnosed (65%, and 35%, respectively)-indicating that autoimmune cytopenias as a manifestation of systemic immune dysregulation are more treatment-refractory and severe. These data underline the importance of identifying the underlying systemic immune dysregulation and providing targeted therapy in pediatric ES.
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Affiliation(s)
- Amanda B Grimes
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Taylor O Kim
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Susan E Kirk
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Jonathan Flanagan
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Michele P Lambert
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rachael F Grace
- Harvard Medical School, Boston, MA, USA.,Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Jenny M Despotovic
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
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10
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Cuker A, Despotovic JM, Grace RF, Kruse C, Lambert MP, Liebman HA, Lyons RM, McCrae KR, Pullarkat V, Wasser JS, Beenhouwer D, Gibbs SN, Yermilov I, Broder MS. Tapering thrombopoietin receptor agonists in primary immune thrombocytopenia: Expert consensus based on the RAND/UCLA modified Delphi panel method. Res Pract Thromb Haemost 2020; 5:69-80. [PMID: 33537531 PMCID: PMC7845076 DOI: 10.1002/rth2.12457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
Background Thrombopoietin receptor agonists (TPO-RAs) are used to treat primary immune thrombocytopenia (ITP). Some patients have discontinued treatment while maintaining a hemostatic platelet count. Objectives To develop expert consensus on when it is appropriate to consider tapering TPO-RAs in ITP, how to taper patients off therapy, how to monitor patients after discontinuation, and how to restart therapy. Methods We used a RAND/UCLA modified Delphi panel method. Ratings were completed independently by each expert before and after a meeting. Second-round ratings were used to develop the panel's guidance. The panel was double-blinded: The sponsor and nonchair experts did not know each other's identities. Results Guidance on when it is appropriate to taper TPO-RAs in children and adults was developed based on patient platelet count, history of bleeding, intensification of treatment, trauma risk, and use of anticoagulants/platelet inhibitors. For example, it is appropriate to taper TPO-RAs in patients who have normal/above-normal platelet counts, have no history of major bleeding, and have not required an intensification of treatment in the past 6 months; it is inappropriate to taper TPO-RAs in patients with low platelet counts. Duration of ITP, months on TPO-RA, or timing of platelet response to TPO-RA did not have an impact on the panel's guidance on appropriateness to taper. Guidance on how to taper patients off therapy, how to monitor patients after discontinuation, and how to restart therapy is also provided. Conclusion This guidance could support clinical decision making and the development of clinical trials that prospectively test the safety of tapering TPO-RAs.
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Affiliation(s)
- Adam Cuker
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Rachael F. Grace
- Dana‐Farber/Boston Children’s Cancer and Blood Disorders CenterHarvard Medical SchoolBostonMAUSA
| | | | - Michele P. Lambert
- Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPAUSA
| | - Howard A. Liebman
- University of Southern California, Norris Cancer HospitalLos AngelesCAUSA
| | | | | | | | | | - David Beenhouwer
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Sarah N. Gibbs
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Michael S. Broder
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
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11
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Al-Samkari H, van Beers EJ, Morton DH, Barcellini W, Eber SW, Glader B, Yaish HM, Chonat S, Kuo KHM, Kollmar N, Despotovic JM, Pospíšilová D, Knoll CM, Kwiatkowski JL, Pastore YD, Thompson AA, Wlodarski MW, Ravindranath Y, Rothman JA, Wang H, Holzhauer S, Breakey VR, Verhovsek MM, Kunz J, Sheth S, Sharma M, Rose MJ, Bradeen HA, McNaull MN, Addonizio K, Al-Sayegh H, London WB, Grace RF. Characterization of the severe phenotype of pyruvate kinase deficiency. Am J Hematol 2020; 95:E281-E285. [PMID: 32619047 DOI: 10.1002/ajh.25926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - D Holmes Morton
- Central Pennsylvania Clinic for Special Children & Adults, Belleville, Pennsylvania
- Lancaster General Hospital, Lancaster, Pennsylvania
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefan W Eber
- Schwerpunktpraxis für Pädiatrische Hämatologie-Onkologie and Children's Hospital, Technical University, Munich, Germany
| | - Bertil Glader
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Hassan M Yaish
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Satheesh Chonat
- Emory University School of Medicine, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kevin H M Kuo
- University of Toronto, University Health Network, Toronto, Ontario, Canada
| | | | - Jenny M Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, Texas
| | | | | | - Janet L Kwiatkowski
- Children's Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Alexis A Thompson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Marcin W Wlodarski
- St. Jude Children's Research Hospital, Memphis, Tennessee
- University of Freiburg, Freiburg, Germany
| | | | | | - Heng Wang
- DDC Clinic for Special Needs Children, Middlefield, Ohio
| | | | | | | | - Joachim Kunz
- Zentrum für Kinder-und Jugendmedizin, Heidelberg, Germany
| | - Sujit Sheth
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Mukta Sharma
- Children's Mercy, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Melissa J Rose
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | | | | | - Kathryn Addonizio
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Harvard Medical School, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Harvard Medical School, Boston, Massachusetts
| | - Wendy B London
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Harvard Medical School, Boston, Massachusetts
| | - Rachael F Grace
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Harvard Medical School, Boston, Massachusetts
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12
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Cirasino L, Robino AM, Podda G, Andrès E, Despotovic JM, Elalfy M, Holbro A, Kondo T, Lambert MP, Loggetto SR, McCrae KR, Lee JW, Cattaneo M. Report of a 'consensus' on the lines of therapy for primary immune thrombocytopenia in adults, promoted by the Italian Gruppo di Studio delle Piastrine. Platelets 2020; 31:461-473. [PMID: 32314933 DOI: 10.1080/09537104.2020.1751105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1. classification of four 'lines of therapy'; 2. acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3I . practicability of splenectomy; 3Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.
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Affiliation(s)
| | - Anna M Robino
- Medicina B3, Ospedale Niguarda Ca' Granda , Milano, Italy
| | - GianMarco Podda
- Medicina 2 ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano , Milano, Italy
| | - Emmanuel Andrès
- Clinique Médicale B Hôpitaux Universitaires de Strasbourg (HUS) , Strasbourg, France
| | | | - Mohsen Elalfy
- Faculty of Medicine, Ain Shams University Hospitals Cairo , Egypt
| | - Andreas Holbro
- Blood Transfusion Center SRC and Hematology, University Hospital Basel, Swiss Red Cross , Basel, Switzerland
| | - Tadakazu Kondo
- Department of Hematology/Oncology, Graduate School of Medicine, Kyoto University , Kyoto, Japan
| | - Michele P Lambert
- The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA, USA
| | - Sandra R Loggetto
- Department of Pediatric Hematology, Sabara Pediatric Hospital , Sao Paulo, Brazil
| | - Keith R McCrae
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic Lerner College of Medicine , Cleveland, OH, USA
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea , Seoul, Korea
| | - Marco Cattaneo
- Medicina 2 ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano , Milano, Italy
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13
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Bianchi P, Fermo E, Lezon‐Geyda K, Beers EJ, Morton HD, Barcellini W, Glader B, Chonat S, Ravindranath Y, Newburger PE, Kollmar N, Despotovic JM, Verhovsek M, Sharma M, Kwiatkowski JL, Kuo KHM, Wlodarski MW, Yaish HM, Holzhauer S, Wang H, Kunz J, Addonizio K, Al‐Sayegh H, London WB, Andres O, Wijk R, Gallagher PG, Grace RFF. Genotype-phenotype correlation and molecular heterogeneity in pyruvate kinase deficiency. Am J Hematol 2020; 95:472-482. [PMID: 32043619 DOI: 10.1002/ajh.25753] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase (PK) deficiency is a rare recessive congenital hemolytic anemia caused by mutations in the PKLR gene. This study reports the molecular features of 257 patients enrolled in the PKD Natural History Study. Of the 127 different pathogenic variants detected, 84 were missense and 43 non-missense, including 20 stop-gain, 11 affecting splicing, five large deletions, four in-frame indels, and three promoter variants. Within the 177 unrelated patients, 35 were homozygous and 142 compound heterozygous (77 for two missense, 48 for one missense and one non-missense, and 17 for two non-missense variants); the two most frequent mutations were p.R510Q in 23% and p.R486W in 9% of mutated alleles. Fifty-five (21%) patients were found to have at least one previously unreported variant with 45 newly described mutations. Patients with two non-missense mutations had lower hemoglobin levels, higher numbers of lifetime transfusions, and higher rates of complications including iron overload, extramedullary hematopoiesis, and pulmonary hypertension. Rare severe complications, including lower extremity ulcerations and hepatic failure, were seen more frequently in patients with non-missense mutations or with missense mutations characterized by severe protein instability. The PKLR genotype did not correlate with the frequency of complications in utero or in the newborn period. With ICCs ranging from 0.4 to 0.61, about the same degree of clinical similarity exists within siblings as it does between siblings, in terms of hemoglobin, total bilirubin, splenectomy status, and cholecystectomy status. Pregnancy outcomes were similar across genotypes in PK deficient women. This report confirms the wide genetic heterogeneity of PK deficiency.
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Affiliation(s)
- Paola Bianchi
- U.O.C. EmatologiaU.O.S. Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan Italy
| | - Elisa Fermo
- U.O.C. EmatologiaU.O.S. Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan Italy
| | | | - Eduard J. Beers
- Division Internal Medicine and DermatologyVan Creveldkliniek, University Medical Center Utrecht Utrecht The Netherlands
| | - Holmes D. Morton
- Central Pennsylvania Clinic for Special Children & AdultsBelleville, PA; Lancaster General Hospital Lancaster PA
| | - Wilma Barcellini
- U.O.C. EmatologiaU.O.S. Fisiopatologia delle Anemie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan Italy
| | - Bertil Glader
- Lucile Packard Children's HospitalStanford University Palo Alto CA
| | - Satheesh Chonat
- Department of PediatricsEmory University School of Medicine, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta Atlanta GA
| | - Yaddanapudi Ravindranath
- School of MedicinePediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine Detroit MI
| | - Peter E. Newburger
- Department of PediatricsUniversity of Massachusetts Medical School Worcester MA
| | - Nina Kollmar
- Department of Pediatric Hematology/OncologyKlinikum Kassel GmbH Kassel Germany
| | | | | | - Mukta Sharma
- Department of PediatricsChildren's Mercy, School of Medicine University of Missouri Kansas City MO
| | - Janet L. Kwiatkowski
- Division of HematologyChildren's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Kevin H. M. Kuo
- Division of Hematology, Department of MedicineUniversity Health Network, University of Toronto Toronto Ontario Canada
| | | | - Hassan M. Yaish
- Primary Children's HospitalUniversity of Utah Salt Lake City UT
| | - Susanne Holzhauer
- CharitéUniversity Medicine, Pediatric Hematology and Oncology Berlin Germany
| | - Heng Wang
- DDC Clinic for Special Needs Children Middlefield OH
| | - Joachim Kunz
- Zentrumfür Kinder‐und Jugendmedizin Heidelberg Germany
| | - Kathryn Addonizio
- Dana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston MA
| | - Hasan Al‐Sayegh
- Dana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston MA
| | - Wendy B. London
- Dana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston MA
| | - Oliver Andres
- Department of PediatricsUniversity of Würzburg Würzburg Germany
| | - Richard Wijk
- Central Diagnostic LaboratoryUniversity Medical Center Utrecht Utrecht The Netherlands
| | - Patrick G. Gallagher
- Department of Pediatrics, Department of Genetics, Department of PathologyYale University School of Medicine New Haven CT
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14
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Kirk SE, Grimes AB, Shelke S, Despotovic JM, Powers JM. The cost of a "benign" condition: Healthcare utilization and infectious outcomes in young children with primary autoimmune neutropenia. Pediatr Blood Cancer 2020; 67:e28146. [PMID: 31886613 DOI: 10.1002/pbc.28146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/05/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Autoimmune neutropenia (AIN) is a common cause of chronic neutropenia in childhood. Despite an expected benign clinical course, many patients undergo extensive evaluation. Data on healthcare utilization and rates of bloodstream infections in young patients with AIN are limited. METHODS All patients with a diagnosis code of leukopenia, neutropenia, or AIN followed within the outpatient hematology clinic of a single institution from 2014 to 2016 were identified. Patients aged ≤5 years with absolute neutrophil count (ANC) ≤500/µL persisting for ≥3 months, a clinical diagnosis of AIN, and documented resolution of neutropenia were included. Data on clinical management, including infectious outcomes and emergency center (EC) encounters, were collected. RESULTS Forty-three patients with AIN (18 male [42%], median age at diagnosis 12 months) met eligibility criteria. Children were followed by hematology for a median duration of 18 (range, 2-85) months. Diagnostic evaluations were variable. Thirty patients (70%) had ≥ 1 EC encounters for evaluation of isolated fever with a total of 113 EC encounters for the overall cohort. Patients with ANC < 500/µL and isolated fever were admitted for observation, which resulted in 24 hospitalizations in 16 patients. Of 138 blood cultures drawn, two were positive, both later determined to be contaminants. CONCLUSION At a large tertiary care center, no bloodstream infections were identified in a cohort of 43 children with AIN presenting to the EC for assessment of fever. A less-intensive, more cost-effective management paradigm, which continues to prioritize patient safety, among young children with AIN is needed.
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Affiliation(s)
- Susan E Kirk
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
| | - Amanda Bell Grimes
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
| | | | - Jenny M Despotovic
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
| | - Jacquelyn M Powers
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology/Oncology, Houston, Texas.,Texas Children's Cancer and Hematology Centers, Houston, Texas
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15
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Kim TO, Flanagan JM, Habibi A, Arulselvan A, Lambert MP, Grace RF, Despotovic JM. Genetic variants in toll-like receptor 4 are associated with lack of steroid-responsiveness in pediatric ITP patients. Am J Hematol 2020; 95:395-400. [PMID: 31903617 DOI: 10.1002/ajh.25716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 12/20/2019] [Accepted: 12/27/2019] [Indexed: 01/19/2023]
Abstract
Although the most common front-line therapies for immune thrombocytopenia (ITP) have been in use for decades, it is still not possible to predict an individual patient's clinical course and response to therapy. Patients are managed with a trial-and-error approach and often suffer side effects of therapies which could have been avoided if response prediction were possible. Corticosteroids are the most frequently used upfront therapy for adults and children with ITP. Our group performed whole exome sequencing on a cohort of pediatric ITP patients, and identified two missense single nucleotide variants (SNV) in Toll-like receptor 4 (TLR4). These coding variants in TLR4 had an increased frequency in Caucasian patients with poor response to upfront steroid therapy. Both TLR4 (D299G; rs4986790) and TLR4 (T399I; rs4986791) had a minor allele frequency (MAF) of 20.7% in those patients unresponsive to steroids, but were present at lower allele frequencies of 2.3% and 3.4% in responders respectively (P < .001). These findings were consistent with the trend identified in an independent cohort of pediatric ITP patients treated with corticosteroids who underwent direct genotyping for both SNVs. This study identified two candidate genetic variants in two unique cohorts of ITP patients which may contribute to steroid response and have prognostic implications for treatment response in ITP.
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Affiliation(s)
- Taylor Olmsted Kim
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Jonathan M. Flanagan
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Ali Habibi
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
| | - Abinaya Arulselvan
- Children's Hospital of Philadelphia, Division of Hematology Philadelphia Pennsylvania
| | - Michele P. Lambert
- Children's Hospital of Philadelphia, Division of Hematology Philadelphia Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics Philadelphia Pennsylvania
| | - Rachael F. Grace
- Harvard Medical School Boston Massachusetts
- Boston Children's Hospital Dana Farber/Boston Children's Cancer and Blood Disorders Center Boston Massachusetts
| | - Jenny M. Despotovic
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
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16
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Gilbert MM, Grimes AB, Kim TO, Despotovic JM. Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use. Patient Prefer Adherence 2020; 14:1237-1250. [PMID: 32801654 PMCID: PMC7383044 DOI: 10.2147/ppa.s192481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/28/2020] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.
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Affiliation(s)
- Megan M Gilbert
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
- Correspondence: Megan M Gilbert Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Suite 1510, Houston, TX77030, USATel +1 (832) 824-4736Fax +1 (832) 825-4846 Email
| | - Amanda B Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Taylor Olmsted Kim
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
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17
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Le Coz C, Bengsch B, Khanna C, Trofa M, Ohtani T, Nolan BE, Henrickson SE, Lambert MP, Kim TO, Despotovic JM, Feldman S, Fadugba OO, Takach P, Ruffner M, Jyonouchi S, Heimall J, Sullivan KE, Wherry EJ, Romberg N. Common variable immunodeficiency-associated endotoxemia promotes early commitment to the T follicular lineage. J Allergy Clin Immunol 2019; 144:1660-1673. [PMID: 31445098 DOI: 10.1016/j.jaci.2019.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/26/2019] [Accepted: 08/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although chiefly a B-lymphocyte disorder, several research groups have identified common variable immunodeficiency (CVID) subjects with numeric and/or functional TH cell alterations. The causes, interrelationships, and consequences of CVID-associated CD4+ T-cell derangements to hypogammaglobulinemia, autoantibody production, or both remain unclear. OBJECTIVE We sought to determine how circulating CD4+ T cells are altered in CVID subjects with autoimmune cytopenias (AICs; CVID+AIC) and the causes of these derangements. METHODS Using hypothesis-generating, high-dimensional single-cell analyses, we created comprehensive phenotypic maps of circulating CD4+ T cells. Differences between subject groups were confirmed in a large and genetically diverse cohort of CVID subjects (n = 69) by using flow cytometry, transcriptional profiling, multiplex cytokine/chemokine detection, and a suite of in vitro functional assays measuring naive T-cell differentiation, B-cell/T-cell cocultures, and regulatory T-cell suppression. RESULTS Although CD4+ TH cell profiles from healthy donors and CVID subjects without AICs were virtually indistinguishable, T cells from CVID+AIC subjects exhibited follicular features as early as thymic egress. Follicular skewing correlated with IgA deficiency-associated endotoxemia and endotoxin-induced expression of activin A and inducible T-cell costimulator ligand. The resulting enlarged circulating follicular helper T-cell population from CVID+AIC subjects provided efficient help to receptive healthy donor B cells but not unresponsive CVID B cells. Despite this, circulating follicular helper T cells from CVID+AIC subjects exhibited aberrant transcriptional profiles and altered chemokine/cytokine receptor expression patterns that interfered with regulatory T-cell suppression assays and were associated with autoantibody production. CONCLUSIONS Endotoxemia is associated with early commitment to the follicular T-cell lineage in IgA-deficient CVID subjects, particularly those with AICs.
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Affiliation(s)
- Carole Le Coz
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Bertram Bengsch
- Department of Medicine II, University Medical Center Freiburg, Freiburg, Germany
| | - Caroline Khanna
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Melissa Trofa
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Takuya Ohtani
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Brian E Nolan
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Sarah E Henrickson
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Michele P Lambert
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Taylor Olmsted Kim
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Tex
| | - Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Tex
| | - Scott Feldman
- Department of Medicine, Division of Allergy and Immunology,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Olajumoke O Fadugba
- Department of Medicine, Division of Allergy and Immunology,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Patricia Takach
- Department of Medicine, Division of Allergy and Immunology,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Melanie Ruffner
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Soma Jyonouchi
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Jennifer Heimall
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Kathleen E Sullivan
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - E John Wherry
- Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Neil Romberg
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
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18
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Grace RF, Shimano KA, Bhat R, Neunert C, Bussel JB, Klaassen RJ, Lambert MP, Rothman JA, Breakey VR, Hege K, Bennett CM, Rose MJ, Haley KM, Buchanan GR, Geddis A, Lorenzana A, Jeng M, Pastore YD, Crary SE, Neier M, Neufeld EJ, Neu N, Forbes PW, Despotovic JM. Second-line treatments in children with immune thrombocytopenia: Effect on platelet count and patient-centered outcomes. Am J Hematol 2019; 94:741-750. [PMID: 30945320 DOI: 10.1002/ajh.25479] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/01/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder with isolated thrombocytopenia and hemorrhagic risk. While many children with ITP can be safely observed, treatments are often needed for various reasons, including to decrease bleeding, or to improve health related quality of life (HRQoL). There are a number of available second-line treatments, including rituximab, thrombopoietin-receptor agonists, oral immunosuppressive agents, and splenectomy, but data comparing treatment outcomes are lacking. ICON1 is a prospective, multi-center, observational study of 120 children starting second-line treatments for ITP designed to compare treatment outcomes including platelet count, bleeding, and HRQoL utilizing the Kids ITP Tool (KIT). While all treatments resulted in increased platelet counts, romiplostim had the most pronounced effect at 6 months (P = .04). Only patients on romiplostim and rituximab had a significant reduction in both skin-related (84% to 48%, P = .01 and 81% to 43%, P = .004) and non-skin-related bleeding symptoms (58% to 14%, P = .0001 and 54% to 17%, P = .0006) after 1 month of treatment. HRQoL significantly improved on all treatments. However, only patients treated with eltrombopag had a median improvement in KIT scores at 1 month that met the minimal important difference (MID). Bleeding, platelet count, and HRQoL improved in each treatment group, but the extent and timing of the effect varied among treatments. These results are hypothesis generating and help to improve our understanding of the effect of each treatment on specific patient outcomes. Combined with future randomized trials, these findings will help clinicians select the optimal second-line treatment for an individual child with ITP.
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Affiliation(s)
- Rachael F. Grace
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Kristin A. Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow TransplantationUCSF Benioff Children's Hospital San Francisco California
| | - Rukhmi Bhat
- Center for Cancer & Blood Disorders, Ann and Robert H. Lurie Childrens Hospital of ChicagoFeinberg School of Medicine, Northwestern University Chicago Illinois
| | - Cindy Neunert
- Division of Hematology, Oncology, and Stem Cell TransplantColumbia University Medical School New York New York
| | - James B. Bussel
- Department of PediatricsWeill Cornell Medicine New York New York
| | - Robert J. Klaassen
- Division of Hematology/OncologyChildren's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Michele P. Lambert
- Division of HematologyThe Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Jennifer A. Rothman
- Division of Pediatric Hematology/OncologyDuke University Medical Center Durham North Carolina
| | - Vicky R. Breakey
- Division of Pediatric Hematology/OncologyMcMaster University Hamilton Ontario Canada
| | - Kerry Hege
- Division of Pediatric Hematology/Oncology, Riley Hospital at IU HealthIndiana University School of Medicine Indianapolis Indiana
| | - Carolyn M. Bennett
- Division of Hematology/Oncology, Aflac Cancer and Blood Disorders CenterEmory University School of Medicine, Children's Healthcare of Atlanta Atlanta Georgia
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's HospitalThe Ohio State University College of Medicine Columbus Ohio
| | - Kristina M. Haley
- Division of Pediatric HematologyOregon Health & Science University Portland Oregon
| | - George R. Buchanan
- Division of Hematology‐OncologyUniversity of Texas Southwestern Medical Center Dallas Texas
| | - Amy Geddis
- Division of Pediatric Hematology/OncologyUniversity of Washington, Seattle Children's Hospital Seattle Washington
| | - Adonis Lorenzana
- Division of Pediatric Hematology/OncologySt. John Ascension Hospital Detroit Michigan
| | - Michael Jeng
- Department of PediatricsStanford School of Medicine Palo Alto California
| | - Yves D. Pastore
- Division of Hematology/OncologyCHU Sainte‐Justine Montreal Québec Canada
| | - Shelley E. Crary
- Department of PediatricsUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Michelle Neier
- Division of Pediatric Hematology/OncologyGoryeb Children's Hospital Morristown New Jersey
| | - Ellis J. Neufeld
- Division of HematologySt. Jude Children's Research Hospital Memphis Tennessee
| | - Nolan Neu
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Peter W. Forbes
- Clinical Research CenterBoston Children's Hospital Boston Massachusetts
| | - Jenny M. Despotovic
- Department of PediatricsHematology/Oncology Section, Baylor College of Medicine Houston Texas
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19
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Kim TO, Grimes AB, Kirk S, Arulselvan A, Lambert MP, Grace RF, Despotovic JM. Association of a positive direct antiglobulin test with chronic immune thrombocytopenia and use of second line therapies in children: A multi-institutional review. Am J Hematol 2019; 94:461-466. [PMID: 30663792 DOI: 10.1002/ajh.25409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is the most common autoimmune cytopenia in children. Approximately, 25% of patients develop chronic disease, which may be unpredictable and challenging to treat. It is not currently possible to predict at the time of presentation which patients will have chronic disease or will experience symptoms requiring second-line therapy defined as treatment beyond corticosteroids, intravenous immunoglobulin, or Rh immune globulin. A multi-institutional retrospective review of 311 pediatric patients with ITP was performed with the goal of identifying clinical characteristics associated with disease course. In a cohort of 216 patients tested and for whom disease status was known, a positive direct antiglobulin test (DAT) was associated with chronic ITP vs spontaneous resolution of disease (29.2% vs 8.1%, P < 0.001) as well as the need for treatment with second line agents (38.5% vs 11.4%, P < 0.001) in 241 patients. Controlling for the effect of Evans syndrome, defined as having two immune cytopenias, a positive DAT was independently associated with chronic ITP (OR = 2.7, 95% CI: 1.0-7.2, P = 0.041) and use of second-line agents (OR: 3.6, 95% CI: 1.7-7.7, P = 0.001) by multivariate logistic regression model. These findings demonstrate an association with positive DAT and chronic disease, as well as refractory disease requiring second-line agents.
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Affiliation(s)
- Taylor Olmsted Kim
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Amanda B. Grimes
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Susan Kirk
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Abinaya Arulselvan
- Children's Hospital of Philadelphia, Division of Hematology Philadelphia Pennsylvania
| | - Michele P. Lambert
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics Philadelphia Pennsylvania
- Children's Hospital of Philadelphia, Department of Pediatrics Philadelphia Pennsylvania
| | - Rachael F. Grace
- Harvard Medical School Boston Massachusetts
- Dana Farber Boston Children's Cancer and Blood Disorders Center Boston Massachusetts
| | - Jenny M. Despotovic
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
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20
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Neunert CE, Despotovic JM. Autoimmune hemolytic anemia and immune thrombocytopenia following hematopoietic stem cell transplant: A critical review of the literature. Pediatr Blood Cancer 2019; 66:e27569. [PMID: 30537439 DOI: 10.1002/pbc.27569] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 01/19/2023]
Abstract
Autoimmune cytopenias (AIC) post-hematopoietic stem cell transplant (HSCT) are rare but exceptionally challenging complication. We conducted a comprehensive literature review and identified a pooled incidence of post-HSCT autoimmune hemolytic anemia and/or immune thrombocytopenia of 2.66% (SE = 0.27) in pediatric patients. Nonmalignant disease, unrelated donor transplant, peripheral or cord blood stem cell source, conditioning regimen without total body irradiation, and presence of chronic graft-versus-host disease were prominent risk factors. Treatment was highly variable, and cytopenias were commonly refractory. AIC represent a significant post-HSCT complication. We report here the incidence, risk factors, and possible biology behind the development of AIC in pediatric post-HSCT patients.
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Affiliation(s)
- C E Neunert
- Department of Pediatrics, Hematology/Oncology/Bone Marrow Transplant, Columbia University School of Medicine, New York, New York
| | - J M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, Texas
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21
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22
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Hashmi SK, Bergstrom K, Bertuch AA, Despotovic JM, Muscal E, Xia F, Bi W, Marcogliese A, Diaz R. PSTPIP1-associated myeloid-related proteinemia inflammatory syndrome: A rare cause of childhood neutropenia associated with systemic inflammation and hyperzincemia. Pediatr Blood Cancer 2019; 66:e27439. [PMID: 30198636 DOI: 10.1002/pbc.27439] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 07/27/2018] [Accepted: 08/06/2018] [Indexed: 11/09/2022]
Abstract
Neutropenia in pediatric patients can be due to a variety of disorders. We describe two patients who underwent extensive evaluation over many years for arthralgias and moderate neutropenia of unclear etiology. Genetic testing identified a pathogenic variant in PSTPIP1 (proline-serine-threonine phosphatase-interacting protein 1) in both patients. Markedly elevated inflammatory markers and zinc levels confirmed the rare diagnosis of PSTPIP1-associated myeloid-related proteinemia inflammatory (PAMI) syndrome, tailoring treatment. Neutropenia is common in patients with PAMI syndrome. Unique mutations seen in PAMI syndrome may account for the specific phenotypic features of this disorder.
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Affiliation(s)
- Saman K Hashmi
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Katie Bergstrom
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Alison A Bertuch
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Jenny M Despotovic
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
| | - Eyal Muscal
- Department of Pediatrics, Section of Immunology/Allergy/Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Fan Xia
- Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Weimin Bi
- Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | | | - Rosa Diaz
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, Texas
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23
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O'Brien SH, Despotovic JM, Neunert CE. Intravenous Immunoglobulin Versus Anti-D Immunoglobulin: When Better Treatment May Not Be the Best Treatment. J Pediatr 2019; 204:11-13. [PMID: 30274924 DOI: 10.1016/j.jpeds.2018.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Sarah H O'Brien
- Center for Innovation in Pediatric Practice The Research Institute at Nationwide Children's Hospital; Division of Pediatric Hematology/Oncology Nationwide Children's Hospital/The Ohio State University Columbus, Ohio.
| | - Jenny M Despotovic
- Texas Children's Hematology Center Baylor College of Medicine Houston, Texas
| | - Cindy E Neunert
- Department of Pediatrics Columbia University Medical Center New York, New York
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24
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Abstract
Immune thrombocytopenia (ITP) has historically been thought to occur in 2 distinct forms: childhood ITP and adult ITP. This division is based largely on the presumption that childhood ITP is often benign and self-limited, whereas ITP in adults tends to be more chronic and difficult to treat. Although data exist to justify a different approach to the diagnosis and treatment in young children and the elderly, ITP in older children, adolescents, and younger adults is likely to share more similar pathology. This article will highlight the most recent data describing the natural history, diagnostic approach, management strategies, and disease-related outcomes in children and adults with ITP. These data reveal many unexpected similarities between the 2 groups, while confirming some of the more well-described differences. Discussion of these findings aims to highlight similarities and differences between ITP in children and adults, which will underscore important areas of future research and/or changes in management guidelines.
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Affiliation(s)
- Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX
| | - Amanda B Grimes
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX
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25
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van Beers EJ, van Straaten S, Morton DH, Barcellini W, Eber SW, Glader B, Yaish HM, Chonat S, Kwiatkowski JL, Rothman JA, Sharma M, Neufeld EJ, Sheth S, Despotovic JM, Kollmar N, Pospíšilová D, Knoll CM, Kuo K, Pastore YD, Thompson AA, Newburger PE, Ravindranath Y, Wang WC, Wlodarski MW, Wang H, Holzhauer S, Breakey VR, Verhovsek M, Kunz J, McNaull MA, Rose MJ, Bradeen HA, Addonizio K, Li A, Al-Sayegh H, London WB, Grace RF. Prevalence and management of iron overload in pyruvate kinase deficiency: report from the Pyruvate Kinase Deficiency Natural History Study. Haematologica 2018; 104:e51-e53. [PMID: 30213831 DOI: 10.3324/haematol.2018.196295] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Eduard J van Beers
- Van Creveldkliniek, University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - Stephanie van Straaten
- Van Creveldkliniek, University Medical Centre Utrecht, University of Utrecht, the Netherlands
| | - D Holmes Morton
- Central Pennsylvania Clinic for Special Children & Adults, Belleville, PA, USA Lancaster General Hospital, Lancaster, PA, USA
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefan W Eber
- Schwerpunktpraxis für Pädiatrische Hämatologie-Onkologie and Children's Hospital, Technical University, Munich, Germany
| | - Bertil Glader
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Hassan M Yaish
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Satheesh Chonat
- Emory University School of Medicine, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, GA, USA
| | - Janet L Kwiatkowski
- Children's Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mukta Sharma
- Children's Mercy Hospital, University of Missouri, Kansas City, MO, USA
| | | | - Sujit Sheth
- Weill Cornell Medical College, New York Presbyterian Hospital, NY, USA
| | - Jenny M Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, TX, USA
| | | | | | | | - Kevin Kuo
- University of Toronto, University Health Network, ON, Canada
| | | | - Alexis A Thompson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | | | | | - Marcin W Wlodarski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Heng Wang
- DDC Clinic for Special Needs Children, Middlefield, OH, USA
| | | | | | | | - Joachim Kunz
- Zentrum für Kinder-und Jugendmedizin,University of Heidelberg, Heidelberg, Germany
| | | | - Melissa J Rose
- Nationwide Children's Hospital,The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Kathryn Addonizio
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Anran Li
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Hasan Al-Sayegh
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Wendy B London
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
| | - Rachael F Grace
- Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, MA, USA
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26
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Grace RF, Despotovic JM, Bennett CM, Bussel JB, Neier M, Neunert C, Crary SE, Pastore YD, Klaassen RJ, Rothman JA, Hege K, Breakey VR, Rose MJ, Shimano KA, Buchanan GR, Geddis A, Haley KM, Lorenzana A, Thompson A, Jeng M, Neufeld EJ, Brown T, Forbes PW, Lambert MP. Physician decision making in selection of second-line treatments in immune thrombocytopenia in children. Am J Hematol 2018; 93:882-888. [PMID: 29659042 DOI: 10.1002/ajh.25110] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder which presents with isolated thrombocytopenia and risk of hemorrhage. While most children with ITP promptly recover with or without drug therapy, ITP is persistent or chronic in others. When needed, how to select second-line therapies is not clear. ICON1, conducted within the Pediatric ITP Consortium of North America (ICON), is a prospective, observational, longitudinal cohort study of 120 children from 21 centers starting second-line treatments for ITP which examined treatment decisions. Treating physicians reported reasons for selecting therapies, ranking the top three. In a propensity weighted model, the most important factors were patient/parental preference (53%) and treatment-related factors: side effect profile (58%), long-term toxicity (54%), ease of administration (46%), possibility of remission (45%), and perceived efficacy (30%). Physician, health system, and clinical factors rarely influenced decision-making. Patient/parent preferences were selected as reasons more often in chronic ITP (85.7%) than in newly diagnosed (0%) or persistent ITP (14.3%, P = .003). Splenectomy and rituximab were chosen for the possibility of inducing long-term remission (P < .001). Oral agents, such as eltrombopag and immunosuppressants, were chosen for ease of administration and expected adherence (P < .001). Physicians chose rituximab in patients with lower expected adherence (P = .017). Treatment choice showed some physician and treatment center bias. This study illustrates the complexity and many factors involved in decision-making in selecting second-line ITP treatments, given the absence of comparative trials. It highlights shared decision-making and the need for well-conducted, comparative effectiveness studies to allow for informed discussion between patients and clinicians.
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Affiliation(s)
- Rachael F. Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center; Boston Massachusetts
| | - Jenny M. Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine; Houston Texas
| | - Carolyn M. Bennett
- Emory University School of Medicine; Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center; Atlanta Georgia
| | | | | | - Cindy Neunert
- Columbia University Medical School; New York New York
| | - Shelley E. Crary
- University of Arkansas for Medical Sciences; Little Rock Arkansas
| | | | | | | | - Kerry Hege
- Riley Hospital at IU Health, Indiana University School of Medicine; Indianapolis Indiana
| | | | - Melissa J. Rose
- Nationwide Children's Hospital, The Ohio State University College of Medicine; Columbus Ohio
| | | | | | - Amy Geddis
- University of Washington, Seattle Children's Hospital; Seattle Washington
| | | | | | - Alexis Thompson
- Ann and Robert H. Lurie Childrens Hospital of Chicago, Northwestern University, Feinberg School of Medicine; Chicago Illinois
| | - Michael Jeng
- Stanford School of Medicine; Palo Alto California
| | | | - Travis Brown
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center; Boston Massachusetts
| | - Peter W. Forbes
- Boston Children's Hospital, Clinical Research Center; Boston Massachusetts
| | - Michele P. Lambert
- Division of Hematology; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania
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27
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Bussel JB, de Miguel PG, Despotovic JM, Grainger JD, Sevilla J, Blanchette VS, Krishnamurti L, Connor P, David M, Boayue KB, Matthews DC, Lambert MP, Marcello LM, Iyengar M, Chan GW, Chagin KD, Theodore D, Bailey CK, Bakshi KK. Eltrombopag for the treatment of children with persistent and chronic immune thrombocytopenia (PETIT): a randomised, multicentre, placebo-controlled study. The Lancet Haematology 2015; 2:e315-25. [DOI: 10.1016/s2352-3026(15)00114-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 01/19/2023]
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28
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O'Connell AE, Volpi S, Dobbs K, Fiorini C, Tsitsikov E, de Boer H, Barlan IB, Despotovic JM, Espinosa-Rosales FJ, Hanson IC, Kanariou MG, Martínez-Beckerat R, Mayorga-Sirera A, Mejia-Carvajal C, Radwan N, Weiss AR, Pai SY, Lee YN, Notarangelo LD. Next generation sequencing reveals skewing of the T and B cell receptor repertoires in patients with wiskott-Aldrich syndrome. Front Immunol 2014; 5:340. [PMID: 25101082 PMCID: PMC4102881 DOI: 10.3389/fimmu.2014.00340] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/04/2014] [Indexed: 12/26/2022] Open
Abstract
The Wiskott–Aldrich syndrome (WAS) is due to mutations of the WAS gene encoding for the cytoskeletal WAS protein, leading to abnormal downstream signaling from the T cell and B cell antigen receptors (TCR and BCR). We hypothesized that the impaired signaling through the TCR and BCR in WAS would subsequently lead to aberrations in the immune repertoire of WAS patients. Using next generation sequencing (NGS), the T cell receptor β and B cell immunoglobulin heavy chain (IGH) repertoires of eight patients with WAS and six controls were sequenced. Clonal expansions were identified within memory CD4+ cells as well as in total, naïve and memory CD8+ cells from WAS patients. In the B cell compartment, WAS patient IGH repertoires were also clonally expanded and showed skewed usage of IGHV and IGHJ genes, and increased usage of IGHG constant genes, compared with controls. To our knowledge, this is the first study that demonstrates significant abnormalities of the immune repertoire in WAS patients using NGS.
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Affiliation(s)
- Amy E O'Connell
- Department of Immunology, Boston Children's Hospital , Boston, MA , USA
| | - Stefano Volpi
- Department of Immunology, Boston Children's Hospital , Boston, MA , USA
| | - Kerry Dobbs
- Department of Immunology, Boston Children's Hospital , Boston, MA , USA
| | - Claudia Fiorini
- Department of Hematology/Oncology, Boston Children's Hospital , Boston, MA , USA
| | - Erdyni Tsitsikov
- Department of Laboratory Medicine, Boston Children's Hospital , Boston, MA , USA
| | - Helen de Boer
- Department of Hematology/Oncology, Boston Children's Hospital , Boston, MA , USA
| | - Isil B Barlan
- Marmara University Medical Center , Istanbul , Turkey
| | | | | | | | | | - Roxana Martínez-Beckerat
- Department of Pediatric Hemato-Oncology, Hospital Mario Catarino Rivas , San Pedro Sula , Honduras
| | | | | | | | | | - Sung-Yun Pai
- Department of Hematology/Oncology, Boston Children's Hospital , Boston, MA , USA
| | - Yu Nee Lee
- Department of Immunology, Boston Children's Hospital , Boston, MA , USA
| | - Luigi D Notarangelo
- Department of Immunology, Boston Children's Hospital , Boston, MA , USA ; Manton Center for Orphan Disease Research, Boston Children's Hospital , Boston, MA , USA
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Thompson JC, Klima J, Despotovic JM, O'Brien SH. Anti-D immunoglobulin therapy for pediatric ITP: before and after the FDA's black box warning. Pediatr Blood Cancer 2013; 60:E149-51. [PMID: 23813881 DOI: 10.1002/pbc.24633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 05/15/2013] [Indexed: 01/19/2023]
Abstract
In March 2010, the Food and Drug Administration (FDA) issued a black box warning for anti-D immunoglobulin (anti-D), an approved treatment for immune thrombocytopenia (ITP). It is unknown if and how clinical practice at U.S children's hospitals has since changed. We sought to describe inpatient anti-D usage, laboratory monitoring, and anti-D complications before and after the FDA warning. Using the Pediatric Health Information System, we collected data from 41 children's hospitals. There was a modest but statistically significant decrease in anti-D usage from pre-warning to post-warning. Severe complication rates were very low and did not change appreciably.
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Affiliation(s)
- Joel C Thompson
- Pediatric Residency Program, Nationwide Children's Hospital, Columbus, Ohio
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Despotovic JM, McGann PT, Smeltzer M, Aygun B, Ware RE. RHD zygosity predicts degree of platelet response to anti-D immune globulin treatment in children with immune thrombocytopenia. Pediatr Blood Cancer 2013; 60:E106-8. [PMID: 23712954 DOI: 10.1002/pbc.24574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/31/2013] [Indexed: 11/11/2022]
Abstract
Anti-D immunoglobulin is a common front-line treatment for childhood immune thrombocytopenia (ITP) that typically results in a rapid and significant increase in platelet count. Unpredictable treatment responses and interpatient variability limit more widespread use. We hypothesized that anti-D response variability is influenced by RHD gene zygosity and erythrocyte D antigen expression. We compared RHD zygosity and quantitative D antigen expression to anti-D treatment results. Hemizygous RHD subjects demonstrated significantly higher platelet increases and peak platelet counts than homozygous RHD subjects. Future studies should investigate the mechanisms by which RHD zygosity and D antigen expression affect platelet responses to anti-D immunoglobulin.
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Cook CM, Smeltzer MP, Mortier NA, Kirk SE, Despotovic JM, Ware RE, Hankins JS. The Clinical and Laboratory Spectrum of Hb C [β6(A3)Glu→Lys,GAG>AAG] Disease. Hemoglobin 2013; 37:16-25. [DOI: 10.3109/03630269.2012.753547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Despotovic JM, Neunert CE. Is anti-D immunoglobulin still a frontline treatment option for immune thrombocytopenia? Hematology Am Soc Hematol Educ Program 2013; 2013:283-285. [PMID: 24319192 DOI: 10.1182/asheducation-2013.1.283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A 5-year-old boy presents with platelet count of 2×10(9)/L and clinical and laboratory evidence of immune thrombocytopenia. He has epistaxis and oral mucosal bleeding. Complete blood count reveals isolated thrombocytopenia without any decline in hemoglobin and he is Rh+. You are asked if anti-D immunoglobulin is an appropriate initial therapy for this child given the 2010 Food and Drug Administration "black-box" warning.
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McGann PT, Despotovic JM, Howard TA, Ware RE. A novel laboratory technique demonstrating the influences of RHD zygosity and the RhCcEe phenotype on erythrocyte D antigen expression. Am J Hematol 2012; 87:266-71. [PMID: 22121029 DOI: 10.1002/ajh.22254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/21/2011] [Accepted: 11/08/2011] [Indexed: 11/11/2022]
Abstract
D antigen is the most immunogenic and clinically relevant antigen within the complex Rh blood group system. Variability of D antigen expression was first described decades ago but has rarely been investigated quantitatively, particularly in the context of RHD zygosity along with RhCcEe serological phenotype. With IRB approval, 107 deidentified blood samples were analyzed. Rh phenotypes were determined serologically by saline technique using monoclonal antibodies against D, C, c, E, and e antigens. RHD zygosity was determined using both PCR-restriction fragment length polymorphisms and quantitative real-time PCR techniques. A novel and robust method was developed for quantitation of erythrocyte D antigen sites using calibrated microspheres and flow cytometry, allowing correlation of D antigen density with RHD zygosity and expression of Rh CcEe antigens. Subjects homozygous for RHD expressed nearly twice the number of D antigen sites compared with RHD hemizygotes (33,560 ± 8,222 for DD versus 17,720 ± 4,471 for Dd, P < 0.0001). Expression of c or E antigens was associated with significantly increased erythrocyte D antigen expression, whereas presence of C or e antigens reduced expression. These data and this novel quantitation method will be important for future studies investigating the clinical relevance of D antigen variability.
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Affiliation(s)
- Patrick T McGann
- Baylor International Hematology Center of Excellence and the Texas Children's Center for Global Health, Houston, Texas, USA.
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Despotovic JM, Lambert MP, Herman JH, Gernsheimer TB, McCrae KR, Tarantino MD, Bussel JB. RhIG for the treatment of immune thrombocytopenia: consensus and controversy (CME). Transfusion 2011; 52:1126-36; quiz 1125. [PMID: 21981825 DOI: 10.1111/j.1537-2995.2011.03384.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anti-D immune globulin (RhIG) is a front-line option in North America for the treatment of immune thrombocytopenia (ITP) in children and adults. Recently, addition of a Food and Drug Administration-mandated black box warning highlighted the risks of intravascular hemolysis, renal failure, and disseminated intravascular coagulation after anti-D infusion, prompting concern within the medical community regarding its use. A working group convened in response to this warning to prepare a consensus document regarding the safety of RhIG because there has been no increased incidence of adverse events since the initial discovery of these reactions many years ago. The efficacy of anti-D is well documented and only briefly reviewed. The estimated incidence and proposed mechanisms for the rare, major treatment-related complications are discussed, and signal detection data associated with heightened risk of acute hemolytic reactions are presented. The importance of considering host factors, given the rarity of severe reactions, is emphasized. Safety profiles of parallel treatment options are reviewed. The working group consensus is that RhIG has comparable safety and efficacy to other front-line agents for the treatment of children and adults with ITP. Safety may be further improved by careful patient selection.
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Affiliation(s)
- Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX 77030, USA.
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