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Elhadad S, Redmond D, Tan A, Huang J, Rodriguez BL, Racine-Brzostek SE, Subrahmanian S, Ahamed J, Laurence J. Defibrotide mitigates endothelial cell injury induced by plasmas from patients with COVID-19 and related vasculopathies. Thromb Res 2023; 225:47-56. [PMID: 37001283 PMCID: PMC10033153 DOI: 10.1016/j.thromres.2023.03.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/24/2023]
Abstract
Background and objectives COVID-19 progression is characterized by systemic small vessel arterial and venous thrombosis. Microvascular endothelial cell (MVEC) activation and injury, platelet activation, and histopathologic features characteristic of acute COVID-19 also describe certain thrombotic microangiopathies, including atypical hemolytic-uremic syndrome (aHUS), thrombotic thrombocytopenic purpura (TTP), and hematopoietic stem cell transplant (HSCT)-associated veno-occlusive disease (VOD). We explored the effect of clinically relevant doses of defibrotide, approved for HSCT-associated VOD, on MVEC activation/injury. Methods Human dermal MVEC were exposed to plasmas from patients with acute TMAs or acute COVID-19 in the presence and absence of defibrotide (5 μg/ml) and caspase 8, a marker of EC activation and apoptosis, was assessed. RNAseq was used to explore potential mechanisms of defibrotide activity. Results Defibrotide suppressed TMA plasma-induced caspase 8 activation in MVEC (mean 60.2 % inhibition for COVID-19; p = 0.0008). RNAseq identified six major cellular pathways associated with defibrotide's alteration of COVID-19-associated MVEC changes: TNF-α signaling; IL-17 signaling; extracellular matrix (ECM)-EC receptor and platelet receptor interactions; ECM formation; endothelin activity; and fibrosis. Communications across these pathways were revealed by STRING analyses. Forty transcripts showing the greatest changes induced by defibrotide in COVID-19 plasma/MVEC cultures included: claudin 14 and F11R (JAM), important in maintaining EC tight junctions; SOCS3 and TNFRSF18, involved in suppression of inflammation; RAMP3 and transgelin, which promote angiogenesis; and RGS5, which regulates caspase activation and apoptosis. Conclusion Our data, in the context of a recent clinical trial in severe COVID-19, suggest benefits to further exploration of defibrotide and these pathways in COVID-19 and related endotheliopathies.
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Affiliation(s)
- Sonia Elhadad
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, United States of America
| | - David Redmond
- Division of Regenerative Medicine, Hartman Institute fort Therapeutic Organ Regeneration, Ansary Stem Cell Institute, United States of America
| | - Adrian Tan
- Genomics Resources Core Facility, Weill Cornell Medicine, United States of America
| | - Jenny Huang
- Division of Regenerative Medicine, Hartman Institute fort Therapeutic Organ Regeneration, Ansary Stem Cell Institute, United States of America
| | - Beatriz Lorenzo Rodriguez
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, United States of America
| | | | - Sandeep Subrahmanian
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States of America
| | - Jasimuddin Ahamed
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States of America
| | - Jeffrey Laurence
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, United States of America.
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Rudebeck CJ, Renard C, Halfon‐Domenech C, Ouachée‐Chardin M, Philippe M, Valla FV, Bertrand Y, Penel‐Page M. Interest of the preventive and curative use of defibrotide on the occurrence and severity of sinusoidal obstruction syndrome after hematopoietic stem cell transplant in children. EJHaem 2022; 3:885-893. [PMID: 36051041 PMCID: PMC9421979 DOI: 10.1002/jha2.480] [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] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/24/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
Defibrotide (DF) is indicated for the treatment of severe sinusoidal obstruction syndrome (SOS) following hematopoietic stem cell transplantation (HSCT), but its prophylactic use against SOS is not recommended yet. This study describes the impact of the preventive and curative use of DF on reducing the incidence and severity of SOS in children. Patients aged 0-19 years, who received allogenic HSCT after myeloablative conditioning regimen with busulfan or total body irradiation in our comprehensive cancer center, between 2013 and 2017, were included. The Baltimore or modified Seattle criteria were used for SOS diagnosis. SOS was graded using the 2017 European Society for Blood and Marrow Transplantation classification defining severity criteria of SOS in children. SOS occurrence tended to decrease with prophylactic DF, but no significant difference was observed in terms of severity. When not treated with preventive DF, 50% (19/38) of the patients with SOS were graded severe to very severe, but only 37% (7/19) had organ dysfunction. Curative DF was administered at a median of 2 days post-HSCT, for a median of 6.5 days. The absence of fatal SOS supports the use of early curative DF with acceptable toxicities and questions the optimal duration of DF treatment.
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Affiliation(s)
- Carl J. Rudebeck
- Institut d'Hématologie et d'Oncologie PédiatriqueHospices Civils de LyonLyonFrance
- University Claude Bernard ‐ Lyon ILyonFrance
| | - Cécile Renard
- Institut d'Hématologie et d'Oncologie PédiatriqueHospices Civils de LyonLyonFrance
| | - Carine Halfon‐Domenech
- Institut d'Hématologie et d'Oncologie PédiatriqueHospices Civils de LyonLyonFrance
- University Claude Bernard ‐ Lyon ILyonFrance
| | | | - Michael Philippe
- Institut d'Hématologie et d'Oncologie PédiatriqueHospices Civils de LyonLyonFrance
| | - Frederic V. Valla
- Service de Réanimation et Soins Intensifs Pédiatriques ‐ Hôpital Femme Mère EnfantHospices Civils de LyonLyonFrance
| | - Yves Bertrand
- Institut d'Hématologie et d'Oncologie PédiatriqueHospices Civils de LyonLyonFrance
- University Claude Bernard ‐ Lyon ILyonFrance
| | - Mathilde Penel‐Page
- Institut d'Hématologie et d'Oncologie PédiatriqueHospices Civils de LyonLyonFrance
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3
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Frame D, Scappaticci GB, Braun TM, Maliarik M, Sisson TH, Pipe SW, Lawrence DA, Richardson PG, Holinstat M, Hyzy RC, Kaul DR, Gregg KS, Lama VN, Yanik GA. Defibrotide Therapy for SARS-CoV-2 ARDS. Chest 2022; 162:346-355. [PMID: 35413279 PMCID: PMC8993696 DOI: 10.1016/j.chest.2022.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND SARS-CoV-2-related ARDS is associated with endothelial dysfunction and profound dysregulation of the thrombotic-fibrinolytic pathway. Defibrotide is a polyanionic compound with fibrinolytic, antithrombotic, and antiinflammatory properties. RESEARCH QUESTION What is the safety and tolerability of defibrotide in patients with severe SARS-CoV-2 infections? STUDY DESIGN AND METHODS We report a prospective, open-label, single-center safety trial of defibrotide for the management of SARS-CoV-2-related ARDS. Eligible participants were 18 years of age or older with clinical and radiographic signs of ARDS, no signs of active bleeding, a serum D-dimer of more than twice upper limit of normal, and positive polymerase chain reaction-based results for SARS-CoV-2. Defibrotide (6.25 mg/kg/dose IV q6h) was administered for a planned 7-day course, with serum D-dimer levels and respiratory function monitored daily during therapy. RESULTS Twelve patients (median age, 63 years) were treated, with 10 patients receiving mechanical ventilation and 6 receiving vasopressor support at study entry. The median D-dimer was 3.25 μg/ml (range, 1.33-12.3) at study entry. The median duration of therapy was 7 days. No hemorrhagic or thrombotic complications occurred during therapy. No other adverse events attributable to defibrotide were noted. Four patients met the day 7 pulmonary response parameter, all four showing a decrease in serum D-dimer levels within the initial 72 h of defibrotide therapy. Three patients died of progressive pulmonary disease 11, 17, and 34 days after study entry. Nine patients (75%) remain alive 64 to 174 days after initiation of defibrotide. Day 30 all-cause mortality was 17% (95% CI, 0%-35%). All patients with a baseline Pao2 to Fio2 ratio of ≥ 125 mm Hg survived, whereas the three patients with a baseline Pao2 to Fio2 ratio of < 125 mm Hg died. INTERPRETATION The use of defibrotide for management of SARS-CoV-2-related ARDS proved safe and tolerable. No hemorrhagic or thrombotic complications were reported during therapy, with promising outcomes in a patient population with a historically high mortality rate. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04530604; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- David Frame
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Department of Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Gianni B. Scappaticci
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Department of Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Thomas M. Braun
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Mary Maliarik
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Thomas H. Sisson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Steven W. Pipe
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
| | - Daniel A. Lawrence
- Department of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Paul G. Richardson
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Michael Holinstat
- Division of Pharmacology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Daniel R. Kaul
- Division of Infectious Disease, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Kevin S. Gregg
- Division of Infectious Disease, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Gregory A. Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI,CORRESPONDENCE TO: Gregory A. Yanik, MD
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4
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Gruhn B, Brodt G, Mentzel HJ, Ernst J. Two Cases of Veno-occlusive Disease/Sinusoidal Obstruction Syndrome After Thioguanine Treatment for Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2022; 44:e572-e575. [PMID: 33885036 PMCID: PMC8876419 DOI: 10.1097/mph.0000000000002172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication of hematopoietic cell transplantation conditioning or high-dose chemotherapy. The underlying pathogenesis involves toxic injury to hepatocytes and sinusoidal endothelial cells. Presenting symptoms include ascites, weight gain, hepatomegaly, and hyperbilirubinemia. Severe VOD/SOS with multiorgan failure has a mortality rate of >80% if left untreated. Thioguanine, a chemotherapy drug used to treat acute lymphoblastic leukemia, has been shown to cause VOD/SOS. Here, we describe cases of 2 patients who developed very severe VOD/SOS after starting thioguanine for acute lymphoblastic leukemia; both achieved complete remission with defibrotide and experienced no defibrotide-related adverse events.
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Affiliation(s)
| | | | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Jena, Germany
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5
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Tilmont R, Yakoub-Agha I, Ramdane N, Srour M, Coiteux V, Magro L, Odou P, Simon N, Beauvais D. Impact of Defibrotide in the Prevention of Acute Graft-Versus-Host Disease Following Allogeneic Hematopoietic Cell Transplantation. Ann Pharmacother 2022; 56:1007-1015. [PMID: 35016532 DOI: 10.1177/10600280211068177] [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: 11/16/2022] Open
Abstract
BACKGROUND Defibrotide is indicated for patients who develop severe sinusoidal obstructive syndrome following allogeneic hematopoietic cell transplantation (allo-HCT). Preclinical data suggested that defibrotide carries a prophylactic effect against acute graft-versus-host disease (aGVHD). OBJECTIVE The purpose of this study was to investigate the effect of defibrotide on the incidence and severity of aGVHD. METHODS This single-center retrospective study included all consecutive transplanted patients between January 2014 and December 2018. A propensity score based on 10 predefined confounders was used to estimate the effect of defibrotide on aGVHD via inverse probability of treatment weighting (IPTW). RESULTS Of the 482 included patients, 64 received defibrotide (defibrotide group) and 418 did not (control group). Regarding main patient characteristics and transplantation modalities, the two groups were comparable, except for a predominance of men in the defibrotide group. The median age was 55 years (interquartile range [IQR]: 40-62). Patients received allo-HCT from HLA-matched related donor (28.6%), HLA-matched unrelated donor (50.8%), haplo-identical donor (13.4%), or mismatched unrelated donor (7.0%). Stem cell source was either bone marrow (49.6%) or peripheral blood (50.4%). After using IPTW, exposure to defibrotide was not significantly associated with occurrence of aGVHD (HR = 0.97; 95% CI 0.62-1.52; P = .9) or occurrence of severe aGVHD (HR = 1.89, 95% CI: 0.98-3.66; P = .058). CONCLUSION AND RELEVANCE Defibrotide does not seem to have a protective effect on aGVHD in patients undergoing allo-HCT. Based on what has been reported to date and on these results, defibrotide should not be considered for the prevention of aGVHD outside clinical trials.
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Affiliation(s)
- Rémi Tilmont
- Service des Maladies du Sang, Hôpital Huriez, CHU Lille, Lille, France
| | | | - Nassima Ramdane
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, CHU Lille, University of Lille, Lille, France
| | - Micha Srour
- Service des Maladies du Sang, Hôpital Huriez, CHU Lille, Lille, France
| | - Valérie Coiteux
- Service des Maladies du Sang, Hôpital Huriez, CHU Lille, Lille, France
| | - Léonardo Magro
- Service des Maladies du Sang, Hôpital Huriez, CHU Lille, Lille, France
| | - Pascal Odou
- Institut de Pharmacie, CHU Lille, Lille, France.,ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, University of Lille, Lille, France
| | - Nicolas Simon
- Institut de Pharmacie, CHU Lille, Lille, France.,ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, University of Lille, Lille, France
| | - David Beauvais
- CHU de Lille, Université de Lille, INSERM Infinite U1285, Lille, France
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6
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Fernández S, Palomo M, Molina P, Díaz-Ricart M, Escolar G, Téllez A, Seguí F, Ventosa H, Torramade-Moix S, Rovira M, Carreras E, Nicolás JM, Castro P. Progressive endothelial cell damage in correlation with sepsis severity. Defibrotide as a contender. J Thromb Haemost 2021; 19:1948-1958. [PMID: 33872468 DOI: 10.1111/jth.15343] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/03/2021] [Accepted: 04/13/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The vascular endothelium plays a key role in sepsis pathophysiology and the associated organ dysfunction. METHODS We evaluated endothelial function in an experimental in vitro model of sepsis, using endothelial cells grown in the presence of serum from patients with septic syndromes (sepsis, severe sepsis, and septic shock), noninfectious systemic inflammatory response syndrome (NI-SIRS) and healthy volunteers. Experiments were performed in the absence and presence of defibrotide (DF) (100 µg/ml) to evaluate its potential protective effect. RESULTS After exposure to patients' sera, there was a progressive endothelial cell activation in correlation with sepsis severity, with a proinflammatory and prothrombotic phenotype, exhibiting significantly increased expression of adhesion receptors at the surface (intercellular adhesion molecule-1, p < .05 and vascular cell adhesion molecule-1, p < .05); higher production and release to the extracellular matrix (ECM) of von Willebrand factor (p < .001); augmented thrombogenicity of the ECM toward platelets (p < .001); and increased phosphorylation of intracellular p38MAPK. DF prevented these changes in all groups. CONCLUSIONS Markers of endothelial damage increased progressively in association with the severity of septic syndromes. The endothelium is therefore an important therapeutic target to prevent complications of sepsis. DF shows promising potential to modulate the endothelial damage associated with sepsis and may constitute a pharmacological tool to decrease its sequelae including multiorgan failure.
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Affiliation(s)
- Sara Fernández
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Patricia Molina
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Maribel Díaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Ginés Escolar
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Adrián Téllez
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Ferran Seguí
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Helena Ventosa
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Sergi Torramade-Moix
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Montserrat Rovira
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
- Stem Cell Transplantation Unit, Department of Haematology, Institute of Haematology and Oncology, Hospital Clinic, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Josep M Nicolás
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
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7
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Lee TB, Yang K, Ko HJ, Shim JR, Choi BH, Lee JH, Ryu JH. Successful defibrotide treatment of a patient with veno-occlusive disease after living-donor liver transplantation: A case report. Medicine (Baltimore) 2021; 100:e26463. [PMID: 34160449 PMCID: PMC8238349 DOI: 10.1097/md.0000000000026463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Veno-occlusive disease (VOD) is characterized by painful hepatomegaly, ascites, weight gain, and jaundice with nonthrombotic, fibrous obliteration of the centrilobular hepatic veins. VOD after liver transplantation is a rare complication, with an incidence of approximately 2%; however, it can be life-threatening in severe cases. The precise etiology and mechanism of VOD after liver transplantation remains unclear. Acute cellular rejection, antibody-mediated rejection, and treatment with tacrolimus or azathioprine may be associated with the development of VOD after liver transplantation. Additionally, the optimal treatment of VOD after liver transplantation has not yet been established and focuses on supportive care. Defibrotide is an anti-ischemic and antithrombotic drug with no systemic anticoagulant effects. Moreover, only a few reports have investigated the use of defibrotide for VOD after liver transplantation, which has shown promising results. PATIENT CONCERNS A 39-year-old woman with primary biliary cholangitis underwent living-donor liver transplantation at our center. She experienced right upper quadrant pain with increased ascites, pleural effusion, and weight gain on postoperative day 14. DIAGNOSES Imaging and pathological tests showed no evidence of rejection or vessel complications. VOD was diagnosed clinically based on the findings of weight gain, ascites, jaundice, and pathological biopsy. INTERVENTIONS Defibrotid, 25 mg/kg/day, was administered intravenously for 21 days. OUTCOMES She showed complete clinical resolution of the VOD. LESSONS Herein, we report a case of successful defibrotide treatment of VOD after living-donor liver transplantation.
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Affiliation(s)
- Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery
| | - Kwangho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery
- Research Institute for Convergence of Biomedical Science and Technology
| | - Hyo Jung Ko
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery
| | - Jae Ryong Shim
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery
| | - Jung Hee Lee
- Department of Pathology, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan, Republic of Korea
| | - Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery
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8
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Tappe W, Aggarwal S, Topaloglu O, Iacobelli M. A Meta-Analysis Evaluating the Incidence of Bleeding Events With Intravenous Defibrotide Treatment Outside the Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome Setting. Clin Appl Thromb Hemost 2021; 26:1076029620935202. [PMID: 32687402 PMCID: PMC7372611 DOI: 10.1177/1076029620935202] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Defibrotide is approved to treat hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) with renal/pulmonary dysfunction following hematopoietic cell transplantation (HCT) in adult and pediatric patients in the United States, and to treat severe hepatic VOD/SOS post-HCT in adult and pediatric patients aged >1 month in the European Union. The defibrotide prescribing information warns that defibrotide may increase bleeding risk in VOD/SOS patients. To broaden our understanding of the incidence of bleeding with defibrotide, we performed a meta-analysis of the published literature of defibrotide use outside of the post-HCT VOD/SOS setting. Of 1857 records identified, 125 reported on defibrotide; 23 contained data on bleeding events. The estimated overall incidence of bleeding events was 1% (95% confidence interval [CI]: 0%-2%) and 8% (95% CI: 3%-14%) in studies using intravenous defibrotide and studies with controls, respectively. The risk ratio for bleeding events with intravenous defibrotide versus controls was 0.36 (95% CI: 0.24-0.52; P < .00001) among studies with data on intravenous defibrotide and controls. This meta-analysis of defibrotide use outside of the post-HCT VOD/SOS setting suggests that the incidence of bleeding with defibrotide is lower than controls.
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9
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González Vicent M, Díaz de Heredia C, González de Pablo J, Molina B, Regueiro A, Pérez Martinez A, Palomo P, López Corral L, García E, Fernández JM, Pérez A, Jiménez MJ, Guerreiro M, Vallejo C, Gallardo AI, López O, Benito A, Marsal J, Duarte M, Bento L, Badell I, Pedraza A, Jiménez Ubieto A, González P, Gómez Centurión I, Costilla L, Beléndez C, Esquirol A, Espigado I, Lavilla E, Díaz MÁ. Defibrotide in hematopoietic stem cell transplantation: A multicenter survey study of the Spanish Hematopoietic Stem Cell Transplantation Group (GETH). Eur J Haematol 2021; 106:842-850. [PMID: 33713387 DOI: 10.1111/ejh.13618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Defibrotide is approved in European Union for the treatment of severe sinusoidal obstruction syndrome (SOS) after HSCT. However, it has also been used for SOS prophylaxis, moderate SOS and in other complications such as transplant-associated thrombotic microangiopathy (TAM). The objective of this study was to evaluate current uses, effectiveness and safety of defibrotide in patients with HSCT. METHODS This multicenter, retrospective study included patients treated with defibrotide for any indication at 28 HSCT centers of the Grupo Español de Trasplante Hematopoyetico (GETH) including the pediatric subgroup Grupo Español de Trasplante de Medula en Niños (GETMON). RESULTS Three hundred and eighty eight patients treated with defibrotide between January 2011 and December 2018 were included. 253 patients were children, and 135 patients were adults. In total, 332 transplants were allogeneic, and the remainder were autologous. Main indications for defibrotide use were severe/very severe SOS in 173 patients, SOS prophylaxis in 135 patients, moderate SOS in 41 patients, TAM in six patients and suspected SOS in 33 patients. Overall survival (OS) at day +100 in the SOS prophylaxis group was 89% (95% CI, 87%-91%). In the group of patients with moderate and severe/very severe SOS, the OS at day +100 was 80% (95% CI, 74%-86%) and 62% (95% CI, 59%-65%), respectively (P = .0015). With a longer follow-up, median of 2 years (4 months-7 years), OS was 63% (95% CI, 59%-67%) in the SOS prophylaxis patients. OS for patients with moderate and severe/very severe SOS groups was 53% (95% CI, 47%-61%) and 26% (95% CI, 22%-30%), respectively (P = .006). 191 patients died, and SOS was the main cause of death in 23 patients (12%). CONCLUSIONS Defibrotide has an acceptable safety profile with an improved response in severe/very severe SOS compared with historical controls, mainly in pediatric patients. Use of defibrotide for prophylaxis may improve prognosis of patients at high risk of complications due to endothelial damage such as those who receive a second transplant. SOS has an important impact on the HSCT long-term survival, as can be concluded from our study.
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Affiliation(s)
| | | | | | | | | | | | - Pilar Palomo
- BMT Unit, Hospital Central de Asturias, Oviedo, Spain
| | | | | | | | | | | | | | - Carlos Vallejo
- BMT Unit, Hospital Universitario de Donosti, San Sebastián, Spain
| | | | - Oriana López
- BMT Unit, Hospital Morales Meseguer, Murcia, Spain
| | - Ana Benito
- BMT Unit, Hospital Regional de Málaga, Málaga, Spain
| | - Julia Marsal
- BMT Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Mónica Duarte
- BMT Unit, Hospital Marqués de Valdecilla, Santander, Spain
| | - Leyre Bento
- BMT Unit, Hospital Son Espases, Mallorca, Spain
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10
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Orlando N, Babini G, Chiusolo P, Valentini CG, De Stefano V, Teofili L. Pre-Exposure to Defibrotide Prevents Endothelial Cell Activation by Lipopolysaccharide: An Ingenuity Pathway Analysis. Front Immunol 2020; 11:585519. [PMID: 33343567 PMCID: PMC7744778 DOI: 10.3389/fimmu.2020.585519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/04/2020] [Indexed: 01/11/2023] Open
Abstract
Defibrotide (DFB) effects on different endothelial cell pathways have been investigated focusing on a limited number of genes or molecules. This study explored the modulation of the gene expression profile of steady-state or lipopolysaccharide (LPS)-activated endothelial cells, following the DFB exposure. Starting from differentially regulated gene expression datasets, we utilized the Ingenuity Pathway Analysis (IPA) to infer novel information about the activity of this drug. We found that effects elicited by LPS deeply differ depending on cells were exposed to DFB and LPS at the same time, or if the DFB priming occurs before the LPS exposure. Only in the second case, we observed a significant down-regulation of various pathways activated by LPS. In IPA, the pathways most affected by DFB were leukocyte migration and activation, vasculogenesis, and inflammatory response. Furthermore, the activity of DFB seemed to be associated with the modulation of six key genes, including matrix-metalloproteinases 2 and 9, thrombin receptor, sphingosine-kinase1, alpha subunit of collagen XVIII, and endothelial-protein C receptor. Overall, our findings support a role for DFB in a wide range of diseases associated with an exaggerated inflammatory response of endothelial cells.
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Affiliation(s)
- Nicoletta Orlando
- Department of Image, Radiation therapy, Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gabriele Babini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Chiusolo
- Department of Image, Radiation therapy, Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Caterina Giovanna Valentini
- Department of Image, Radiation therapy, Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio De Stefano
- Department of Image, Radiation therapy, Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luciana Teofili
- Department of Image, Radiation therapy, Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Macciò A, Madeddu C, Caocci G, Oppi S, La Nasa G. Defibrotide in the COVID-19 coagulopathy: What is the timing? J Thromb Haemost 2020; 18:3113-3115. [PMID: 32945111 PMCID: PMC7537223 DOI: 10.1111/jth.15100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, Medical Oncology Unit, University of Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Hematology and Transplant Center, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Sara Oppi
- Hematology and Transplant Center, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Giorgio La Nasa
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Hematology and Transplant Center, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
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12
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Richardson E, Carlo-Stella C, Jara R, Vlodavsky I, Iacobelli M, Fareed J, Mo C, O'Gorman P, Yanik G, Palomo M, Diaz-Ricart M, Moraleda JM. Response to Maccio et al, "Multifactorial pathogenesis of COVID-19-related coagulopathy: Can defibrotide have a role in the early phases of coagulation disorders?". J Thromb Haemost 2020; 18:3111-3113. [PMID: 32860297 PMCID: PMC9770769 DOI: 10.1111/jth.15088] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Edward Richardson
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Carmelo Carlo-Stella
- Department of Oncology and Hematology, Humanitas Clinical and Research Center - IRCCS, Rozzano-Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Rozzano-Milano, Italy
| | - Ruben Jara
- Intensive Care Unit, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain
| | - Israel Vlodavsky
- Technion Integrated Cancer Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - Jawed Fareed
- Department of Molecular Pharmacology and Therapeutics, Hemostasis and Thrombosis Research Laboratories, Loyola University Medical Center, Chicago, IL, USA
| | - Clifton Mo
- Department of Hematologic Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Peter O'Gorman
- Mater University Hospital, UCD School of Medicine and Medical Science, Dublin, Ireland
| | - Gregory Yanik
- Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Centre Diagnostic Biomedic, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Jose M Moraleda
- Department of Hematology, Stem Cell Transplant and Cell Therapy Unit, IMIB-Arrixaca, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain
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13
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Macciò A, Madeddu C, Caocci G, La Nasa G. Multifactorial pathogenesis of COVID-19-related coagulopathy: Can defibrotide have a role in the early phases of coagulation disorders? J Thromb Haemost 2020; 18:3106-3108. [PMID: 32692894 PMCID: PMC7405280 DOI: 10.1111/jth.15021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/10/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, Medical Oncology Unit, University of Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Hematology and Transplant Center, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Giorgio La Nasa
- Department of Medical Sciences and Public Health, University of Cagliari, Hematology and Transplant Center, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari, Italy
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14
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Roy Moulik N, Johnson I, Van Bruggen L, Petterson T, Mycroft J, Vaidya SJ. Defibrotide treatment but not prophylaxis is useful in hepatic sinusoidal obstruction syndrome in children undergoing autologous stem cell transplant following high-dose chemotherapy: A single-center experience from the Royal Marsden Hospital, UK. Pediatr Blood Cancer 2020; 67:e28677. [PMID: 32865880 DOI: 10.1002/pbc.28677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/29/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatic sinusoidal obstruction syndrome (SOS) is a serious complication of autologous stem cell transplant (ASCT) in children with historically high mortality rates. Defibrotide has shown proven benefit in its treatment and may have a modest role in prevention. We report our experience with SOS in children undergoing autologous transplant. METHODS Case records of 82 consecutive patients undergoing ASCT following high-dose chemotherapy between 2010 and 2017 were reviewed. Defibrotide was used for treatment of all with SOS and prophylactically in patients receiving busulfan-based conditioning until 2014. RESULTS Fourteen of the 82 children (17%) were diagnosed with SOS. The incidence was higher in those receiving busulfan-based conditioning (13/42 vs 1/40, P = 0.008). Mean (±SD) time to diagnosis of SOS was 19 (±5.6) days following stem cell rescue. Bilirubin levels and ultrasound were normal in 7/14 and 3/14 patients. Coagulopathy was noted in 10/14; one child developed multiorgan involvement. Nine children had mild SOS, whereas two and three had moderate and severe SOS, respectively. Intensive care was required for four of five non-mild cases. Patients with SOS had significantly delayed platelet recovery, higher transfusion requirement, and longer hospital stay. Unavailability of defibrotide prophylaxis for 17/42 receiving busulfan did not change the incidence of SOS (7/25 with defibrotide vs 6 /17 without defibrotide, P = 0.74). There was no significant difference in the severity of SOS between these groups. CONCLUSION Hepatic SOS was more commonly seen in children receiving busulfan-based conditioning. Stopping the use of prophylactic defibrotide did not increase incidence or severity of SOS. Overall outcome was excellent with supportive care and timely treatment with defibrotide.
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Affiliation(s)
- Nirmalya Roy Moulik
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Indranee Johnson
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Lucia Van Bruggen
- Department of Pharmacy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Toni Petterson
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Julie Mycroft
- Department of Pharmacy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Sucheta J Vaidya
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
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15
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Lang P, Eichholz T, Bakchoul T, Streiter M, Petrasch M, Bösmüller H, Klein R, Rabsteyn A, Lang AM, Adams C, Klingel K, Gessner M, Rosenberger P, Ruef P, Handgretinger R. Defibrotide for the Treatment of Pediatric Inflammatory Multisystem Syndrome Temporally Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in 2 Pediatric Patients. J Pediatric Infect Dis Soc 2020; 9:622-625. [PMID: 32951037 PMCID: PMC7543556 DOI: 10.1093/jpids/piaa117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/16/2020] [Indexed: 01/04/2023]
Abstract
The pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection is a severe complication of coronavirus disease 2019. Since impaired coagulation and thrombosis/endotheliitis are suspected pathomechanisms, we treated 2 patients with defibrotide, a profibrinolytic, antithrombotic, antiinflammatory oligonucleotide. Symptoms resolved during treatment. Moreover, coagulation parameters indicating hypofibrinolysis and complement activation normalized. The pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection is a severe complication of coronavirus disease 2019. Since impaired coagulation and thrombosis/endotheliitis are suspected pathomechanisms, 2 patients received defibrotide, a profibrinolytic, antithrombotic, antiinflammatory oligonucleotide. Symptoms resolved and hypofibrinolysis/complement activation normalized during treatment.
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Affiliation(s)
- Peter Lang
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Thomas Eichholz
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Institute of Transfusion Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Monika Streiter
- Children’s Hospital, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Maurice Petrasch
- Children’s Hospital, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Hans Bösmüller
- Institute of Pathology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Reinhild Klein
- Department of Haematology/Oncology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Armin Rabsteyn
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Anne-Marie Lang
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Constantin Adams
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Karin Klingel
- Institute of Pathology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Michaela Gessner
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Peter Rosenberger
- University Hospital for Intensive Care and Anaesthesiology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Peter Ruef
- Children’s Hospital, SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany
| | - Rupert Handgretinger
- Children’s University Hospital, Eberhard Karls University Tuebingen, Tuebingen, Germany,Correspondence: Rupert Handgretinger, Children’s University Hospital Tuebingen, Hoppe-Seyler Str. 1, 72076 Tuebingen, Germany ()
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16
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García-Bernal D, Palomo M, Martínez CM, Millán-Rivero JE, García-Guillén AI, Blanquer M, Díaz-Ricart M, Sackstein R, Carreras E, Moraleda JM. Defibrotide inhibits donor leucocyte-endothelial interactions and protects against acute graft-versus-host disease. J Cell Mol Med 2020; 24:8031-8044. [PMID: 32519822 PMCID: PMC7348164 DOI: 10.1111/jcmm.15434] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/05/2020] [Accepted: 05/12/2020] [Indexed: 12/18/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo‐HCT) is an effective therapy for the treatment of high‐risk haematological malignant disorders and other life‐threatening haematological and genetic diseases. Acute graft‐versus‐host disease (aGvHD) remains the most frequent cause of non‐relapse mortality following allo‐HCT and limits its extensive clinical application. Current pharmacologic agents used for prophylaxis and treatment of aGvHD are not uniformly successful and have serious secondary side effects. Therefore, more effective and safe prophylaxis and therapy for aGvHD are an unmet clinical need. Defibrotide is a multi‐target drug successfully employed for prophylaxis and treatment of veno‐occlusive disease/sinusoidal obstruction syndrome. Recent preliminary clinical data have suggested some efficacy of defibrotide in the prevention of aGvHD after allo‐HCT. Using a fully MHC‐mismatched murine model of allo‐HCT, we report here that defibrotide, either in prophylaxis or treatment, is effective in preventing T cell and neutrophil infiltration and aGvHD‐associated tissue injury, thus reducing aGvHD incidence and severity, with significantly improved survival after allo‐HCT. Moreover, we performed in vitro mechanistic studies using human cells revealing that defibrotide inhibits leucocyte‐endothelial interactions by down‐regulating expression of key endothelial adhesion molecules involved in leucocyte trafficking. Together, these findings provide evidence that defibrotide may represent an effective and safe clinical alternative for both prophylaxis and treatment of aGvHD after allo‐HCT, paving the way for new therapeutic approaches.
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Affiliation(s)
- David García-Bernal
- Hematopoietic Transplant and Cellular Therapy Unit, Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain.,Internal Medicine Department, Medicine School, University of Murcia, Murcia, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Barcelona, Spain.,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CBD), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Carlos M Martínez
- Experimental Pathology Unit, Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Murcia, Spain
| | - José E Millán-Rivero
- Hematopoietic Transplant and Cellular Therapy Unit, Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain.,Internal Medicine Department, Medicine School, University of Murcia, Murcia, Spain
| | - Ana I García-Guillén
- Hematopoietic Transplant and Cellular Therapy Unit, Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain
| | - Miguel Blanquer
- Hematopoietic Transplant and Cellular Therapy Unit, Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain.,Internal Medicine Department, Medicine School, University of Murcia, Murcia, Spain
| | - Maribel Díaz-Ricart
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CBD), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Robert Sackstein
- Department of Translational Medicine, and the Translational Glycobiology Institute, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Jose M Moraleda
- Hematopoietic Transplant and Cellular Therapy Unit, Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Virgen de la Arrixaca University Hospital, University of Murcia, Murcia, Spain.,Internal Medicine Department, Medicine School, University of Murcia, Murcia, Spain
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17
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Laberko A, Aksenova M, Shipitsina I, Khamin I, Shcherbina A, Balashov D, Maschan A. Serious Hemorrhagic Complications After Successful Treatment of Hematopoietic Stem Cell Transplantation-Associated Thrombotic Microangiopathy With Defibrotide in Pediatric Patient With Myelodysplastic Syndrome. Front Pediatr 2020; 8:155. [PMID: 32432059 PMCID: PMC7214790 DOI: 10.3389/fped.2020.00155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/20/2020] [Indexed: 01/23/2023] Open
Abstract
Background: Transplant-associated thrombotic microangiopathy (TAM) is a life-threatening complication of hematopoietic stem cell transplantation (HSCT). There is some evidence of endothelial injury playing a significant role in TAM development. The efficacy of defibrotide was demonstrated for prophylaxis and treatment of another HSCT-associated endothelial damage syndrome-liver veno-occlusive disease. The data for defibrotide usage in TAM are limited. Case Description: A 9-year old boy underwent HSCT from a matched unrelated donor for monosomy seven-associated myelodysplastic syndrome treatment. A myeloablative preparative regimen and post-transplant immunosuppression with cyclophosphamide on days +3 and +4 and a combination of tacrolimus with mycophenolate mofetil from day +5 were used. From day +61, sustained fever with progressive neurologic impairment and no evidence of infection was observed. On day +68, the patient developed severe TAM with acute kidney injury requiring renal replacement therapy (RRT). Defibrotide therapy 25 mg/kg/day was administered for 7 days with resolution of TAM symptoms. It was followed by multiple hemorrhagic episodes-epistaxis, hemorrhagic cystitis, and renal hemorrhage, which are presumed to be the complications of defibrotide therapy. Conclusion: Defibrotide could be an effective therapy for TAM, but adequate doses, duration of therapy, and drug safety profile both for pediatric and adult patients need to be evaluated by randomized prospective studies.
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Affiliation(s)
- Alexandra Laberko
- Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Marina Aksenova
- Nephrology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- Nephrology, Y. Veltischev Research and Clinical Institute for Pediatrics at N. Pirogov Russian National Research Medical University, Moscow, Russia
| | - Irina Shipitsina
- Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Igor Khamin
- Intensive Care, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry Balashov
- Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexei Maschan
- Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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18
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Bonifazi F, Barbato F, Ravaioli F, Sessa M, Defrancesco I, Arpinati M, Cavo M, Colecchia A. Diagnosis and Treatment of VOD/SOS After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:489. [PMID: 32318059 PMCID: PMC7147118 DOI: 10.3389/fimmu.2020.00489] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS) is a rare complication characterized by hepatomegaly, right-upper quadrant pain, jaundice, and ascites, occurring after high-dose chemotherapy, hematopoietic stem cell transplantation (HSCT) and, less commonly, other conditions. We review pathogenesis, clinical appearance and diagnostic criteria, risk factors, prophylaxis, and treatment of the VOD occurring post-HSCT. The injury of the sinusoidal endothelial cells with loss of wall integrity and sinusoidal obstruction is the basis of development of postsinusoidal portal hypertension responsible for clinical syndrome. Risk factors associated with the onset of VOD and diagnostic tools have been recently updated both in the pediatric and adult settings and here are reported. Treatment includes supportive care, intensive management, and specific drug therapy with defibrotide. Because of its severity, particularly in VOD with associated multiorgan disease, prophylaxis approaches are under investigation. During the last years, decreased mortality associated to VOD/SOS has been reported being it attributable to a better intensive and multidisciplinary approach.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Barbato
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariarosaria Sessa
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Irene Defrancesco
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Mario Arpinati
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Gastroenterology Unit, Borgo Trento University Hospital, Verona, Italy
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19
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Richardson PG, Smith AR, Kernan NA, Lehmann L, Soiffer RJ, Ryan RJ, Tappe W, Grupp S. Pooled analysis of Day 100 survival for defibrotide-treated patients with hepatic veno-occlusive disease/sinusoidal obstruction syndrome and ventilator or dialysis dependence following haematopoietic cell transplantation. Br J Haematol 2020; 190:583-587. [PMID: 32157682 PMCID: PMC7497046 DOI: 10.1111/bjh.16552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/01/2020] [Indexed: 12/31/2022]
Abstract
For patients with untreated hepatic veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) with multi-organ dysfunction (MOD), mortality is >80%. We conducted a pooled analysis of three studies that assessed Day 100 survival in relationship to MOD severity, with dialysis and/or ventilator dependence representing the most severe organ dysfunction. All patients in the analysis were diagnosed using Baltimore criteria/biopsy. This analysis of patients with VOD/SOS and MOD after haematopoietic cell transplantation (HCT; n = 651) demonstrated higher Day 100 survival rates amongst defibrotide-treated patients with VOD/SOS with less versus more severe forms of MOD. Even patients with severe forms of MOD post-HCT benefitted from defibrotide.
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Affiliation(s)
- Paul G Richardson
- Division of Hematologic Malignancy, Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Nancy A Kernan
- Pediatric BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leslie Lehmann
- Division of Hematologic Malignancy, Department of Medical Oncology, Center for Stem Cell Transplantation, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert J Soiffer
- Division of Hematologic Malignancy, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Stephan Grupp
- Division of Pediatric Oncology, Department of Pediatrics, Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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20
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Palomo M, Vera M, Martin S, Torramadé‐Moix S, Martinez‐Sanchez J, Belen Moreno A, Carreras E, Escolar G, Cases A, Díaz‐Ricart M. Up-regulation of HDACs, a harbinger of uraemic endothelial dysfunction, is prevented by defibrotide. J Cell Mol Med 2020; 24:1713-1723. [PMID: 31782253 PMCID: PMC6991634 DOI: 10.1111/jcmm.14865] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/24/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022] Open
Abstract
Endothelial dysfunction is an earlier contributor to the development of atherosclerosis in chronic kidney disease (CKD), in which the role of epigenetic triggers cannot be ruled out. Endothelial protective strategies, such as defibrotide (DF), may be useful in this scenario. We evaluated changes induced by CKD on endothelial cell proteome and explored the effect of DF and the mechanisms involved. Human umbilical cord vein endothelial cells were exposed to sera from healthy donors (n = 20) and patients with end-stage renal disease on haemodialysis (n = 20). Differential protein expression was investigated by using a proteomic approach, Western blot and immunofluorescence. HDAC1 and HDAC2 overexpression was detected. Increased HDAC1 expression occurred at both cytoplasm and nucleus. These effects were dose-dependently inhibited by DF. Both the HDACs inhibitor trichostatin A and DF prevented the up-regulation of the endothelial dysfunction markers induced by the uraemic milieu: intercellular adhesion molecule-1, surface Toll-like receptor-4, von Willebrand Factor and reactive oxygen species. Moreover, DF down-regulated HDACs expression through the PI3/AKT signalling pathway. HDACs appear as key modulators of the CKD-induced endothelial dysfunction as specific blockade by trichostatin A or by DF prevents endothelial dysfunction responses to the CKD insult. Moreover, DF exerts its endothelial protective effect by inhibiting HDAC up-regulation likely through PI3K/AKT.
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Affiliation(s)
- Marta Palomo
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
- Josep Carreras Leukaemia Research InstituteHospital Clinic/University of Barcelona CampusBarcelonaSpain
- Barcelona Endothelium Team (BET)BarcelonaSpain
| | - Manel Vera
- Nephrology DepartmentHospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
| | - Susana Martin
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
| | - Sergi Torramadé‐Moix
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
| | - Julia Martinez‐Sanchez
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
- Josep Carreras Leukaemia Research InstituteHospital Clinic/University of Barcelona CampusBarcelonaSpain
- Barcelona Endothelium Team (BET)BarcelonaSpain
| | - Ana Belen Moreno
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
| | - Enric Carreras
- Josep Carreras Leukaemia Research InstituteHospital Clinic/University of Barcelona CampusBarcelonaSpain
- Barcelona Endothelium Team (BET)BarcelonaSpain
| | - Ginés Escolar
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
| | - Aleix Cases
- Nephrology DepartmentHospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
| | - Maribel Díaz‐Ricart
- HematopathologyCentre Diagnòstic Biomèdic (CDB)Hospital ClinicInstitut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de Barcelona (UB)BarcelonaSpain
- Barcelona Endothelium Team (BET)BarcelonaSpain
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21
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Baladé Martínez L, Cabezuelo MM, Villamañan Bueno E, Rodríguez Martín E, Herrero Ambrosio A. Defibrotide for the treatment of severe hepatic sinusoidal obstruction syndrome: a single-centre experience. Eur J Hosp Pharm 2019; 26:343-346. [PMID: 31798859 DOI: 10.1136/ejhpharm-2018-001575] [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] [Received: 04/02/2018] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/04/2022] Open
Abstract
Objectives Determine the effectiveness and cost of defibrotide in patients with severe hepatic sinusoidal obstruction syndrome following haematopoietic stem cell transplantation in a tertiary hospital. Methods A retrospective observational study. Adults or children treated with defibrotide at a mean dose of 6.8 mg/kg every 6 hours, until the total bilirubin levels are normalised, were included. Main endpoint was complete response, defined as normalised total serum bilirubin levels and resolution of multiple organ failure. Secondary endpoints were survival by 100 days post-transplant, influence of risks factors in effectiveness and cost of treatment. Results 51 patients (36 adults and 15 children) received defibrotide; median dose of defibrotide administered was 25.19 mg/kg/day (10.0-100.3). Complete response was achieved in 19 (37.3%) patients. By 100 days post-transplant complete response was achieved in 18 (35.3%) patients and the survival rate was 29 (56.9%) patients. There were no significant differences in effectiveness between adults versus paediatrics and between patients who presented risk factors. The mean cost of treatment per patient was €32 916, mean costs in adults was €104 292 and €17 394 in children. Conclusion Regarding the results of our study, it is convenient to identify the patients who will be able to benefit from this treatment according to clinical conditions, medical history and prognosis. Given the great economic impact of defibrotide, we consider that more cost-effectiveness studies are required. Trial registration number EPA-OD, number LBM-DEF-2016-01.
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22
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Martinez-Sanchez J, Hamelmann H, Palomo M, Mir E, Moreno-Castaño AB, Torramade S, Rovira M, Escolar G, Cordes S, Kalupa M, Mertlitz S, Riesner K, Carreras E, Penack O, Diaz-Ricart M. Acute Graft-vs.-Host Disease-Associated Endothelial Activation in vitro Is Prevented by Defibrotide. Front Immunol 2019; 10:2339. [PMID: 31649666 PMCID: PMC6794443 DOI: 10.3389/fimmu.2019.02339] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/17/2019] [Indexed: 01/10/2023] Open
Abstract
Angiogenesis and endothelial activation and dysfunction have been associated with acute graft-vs.-host disease (aGVHD), pointing to the endothelium as a potential target for pharmacological intervention. Defibrotide (DF) is a drug with an endothelium-protective effect that has been approved for the treatment of veno-occlusive disease/sinusoidal obstruction syndrome after allogeneic hematopoietic cell transplantation. Clinical data suggest that DF also reduces the incidence of aGVHD; however, the mechanisms of DF-mediated aGVHD regulation have not been examined. To investigate possible DF-mediated prophylactic and therapeutic mechanisms in aGVHD, we performed in vitro studies using endothelial cell (EC) lines. We found that DF significantly and dose-dependently suppressed EC proliferation and notably reduced their ability to form vascular tubes in Matrigel. To explore whether DF administered prophylactically or therapeutically has a significant effect on aGVHD endothelial dysfunction, ECs were exposed to media containing sera from patients with aGVHD (n = 22) in the absence or presence of DF and from patients that did not develop aGVHD (n = 13). ECs upregulated adhesion molecules (vascular cell adhesion molecule 1, intercellular adhesion molecule 1), the adherence junction protein VE-cadherin, von Willebrand factor (VWF), and Akt phosphorylation in response to aGVHD sera. These responses were suppressed upon treatment with DF. In summary, DF inhibits vascular angiogenesis and endothelial activation induced by sera from aGVHD patients. Our results support the view that DF has notable positive effects on endothelial biology during aGVHD.
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Affiliation(s)
- Julia Martinez-Sanchez
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Hannah Hamelmann
- Hematology, Oncology and Tumor Immunology Department, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany.,Department of Hematology and Oncology, Berlin Institute of Health, Berlin, Germany
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Enrique Mir
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Ana Belen Moreno-Castaño
- Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Sergi Torramade
- Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Stem Cell Transplantation Unit, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ginés Escolar
- Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Steffen Cordes
- Hematology, Oncology and Tumor Immunology Department, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany.,Department of Hematology and Oncology, Berlin Institute of Health, Berlin, Germany
| | - Martina Kalupa
- Hematology, Oncology and Tumor Immunology Department, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany.,Department of Hematology and Oncology, Berlin Institute of Health, Berlin, Germany
| | - Sarah Mertlitz
- Hematology, Oncology and Tumor Immunology Department, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany.,Department of Hematology and Oncology, Berlin Institute of Health, Berlin, Germany
| | - Katarina Riesner
- Hematology, Oncology and Tumor Immunology Department, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany.,Department of Hematology and Oncology, Berlin Institute of Health, Berlin, Germany
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Olaf Penack
- Hematology, Oncology and Tumor Immunology Department, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany.,Department of Hematology and Oncology, Berlin Institute of Health, Berlin, Germany
| | - Maribel Diaz-Ricart
- Department of Hematopathology, Biomedical Diagnosis Center (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
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23
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Abstract
Antonio Pagliuca is Professor of hematopoietic stem cell transplantation at King's College London (UK) and medical director at King's College Hospital where, until last year, he had been the transplant director for the past 24 years. He also has roles within NHS England as national clinical lead for regenerative medicine and is a trustee on both the Anthony Nolan trust (London, UK) and Leukemia UK (London, UK). Here he speaks to Commissioning Editor Jennifer Straiton and discusses the interim results of the DEFIFrance study, recently presented at the European Society for Blood and Marrow Transplant (EBMT), which looked at the real-world use of the European Society for Blood and Marrow Transplant severity grading criteria. The study investigates the use of defibrotide as a treatment of patients with post-transplant hepatic veno-occlusive disease and demonstrates how it can benefit from early intervention.
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Affiliation(s)
- Antonio Pagliuca
- Kings College Hospital, Department of Hematology, Denmark Hill, London, SE5 9RS, UK
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24
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Maximova N, Caddeo G, Zanon D, Maestro A, Simeone R. Drop of Butyrylcholinesterase Activity after Cyclophosphamide Conditioning as a Predictive Marker of Liver Transplant-Related Complications and Its Correlation with Transplant-Related Mortality in Pediatric Hematopoietic Stem Cell Recipients. J Clin Med 2019; 8:E825. [PMID: 31185690 DOI: 10.3390/jcm8060825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/01/2019] [Accepted: 06/05/2019] [Indexed: 11/17/2022] Open
Abstract
Transplant-related liver complications are a potentially fatal condition of hematopoietic stem cell transplantation (HSCT) in pediatric patients, actually representing one of the main factors involved in transplant-related mortality (TRM). The search for a specific marker capable of predicting the development of this condition is a relevant clinical issue. We have observed a variable reduction in serum butyrylcholinesterase (BChE) activity after a cyclophosphamide-containing conditioning regimen. This study aims to determine the cutoff of BChE activity reduction that might be a specific prognostic marker for liver complications after HSCT. Our results show that the reduction of BChE values below 2000 U/L the day before the transplantation is an indicator strongly associated with the transplant-related liver complications (p < 0.0001). The incidence of overall survival at 1 year was significantly higher in the BChE > 2000 U/L group compared to the BChE < 2000 U/L group (84.7% versus 58.5%, p < 0.001), while the TRM rate was significantly lower (8.1% versus 23.1%, p < 0.05). None of the patients undergoing prophylaxis with defibrotide developed severe liver complications. Starting defibrotide treatment at the first signs of hepatic dysfunction in patients with particularly low BChE activity levels reduces severe liver transplant-related complications.
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25
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Ní Chonghaile M, Wolownik K. Identification and Management: Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease Eelated to Hematopoietic Stem Cell Transplantation
. Clin J Oncol Nurs 2019; 22:E7-E17. [PMID: 29350698 DOI: 10.1188/18.cjon.e7-e17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 11/17/2022]
Abstract
BACKGROUND Sinusoidal obstruction syndrome (SOS), also called hepatic veno-occlusive disease (VOD), is a potentially life-threatening complication of hematopoietic stem cell transplantation (HSCT) that affects about 1 in 7 patients undergoing this procedure. SOS/VOD is caused by the conditioning regimens administered prior to HSCT; in some cases, SOS/VOD results from chemotherapy alone. SOS/VOD usually develops within three weeks following HSCT; however, it can have later onset.
. OBJECTIVES Clearly understanding how SOS/VOD develops may support prompt detection and treatment when the condition arises.
. METHODS Research on identification and management of SOS/VOD is summarized, and data from clinical trials are reviewed.
. FINDINGS This article describes the syndrome, risk factors, signs and symptoms, and appropriate supportive care and treatment. The authors also offer some practical tips for detecting SOS/VOD and providing patient care, as well as the latest information on treating and preventing this condition.
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26
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Maximova N, Granzotto M, Barbieri F, Marcuzzi A, Tommasini A, Monasta L, Simeone R, Zanon D, Sala R. Monocyte-predominant engraftment, cytokine levels and early transplant-related complications in pediatric hematopoietic stem cell recipients. Cancer Med 2019; 8:890-901. [PMID: 30690926 PMCID: PMC6434198 DOI: 10.1002/cam4.1912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 11/25/2022] Open
Abstract
Myeloablative conditioning is a well‐established procedure that precedes hematopoietic stem cell transplantation (HSCT), particularly in pediatric patients. In the period directly following transplantation, several factors may contribute to complications that lead to the activation or damage of endothelial cells, involved in the pathogenesis of vascular endothelial syndromes (VES). However, to date, sufficiently specific and sensitive diagnostic markers for the various forms of VES have not been identified. This was a retrospective single‐center study of patients who underwent allogeneic HSCT. For this cohort of patients, parameters including type of engraftment, donor characteristics, and cytokine production were measured and correlated with a high prevalence of short‐term complications after HSCT. The aim of this study was to identify specific parameters useful for improving diagnostics and predicting adverse effects in VES. We confirmed that monocyte‐predominant engraftment was related to a higher risk for an early transplant‐related complication termed sinusoidal obstruction syndrome (SOS). The increased production of specific cytokines, in particular RANTES, represents a marker associated with prevalent engraftment. In addition, patients undergoing prophylaxis with defibrotide had “classical” engraftment, a common cytokine profile and a lower incidence of life‐threatening transplant‐related complications. The beneficial effect of defibrotide might be a starting point for developing selective prophylaxis for patients with monocyte engraftment to prevent severe early transplant‐related complications. The onset of vascular endothelial syndromes after hematopoietic stem cell transplantation is significantly associated with monocyte‐predominant engraftment (P < 0.0001). The increased production of specific cytokines, in particular RANTES, represents a marker associated with monocyte‐predominant engraftment. There is close association between the prophylactic administration of defibrotide, a powerful endothelial protector, and the incidence of vascular endothelial syndromes (P < 0.0001). Given the high cost of defibrotide, selective prophylaxis may be considered for patients with extremely high values of RANTES or with monocyte engraftment.
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Affiliation(s)
- Natalia Maximova
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.,Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Marilena Granzotto
- Department of Laboratory Medicine, ASUITS, Trieste, Italy.,Department of Transfusion Medicine, ASUITS, Trieste, Italy
| | - Francesca Barbieri
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Annalisa Marcuzzi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Alberto Tommasini
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.,Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Lorenzo Monasta
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.,Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Roberto Simeone
- Department of Laboratory Medicine, ASUITS, Trieste, Italy.,Department of Transfusion Medicine, ASUITS, Trieste, Italy
| | - Davide Zanon
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.,Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Roberto Sala
- Department of Medicine and Surgery, University of Parma, Parma, Italy
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27
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Abstract
Malignant mesothelioma is a highly aggressive form of cancer with poor prognosis due to lack of markers for early diagnosis and resistance to conventional therapies. Heparanase, the sole heparan sulfate (HS) degrading endoglycosidase, regulates multiple biological activities that enhance tumor growth, metastasis, angiogenesis, and inflammation. Heparanase accomplishes this by degrading HS and thereby facilitating cell invasion and regulating the bioavailability of heparin-binding proteins. Applying pre-clinical and clinical models of human mesothelioma and potent inhibitors of heparanase enzymatic activity (PG545, Defibrotide) we investigated the significance of heparanase in the pathogenesis of mesothelioma. We found that mesothelioma tumor growth was markedly attenuated by heparanase gene silencing and by heparanase inhibitors. Furthermore, heparanase inhibitors were more potent in vivo than conventional chemotherapy. Clinically, heparanase levels in patients’ pleural effusions could distinguish between malignant and benign effusions, and heparanase H-score (immunostaining of tumor specimens) above 90 was associated with reduced patient survival. These results strongly imply that heparanase plays an important role in mesothelioma tumor progression, thus encouraging the use of heparanase inhibitors in combination with existing drugs as a new therapeutic modality in mesothelioma clinical trials.
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Affiliation(s)
- Moshe Lapidot
- Cancer and Vascular Biology Research Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Uri Barash
- Cancer and Vascular Biology Research Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Israel Vlodavsky
- Cancer and Vascular Biology Research Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Harvey Pass
- Department of Cardiothoracic Surgery, Langone Medical Center, New York University School of Medicine, New York, USA
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28
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Kernan NA, Richardson PG, Smith AR, Triplett BM, Antin JH, Lehmann L, Messinger Y, Liang W, Hume R, Tappe W, Soiffer RJ, Grupp SA. Defibrotide for the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome following nontransplant-associated chemotherapy: Final results from a post hoc analysis of data from an expanded-access program. Pediatr Blood Cancer 2018; 65:e27269. [PMID: 29873895 PMCID: PMC6685707 DOI: 10.1002/pbc.27269] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/18/2018] [Accepted: 05/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially fatal complication of conditioning for hematopoietic stem cell transplantation (HSCT) but can occur after nontransplant-associated chemotherapy. Following HSCT, VOD/SOS with multi-organ dysfunction (MOD) may be associated with >80% mortality. Defibrotide is approved to treat severe hepatic VOD/SOS post-HSCT in patients aged >1 month in the European Union and hepatic VOD/SOS with renal or pulmonary dysfunction post-HSCT in the United States. Prior to US approval, defibrotide was available to treat VOD/SOS through an expanded-access treatment (T-IND) program. A post hoc analysis of nontransplant-associated VOD/SOS patients treated with defibrotide initiated within 30 days of starting chemotherapy and followed for 70 days is presented. PROCEDURE Patients were diagnosed by Baltimore or modified Seattle criteria or biopsy, and received defibrotide 25 mg/kg/day in four divided doses (≥21 days recommended). RESULTS Of the 1,154 patients in the T-IND, 137 had nontransplant-associated VOD/SOS, 82 of whom developed VOD/SOS within 30 days of starting chemotherapy. Of them, 66 (80.5%) were aged ≤16 years. Across all the 82 patients, Kaplan-Meier estimated day +70 survival was 74.1%, 65.8% in patients with MOD (n = 38), and 81.3% in patients without MOD (n = 44). By age group, Kaplan-Meier estimated day +70 survival was 80.1% in pediatric patients (n = 66) and 50.0% in adults (n = 16). Treatment-related adverse events occurred in 26.8%. CONCLUSIONS In this post hoc analysis of 82 patients initiating defibrotide within 30 days of starting chemotherapy, Kaplan-Meier estimated survival was 74.1% at 70 days after defibrotide initiation. Safety profile was consistent with prior defibrotide studies.
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Affiliation(s)
- Nancy A. Kernan
- Pediatric BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul G. Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Angela R. Smith
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Brandon M. Triplett
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Joseph H. Antin
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Leslie Lehmann
- Center for Stem Cell Transplantation, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Yoav Messinger
- Cancer and Blood Disorders Program, Children’s Minnesota, MN, USA
| | - Wei Liang
- formerly of Jazz Pharmaceuticals, Palo Alto, CA, USA
| | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | - Robert J. Soiffer
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stephan A. Grupp
- Pediatric Oncology, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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29
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Abstract
The initial signs of hepatic sinusoidal obstruction syndrome (HSOS) can be challenging to recognize in children, especially outside the hematopoietic stem cell transplantation setting. To assist clinicians to promptly identify HSOS, the European Society for Blood and Marrow Transplantation has proposed pediatric HSOS diagnostic criteria which emphasize unexplained consumptive and transfusion-refractory thrombocytopenia. To highlight the importance of these "bellwether" early signs of HSOS and the efficacy of pre-emptive treatment with defibrotide, we describe the case of a child with a right 11th rib primitive neuroectodermal tumor who developed HSOS following focal radiotherapy and actinomycin-D treatment.
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Affiliation(s)
- Revathi Rajagopal
- Department of Hematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Pediatric Hematology and Oncology Unit, Department of Pediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Marianne B Phillips
- Department of Hematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
| | - Nicholas G Gottardo
- Department of Hematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
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30
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Kernan NA, Grupp S, Smith AR, Arai S, Triplett B, Antin JH, Lehmann L, Shore T, Ho VT, Bunin N, Iacobelli M, Liang W, Hume R, Tappe W, Soiffer R, Richardson P. Final results from a defibrotide treatment-IND study for patients with hepatic veno-occlusive disease/sinusoidal obstruction syndrome. Br J Haematol 2018; 181:816-827. [PMID: 29767845 PMCID: PMC6032999 DOI: 10.1111/bjh.15267] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/19/2018] [Indexed: 12/17/2022]
Abstract
Hepatic veno‐occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life‐threatening complication of haematopoietic stem cell transplant (HSCT) conditioning and chemotherapy. Defibrotide is approved for treatment of hepatic VOD/SOS with pulmonary or renal dysfunction [i.e., multi‐organ dysfunction (MOD)] after HSCT in the United States and severe VOD/SOS after HSCT in patients aged older than 1 month in the European Union. Defibrotide was available as an investigational drug by an expanded‐access treatment programme (T‐IND; NCT00628498). In the completed T‐IND, the Kaplan–Meier estimated Day +100 survival for 1000 patients with documented defibrotide treatment after HSCT was 58·9% [95% confidence interval (CI), 55·7–61·9%]. Day +100 survival was also analysed by age and MOD status, and post hoc analyses were performed to determine Day +100 survival by transplant type, timing of VOD/SOS onset (≤21 or >21 days) and timing of defibrotide treatment initiation after VOD/SOS diagnosis. Day +100 survival in paediatric patients was 67·9% (95% CI, 63·8–71·6%) and 47·1% (95% CI, 42·3–51·8%) in adults. All patient subgroups without MOD had higher Day +100 survival than those with MOD; earlier defibrotide initiation was also associated with higher Day +100 survival. The safety profile of defibrotide in the completed T‐IND study was similar to previous reports.
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Affiliation(s)
- Nancy A Kernan
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Stephan Grupp
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sally Arai
- Stanford University Medical Center, Stanford, CA, USA
| | | | - Joseph H Antin
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Leslie Lehmann
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Vincent T Ho
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nancy Bunin
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Wei Liang
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | - Robert Soiffer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Paul Richardson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Dilli D, Kılıç E, Yumuşak N, Beken S, Uçkan Çetinkaya D, Karabulut R, Zenciroğlu AL. Additive effect of mesenchymal stem cells and defibrotide in an arterial rat thrombosis model. ARCH ARGENT PEDIATR 2018; 115:249-256. [PMID: 28504490 DOI: 10.5546/aap.2017.eng.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/29/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND/AIM In this study, we aimed to investigate the additive effect of mesenchymal stem cells (MSC) and defibrotide (DFT) in a rat model of femoral arterial thrombosis. METHODS Thirty Sprague Dawley rats were included. An arterial thrombosis model by ferric chloride (FeCl3) was developed in the left femoral artery. The rats were equally assigned to 5 groups: Group 1-Sham-operated (without arterial injury); Group 2-Phosphate buffered saline (PBS) injected; Group 3-MSC; Group 4-DFT; Group 5-MSC + DFT. All had two intraperitoneal injections of 0.5 ml: the 1st injection was 4 h after the procedure and the 2nd one 48 h after the 1st injection. The rats were sacrificed 7 days after the 2nd injection. RESULTS Although the use of human bone marrow-derived (hBM) hBM-MSC or DFT alone enabled partial resolution of the thrombus, combining them resulted in near-complete resolution. Neovascularization was two-fold better in hBM-MSC + DFT treated rats (11.6 ± 2.4 channels) compared with the hBM-MSC (3.8 ± 2.7 channels) and DFT groups (5.5 ± 1.8 channels) (P < 0.0001 and P= 0.002, respectively). CONCLUSION The combined use of hBM-MSC and DFT in a rat model of arterial thrombosis showed additive effect resulting in near-complete resolution of the thrombus.
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Affiliation(s)
- Dilek Dilli
- Department of Neonatology, Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Emine Kılıç
- Department of Life Sciences, Hemosoft IT and Training Services, Technopolis of Hacettepe University, Ankara, Turkey.,PEDI-STEM Center for Stem Cell Research and Development, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nihat Yumuşak
- Department of Veterinary Pathology, Harran University Faculty of Veterinary Medicine, Şanlıurfa, Turkey
| | - Serdar Beken
- Department of Neonatology, Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
| | - Duygu Uçkan Çetinkaya
- PEDI-STEM Center for Stem Cell Research and Development, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ramazan Karabulut
- Departments of Pediatric Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ayşegu L Zenciroğlu
- Department of Neonatology, Dr Sami Ulus Maternity and Children Research and Training Hospital, Ankara, Turkey
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Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a potentially lethal disease that presents with rapidly progressive multiple organ thromboses. Anticoagulation, corticosteroids, intravenous immunoglobulin, and plasma exchange are the most commonly used treatments for CAPS patients. However, the high mortality despite these medications necessitates new treatment strategies. Following a brief review of current diagnostic and management strategies, we discuss the candidate therapies, i.e., hydroxychloroquine, rituximab, eculizumab, sirolimus, and defibrotide, that can be considered in CAPS patients refractory to traditional treatment.
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Affiliation(s)
- Ozan Unlu
- Hospital for Special Surgery, New York, NY 10021;
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY 10021
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Richardson PG, Grupp SA, Pagliuca A, Krishnan A, Ho VT, Corbacioglu S. Defibrotide for the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome with multiorgan failure. Int J Hematol Oncol 2017; 6:75-93. [PMID: 30302228 PMCID: PMC6171967 DOI: 10.2217/ijh-2017-0015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 05/02/2017] [Accepted: 06/30/2017] [Indexed: 12/12/2022] Open
Abstract
Hepatic veno-occlusive disease, also called sinusoidal obstruction syndrome (VOD/SOS), is a potentially life-threatening and unpredictable complication of hematopoietic stem cell transplantation (HSCT). Characterized by a prothrombotic-hypofibrinolytic state, VOD/SOS typically presents with hyperbilirubinemia, ascites, weight gain and painful hepatomegaly; VOD/SOS with multiorgan failure may be associated with >80% mortality. Treatment has been mainly supportive. However, defibrotide is now approved in the USA for treatment of hepatic VOD/SOS with renal or pulmonary dysfunction following HSCT and in the European Union for treatment of severe hepatic VOD/SOS post-HSCT. In vitro evidence suggests defibrotide may restore thrombotic-fibrinolytic balance at the endothelial level and protect endothelial cells. Defibrotide has demonstrated significant reduction in VOD/SOS-related mortality and resolved VOD/SOS-related symptoms, with a manageable safety profile.
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Affiliation(s)
- Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Stephan A Grupp
- Pediatric Oncology, The Children's Hospital of Philadelphia & the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital, London, UK
| | - Amrita Krishnan
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Vincent T Ho
- Hematopoietic Stem Cell Transplantation, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology & Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
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Abstract
OBJECTIVE To review the efficacy and safety of defibrotide as well as its pharmacology, mechanism of action, pharmacokinetics (PK), drug-drug interactions, dosing, cost considerations, and place in therapy. DATA SOURCES A PubMed search was performed through August 2017 using the terms defibrotide, oligonucleotide, hepatic veno-occlusive disease (VOD), sinusoidal obstruction syndrome (SOS), and hematopoietic cell transplantation (HCT). Other data sources were from references of identified studies, review articles, and conference abstracts plus manufacturer product labeling and website, the Food and Drug Administration website, and clinicaltrials.gov. STUDY SELECTION AND DATA EXTRACTION English-language trials that examined defibrotide's pharmacodynamics, mechanism, PK, efficacy, safety, dosing, and cost-effectiveness were included. DATA SYNTHESIS Trials have confirmed the safety and efficacy of defibrotide for treatment of VOD/SOS in adult and pediatric HCT patients, with complete response rates and day +100 overall survival rates ranging from 25.5% to 76% and 35% to 64%, respectively. The British Committee for Standards in Haematology/British Society for Blood and Marrow Transplantation Guidelines recommend defibrotide prophylaxis in pediatric and adult HCT patients with risk factors for VOD/SOS; however, its prophylactic use in the United States is controversial. Although there are efficacy data to support this strategy, cost-effectiveness data have not shown it to be cost-effective. Defibrotide has manageable toxicities, with low rates of grade 3 to 4 adverse effects. CONCLUSIONS Defibrotide is the first medication approved in the United States for the treatment of adults and children with hepatic VOD/SOS, with renal or pulmonary dysfunction following HCT. Data evaluating defibrotide for VOD/SOS prevention are conflicting and have not shown cost-effectiveness.
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Affiliation(s)
- May T Aziz
- 1 Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Payal P Kakadiya
- 1 Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA
| | - Samantha M Kush
- 1 Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA
| | - Kylie Weigel
- 1 Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,3 Massachusetts General Hospital, Boston, MA, USA
| | - Denise K Lowe
- 1 Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, VA, USA.,2 Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
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Richardson PG, Smith AR, Triplett BM, Kernan NA, Grupp SA, Antin JH, Lehmann L, Miloslavsky M, Hume R, Hannah AL, Nejadnik B, Soiffer RJ. Earlier defibrotide initiation post-diagnosis of veno-occlusive disease/sinusoidal obstruction syndrome improves Day +100 survival following haematopoietic stem cell transplantation. Br J Haematol 2017; 178:112-118. [PMID: 28444784 DOI: 10.1111/bjh.14727] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/14/2017] [Indexed: 11/28/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a progressive, potentially fatal complication of conditioning for haematopoietic stem cell transplant (HSCT). The VOD/SOS pathophysiological cascade involves endothelial-cell activation and damage, and a prothrombotic-hypofibrinolytic state. Severe VOD/SOS (typically characterized by multi-organ dysfunction) may be associated with >80% mortality. Defibrotide is approved for treating severe hepatic VOD/SOS post-HSCT in the European Union, and for hepatic VOD/SOS with renal or pulmonary dysfunction post-HSCT in the United States. Previously, defibrotide (25 mg/kg/day in 4 divided doses for a recommended ≥21 days) was available through an expanded-access treatment protocol for patients with VOD/SOS. Data from this study were examined post-hoc to determine if the timing of defibrotide initiation post-VOD/SOS diagnosis affected Day +100 survival post-HSCT. Among 573 patients, defibrotide was started on the day of VOD/SOS diagnosis in approximately 30%, and within 7 days in >90%. The relationship between Day +100 survival and treatment initiation before/after specific days post-diagnosis showed superior survival when treatment was initiated closer to VOD/SOS diagnosis with a statistically significant trend over time for better outcomes with earlier treatment initiation (P < 0·001). These results suggest that initiation of defibrotide should not be delayed after diagnosis of VOD/SOS.
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Affiliation(s)
- Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Brandon M Triplett
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nancy A Kernan
- Pediatric BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephan A Grupp
- Pediatric Oncology, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H Antin
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Leslie Lehmann
- Center for Stem Cell Transplantation, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Robin Hume
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | | | - Robert J Soiffer
- Stem Cell/Bone Marrow Transplantation Program, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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36
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Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), represents the most frequent complication in patients in early phase following hematopoietic stem-cell transplantation (HSCT). In its severe form, VOD/SOS can be associated with multiorgan failure and with a mortality rate >80% by day +100. Defibrotide (DF) (a mixture of 90% single-stranded phosphodiester oligonucleotides and 10% double-stranded phosphodiester oligonucleotides derived from controlled depolarization of porcine intestinal mucosal DNA) has been proposed for the treatment of SOS due to its ability to restore thrombo-fibrinolytic balance and protect endothelial cells. The present review highlights why the mechanisms of action of DF allow its successful use in the prevention and treatment of SOS following HSCT.
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Affiliation(s)
- Alessandro Fulgenzi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Maria Elena Ferrero
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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37
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Umemura K, Iwaki T, Kimura T, Ogawa C, Fukuda T, Taniguchi S, Horibe K, Goto H, Yoshimura K, Watanabe Y, Nitani C, Kikuta A. Pharmacokinetics and Safety of Defibrotide in Healthy Japanese Subjects. Clin Pharmacol Drug Dev 2016; 5:548-551. [PMID: 27870480 PMCID: PMC5132046 DOI: 10.1002/cpdd.262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 02/17/2016] [Accepted: 03/03/2016] [Indexed: 01/09/2023]
Affiliation(s)
- Kazuo Umemura
- Department of Pharmacology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takayuki Iwaki
- Department of Pharmacology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Chitose Ogawa
- Department of Pediatric Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | | | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroaki Goto
- Division of Hemato-Oncology/Regenerative Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kenichi Yoshimura
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Yasutaka Watanabe
- Clinical Trial Support Center, National Cancer Center Hospital East, Tokyo, Japan
| | - Chika Nitani
- Department of Pediatric Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University, Fukushima, Japan
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38
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Hopps SA, Borders EB, Hagemann TM. Prophylaxis and treatment recommendations for sinusoidal obstruction syndrome in adult and pediatric patients undergoing hematopoietic stem cell transplant: a review of the literature. J Oncol Pharm Pract 2015; 22:496-510. [PMID: 26126501 DOI: 10.1177/1078155215591387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sinusoidal obstruction syndrome, a complication occurring early after hematopoietic stem cell transplantation, is a concern for clinicians. There are no guidelines to direct clinicians on the optimal way to prevent and treat this disease. Newer data show that defibrotide is a promising drug both for prevention and treatment, although it is not yet FDA approved.
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Affiliation(s)
- Sarah A Hopps
- College of Pharmacy, University of Oklahoma, Oklahoma City, OK, USA
| | - Emily B Borders
- College of Pharmacy, University of Oklahoma, Oklahoma City, OK, USA
| | - Tracy M Hagemann
- College of Pharmacy, University of Oklahoma, Oklahoma City, OK, USA
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39
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Carreras E. How I manage sinusoidal obstruction syndrome after haematopoietic cell transplantation. Br J Haematol 2014; 168:481-91. [PMID: 25401997 DOI: 10.1111/bjh.13215] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/15/2014] [Indexed: 12/24/2022]
Abstract
Sinusoidal obstruction syndrome (SOS), also called veno-occlusive disease of the liver, is one of the most relevant complications of endothelial origin that appears early after haematopoietic cell transplantation (HCT). Despite its relatively low incidence and the fact that most cases of SOS resolve spontaneously, the cases that evolve to multi-organ failure (MOF; severe SOS) have a mortality rate higher than 80% and represent one of the major clinical problems after HCT. For this reason, transplantation teams must have a pre-established policy regarding preventive measures in high-risk patients, strict daily control of weight and fluid balance during HCT, homogeneous diagnostic criteria, appropriate complementary studies for a correct differential diagnosis and measures to prevent and manage hepatorenal syndrome; in addition they must also be ready to start early treatment with defibrotide in patients with a possible severe SOS. Due to the lack of definitive evidence to enable the establishment of general recommendations in the management of SOS, this review analyses all of these aspects based on the author's personal experience.
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Affiliation(s)
- Enric Carreras
- Haematology Department, Hospital Clinic, Barcelona, Spain; Spanish Bone Marrow Donor Program, Josep Carreras Foundation, Barcelona, Spain; Josep Carreras Leukaemia Research Institute, Barcelona, Spain
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Dignan FL, Wynn RF, Hadzic N, Karani J, Quaglia A, Pagliuca A, Veys P, Potter MN. BCSH/BSBMT guideline: diagnosis and management of veno-occlusive disease (sinusoidal obstruction syndrome) following haematopoietic stem cell transplantation. Br J Haematol 2013; 163:444-57. [PMID: 24102514 DOI: 10.1111/bjh.12558] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
DIAGNOSIS It is recommended that the diagnosis of veno-occlusive disease (sinusoidal obstruction syndrome) [VOD (SOS)] be based primarily on established clinical criteria (modified Seattle or Baltimore criteria) (1A). Ultrasound imaging may be helpful in the exclusion of other disorders in patients with suspected VOD (SOS) (1C). It is recommended that liver biopsy be reserved for patients in whom the diagnosis of VOD (SOS) is unclear and there is a need to exclude other diagnoses (1C). It is recommended that liver biopsies are undertaken using the transjugular approach in order to reduce the risks associated with the procedure (1C). It is suggested that the role of plasminogen activator inhibitor 1 levels remains an area for further research but that these levels should not form part of the routine diagnostic work-up for VOD (SOS) at present (2C). RISK FACTORS It is recommended that patients are assessed for risk factors for VOD (SOS) and that these risk factors are addressed prior to haematopoietic stem cell transplantation (1A). PROPHYLAXIS Defibrotide is recommended at a dose of 6.25 mg/kg intravenously four times daily for the prevention of VOD (SOS) in children undergoing allogeneic stem cell transplantation with the following risk factors: pre-existing hepatic disease, second myeloablative transplant, allogeneic transplant for leukaemia beyond second relapse, conditioning with busulfan-containing regimens, prior treatment with gemtuzumab ozogamicin, diagnosis of primary haemophagocytic lymphohistiocytosis, adrenoleucodystrophy or osteopetrosis (1A). Defibrotide is suggested at a dose of 6.25 mg/kg intravenously four times daily for the prevention of VOD (SOS) in adults undergoing allogeneic stem cell transplantation with the following risk factors: pre-existing hepatic disease, second myeloablative transplant, allogeneic transplant for leukaemia beyond second relapse, conditioning with busulfan-containing regimens, prior treatment with gemtuzumab ozogamicin, diagnosis of primary haemophagocytic lymphohistiocytosis, adrenoleucodystrophy or osteopetrosis (2B). Prostaglandin E1 is not recommended in the prophylaxis of VOD (SOS) due to lack of efficacy and toxicity (1B). Pentoxifylline is not recommended in the prophylaxis of VOD (SOS) due to lack of efficacy (1A). Ursodeoxycholic acid is suggested for use in the prophylaxis of VOD (SOS) (2C). Heparin (unfractionated and low molecular weight) is not suggested for use in the prophylaxis of VOD (SOS) due to the risk of increased toxicity (2B). Antithrombin is not suggested for the prophylaxis of VOD (SOS) due to lack of efficacy (2B). TREATMENT Defibrotide is recommended in the treatment of VOD (SOS) in adults and children (1B). Tissue plasminogen activator is not recommended for use in the treatment of VOD (SOS) due to the associated risk of haemorrhage (1B). N-acetylcysteine is not routinely recommended for use in the treatment of veno-occlusive disease due to lack of efficacy (1A). Methylprednisolone may be considered for use in the treatment of veno-occlusive disease with the appropriate caveats of caution regarding infection (2C). Judicious clinical care, particularly in the management of fluid balance, is recommended in the management of VOD (SOS) (1C). Early discussion with critical care specialists and a specialist hepatology unit is recommended in the management of VOD (SOS) and other treatment options including transjugular intrahepatic portosystemic shunt or hepatic transplantation may be considered (1C). SUMMARY A joint working group established by the Haemato-oncology subgroup of the British Committee for Standards in Haematology (BCSH) and the British Society for Blood and Marrow Transplantation (BSBMT) has reviewed the available literature and made recommendations for the diagnosis and management of veno-occlusive disease of the liver following haematopoietic stem cell transplantation (HSCT). This guideline includes recommendations for both prophylaxis and treatment of the condition and includes recommendations for children and adults undergoing HSCT.
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Affiliation(s)
- Fiona L Dignan
- Department of Haematology, Central Manchester NHS Foundation Trust, Manchester, UK
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41
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Richardson PG, Ho VT, Giralt S, Arai S, Mineishi S, Cutler C, Antin JH, Stavitzski N, Niederwieser D, Holler E, Carreras E, Soiffer R. Safety and efficacy of defibrotide for the treatment of severe hepatic veno-occlusive disease. Ther Adv Hematol 2012; 3:253-65. [PMID: 23606935 PMCID: PMC3627330 DOI: 10.1177/2040620712441943] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome, is a potentially life-threatening complication of chemotherapeutic conditioning used in preparation for hematopoietic stem-cell transplantation (SCT). VOD may occur in up to 62% of patients undergoing SCT, with onset generally within the first month after SCT. In severe cases, 100-day mortality is in excess of 80%. Current management consists of best supportive care, with no agents to date approved for treatment in the USA or the EU. Defibrotide, a polydisperse oligonucleotide, has been shown in phase II and III trials to improve complete response and survival in patients undergoing SCT with severe VOD. This article reviews our current understanding of VOD, and examines recent clinical findings on defibrotide for the treatment and prophylaxis of VOD.
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Affiliation(s)
- Paul G Richardson
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02115, USA
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Gatto B, Vianini E, Lucatello L, Sissi C, Moltrasio D, Pescador R, Porta R, Palumbo M. Effective DNA inhibitors of cathepsin g by in vitro selection. Int J Mol Sci 2008; 9:1008-1023. [PMID: 19325843 PMCID: PMC2658781 DOI: 10.3390/ijms9061008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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: 05/05/2008] [Revised: 06/06/2008] [Accepted: 06/10/2008] [Indexed: 11/16/2022] Open
Abstract
Cathepsin G (CatG) is a chymotrypsin-like protease released upon degranulation of neutrophils. In several inflammatory and ischaemic diseases the impaired balance between CatG and its physiological inhibitors leads to tissue destruction and platelet aggregation. Inhibitors of CatG are suitable for the treatment of inflammatory diseases and procoagulant conditions. DNA released upon the death of neutrophils at injury sites binds CatG. Moreover, short DNA fragments are more inhibitory than genomic DNA. Defibrotide, a single stranded polydeoxyribonucleotide with antithrombotic effect is also a potent CatG inhibitor. Given the above experimental evidences we employed a selection protocol to assess whether DNA inhibition of CatG may be ascribed to specific sequences present in defibrotide DNA. A Selex protocol was applied to identify the single-stranded DNA sequences exhibiting the highest affinity for CatG, the diversity of a combinatorial pool of oligodeoxyribonucleotides being a good representation of the complexity found in defibrotide. Biophysical and biochemical studies confirmed that the selected sequences bind tightly to the target enzyme and also efficiently inhibit its catalytic activity. Sequence analysis carried out to unveil a motif responsible for CatG recognition showed a recurrence of alternating TG repeats in the selected CatG binders, adopting an extended conformation that grants maximal interaction with the highly charged protein surface. This unprecedented finding is validated by our results showing high affinity and inhibition of CatG by specific DNA sequences of variable length designed to maximally reduce pairing/folding interactions.
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Affiliation(s)
- Barbara Gatto
- Department of Pharmaceutical Sciences, University of Padova, Via Marzolo 5, 35131 Padova, Italy
- Author to whom correspondence should be addressed; E-mail:
| | - Elena Vianini
- Department of Pharmaceutical Sciences, University of Padova, Via Marzolo 5, 35131 Padova, Italy
| | - Lorena Lucatello
- Department of Pharmaceutical Sciences, University of Padova, Via Marzolo 5, 35131 Padova, Italy
| | - Claudia Sissi
- Department of Pharmaceutical Sciences, University of Padova, Via Marzolo 5, 35131 Padova, Italy
| | - Danilo Moltrasio
- Gentium S.p.A., Piazza XX Settembre 2, 22079 Villa Guardia, Italy
| | - Rodolfo Pescador
- Gentium S.p.A., Piazza XX Settembre 2, 22079 Villa Guardia, Italy
| | - Roberto Porta
- Gentium S.p.A., Piazza XX Settembre 2, 22079 Villa Guardia, Italy
| | - Manlio Palumbo
- Department of Pharmaceutical Sciences, University of Padova, Via Marzolo 5, 35131 Padova, Italy
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Senzolo M, Germani G, Cholongitas E, Burra P, Burroughs AK. Veno occlusive disease: update on clinical management. World J Gastroenterol 2007; 13:3918-24. [PMID: 17663504 PMCID: PMC4171162 DOI: 10.3748/wjg.v13.i29.3918] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 01/10/2007] [Accepted: 01/25/2007] [Indexed: 02/06/2023] Open
Abstract
Hepatic veno-occlusive disease is a clinical syndrome characterized by hepatomegaly, ascites, weight gain and jaundice, due to sinusoidal congestion which can be caused by alkaloid ingestion, but the most frequent cause is haematopoietic stem cell transplantation (STC) and is also seen after solid organ transplantation. The incidence of veno occlusive disease (VOD) after STC ranges from 0 to 70%, but is decreasing. Survival is good when VOD is a mild form, but when it is severe and associated with an increase of hepatic venous pressure gradient > 20 mmHg, and mortality is about 90%. Prevention remains the best therapeutic strategy, by using non-myeloablative conditioning regimens before STC. Prophylactic administration of ursodeoxycholic acid, being an antioxidant and antiapoptotic agent, can have some benefit in reducing overall mortality. Defibrotide, which has pro-fibrinolytic and antithrombotic properties, is the most effective therapy; decompression of the sinusoids by a transjugular intrahepatic portosystemic shunt (TIPS) can be tried, especially to treat VOD after liver transplantation and when multiorgan failure (MOF) is not present. Liver transplantation can be the last option, but can not be considered a standard rescue therapy, because usually the concomitant presence of multiorgan failure contraindicates this procedure.
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