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Berentsen S, Datta SS. Time for newer approach in age-old AIHA: Daratumumab? Lancet Reg Health Southeast Asia 2024; 25:100410. [PMID: 38694485 PMCID: PMC11061252 DOI: 10.1016/j.lansea.2024.100410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 05/04/2024]
Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
| | - Suvro Sankha Datta
- Tata Medical Centre, Department of Transfusion Medicine, Kolkata, West Bengal, India
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2
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Datta SS, Berentsen S. Management of autoimmune haemolytic anaemia in low-to-middle income countries: current challenges and the way forward. Lancet Reg Health Southeast Asia 2024; 23:100343. [PMID: 38601175 PMCID: PMC11004394 DOI: 10.1016/j.lansea.2023.100343] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/28/2023] [Accepted: 12/13/2023] [Indexed: 04/12/2024]
Abstract
Autoimmune haemolytic anaemia (AIHA) is a common term for several disorders that differ from one another in terms of aetiology, pathogenesis, clinical features, and treatment. Therapy is becoming increasingly differentiated and evidence-based, and several new established and investigational therapeutic approaches have appeared during recent years. While this development has resulted in therapeutic improvements, it also carries increased medical and financial requirements for optimal diagnosis, subgrouping, and individualization of therapy, including the use of more advanced laboratory tests and expensive drugs. In this brief Viewpoint review, we first summarize the diagnostic workup of AIHA subgroups and the respective therapies that are currently considered optimal. We then compare these principles with real-world data from India, the world's largest nation by population and a typical low-to-middle income country. We identify major deficiencies and limitations in general and laboratory resources, real-life diagnostic procedures, and therapeutic practices. Incomplete diagnostic workup, overuse of corticosteroids, lack of access to more specific treatments, and poor follow-up of patients are the rule more than exceptions. Although it may not seem realistic to resolve all challenges, we try to outline some ways towards an improved management of patients with AIHA.
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Affiliation(s)
- Suvro Sankha Datta
- Tata Medical Centre, Department of Transfusion Medicine, Kolkata, West Bengal, India
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
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3
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Małecka A, Østlie I, Trøen G, Małecki J, Delabie J, Tierens A, Munthe LA, Berentsen S, Tjønnfjord GE. Gene expression analysis revealed downregulation of complement receptor 1 in clonal B cells in cold agglutinin disease. Clin Exp Immunol 2024; 216:45-54. [PMID: 38133636 PMCID: PMC10929701 DOI: 10.1093/cei/uxad135] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/03/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
Cold agglutinin disease (CAD) is a rare B-cell lymphoproliferative disorder of the bone marrow, manifested by autoimmune hemolytic anemia caused by binding of monoclonal IgM autoantibodies to the I antigen. Underlying genetic changes have previously been reported, but their impact on gene expression profile has been unknown. Here, we define differentially expressed genes in CAD B cells. To unravel downstream alteration in cellular pathways, gene expression by RNA sequencing was undertaken. Clonal B-cell samples from 12 CAD patients and IgM-expressing memory B cells from 4 healthy individuals were analyzed. Differential expression analysis and filtering resulted in 93 genes with significant differential expression. Top upregulated genes included SLC4A1, SPTA1, YBX3, TESC, HBD, AHSP, TRAF1, HBA2, RHAG, CA1, SPTB, IL10, UBASH3B, ALAS2, HBA1, CRYM, RGCC, KANK2, and IGHV4-34. They were upregulated at least 8-fold, while complement receptor 1 (CR1/CD35) was downregulated 11-fold in clonal CAD B cells compared to control B cells. Flow cytometry analyses further confirmed reduced CR1 (CD35) protein expression by clonal CAD IgM+ B cells compared to IgM+ memory B cells in controls. CR1 (CD35) is an important negative regulator of B-cell activation and differentiation. Therefore, reduced CR1 (CD35) expression may increase activation, proliferation, and antibody production in CAD-associated clonal B cells.
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Affiliation(s)
- Agnieszka Małecka
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B-cell malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Ingunn Østlie
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Gunhild Trøen
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | | | - Jan Delabie
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Anne Tierens
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Ludvig A Munthe
- KG Jebsen Centre for B-cell malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital, Oslo, Norway
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Trust, Haugesund, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B-cell malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Hansen DL, Maquet J, Lafaurie M, Möller S, Berentsen S, Frederiksen H, Moulis G, Gaist D. Primary autoimmune haemolytic anaemia is associated with increased risk of ischaemic stroke: A binational cohort study from Denmark and France. Br J Haematol 2024; 204:1072-1081. [PMID: 38098244 DOI: 10.1111/bjh.19242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/09/2023] [Accepted: 11/22/2023] [Indexed: 03/14/2024]
Abstract
Primary autoimmune haemolytic anaemia (AIHA) causes the destruction of red blood cells and a subsequent pro-thrombotic state, potentially increasing the risk of ischaemic stroke. We investigated the risk of ischaemic stroke in patients with AIHA in a binational study. We used prospectively collected data from nationwide registers in Denmark and France to identify cohorts of patients with primary AIHA and age- and sex-matched general population comparators. We followed the patient and comparison cohorts for up to 5 years, with the first hospitalization of a stroke during follow-up as the main outcome. We estimated cumulative incidence, cause-specific hazard ratios (csHR) and adjusted for comorbidity and exposure to selected medications. The combined AIHA cohorts from both countries comprised 5994 patients and the 81 525 comparators. There were 130 ischaemic strokes in the AIHA cohort and 1821 among the comparators. Country-specific estimates were comparable, and the overall adjusted csHR was 1.36 [95% CI: 1.13-1.65], p = 0.001; the higher rate was limited to the first year after AIHA diagnosis (csHR 2.29 [95% CI: 1.77-2.97], p < 10-9 ) and decreased thereafter (csHR 0.89 [95% CI: 0.66-1.20], p = 0.45) (p-interaction < 10-5 ). The findings indicate that patients diagnosed with primary AIHA are at higher risk of ischaemic stroke in the first year after diagnosis.
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Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Julien Maquet
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Odense University Hospital, Odense, Denmark
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
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Röth A, Barcellini W, D'Sa S, Miyakawa Y, Broome CM, Michel M, Kuter DJ, Jilma B, Tvedt THA, Weitz IC, Yoo R, Jayawardene D, Vagge DS, Kralova K, Shafer F, Wardȩcki M, Lee M, Berentsen S. Sustained inhibition of complement C1s with sutimlimab over 2 years in patients with cold agglutinin disease. Am J Hematol 2023. [PMID: 37246953 DOI: 10.1002/ajh.26965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/30/2023]
Abstract
Cold agglutinin disease (CAD) is a rare, autoimmune, classical complement pathway (CP)-mediated hemolytic anemia. Sutimlimab selectively inhibits C1s of the C1 complex, preventing CP activation while leaving the alternative and lectin pathways intact. In Part A (26 weeks) of the open-label, single-arm, Phase 3 CARDINAL study in patients with CAD and a recent history of transfusion, sutimlimab demonstrated rapid effects on hemolysis and anemia. Results of the CARDINAL study Part B (2-year extension) study, described herein, demonstrated that sutimlimab sustains improvements in hemolysis, anemia, and quality of life over a median of 144 weeks of treatment. Mean last-available on-treatment values in Part B were improved from baseline for hemoglobin (12.2 g/dL on-treatment versus 8.6 g/dL at baseline), bilirubin (16.5 μmol/L on-treatment versus 52.1 μmol/L at baseline), and FACIT-Fatigue scores (40.5 on-treatment versus 32.4 at baseline). In the 9-week follow-up period after sutimlimab cessation, CP inhibition was reversed, and hemolytic markers and fatigue scores approached pre-sutimlimab values. Overall, sutimlimab was generally well tolerated in Part B. All 22 patients experienced ≥1 treatment-emergent adverse event (TEAE); 12 (54.5%) patients experienced ≥1 serious TEAE, including seven (31.8%) with ≥1 serious infection. Three patients discontinued due to a TEAE. No patients developed systemic lupus erythematosus or meningococcal infections. After cessation of sutimlimab, most patients reported adverse events consistent with recurrence of CAD. In conclusion, the CARDINAL 2-year results provide evidence of sustained sutimlimab effects for CAD management, but that disease activity reoccurs after treatment cessation. NCT03347396. Registered November 20, 2017.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shirley D'Sa
- UCLH Centre for Waldenström's Macroglobulinemia and Related Conditions, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Catherine M Broome
- Division of Hematology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Marc Michel
- Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, UPEC, Créteil, France
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Ilene C Weitz
- Keck School of Medicine of USC, Los Angeles, California, USA
| | | | | | | | | | | | | | | | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
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Gelbenegger G, Berentsen S, Jilma B. Monoclonal antibodies for treatment of cold agglutinin disease. Expert Opin Biol Ther 2023; 23:395-406. [PMID: 37128907 DOI: 10.1080/14712598.2023.2209265] [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] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Cold agglutinin disease (CAD) is a difficult-to-treat autoimmune hemolytic anemia and B cell lymphoproliferative disorder associated with fatigue, acrocyanosis and a risk of thromboembolic events. Cold-induced binding of autoantibodies agglutinates red blood cells and triggers the classical complement pathway, leading to predominantly extravascular hemolysis. AREAS COVERED This review summarizes clinical and experimental antibody-based treatments for CAD and analyzes the risks and benefits of B cell and complement directed therapies, and discusses potential future treatments for CAD. EXPERT OPINION Conventional treatment of CAD includes a B cell targeted treatment approach with rituximab, yielding only limited treatment success. Addition of a cytotoxic agent (e.g. bendamustine) increases efficacy but this is accompanied by an increased risk of neutropenia and infection. Novel complement-directed therapies have emerged and were shown to have a good efficacy against hemolysis and safety profile but are expensive and unable to address circulatory symptoms. Complement inhibition with sutimlimab may be used as a bridging strategy until B cell directed therapy with rituximab takes effect or continued indefinitely if needed. Future antibody-based treatment approaches for CAD involve the further development of complement-directed antibodies, combination of rituximab and bortezomib, and daratumumab. Non-antibody based prospective treatments may include the use of Bruton tyrosine kinase inhibitors.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Berentsen S. Sutimlimab for the Treatment of Cold Agglutinin Disease. Hemasphere 2023; 7:e879. [PMID: 37153870 PMCID: PMC10155901 DOI: 10.1097/hs9.0000000000000879] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/15/2023] [Indexed: 05/10/2023] Open
Abstract
Cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia and a bone marrow clonal lymphoproliferative disorder. Hemolysis in CAD is complement-dependent and mediated by the classical activation pathway. Patients also frequently suffer from fatigue and cold-induced circulatory symptoms. Although not all patients need treatment, the symptom burden has previously been underestimated. Effective therapies target the clonal lymphoproliferation or the complement activation. Sutimlimab, a humanized monoclonal IgG4 antibody that binds and inactivates complement protein C1s, is the most extensively investigated complement inhibitor for the treatment of CAD. This review addresses the preclinical studies of sutimlimab and the studies of pharmacokinetics and pharmacodynamics. We then describe and discuss the prospective clinical trials that established sutimlimab as a rapidly acting, highly efficacious, and low-toxic therapeutic agent. This complement inhibitor does not improve the cold-induced circulatory symptoms, which are not complement-mediated. Sutimlimab is approved for the treatment of CAD in the US, Japan, and the European Union. A tentative therapeutic algorithm is presented. The choice of therapy for CAD should be based on an individual assessment, and patients requiring therapy should be considered for inclusion in clinical trials.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
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Berentsen S, Fattizzo B, Barcellini W. The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket? Front Immunol 2023; 14:1180509. [PMID: 37168855 PMCID: PMC10165002 DOI: 10.3389/fimmu.2023.1180509] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
- *Correspondence: Sigbjørn Berentsen,
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Abstract
Therapies for cold agglutinin disease have been directed at the pathogenic B-cell clone. Sutimlimab, a monoclonal antibody that targets C1s, is the first complement inhibitor to be extensively studied in cold agglutinin disease. Sutimlimab selectively blocks the classical activation pathway and leaves the alternative and lectin pathways intact. Trials have documented high response rates with rapid improvement in hemolysis, hemoglobin levels and fatigue scores and low toxicity. Sutimlimab was recently approved in the USA. This drug appears to be particularly useful in severely anemic patients who require a rapid response, in acute exacerbations that do not resolve spontaneously and in patients in whom chemoimmunotherapy is contraindicated or has failed. The choice of therapy in cold agglutinin disease should be individualized.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
| | - Wilma Barcellini
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shirley D'Sa
- University College London Hospitals Centre for Waldenström and Associated Conditions, University College London Hospitals National Health Service Foundation Trust, London, UK
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Berentsen S, Tjønnfjord GE. Current treatment options in cold agglutinin disease: B-cell directed or complement directed therapy? Transfus Med Rev 2022; 36:181-187. [DOI: 10.1016/j.tmrv.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 10/15/2022]
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Hansen DL, Möller S, Berentsen S, Frederiksen H. Mortality in cold agglutinin disease shows seasonal pattern. Transfusion 2022; 62:1460-1461. [PMID: 35531960 PMCID: PMC9541684 DOI: 10.1111/trf.16894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
| | - Sören Möller
- Department of Clinical Research University of Southern Denmark Odense Denmark
- OPEN, Odense University Hospital Odense Denmark
| | - Sigbjørn Berentsen
- Department of Research and Innovation Haugesund Hospital Haugesund Norway
| | - Henrik Frederiksen
- Department of Hematology Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Anemia, Hemolytic, Autoimmune/therapy
- Blood Transfusion
- Complement Inactivating Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/pathology
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Immunologic Factors/therapeutic use
- Rituximab/therapeutic use
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Affiliation(s)
- Sigbjørn Berentsen
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
| | - Wilma Barcellini
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
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Małecka A, Trøen G, Delabie J, Małecki J, Østlie I, Tierens A, Randen U, Berentsen S, Tjønnfjord GE. The mutational landscape of cold agglutinin disease: CARD11 and CXCR4 mutations are correlated with lower hemoglobin levels. Am J Hematol 2021; 96:E279-E283. [PMID: 33891703 DOI: 10.1002/ajh.26205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Agnieszka Małecka
- Department of Haematology Oslo University Hospital Oslo Norway
- Department of Pathology Oslo University Hospital Oslo Norway
- KG Jebsen Centre for B‐cell Malignancies and Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Gunhild Trøen
- Department of Pathology Oslo University Hospital Oslo Norway
| | - Jan Delabie
- Hematology and Transfusion Medicine Laboratory Medicine Program University Health Network Toronto Ontario Canada
- University of Toronto Toronto Ontario Canada
| | | | - Ingunn Østlie
- Department of Pathology Oslo University Hospital Oslo Norway
| | - Anne Tierens
- Hematology and Transfusion Medicine Laboratory Medicine Program University Health Network Toronto Ontario Canada
- University of Toronto Toronto Ontario Canada
| | - Ulla Randen
- Department of Pathology Akershus University Hospital Oslo Norway
| | - Sigbjørn Berentsen
- Department of Research and Innovation Haugesund Hospital Haugesund Norway
| | - Geir E. Tjønnfjord
- Department of Haematology Oslo University Hospital Oslo Norway
- KG Jebsen Centre for B‐cell Malignancies and Institute of Clinical Medicine University of Oslo Oslo Norway
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Hansen DL, Berentsen S, Fattizzo B, Hansen PL, Barcellini W, Frederiksen H. Seasonal variation in the incidence of cold agglutinin disease in Norway, Denmark, and Italy. Am J Hematol 2021; 96:E262-E265. [PMID: 33864697 DOI: 10.1002/ajh.26196] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Dennis Lund Hansen
- Department of Haematology Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
| | - Sigbjørn Berentsen
- Department of Research and Innovation Haugesund Hospital Haugesund Norway
| | - Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
- Department of Oncology and Onco‐Hematology University of Milan Milan Italy
| | | | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | - Henrik Frederiksen
- Department of Haematology Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
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Röth A, Barcellini W, D'Sa S, Miyakawa Y, Broome CM, Michel M, Kuter DJ, Jilma B, Tvedt THA, Fruebis J, Jiang X, Lin S, Reuter C, Morales-Arias J, Hobbs W, Berentsen S. Sutimlimab in Cold Agglutinin Disease. N Engl J Med 2021; 384:1323-1334. [PMID: 33826820 DOI: 10.1056/nejmoa2027760] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cold agglutinin disease is a rare autoimmune hemolytic anemia characterized by hemolysis that is caused by activation of the classic complement pathway. Sutimlimab, a humanized monoclonal antibody, selectively targets the C1s protein, a C1 complex serine protease responsible for activating this pathway. METHODS We conducted a 26-week multicenter, open-label, single-group study to assess the efficacy and safety of intravenous sutimlimab in patients with cold agglutinin disease and a recent history of transfusion. The composite primary end point was a normalization of the hemoglobin level to 12 g or more per deciliter or an increase in the hemoglobin level of 2 g or more per deciliter from baseline, without red-cell transfusion or medications prohibited by the protocol. RESULTS A total of 24 patients were enrolled and received at least one dose of sutimlimab; 13 patients (54%) met the criteria for the composite primary end point. The least-squares mean increase in hemoglobin level was 2.6 g per deciliter at the time of treatment assessment (weeks 23, 25, and 26). A mean hemoglobin level of more than 11 g per deciliter was maintained in patients from week 3 through the end of the study period. The mean bilirubin levels normalized by week 3. A total of 17 patients (71%) did not receive a transfusion from week 5 through week 26. Clinically meaningful reductions in fatigue were observed by week 1 and were maintained throughout the study. Activity in the classic complement pathway was rapidly inhibited, as assessed by a functional assay. Increased hemoglobin levels, reduced bilirubin levels, and reduced fatigue coincided with inhibition of the classic complement pathway. At least one adverse event occurred during the treatment period in 22 patients (92%). Seven patients (29%) had at least one serious adverse event, none of which were determined by the investigators to be related to sutimlimab. No meningococcal infections occurred. CONCLUSIONS In patients with cold agglutinin disease who received sutimlimab, selective upstream inhibition of activity in the classic complement pathway rapidly halted hemolysis, increased hemoglobin levels, and reduced fatigue. (Funded by Sanofi; CARDINAL ClinicalTrials.gov number, NCT03347396.).
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MESH Headings
- Aged
- Aged, 80 and over
- Anemia, Hemolytic, Autoimmune/blood
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/therapy
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Blood Transfusion
- Complement C1s/antagonists & inhibitors
- Fatigue/drug therapy
- Fatigue/etiology
- Female
- Hemoglobins/analysis
- Hemolysis/drug effects
- Humans
- Male
- Middle Aged
- Quality of Life
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Affiliation(s)
- Alexander Röth
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Wilma Barcellini
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Shirley D'Sa
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Yoshitaka Miyakawa
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Catherine M Broome
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Marc Michel
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - David J Kuter
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Bernd Jilma
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Tor H A Tvedt
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Joachim Fruebis
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Xiaoyu Jiang
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Stella Lin
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Caroline Reuter
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Jaime Morales-Arias
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - William Hobbs
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
| | - Sigbjørn Berentsen
- From the Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany (A.R.); Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy (W.B.); the Centre for Waldenström's Macroglobulinaemia and Related Conditions, University College London Hospitals National Health Service Foundation Trust, London (S.D.); the Thrombosis and Hemostasis Center, Saitama Medical University Hospital, Saitama, Japan (Y.M.); the Division of Hematology, MedStar Georgetown University Hospital, Washington, DC (C.M.B.); the Department of Internal Medicine, Henri-Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France (M.M.); the Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston (D.J.K.), Bioverativ, Cambridge (J.F.), and Sanofi, Waltham (X.J., S.L., C.R., J.M.-A., W.H.) - all in Massachusetts; the Department of Clinical Pharmacology, Medical University of Vienna, Vienna (B.J.); and the Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen (T.H.A.T.), and the Department of Research and Innovation, Haugesund Hospital, Haugesund (S.B.) - both in Norway
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Schaevers V, De Bondt K, Duerinckx N, Berentsen S, De Vos M, Stulens S, De Castro CF, Vandenbossche V, Vos R, Dobbels F. Development, Validation and Implementation of an Instrument to Measure Knowledge in Transplant Recipients. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Tomkins O, Berentsen S, Arulogun S, Sekhar M, D'Sa S. Daratumumab for disabling cold agglutinin disease refractory to B-cell directed therapy. Am J Hematol 2020; 95:E293-E295. [PMID: 32652632 DOI: 10.1002/ajh.25932] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Oliver Tomkins
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Suzanne Arulogun
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mallika Sekhar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Shirley D'Sa
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Abstract
Autoimmune hemolytic anemias mediated by cold agglutinins can be divided into cold agglutinin disease (CAD), which is a well-defined clinicopathologic entity and a clonal lymphoproliferative disorder, and secondary cold agglutinin syndrome (CAS), in which a similar picture of cold-hemolytic anemia occurs secondary to another distinct clinical disease. Thus, the pathogenesis in CAD is quite different from that of polyclonal autoimmune diseases such as warm-antibody AIHA. In both CAD and CAS, hemolysis is mediated by the classical complement pathway and therefore can result in generation of anaphylotoxins, such as complement split product 3a (C3a) and, to some extent, C5a. On the other hand, infection and inflammation can act as triggers and drivers of hemolysis, exemplified by exacerbation of CAD in situations with acute phase reaction and the role of specific infections (particularly Mycoplasma pneumoniae and Epstein-Barr virus) as causes of CAS. In this review, the putative mechanisms behind these phenomena will be explained along with other recent achievements in the understanding of pathogenesis in these disorders. Therapeutic approaches have been directed against the clonal lymphoproliferation in CAD or the underlying disease in CAS. Currently, novel targeted treatments, in particular complement-directed therapies, are also being rapidly developed and will be reviewed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
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Berentsen S, Malecka A, Randen U, Tjønnfjord GE. Cold agglutinin disease: where do we stand, and where are we going? Clin Adv Hematol Oncol 2020; 18:35-44. [PMID: 32511221] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Primary cold agglutinin disease (CAD) is characterized by a very indolent bone marrow clonal B-cell lymphoproliferative disorder that initiates an autoimmune hemolytic anemia. The clonal B cells produce a monoclonal autoantibody termed cold agglutinin, most often of the immunoglobulin (Ig) Mκ class. After binding to its antigen, the IgM initiates a complement classical pathway-driven erythrocyte destruction, predominantly mediated by opsonization with complement protein C3b and extravascular hemolysis in the liver. We review the molecular biology, histopathology, clinical features, and diagnostic procedures in CAD. Some patients are only slightly anemic and do not require treatment, but moderate or severe anemia frequently occurs, and the disease burden has been underestimated. CAD should not be treated with corticosteroids. Several B-cell-directed treatment options are available, and complement-directed approaches are being rapidly developed. Current and possible future therapies are reviewed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation at Haugesund Hospital, Haugesund, Norway
| | - Agnieszka Malecka
- Department of Haematology and Department of Pathology, Oslo University, Oslo, Norway
- KG Jebsen Centre for B-Cell Malignancies, University of Oslo, Oslo, Norway
| | - Ulla Randen
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B-Cell Malignancies, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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20
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Berentsen S, Hill A, Hill QA, Tvedt THA, Michel M. Novel insights into the treatment of complement-mediated hemolytic anemias. Ther Adv Hematol 2019; 10:2040620719873321. [PMID: 31523413 PMCID: PMC6734604 DOI: 10.1177/2040620719873321] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [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: 05/31/2019] [Accepted: 08/08/2019] [Indexed: 12/20/2022] Open
Abstract
Complement-mediated hemolytic anemias can either be caused by deficiencies in regulatory complement components or by autoimmune pathogenesis that triggers inappropriate complement activation. In paroxysmal nocturnal hemoglobinuria (PNH) hemolysis is entirely complement-driven. Hemolysis is also thought to be complement-dependent in cold agglutinin disease (CAD) and in paroxysmal cold hemoglobinuria (PCH), whereas warm antibody autoimmune hemolytic anemia (wAIHA) is a partially complement-mediated disorder, depending on the subtype of wAIHA and the extent of complement activation. The pathophysiology, clinical presentation, and current therapies for these diseases are reviewed in this article. Novel, complement-directed therapies are being rapidly developed. Therapeutic terminal complement inhibition using eculizumab has revolutionized the therapy and prognosis in PNH but has proved less efficacious in CAD. Upstream complement modulation is currently being investigated and appears to be a highly promising therapy, and two such agents have entered phase II and III trials. Of these, the anti-C1s monoclonal antibody sutimlimab has shown favorable activity in CAD, while the anti-C3 cyclic peptide pegcetacoplan appears to be promising in PNH as well as CAD, and may also have a therapeutic potential in wAIHA.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, P.O. Box 2170, Haugesund, 5504, Norway
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | - Marc Michel
- Department of Medicine, Henri Mondor Hospital, Université Paris-Est, Assistance Publique Hôpitaux de Paris Creteil, Creteil, France
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21
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Berentsen S, Röth A, Randen U, Jilma B, Tjønnfjord GE. Cold agglutinin disease: current challenges and future prospects. J Blood Med 2019; 10:93-103. [PMID: 31114413 PMCID: PMC6497508 DOI: 10.2147/jbm.s177621] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [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: 01/10/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022] Open
Abstract
Cold agglutinin disease (CAD) is a complement-dependent, classical pathway-mediated immune hemolytic disease, accounting for 15–25% of autoimmune hemolytic anemia, and at the same time, a distinct clonal B-cell lymphoproliferative disorder of the bone marrow. The disease burden is often high, but not all patients require pharmacological treatment. Several therapies directed at the pathogenic B-cells are now available. Rituximab plus bendamustine or rituximab monotherapy should be considered first-line treatment, depending on individual patient characteristics. Novel treatment options that target the classical complement pathway are under development and appear very promising, and the C1s inhibitor sutimlimab is currently being investigated in two clinical Phase II and III trials. These achievements have raised new challenges and further prospects, which are discussed. Patients with CAD requiring therapy should be considered for clinical trials.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulla Randen
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,KG Jebsen's Center for B-cell Malignancies, University of Oslo, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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22
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Kvistad SAS, Gunnes MW, Hagen KG, Berentsen S. A three year-old boy with back pain, fever and cola-coloured urine. Tidsskr Nor Laegeforen 2019; 139:18-0532. [PMID: 30917633 DOI: 10.4045/tidsskr.18.0532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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23
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Berentsen S. Complement Activation and Inhibition in Autoimmune Hemolytic Anemia: Focus on Cold Agglutinin Disease. Semin Hematol 2018; 55:141-149. [PMID: 30032751 DOI: 10.1053/j.seminhematol.2018.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [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: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 12/25/2022]
Abstract
The classical complement pathway and, to some extent, the terminal pathway, are involved in the immune pathogenesis of autoimmune hemolytic anemia (AIHA). In primary cold agglutinin disease (CAD), secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria, the hemolytic process is entirely complement dependent. Complement activation also plays an important pathogenetic role in some warm-antibody AIHAs, especially when immunoglobulin M is involved. This review describes the complement-mediated hemolysis in AIHA with a major focus on CAD, in which activation of the classical pathway is essential and particularly relevant for complement-directed therapy. Several complement inhibitors are candidate therapeutic agents in CAD and other AIHAs, and some of these drugs seem very promising. The relevant in vitro findings, early clinical data and future perspectives are reviewed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna HF, Haugesund, Norway.
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24
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation; Haugesund Hospital; Haugesund Norway
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25
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MESH Headings
- Algorithms
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/microbiology
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/therapy
- Anti-Bacterial Agents/therapeutic use
- Blood Transfusion
- Fever/microbiology
- Humans
- Male
- Middle Aged
- Mycoplasma pneumoniae/isolation & purification
- Pneumonia, Mycoplasma/complications
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/diagnostic imaging
- Pneumonia, Mycoplasma/drug therapy
- Tomography, X-Ray Computed
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26
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Fluge Ø, Mannsåker B, Torp A, Mjaaland I, Helgeland L, Klos J, Mella O, Berentsen S, Meyer P. Consolidative Radiotherapy to Residual Masses After Chemotherapy Is Associated With Improved Outcome in Diffuse Large B-Cell Lymphoma. A Retrospective, Population-Based Study. Clin Lymphoma Myeloma Leuk 2017; 18:125-135.e3. [PMID: 29352718 DOI: 10.1016/j.clml.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/27/2017] [Accepted: 12/18/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND The role of consolidative radiotherapy (RT) in advanced diffuse large B-cell lymphoma (DLBCL) is not established. PATIENTS AND METHODS In a population-based retrospective analysis of patients with DLBCL in Western Norway during 2003 to 2008, 170 consecutive patients admitted to Haukeland University Hospital (HUS) and 94 to Stavanger University Hospital (SUS) were included. The mean age was 64 years (range, 17-95 years), 147 patients (56%) were male, 80 patients (30%) had stage I/II, 126 patients (48%) stage III/IV, and 57 patients (22%) had primary extranodal disease. RESULTS There were no differences between hospitals in patient characteristics, use of rituximab, number of chemotherapy courses or cumulative doses, or in distribution of response categories after chemotherapy. The use of RT was significantly different: 17 patients (23%) received RT at SUS and 92 patients (65%) at HUS (P < .001). For 219 patients with International Prognostic Index (IPI) score of 0 to 3, 5-year cancer-specific survival (CSS) was 67% at SUS and 81% at HUS (P = .012). For 73 patients with complete response after chemotherapy there were no differences in survival between patients with and without RT. For 138 patients with any residual mass after chemotherapy, there were highly significant differences in favor of receiving RT (n = 81) versus no RT (n = 57): 5-year CSS 89% versus 69% (P < .001), and 5-year overall survival 82% versus 59% (P = .005). The effect of RT on residual mass was evident in most subgroups, mainly in low to intermediate risk, but not in high-risk (IPI 4-5) patients. CONCLUSION With the limitations of a retrospective study, these data suggest that consolidative RT might improve survival in DLBCL patients with a residual mass after chemotherapy, also in advanced disease.
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Affiliation(s)
- Øystein Fluge
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.
| | - Bård Mannsåker
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - Anders Torp
- Department of Otolaryngology - Head and Neck Surgery, Sørlandet Hospital, Kristiansand, Norway
| | - Ingvil Mjaaland
- Department of Hematology and Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Lars Helgeland
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Jan Klos
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
| | - Olav Mella
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Peter Meyer
- Department of Hematology and Oncology, Stavanger University Hospital, Stavanger, Norway
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27
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Małecka A, Trøen G, Tierens A, Østlie I, Małecki J, Randen U, Wang J, Berentsen S, Tjønnfjord GE, Delabie JMA. Frequent somatic mutations of
KMT
2D
(
MLL
2
) and
CARD
11
genes in primary cold agglutinin disease. Br J Haematol 2017; 183:838-842. [DOI: 10.1111/bjh.15063] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Agnieszka Małecka
- Department of Pathology Oslo University HospitalOslo Norway
- Faculty of Medicine University of Oslo Oslo Norway
| | - Gunhild Trøen
- Department of Pathology Oslo University HospitalOslo Norway
| | - Anne Tierens
- Laboratory Medicine Program University Health Network and University of Toronto Toronto ON Canada
| | - Ingunn Østlie
- Department of Pathology Oslo University HospitalOslo Norway
| | | | - Ulla Randen
- Department of Pathology Oslo University HospitalOslo Norway
| | - Junbai Wang
- Department of Pathology Oslo University HospitalOslo Norway
| | - Sigbjørn Berentsen
- Department of Research and Innovation Haugesund Hospital Helse Fonna HaugesundNorway
| | - Geir E. Tjønnfjord
- Department of Haematology Oslo University Hospital and Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Jan M. A. Delabie
- Laboratory Medicine Program University Health Network and University of Toronto Toronto ON Canada
- Center for Cancer Biomedicine University of Oslo Oslo Norway
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28
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Berentsen S. Neutrophil aggregation on the peripheral blood smear in a patient with cold agglutinin disease. Ann Hematol 2017; 96:1767-1768. [PMID: 28752395 DOI: 10.1007/s00277-017-3077-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/12/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway.
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29
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Abstract
Primary chronic cold agglutinin disease (CAD) is an autoimmune haemolytic anaemia in which a specific bone marrow lymphoproliferative disorder causes production of cold agglutinins (CA). Binding of CA to erythrocyte surface antigens results in a predominantly extravascular haemolysis that is entirely complement dependent. Because of complement activation, exacerbations are common during febrile infections, trauma or major surgery. Involvement of the terminal complement pathway with C5-mediated intravascular haemolysis is probably not prominent in stable disease but is supposed to be of importance in exacerbations following acute phase reaction.We report on a patient with CAD prone to exacerbation of haemolysis during acute phase reactions who was scheduled for cardiac surgery. To prevent her having an exacerbation of haemolysis, we chose to treat her prophylactically with eculizumab along with the usual perioperative precautions. Aortic valve replacement was undertaken with full cardiopulmonary bypass at normothermia. The procedure was successful; no exacerbation of haemolysis was observed, and transfusion requirements did not exceed what could be expected.
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Affiliation(s)
- Eirik Tjønnfjord
- Hematology and Oncology, Kalnes Sykehus Østfold, Kalnes, Grålum, Norway
| | - Øystein A Vengen
- Department of Cardiothoracic Surgery, Oslo Universitetssykehus, Oslo, Norway
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund sjukehus, Haugesund, Norway
| | - Geir Erland Tjønnfjord
- Department of Hematology, Institute of Clinical Medicine, Oslo Universitetssykehus, Oslo, Norway
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30
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Tjønnfjord E, Vengen ØA, Berentsen S, Tjønnfjord GE. Prophylactic use of eculizumab during surgery in chronic cold agglutinin disease. BMJ Case Rep 2017; 2017:bcr-2016-219066. [PMID: 28487302 DOI: 10.1136/bcr-2016-219066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary chronic cold agglutinin disease (CAD) is an autoimmune haemolytic anaemia in which a specific bone marrow lymphoproliferative disorder causes production of cold agglutinins (CA). Binding of CA to erythrocyte surface antigens results in a predominantly extravascular haemolysis that is entirely complement dependent. Because of complement activation, exacerbations are common during febrile infections, trauma or major surgery. Involvement of the terminal complement pathway with C5-mediated intravascular haemolysis is probably not prominent in stable disease but is supposed to be of importance in exacerbations following acute phase reaction.We report on a patient with CAD prone to exacerbation of haemolysis during acute phase reactions who was scheduled for cardiac surgery. To prevent her having an exacerbation of haemolysis, we chose to treat her prophylactically with eculizumab along with the usual perioperative precautions. Aortic valve replacement was undertaken with full cardiopulmonary bypass at normothermia. The procedure was successful; no exacerbation of haemolysis was observed, and transfusion requirements did not exceed what could be expected.
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Affiliation(s)
- Eirik Tjønnfjord
- Hematology and Oncology, Kalnes Sykehus Østfold, Kalnes, Grålum, Norway
| | - Øystein A Vengen
- Department of Cardiothoracic Surgery, Oslo Universitetssykehus, Oslo, Norway
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund sjukehus, Haugesund, Norway
| | - Geir Erland Tjønnfjord
- Department of Hematology, Institute of Clinical Medicine, Oslo Universitetssykehus, Oslo, Norway
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31
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Abstract
Primary chronic cold agglutinin disease (CAD) is a well-defined clinicopathologic entity in which a specific, clonal lymphoproliferative B-cell bone marrow disorder results in autoimmune hemolytic anemia. The immune hemolysis is entirely complement-dependent, predominantly mediated by activation of the classical pathway and phagocytosis of erythrocytes opsonized with complement protein C3b. Typical clinical features in CAD have diagnostic and therapeutic implications. Pharmacologic treatment should be offered to patients with symptom-producing anemia or disabling circulatory symptoms. CAD should not be treated with corticosteroids. Based on an individualized approach, rituximab monotherapy or rituximab-fludarabine in combination is recommended as first-line therapy. Rituximab-bendamustine is still an investigational therapy. Although complement-modulating agents are still to be considered experimental in CAD, therapy with the anti-C1s monoclonal antibody TNT009 seems promising.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna, Haugesund, Norway
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32
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Małecka A, Trøen G, Tierens A, Østlie I, Małecki J, Randen U, Berentsen S, Tjønnfjord GE, Delabie JMA. Immunoglobulin heavy and light chain gene features are correlated with primary cold agglutinin disease onset and activity. Haematologica 2016; 101:e361-4. [PMID: 27198717 DOI: 10.3324/haematol.2016.146126] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Gunhild Trøen
- Department of Pathology, Oslo University Hospital, Norway
| | - Anne Tierens
- Laboratory Medicine Program, University Health Network and University of Toronto, ON, Canada
| | - Ingunn Østlie
- Department of Pathology, Oslo University Hospital, Norway
| | - Jędrzej Małecki
- Department of Biological Sciences, University of Oslo, Norway
| | - Ulla Randen
- Department of Pathology, Oslo University Hospital, Norway
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna, Haugesund, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Jan M A Delabie
- Laboratory Medicine Program, University Health Network and University of Toronto, ON, Canada
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33
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Abstract
The classification of autoimmune hemolytic anemias and the complement system are reviewed. In autoimmune hemolytic anemia of the warm antibody type, complement-mediated cell lysis is clinically relevant in a proportion of the patients but is hardly essential for hemolysis in most patients. Cold antibody-mediated autoimmune hemolytic anemias (primary cold agglutinin disease, secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria) are entirely complement-mediated disorders. In cold agglutinin disease, efficient therapies have been developed in order to target the pathogenic B-cell clone, but complement modulation remains promising in some clinical situations. No established therapy exists for secondary cold agglutinin syndrome and paroxysmal cold hemoglobinuria, and the possibility of therapeutic complement inhibition is interesting. Currently, complement modulation is not clinically documented in any autoimmune hemolytic anemia. The most relevant candidate drugs and possible target levels of action are discussed.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Development, Haugesund Hospital, Helse Fonna HF, Haugesund, Norway
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34
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Abstract
Cold antibody types account for about 25% of autoimmune hemolytic anemias. Primary chronic cold agglutinin disease (CAD) is characterized by a clonal lymphoproliferative disorder. Secondary cold agglutinin syndrome (CAS) complicates specific infections and malignancies. Hemolysis in CAD and CAS is mediated by the classical complement pathway and is predominantly extravascular. Not all patients require treatment. Successful CAD therapy targets the pathogenic B-cell clone. Complement modulation seems promising in both CAD and CAS. Further development and documentation are necessary before clinical use. We review options for possible complement-directed therapy.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Medicine, Haugesund Hospital, Karmsundgata 120, Haugesund NO-5504, Norway.
| | - Ulla Randen
- Department of Pathology, Oslo University Hospital, Ullernchausseen 70, NO-0310 Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20, NO-0372 Oslo, Norway
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35
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Randen U, Trøen G, Tierens A, Steen C, Warsame A, Beiske K, Tjønnfjord GE, Berentsen S, Delabie J. Primary cold agglutinin-associated lymphoproliferative disease: a B-cell lymphoma of the bone marrow distinct from lymphoplasmacytic lymphoma. Haematologica 2013; 99:497-504. [PMID: 24143001 DOI: 10.3324/haematol.2013.091702] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Primary chronic cold agglutinin disease is a rare hemolytic disease mediated by monoclonal IGHV4-34-encoded cold agglutinins with a predominant specificity for the blood group antigen I. Bone marrow from 54 patients was studied to type the underlying lymphoproliferative disorder better. Bone marrow biopsies showed circumscribed intra-parenchymatous nodules with small monotonous monoclonal B cells in 40/54 patients (median infiltration: 10% of marrow cells) with a CD20(+), IgMs(+), IgDs(+), CD27(+), CD5(-/+), CD11c(-), CD23(-), CD38(-) immunophenotype. Neither plasmacytoid cytological features nor expression of plasma cell differentiation-associated transcription factors MUM1, XBP1 and BLIMP1 were noted in these B cells. However, a limited number of mature monoclonal IgM(+), IgD(-) plasma cells were present outside the lymphoid nodules and were diffusely scattered throughout the marrow. Of interest, the MYD88 L265P mutation, typical of lymphoplasmacytic lymphoma, was not detected (17/17 cases). Somatically mutated monoclonal IGHV4-34 gene rearrangement was demonstrated in eight patients with frozen samples (mean sequence homology 95.4%). However, mutations of BCL6 intron 1 were not demonstrated, except in one patient, suggesting that the lymphoma cells had not matured in the germinal center. In conclusion, cold agglutinin-associated lymphoproliferative disease displays homogeneous histological and immunophenotypic features. The absence of plasmacytoid cells, the presence of plasma cells predominantly outside the nodular lymphoid infiltrates, IGHV4-34 restriction and absence of MYD88 L265P mutation strongly suggest that cold agglutinin-associated lymphoproliferative disease is a distinct entity that is different from lymphoplasmacytic lymphoma.
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36
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37
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Berentsen S, Graves W, Seidenberg M, Binder J. The Neural Basis of Successful Oral Word Reading in Chronic Aphasia (S29.002). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s29.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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38
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Berentsen S. Flere sykdommer med samme kliniske presentasjon. Tidsskriftet 2012; 132:968. [DOI: 10.4045/tidsskr.12.0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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39
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Berentsen S. Jernkelering ved myelodysplastisk syndrom. Tidsskriftet 2012; 132:1972-3. [DOI: 10.4045/tidsskr.12.0771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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40
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41
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42
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Berentsen S. Nevropsykiatrisk sykdom med hematologiske funn. Tidsskriftet 2009; 129:35. [DOI: 10.4045/tidsskr.2009.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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43
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44
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45
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Abstract
Chronic cold agglutinin disease (CAD) is a subgroup of autoimmune hemolytic anemia. Primary CAD has traditionally been defined by the absence of any underlying or associated disease. The results of therapy with corticosteroids, alkylating agents and interferon-a have been poor. Cold reactive immunoglobulins against erythrocyte surface antigens are essential to pathogenesis of CAD. These cold agglutinins are monoclonal, usually IgMκ auto antibodies with heavy chain variable regions encoded by the VH4-34 gene segment. By flowcytometric and immunohistochemical assessments, a monoclonal CD20+κ+B-lymphocyte population has been demonstrated in the bone marrow of 90% of the patients, and lymphoplasmacytic lymphoma is a frequent finding. Novel attempts at treatment for primary CAD have mostly been directed against the clonal B-lymphocytes. Phase 2 studies have shown that therapy with the chimeric anti-CD20 antibody rituximab produced partial response rates of more than 50% and occasional complete responses. Median response duration, however, was only 11 months. In this review, we discuss the clinical and pathogenetic features of primary CAD, emphasizing the more recent data on its close association with clonal lymphoproliferative bone marrow disorders and implications for therapy. We also review the management and outline some perspectives on new therapy modalities.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Alkylating Agents/therapeutic use
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/epidemiology
- Anemia, Hemolytic, Autoimmune/etiology
- Anemia, Hemolytic, Autoimmune/pathology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- B-Lymphocytes/pathology
- Bone Marrow/pathology
- Clone Cells/pathology
- Cryoglobulins/analysis
- Cryoglobulins/immunology
- Humans
- Immunotherapy
- Interferon-alpha/therapeutic use
- Lymphoproliferative Disorders/complications
- Lymphoproliferative Disorders/drug therapy
- Lymphoproliferative Disorders/pathology
- Rituximab
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46
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Abstract
Primary chronic cold agglutinin disease (CAD) is an autoimmune hemolytic anemia induced by cold reactive autoantibodies (cold agglutinins) against erythrocyte surface antigens. Corticosteroids or alkylating agents have been used in the treatment of CAD, but the results have been disappointing. The cold agglutinins in CAD patients are monoclonal immunoglobulins, usually of the IgMkappa type encoded by the V(H)4-34 gene segment. Flowcytometric assessment of lymphocytes from bone marrow aspirates and immunohistochemical assessment of biopsy samples have revealed a monoclonal CD20(+) kappa(+) B lymphocyte population in 90% of the patients. These pathogenetic features have provided a basis for novel therapies in primary CAD. Infusions of rituximab, a chimeric human-murine anti-CD20 antibody known to be effective in B-cell lymphoma, produced partial response rates of approximately 50% and occasional complete responses. Median response duration, however, was only 11 months. Complement C3 and C4 depletion in many CAD patients, as well as Fc-gamma-RIIIa receptor polymorphism, have been proposed as explanations for the inconstant efficacy of rituximab therapy. In order to increase response rates and response duration, we are undertaking a phase 2 study of rituximab and fludarabine combination therapy. The preliminary results are encouraging, but further studies are required in order to allow firm conclusions.
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47
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Berentsen S, Ulvestad E, Langholm R, Beiske K, Hjorth-Hansen H, Ghanima W, Sørbø JH, Tjønnfjord GE. Primary chronic cold agglutinin disease: a population based clinical study of 86 patients. Haematologica 2006; 91:460-6. [PMID: 16585012] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Our knowledge of primary chronic cold agglutinin disease (CAD) is incomplete. The aim of this study was to collect comprehensive and precise data the on epidemiology, clinical and pathological features, course, and therapy of CAD. DESIGN AND METHODS We performed a population-based retrospective follow-up study of as many as possible of all CAD patients in Norway. Eighty-six patients were studied. RESULTS The prevalence of primary CAD was 16 cases per million inhabitants. The incidence rate was 1 per million per year. The median age at onset was 67 years (range, 30-92) and the male to female ratio was 0.55. The median survival was 12.5 years from onset. Autoimmune diseases other than CAD were reported in 8% of patients, cold-induced circulatory symptoms in 91%, and exacerbation of hemolytic anemia during febrile illness in 74%. At least 51% had received red blood cell transfusions. The mean initial hemoglobin level was 9.2 g/dL (range, 4.5-15.6) and the median monoclonal immunoglobulin level 4.0 g/L (range, 0.0-47.3). Most laboratory findings did not change significantly during a median follow-up of 5 years. Monoclonal IgM was detected in 90%; IgG and IgA in 3.5% each; with kappa light chains in 94%. An abnormal kappa/lambda ratio in bone marrow was found in 90%, lymphoma in 76%, and lymphoplasmacytic lymphoma in 50%. Transformation to aggressive lymphoma occurred in 3.5% during 10 years. Rituximab therapy was the only treatment showing acceptable response rates (60%). INTERPRETATION AND CONCLUSIONS Primary CAD represents a spectrum of clonal lymphoproliferative bone marrow disorders, in most cases with morphological signs of lymphoma. Despite a favorable prognosis for survival, the disease is not indolent in terms of clinical manifestations.
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Berentsen S. [Lead poisoning]. Tidsskr Nor Laegeforen 2005; 125:3407. [PMID: 16357877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
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Berentsen S, Ulvestad E, Gjertsen BT, Hjorth-Hansen H, Langholm R, Knutsen H, Ghanima W, Shammas FV, Tjønnfjord GE. Rituximab for primary chronic cold agglutinin disease: a prospective study of 37 courses of therapy in 27 patients. Blood 2004; 103:2925-8. [PMID: 15070665 DOI: 10.1182/blood-2003-10-3597] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Conventional therapies for primary chronic cold agglutinin disease (CAD) are ineffective, but remissions after treatment with the anti-CD20 antibody rituximab have been described in a small, prospective trial and in some case reports. In this study we report on 37 courses of rituximab administered prospectively to 27 patients. Fourteen of 27 patients responded to their first course of rituximab, and 6 of 10 responded to re-treatment. In both groups combined, responses were achieved after 20 of 37 courses, giving an overall response rate of 54%. We observed 1 complete and 19 partial responses. Two nonresponders and 3 patients who experienced relapse received second-line therapy with interferon-alpha combined with a new course of rituximab, and 1 nonresponder and 2 patients who experienced relapse achieved partial responses. Responders achieved a median increase in hemoglobin levels of 40 g/L (4 g/dL). Median time to response was 1.5 months, and median observed response duration was 11 months. We conclude that rituximab is an effective and well-tolerated therapy for CAD. Histologic and flow cytometric findings suggest that some of the effect may be mediated by mechanisms other than the elimination of clonal lymphocytes. We were unable to predict responses from the hematologic, immunologic, or histologic parameters before therapy.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/blood
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/immunology
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Drug Tolerance
- Hemoglobins/metabolism
- Humans
- Immunoglobulin M/blood
- Interferon Type I/administration & dosage
- Interferon Type I/therapeutic use
- Prospective Studies
- Recombinant Proteins
- Rituximab
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Egge J, Berentsen S, Storesund B, Rød R, Waage K. [Treatment of massive pulmonary embolism with local thrombolysis]. Tidsskr Nor Laegeforen 2002; 122:2263-6. [PMID: 12448264] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND The diagnosis and therapy of pulmonary embolism may still be difficult. Patients with massive central emboli have an unacceptable risk of treatment failure and death when treated with conventional anticoagulants. PATIENTS AND RESULTS Three patients with massive pulmonary embolism were treated with local catheter-directed thrombolysis and mechanical fragmentation. Nearly total thrombolysis was achieved, as estimated by angiography and spiral CT scan. Clinical improvement was confirmed by blood gas measurements, pulse oximetry, and echocardiographic assessment. INTERPRETATION Based on data from the literature, thrombolytic therapy is more efficient than conventional anticoagulation in patients with massive central pulmonary embolism affecting the systemic circulation. Local, catheter-directed thrombolysis with mechanical fragmentation and direct infusion into the thrombus produced very good results in our patients. Other published data confirm that this method is feasible, safe and effective. In selected patients, this therapy is a good alternative to systemic thrombolysis, although it remains to be established which method is best.
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Affiliation(s)
- Jon Egge
- Radiologisk avdeling, Haugesund sjukehus 5513 Haugesund.
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