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Ariceta G. Pharmacological and clinical profile of ravulizumab 100 mg/mL formulation for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Expert Rev Clin Pharmacol 2023; 16:401-410. [PMID: 37128905 DOI: 10.1080/17512433.2023.2209317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are two rare and severe conditions caused by chronic complement (C') system dysregulation. Treatment with eculizumab, a recombinant, humanized monoclonal antibody against complement C5, changed the natural history of both diseases inducing remission and improving patient outcome. Ravulizumab, a new long-acting next-generation C5 inhibitor has been recently approved for treatment of PNH and aHUS. AREAS COVERED Main characteristics of ravulizumab are described: composition, dosing, efficacy and safety profile. Further, an overview of seminal studies and clinical trials using ravulizumab to treat PNH and aHUS in children and adults is detailed. Literature review was performed using the following key words: paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and ravulizumab. EXPERT OPINION Ravulizumab profile to treat PNH and aHUS is equivalent to eculizumab in efficacy and safety but allows extended dosing interval to every 4-8 weeks based on patient weight, and requires reduced infusion time. Less travels to infusion centers and medical visits and decreasing job and school absences, significantly increases patient and families' QoL, while reducing cost. Further infusion time is reduced Ravulizumab will possibly become the treatment of choice for patients with PNH and aHUS on chronic C5 inhibition.
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Affiliation(s)
- Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autonoma Barcelona, Spain
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Szlendak U, Krzymieniewska B, Mendek-Czajkowska E, Rogatko-Koroś M, Witkowska A, Włodarska J, Drozd-Sokołowska J, Spychalska J, Budziszewska B, Patkowska E, Woźniak J, Krzywdzińska A, Jurek S, Juszczyński P, Jaworska M, Rosłon M, Gruber-Bzura B, Wasilewski R, Baran B, Windyga J, Nowak J. Persistent imbalance, anti-apoptotic, and anti-inflammatory signature of circulating C-C chemokines and cytokines in patients with paroxysmal nocturnal hemoglobinuria. Cytokine 2021; 150:155780. [PMID: 34896730 DOI: 10.1016/j.cyto.2021.155780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal non-malignant disease in which hematopoietic cell apoptosis may play an important pathophysiological role. Previous studies of the content of phosphatidylinositol (3,4,5)-trisphosphate (PI(3,4,5)P3) indicated the possibility of remote transmission of anti-apoptotic signals between pathological and normal hematopoietic progenitors. METHODS The study determined the plasma levels of beta chemokines and cytokines in N = 19 patients with PNH and 31 healthy controls. The research material was peripheral blood plasma (EDTA) stored at -80 °C until the test. Beta chemokine and cytokine concentrations were tested in duplicate with Bio-Plex Pro Human Cytokine Assay (Bio-Rad, Hercules, CA, USA) using a Luminex 200 flow cytometer and xPONENT software (Luminex Corporation, Austin, TX, USA). In peripheral blood CD34+ cells we tested the proportions of PI(3,4,5)P3+ and Annexin binding apoptotic phenotype using FC and phosflow. RESULTS Compared to the control group, the PNH group showed a significant increase in the plasma concentration of some beta chemokines and cytokines, including MIP-1alpha/CCL3, eotaxin/CCL11, MCP1/CCL2, IL4 and G-CSF. In the group of PNH patients, a significant decrease in the concentration of some cytokines was also observed: RANTES/CCL5, MIP-1beta/CCL4, PDGF-BB and IL9. At the same time, the plasma concentrations of the chemokine IP-10/CXCL10 and the cytokines IFN-gamma, TNF, IL6 and IL10 showed no significant deviations from the values for the control group. Anti-apoptotic phenotype and phosphatidylinositol (3,4,5)-trisphosphate content in PNH clone of CD34+ cells were associated with the level of CCL3 and negatively associated with CCL5, CCL4, PDGF-BB and IL9. CONCLUSIONS This data suggest the existence of apoptotic and PI(3,4,5)P3 imbalance in PNH CD34+ cells driven by anti-apoptotic cytokine biosignature in PNH. Plasma cytokines and intracellular enzymes that regulate the phosphoinositide pathways may become a therapeutic target in PNH.
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Affiliation(s)
- Urszula Szlendak
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Beata Krzymieniewska
- Laboratory of Immunophenotyping, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Ewa Mendek-Czajkowska
- Specialist Outpatient Clinic, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Marta Rogatko-Koroś
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Witkowska
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Joanna Włodarska
- Day Treatment Department, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantology and Internal Medicine, University Clinical Center, Medical University of Warsaw, Warsaw, Poland
| | - Justyna Spychalska
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Bożena Budziszewska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Elżbieta Patkowska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jolanta Woźniak
- Laboratory of Immunophenotyping, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Krzywdzińska
- Laboratory of Immunophenotyping, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Sławomir Jurek
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Przemysław Juszczyński
- Department of Experimental Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Małgorzata Jaworska
- Department of Biochemistry and Biopharmaceuticals, National Medicines Institute, Warsaw, Poland
| | - Magdalena Rosłon
- Department of Biochemistry and Biopharmaceuticals, National Medicines Institute, Warsaw, Poland
| | - Beata Gruber-Bzura
- Department of Biochemistry and Biopharmaceuticals, National Medicines Institute, Warsaw, Poland
| | - Robert Wasilewski
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Beata Baran
- Department of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jacek Nowak
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.
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Lima M. Laboratory studies for paroxysmal nocturnal hemoglobinuria, with emphasis on flow cytometry. Pract Lab Med 2020; 20:e00158. [PMID: 32195308 PMCID: PMC7078534 DOI: 10.1016/j.plabm.2020.e00158] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/28/2020] [Accepted: 02/28/2020] [Indexed: 12/15/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal hematopoietic stem cell disorder caused by somatic mutations in the PIG-A gene, leading to the production of blood cells with absent or decreased expression of glycosylphosphatidylinositol-anchored proteins, including CD55 and CD59. Clinically, PNH is classified into three variants: classic (hemolytic), in the setting of another specified bone marrow disorder (such as aplastic anemia or myelodysplastic syndrome) and subclinical (asymptomatic). PNH testing is recommended for patients with intravascular hemolysis, acquired bone marrow failure syndromes and thrombosis with unusual features. Despite the availability of consensus guidelines for PNH diagnosis and monitoring, there are still discrepancies on how PNH tests are carried out, and these technical variations may lead to an incorrect diagnosis. Herein, we provide a brief historical overview of PNH, focusing on the laboratory tests available and on the current recommendations for PNH diagnosis and monitoring based in flow cytometry.
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Affiliation(s)
- Margarida Lima
- Laboratório de Citometria, Unidade de Diagnóstico Hematológico, Serviço de Hematologia Clínica, Hospital de Santo António (HSA), Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal
- Unidade Multidisciplinar de Investigação Biomédica, Instituto de Ciências Biomédicas da Universidade do Porto (UMIB/ICBAS/UP), Porto, Portugal
- Laboratório de Citometria, Hospital de Santo António (HSA), Centro Hospitalar Universitário do Porto (CHUP), Ex-CICAP, Rua D. Manuel II, s/n, 4099-001, Porto, Portugal.
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Manivannan P, Tyagi S, Pati HP, Saxena R. FLAER Based Assay According to Newer Guidelines Increases Sensitivity of PNH Clone Detection. Indian J Hematol Blood Transfus 2019; 36:526-534. [PMID: 32647428 DOI: 10.1007/s12288-019-01220-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 11/21/2022] Open
Abstract
Flow cytometry has become 'gold standard' for detecting abnormal clones in paroxysmal nocturnal hemoglobinuria (PNH), aplastic anemia (AA) and myelodysplastic syndrome (MDS). This pilot study was conducted in 2015 with a primary aim to evaluate the utility of single tube fluorescent aerolysin (FLAER) based testing and its comparison with two tubes non-FLAER based testing (CD55, CD59, CD24 and CD66b) in detecting abnormal PNH clones in these newly diagnosed cases. The secondary aim was an attempt to distinguish PNH from AA/MDS cases associated with PNH clones based on clinical, laboratory features and clone size at diagnosis. In this study, the abnormal PNH clones were detected using a single tube FLAER based testing and two tubes non-FLAER based testing in all cases of PNH (n = 12), healthy subjects (n = 18) and AA/MDS with PNH clone (n = 9) and compared with clinical and laboratory features at diagnosis. The receiver operator curve (ROC) analysis defined the optimal cut-offs for FLAER in granulocytes (> 0.7%) and monocytes (> 0.9%). There was significant positive correlation between FLAER and non-FLAER based testing in these cells (r > 0.3 and p < 0.05). FLAER based testing helped us in picking up smaller clones which were missed by latter technique in four patients thereby increasing its sensitivity and also technically proved to be cost-effective (Rs. 1800 vs. Rs. 2100). Even in PNH patients, the clone size was slightly higher by using FLAER when compared to non-FLAER based antibodies panel. The clone size of monocytes was always higher than granulocytes in both PNH and AA/MDS groups. Bone marrow cellularity and mean size of granulocytes and monocytes clone at diagnosis showed a striking statistically significant 'p' value of < 0.0001 between these groups. In this pilot study, a single tube FLAER based PNH testing had improved clone detection in all cases of PNH, AA/MDS with PNH clones. The clone size was > 30% in majority of PNH cases whereas in AA/MDS, it was usually < 10% at diagnosis. Hence this newer technique not only increased the sensitivity of PNH clone detection but also proved to be cost-effective.
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Affiliation(s)
| | - Seema Tyagi
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110068 India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110068 India
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110068 India
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Berentsen S, Hill A, Hill QA, Tvedt THA, Michel M. Novel insights into the treatment of complement-mediated hemolytic anemias. Ther Adv Hematol 2019; 10:2040620719873321. [PMID: 31523413 PMCID: PMC6734604 DOI: 10.1177/2040620719873321] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/08/2019] [Indexed: 12/20/2022] Open
Abstract
Complement-mediated hemolytic anemias can either be caused by deficiencies in regulatory complement components or by autoimmune pathogenesis that triggers inappropriate complement activation. In paroxysmal nocturnal hemoglobinuria (PNH) hemolysis is entirely complement-driven. Hemolysis is also thought to be complement-dependent in cold agglutinin disease (CAD) and in paroxysmal cold hemoglobinuria (PCH), whereas warm antibody autoimmune hemolytic anemia (wAIHA) is a partially complement-mediated disorder, depending on the subtype of wAIHA and the extent of complement activation. The pathophysiology, clinical presentation, and current therapies for these diseases are reviewed in this article. Novel, complement-directed therapies are being rapidly developed. Therapeutic terminal complement inhibition using eculizumab has revolutionized the therapy and prognosis in PNH but has proved less efficacious in CAD. Upstream complement modulation is currently being investigated and appears to be a highly promising therapy, and two such agents have entered phase II and III trials. Of these, the anti-C1s monoclonal antibody sutimlimab has shown favorable activity in CAD, while the anti-C3 cyclic peptide pegcetacoplan appears to be promising in PNH as well as CAD, and may also have a therapeutic potential in wAIHA.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, P.O. Box 2170, Haugesund, 5504, Norway
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | - Marc Michel
- Department of Medicine, Henri Mondor Hospital, Université Paris-Est, Assistance Publique Hôpitaux de Paris Creteil, Creteil, France
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Manivannan P, Ahuja A, Pati HP. Diagnosis of Paroxysmal Nocturnal Hemoglobinuria: Recent Advances. Indian J Hematol Blood Transfus 2017; 33:453-462. [PMID: 29075054 PMCID: PMC5640555 DOI: 10.1007/s12288-017-0868-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/21/2017] [Indexed: 11/29/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal hematopoietic stem cell disorder with its protean clinical manifestations. This is due to partial or complete absence of 'glycophosphatidyl-inositol-anchor proteins' (GPI-AP). The main aim of this review is to highlight various diagnostic modalities available, basic principle of each test and recent advances in the diagnosis of PNH. Recently among various tests available, the flow cytometry has become 'the gold standard' for PNH testing. In order to overcome the difficulties encountered by the testing and research laboratories throughout the world, International Clinical Cytometry Society has come up with guidelines regarding the indications for testing, protocol for sample collection, processing, panel of antibodies as well as gating strategies to be used, how to interpret the test and reporting format to be used. It is essential to test at least two GPI-linked markers on at least two different lineages particularly on red cells and granulocytes/monocytes. The fluorescent aerolysin combined with other monoclonal antibodies in multicolour flow cytometry offered an improved assay not only for diagnosis but also for monitoring of PNH clones. It is equally important to diagnose this rare entity with high index of suspicion.
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Affiliation(s)
| | - Ankur Ahuja
- Department of Laboratory Services, Army Hospital for Research and Referral, New Delhi, India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Kim H, Kim IS, Cho SH, Lee HJ, Chang CL, Yoon KT. The first case of paroxysmal nocturnal hemoglobinuria and Budd-Chiari syndrome treated with complement inhibitor eculizumab in Korea. Blood Res 2017; 52:145-148. [PMID: 28698856 PMCID: PMC5503897 DOI: 10.5045/br.2017.52.2.145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/25/2016] [Accepted: 01/03/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hyerim Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Biomedical Research Institute Research Institute, Pusan National University Hospital, Busan, Korea
| | - In-Suk Kim
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Su-Hee Cho
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun Ji Lee
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Chulhun L Chang
- Department of Laboratory Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Ki Tae Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Morado M, Freire Sandes A, Colado E, Subirá D, Isusi P, Soledad Noya M, Belén Vidriales M, Sempere A, Ángel Díaz J, Minguela A, Álvarez B, Serrano C, Caballero T, Rey M, Pérez Corral A, Cristina Fernández Jiménez M, Magro E, Lemes A, Benavente C, Bañas H, Merino J, Castejon C, Gutierrez O, Rabasa P, Vescosi Gonçalves M, Perez-Andres M, Orfao A. Diagnostic screening of paroxysmal nocturnal hemoglobinuria: Prospective multicentric evaluation of the current medical indications. CYTOMETRY PART B-CLINICAL CYTOMETRY 2016; 92:361-370. [PMID: 27598686 DOI: 10.1002/cyto.b.21480] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/29/2016] [Accepted: 09/01/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although consensus guidelines have been proposed in 2010 for the diagnostic screening of paroxysmal nocturnal hemoglobinuria (PNH) by flow cytometry (FCM), so far no study has investigated the efficiency of such medical indications in multicentric vs. reference laboratory settings. METHODS Here we evaluate the efficiency of consensus medical indications for PNH testing in 3,938 peripheral blood samples submitted to FCM testing in 24 laboratories in Spain and one reference center in Brazil. RESULTS Overall, diagnostic screening based on consensus medical indications was highly efficient (14% of PNH+ samples) both in the multicenter setting in Spain (10%) and the reference laboratory in Brazil (16%). The highest frequency of PNH+ cases was observed among patients screened because of bone marrow (BM) failure syndrome (33%), particularly among those with aplastic anemia (AA; 45%) and to a less extent also a myelodysplastic syndrome (MDS; 10%). Among the other individuals studied, the most efficient medical indications for PNH screening included: hemolytic anemia (19%), hemoglobinuria (48%) and unexplained cytopenias (9%). In contrast, only a minor fraction of the patients who had been submitted for PNH testing because of unexplained thrombosis in the absence of cytopenia, were positive (0.4%). CONCLUSIONS In summary, our results demonstrate that the current medical indications for PNH screening by FCM are highly efficient, although improved screening algorithms are needed for patients presenting with thrombosis and normal blood cell counts. © 2016 International Clinical Cytometry Society.
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Affiliation(s)
- Marta Morado
- Servicio Hematologia. Hospital Universitario La Paz, Madrid, Spain
| | - Alex Freire Sandes
- División de Hematología y Citometría de Flujo, Fleury Group, São Paulo, Brazil
| | - Enrique Colado
- Servicio Hematologia. Hospital Central Asturias, Oviedo, Spain
| | - Dolores Subirá
- Servicio Hematologia. Hospital Universitario Guadalajara, Guadalajara, Spain
| | - Paloma Isusi
- Servicio Hematologia. Hospital Basurto, Bilbao, Spain
| | - María Soledad Noya
- Servicio Hematologia. Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - María Belén Vidriales
- Department of Hematology, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Spain; Instituto de Biología Molecular y Celular del Cáncer (CIC-CSIC), Salamanca, Spain
| | - Amparo Sempere
- Servicio Hematologia. Hospital Universitario La Fe, Valencia, Spain
| | - José Ángel Díaz
- Servicio Hematologia. Hospital Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Alfredo Minguela
- Servicio de Inmunologia. Hospital Virgen de la Arrixaca e Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
| | | | | | - Teresa Caballero
- Servicio Hematologia. Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Mercedes Rey
- Laboratorio de Inmunologia, Hospital Donostia, San Sebastián, Spain
| | | | | | - Elena Magro
- Servicio Hematologia. Hospital Universitario Principe de Asturias, Alcalá de Henares, Spain
| | - Angelina Lemes
- Servicio Hematologia. Hospital Universitario Dr. Negrin. Las Palmas de Gran Canaria, Spain
| | - Celina Benavente
- Servicio Hematologia. Hospital Clínico San Carlos, Madrid, Spain
| | - Helena Bañas
- Servicio Hematologia. Hospital San Pedro Alcantara, Caceres, Spain
| | - Juana Merino
- Servicio Inmunologia. Clinica Universitaria de Navarra, Spain
| | | | | | - Pilar Rabasa
- Servicio Hematologia. Hospital San Pedro, Logroño, Spain
| | | | - Martin Perez-Andres
- Cancer Research Centre (IBMCC, USAL-CSIC), Institute for Biomedical Research of Salamanca (IBSAL) and Department of Medicine and Cytometry Service (NUCLEUS Research Support Platform), University of Salamanca (USAL), Salamanca, Spain
| | - Alberto Orfao
- Cancer Research Centre (IBMCC, USAL-CSIC), Institute for Biomedical Research of Salamanca (IBSAL) and Department of Medicine and Cytometry Service (NUCLEUS Research Support Platform), University of Salamanca (USAL), Salamanca, Spain
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Fletcher M, Whitby L, Whitby A, Barnett D. Current international flow cytometric practices for the detection and monitoring of paroxysmal nocturnal haemoglobinuria clones: A UK NEQAS survey. CYTOMETRY PART B-CLINICAL CYTOMETRY 2016; 92:266-274. [PMID: 26934069 DOI: 10.1002/cyto.b.21368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 02/09/2016] [Accepted: 02/25/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Paroxysmal nocturnal haemoglobinuria (PNH) is a rare acquired genetic disorder, with an incidence of approximately 1.3 new cases per million population per year. Evidence from the UK National External Quality Assessment Service for Leucocyte Immunophenotyping (UK NEQAS LI) programme suggested major discrepancies on how PNH testing is undertaken. To investigate this we surveyed laboratories in the UK NEQAS LI PNH programme and report here the findings. METHODS A questionnaire was distributed to all centres registered in UK NEQAS LI flow cytometry programmes (n = 1587). Comprising several subsections, it covered the majority of clinical flow cytometric practices. Participants completed a general section and then the subsections relevant to their laboratory repertoire. One subsection contained 34 questions regarding practices in PNH clone detection. RESULTS A total of 105 laboratories returned results for the PNH section; the results demonstrated lack of consensus in all areas of PNH testing. Variation was seen in gating and testing strategies, sensitivity levels and final reporting of test results. Several incorrect practices were highlighted such as inappropriate antibody selection and failure to wash the red blood cells (RBCs) prior to analysis. CONCLUSION Despite the availability of consensus guidelines there appears to be no agreement in the detection and monitoring of PNH. We found only fourteen centres using methods compatible with the International Clinical Cytometry Society guidelines. Of specific note we found that no two laboratories used the same method. This technical variation could lead to incorrect diagnoses, highlighting the need for better adoption and understanding of consensus practices. © 2016 International Clinical Cytometry Society.
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Affiliation(s)
- Matthew Fletcher
- Department of Haematology, UK NEQAS for Leucocyte Immunophenotyping (UK NEQAS LI), Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Liam Whitby
- Department of Haematology, UK NEQAS for Leucocyte Immunophenotyping (UK NEQAS LI), Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Alison Whitby
- Department of Haematology, UK NEQAS for Leucocyte Immunophenotyping (UK NEQAS LI), Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - David Barnett
- Department of Haematology, UK NEQAS for Leucocyte Immunophenotyping (UK NEQAS LI), Royal Hallamshire Hospital, Sheffield, United Kingdom
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Blockage of CD59 Function Restores Activities of Neutralizing and Nonneutralizing Antibodies in Triggering Antibody-Dependent Complement-Mediated Lysis of HIV-1 Virions and Provirus-Activated Latently Infected Cells. J Virol 2015; 89:9393-406. [PMID: 26136568 DOI: 10.1128/jvi.01614-15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 06/23/2015] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Both HIV-1 virions and infected cells use their surface regulators of complement activation (RCA) to resist antibody-dependent complement-mediated lysis (ADCML). Blockage of the biological function of RCA members, particularly CD59 (a key RCA member that controls formation of the membrane attack complex at the terminal stage of the complement activation cascades via all three activation pathways), has rendered both HIV-1 virions and infected cells sensitive to ADCML mediated by anti-Env antibodies (Abs) or sera/plasma from patients at different stages of viral infection. In the current study, we used the well-characterized anti-HIV-1 neutralizing Abs (nAbs), including 2G12, 2F5, and 4E10, and non-nAbs, including 2.2C, A32, N5-i5, and N12-i15, to investigate whether the enhancement of ADCML by blockage of CD59 function is mediated by nAbs, non-nAbs, or both. We found that all nAbs and two non-nAbs (N5-i5 and A32) strongly reacted to three HIV-1 laboratory strains (R5, X4, and R5/X4), six primary isolates, and provirus-activated ACH-2 cells examined. In contrast, two non-nAbs, 2.2C and N12-i15, reacted weakly and did not react to these targets, respectively. After blockage of CD59 function, the reactive Abs, regardless of their neutralizing activities, significantly enhanced specific ADCML of HIV-1 virions (both laboratory strains and primary isolates) and provirus-activated latently infected cells. The ADMCL efficacy positively correlated with the enzyme-linked immunosorbent assay-reactive intensity of those Abs with their targets. Thus, blockage of RCA function represents a novel approach to restore activities of both nAbs and non-nAbs in triggering ADCML of HIV-1 virions and provirus-activated latently infected cells. IMPORTANCE There is a renewed interest in the potential role of non-nAbs in the control of HIV-1 infection. Our data, for the first time, demonstrated that blockage of the biological function of RCA members rendered both HIV-1 virions and infected cells sensitive to ADCML mediated by not only nAbs but also non-nAbs. Our results are significant in developing novel immune-based approaches to restore the functions of nAbs and non-nAbs in the circulation of HIV-1-infected individuals to specifically target and clear HIV-1 virions and infected cells. Our data also provide new insights into the mechanisms by which HIV-1 virions and infected cells escape Ab-mediated immunity and could aid in the design and/or development of therapeutic HIV-1 vaccines. In addition, a combination of antiretroviral therapy with RCA blockage, provirus activators, and therapeutic vaccines may represent a novel approach to eliminate HIV-1 reservoirs, i.e., the infected cells harboring replication-competent proviruses and residual viremia.
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De Cobelli F, Pezzetti G, Margari S, Esposito A, Giganti F, Agostini G, Del Maschio A. New Insights in Abdominal Pain in Paroxysmal Nocturnal Hemoglobinuria (PNH): A MRI Study. PLoS One 2015; 10:e0122832. [PMID: 25897796 PMCID: PMC4405271 DOI: 10.1371/journal.pone.0122832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/15/2015] [Indexed: 01/22/2023] Open
Abstract
Introduction Abdominal pain in PNH has never been investigated by in-vivo imaging studies. With MRI, we aimed to assess mesenteric vessels flow and small bowel wall perfusion to investigate the ischemic origin of abdominal pain. Materials and Methods Six PNH patients with (AP) and six without (NOP) abdominal pain underwent MRI. In a blinded fashion, mean flow (MF, quantity of blood moving through a vessel within a second, in mL·s-1) and stroke volume (SV, volume of blood pumped out at each heart contraction, in mL) of Superior Mesenteric Vein (SMV) and Artery (SMA), areas under the curve at 60 (AUC60) and 90 seconds (AUC90) and Ktrans were assessed by two operators. Results Mean total perfusion and flow parameters were lower in AP than in NOP group. AUC60: 84.81 ± 11.75 vs. 131.73 ± 18.89 (P < 0.001); AUC90: 102.33 ± 14.16 vs. 152.58 ± 22.70 (P < 0.001); Ktrans: 0.0346 min-1 ± 0.0019 vs. 0.0521 ± 0.0015 (P = 0.093 duodenum, 0.009 jejunum/ileum). SMV: MF 4.67 ml/s ± 0.85 vs. 8.32 ± 2.14 (P = 0.002); SV 3.85 ml ± 0.76 vs. 6.55 ± 1.57 (P = 0.02). SMA: MF 6.95 ± 2.61 vs. 11.2 ± 2.32 (P = 0.07); SV 6.52 ± 2.19 vs. 8.78 ± 1.63 (P = 0.07). We found a significant correlation between MF and SV of SMV and AUC60 (MF:ρ = 0.88, P < 0.001; SV: ρ = 0.644, P = 0.024), AUC90 (MF: ρ = 0.874, P < 0.001; SV:ρ = 0.774, P = 0.003) and Ktrans (MF:ρ = 0.734, P = 0.007; SV:ρ = 0.581, P = 0.047). Conclusions Perfusion and flow MRI findings suggest that the impairment of small bowel blood supply is significantly associated with abdominal pain in PNH.
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Affiliation(s)
- Francesco De Cobelli
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
- * E-mail:
| | - Giulio Pezzetti
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Sergio Margari
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonio Esposito
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesco Giganti
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulia Agostini
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alessandro Del Maschio
- Department of Radiology and Center for Experimental Imaging, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Lan J, Yang K, Byrd D, Hu N, Amet T, Shepherd N, Desai M, Gao J, Gupta S, Sun Y, Yu Q. Provirus activation plus CD59 blockage triggers antibody-dependent complement-mediated lysis of latently HIV-1-infected cells. THE JOURNAL OF IMMUNOLOGY 2014; 193:3577-89. [PMID: 25149467 DOI: 10.4049/jimmunol.1303030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Latently HIV-1-infected cells are recognized as the last barrier toward viral eradication and cure. To purge these cells, we combined a provirus stimulant with a blocker of human CD59, a key member of the regulators of complement activation, to trigger Ab-dependent complement-mediated lysis. Provirus stimulants including prostratin and histone deacetylase inhibitors such as romidepsin and suberoylanilide hydroxamic acid activated proviruses in the latently HIV-1-infected T cell line ACH-2 as virion production and viral protein expression on the cell surface were induced. Romidepsin was the most attractive provirus stimulant as it effectively activated proviruses at nanomolar concentrations that can be achieved clinically. Antiretroviral drugs including two protease inhibitors (atazanavir and darunavir) and an RT inhibitor (emtricitabine) did not affect the activity of provirus stimulants in the activation of proviruses. However, saquinavir (a protease inhibitor) markedly suppressed virus production, although it did not affect the percentage of cells expressing viral Env on the cell surface. Provirus-activated ACH-2 cells expressed HIV-1 Env that colocalized with CD59 in lipid rafts on the cell surface, facilitating direct interaction between them. Blockage of CD59 rendered provirus-activated ACH-2 cells and primary human CD4(+) T cells that were latently infected with HIV-1 sensitive to Ab-dependent complement-mediated lysis by anti-HIV-1 polyclonal Abs or plasma from HIV-1-infected patients. Therefore, a combination of provirus stimulants with regulators of complement activation blockers represents a novel approach to eliminate HIV-1.
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Affiliation(s)
- Jie Lan
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202; Center for AIDS Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Kai Yang
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202; Center for AIDS Research, Indiana University School of Medicine, Indianapolis, IN 46202; Zhejiang Provincial Key Laboratory for Technology and Application of Model Organisms, Wenzhou Medical College, Wenzhou 325035, China
| | - Daniel Byrd
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202; Center for AIDS Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Ningjie Hu
- Zhejiang Provincial Key Laboratory for Technology and Application of Model Organisms, Wenzhou Medical College, Wenzhou 325035, China
| | - Tohti Amet
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202; Center for AIDS Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Nicole Shepherd
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202; Center for AIDS Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Mona Desai
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202; and
| | - Jimin Gao
- Zhejiang Provincial Key Laboratory for Technology and Application of Model Organisms, Wenzhou Medical College, Wenzhou 325035, China
| | - Samir Gupta
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202; and
| | - Yongtao Sun
- Department of Infectious Diseases, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Qigui Yu
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN 46202; Center for AIDS Research, Indiana University School of Medicine, Indianapolis, IN 46202; Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202; and
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Yang HS, Yang M, Li X, Tugulea S, Dong H. Diagnosis of paroxysmal nocturnal hemoglobinuria in peripheral blood and bone marrow with six-color flow cytometry. Biomark Med 2013; 7:99-111. [PMID: 23387491 DOI: 10.2217/bmm.12.80] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Identification of paroxysmal nocturnal hemoglobinuria (PNH) by detecting a glycophosphatidylinositol-anchored defect by flow cytometry is presently the standard method of choice for diagnosing PNH. However, the selection of suitable markers will be critical and significantly affect the determination and quantification of PNH clones in various cell lineages. MATERIALS & METHODS In this study, we investigated the performance of various immunophenotypic markers including CD59, GPHA (a clustered antigen, CD235a), CD33, CD15 and fluorescent aerolysin (FLAER) combined with CD16, CD24 and CD14 in a PNH panel using six-color flow cytometry. RESULTS The results strongly indicate that these markers can collectively and effectively identify and quantify PNH clones in erythrocyte, granulocyte and monocyte populations derived from peripheral blood and bone marrow (BM). A sensitivity threshold as low as 0.01% in identifying PNH clones in erythrocyte and granulocyte populations from peripheral blood is achieved by this panel in a series dilution assay. In addition, a direct side-by-side comparison between BM and peripheral blood from the same patients suggests that the FLAER PNH test is capable of identifying to PNH clones in BM specimens. CONCLUSION The data support the premise that a six-color flow cytometry PNH panel using the combination of CD59, CD235a, CD33, CD15, FLAER, CD16, CD24 and CD14 can enhance and improve the current methods used in diagnosis and management of PNH by specifically identifying PNH clones in the erythrocyte, granulocyte and monocyte population.
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Affiliation(s)
- Hai-Su Yang
- Esoterix Genetic Laboratories LLC, 521 W 57th Street, New York, NY 10019, USA.
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Marinov I, Kohoutová M, Tkáčová V, Lysák D, Holubová M, Stehlíková O, Železníková T, Žontar D, Illingworth A. Intra- and interlaboratory variability of paroxysmal nocturnal hemoglobinuria testing by flow cytometry following the 2012 Practical Guidelines for high-sensitivity paroxysmal nocturnal hemoglobinuria testing. CYTOMETRY PART B-CLINICAL CYTOMETRY 2013; 84:229-36. [DOI: 10.1002/cyto.b.21075] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/06/2012] [Accepted: 12/19/2012] [Indexed: 11/05/2022]
Affiliation(s)
- Iuri Marinov
- Institute of Hematology and Blood Transfusion; Prague; Czech Republic
| | - Martina Kohoutová
- Institute of Hematology and Blood Transfusion; Prague; Czech Republic
| | - Vlasta Tkáčová
- Institute of Hematology and Blood Transfusion; Prague; Czech Republic
| | - Daniel Lysák
- Department of Hematology and Oncology; Charles University Hospital; Pilsen; Czech Republic
| | - Monika Holubová
- Department of Hematology and Oncology; Charles University Hospital; Pilsen; Czech Republic
| | - Olga Stehlíková
- Department of Internal Medicine-Hemato-Oncology; University Hospital Brno; Brno; Czech Republic
| | - Tatiana Železníková
- Department of Hematology and Blood Transfusion; St. Elisabeth Oncology Institute; Bratislava; Slovakia
| | - Darja Žontar
- Department of Hematology; University Medical Center; Ljubljana; Slovenia
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Marinov I, Kohoutová M, Tkáčová V, Pešek A, Čermák J, Cetkovský P. Performance characteristics of consensus approaches for small and minor paroxysmal nocturnal hemoglobinuria clone determination by flow cytometry. Clin Chem Lab Med 2013; 51:2133-9. [DOI: 10.1515/cclm-2013-0251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 06/02/2013] [Indexed: 11/15/2022]
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Thrombin generates previously unidentified C5 products that support the terminal complement activation pathway. Blood 2012; 120:1717-25. [PMID: 22802338 DOI: 10.1182/blood-2012-02-412080] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The coagulation and complement pathways simultaneously promote homeostasis in response to injury but cause tissue damage when unregulated. Mechanisms by which they cooperate are poorly understood. To delineate their interactions, we studied the effects of thrombin and C5 convertase on C5 in purified and plasma-based systems, measuring release of the anaphylatoxin C5a, and generation of C5b, the initial component of the lytic membrane attack complex. Thrombin cleaved C5 poorly at R751, yielding minimal C5a and C5b. However, thrombin efficiently cleaved C5 at a newly identified, highly conserved R947 site, generating previously undescribed intermediates C5(T) and C5b(T). Tissue factor-induced clotting of plasma led to proteolysis of C5 at a thrombin-sensitive site corresponding to R947 and not R751. Combined treatment of C5 with thrombin and C5 convertase yielded C5a and C5b(T), the latter forming a C5b(T)-9 membrane attack complex with significantly more lytic activity than with C5b-9. Our findings provide a new paradigm for complement activation, in which thrombin and C5 convertase are invariant partners, enhancing the terminal pathway via the generation of newly uncovered C5 intermediates. Delineating the molecular links between coagulation and complement will provide new therapeutic targets for diseases associated with excess fibrin deposition and complement activation.
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Ge M, Li X, Shi J, Shao Y, Zheng Y. Clinical features and prognostic factors of Asian patients with paroxysmal nocturnal hemoglobinuria: results from a single center in China. Ann Hematol 2012; 91:1121-8. [PMID: 22281992 DOI: 10.1007/s00277-012-1413-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 01/16/2012] [Indexed: 11/25/2022]
Affiliation(s)
- Meili Ge
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, 288 Nanjing Road, Tianjin, 300020, People's Republic of China
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Krauss JS. The Laboratory Diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH): Update 2010. Lab Med 2012. [DOI: 10.1309/lmr59zn0mfzmgqrb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Kelly R, Richards S, Hillmen P, Hill A. The pathophysiology of paroxysmal nocturnal hemoglobinuria and treatment with eculizumab. Ther Clin Risk Manag 2011; 5:911-21. [PMID: 20011245 PMCID: PMC2789686 DOI: 10.2147/tcrm.s3334] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria is a rare disorder of hemopoietic stem cells. Affected individuals have a triad of clinical associations – intravascular hemolysis, an increased risk of thromboembolism, and bone marrow failure. Most of the symptoms experienced in this disease occur due to the absence of complement regulatory proteins on the surface of the red blood cells. Complement activation is thus not checked and causes destruction of these cells. Eculizumab is a monoclonal antibody treatment which specifically binds to the complement protein C5, preventing its cleavage, and so halts the complement cascade and prevents the formation of the terminal complement proteins. Eculizumab prevents intravascular hemolysis, stabilizes hemoglobin levels, reduces or stops the need for blood transfusions, and improves fatigue and patient quality of life as well as reducing pulmonary hypertension, decreasing the risk of thrombosis and protecting against worsening renal function. It is not a curative therapy but has a great benefit on those with this rare debilitating condition.
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Affiliation(s)
- Richard Kelly
- Institute of Oncology, St. James's University Hospital, Leeds, UK
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Abstract
The complement system is an important part of innate immunity; however, as with other parts of the immune system, the complement system can become pathologically activated and create or worsen disease. Anticomplement reagents have been studied for several years, but only recently have they emerged as a viable therapeutic tool. Here, we describe the role of the complement system in a wide array of diseases, as well as the use of anticomplement therapy as treatment for these diseases in animal models and in human clinical trials. Specifically, we will discuss the role of anticomplement therapy in paroxysmal nocturnal hemoglobinuria, glomerulonephritis, and heart disease, including coronary artery disease, myocardial infarction, and coronary revascularization procedures such as percutaneous coronary angioplasty and coronary artery bypass graft surgery.
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Immunohematopoietic stem cell transplantation in Cape Town: a ten-year outcome analysis in adults. Hematol Oncol Stem Cell Ther 2010; 2:320-32. [PMID: 20118055 DOI: 10.1016/s1658-3876(09)50020-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Immunohematopoietic stem cell transplantation has curative potential in selected hematologic disorders. Stem cell transplantation was introduced into South Africa in 1970 as a structured experimental and clinical program. In this report, we summarize the demography and outcome by disease category, gender, and type of procedure in patients older than 18 years of age who were seen from April 1995 to December 2002. PATIENTS AND METHODS This retrospective analysis included 247 individuals over 18 years of age for whom complete data were available. These patients received grafts mostly from peripheral blood with the appropriate stem cell population recovered by apheresis. RESULTS Patient ages ranged from 20 to 65 years with a median age of 42 years. There were 101 females and 146 males. There were no withdrawals and 63% survived to the end of the study. At 96 months of follow-up, a stable plateau was reached for each disease category. Median survival was 3.3 years (n=6, 14.6%) for acute lymphoblastic anemia, 3.1 years (n=44, 18%) for acute myeloid leukemia, 2.8 years (n=47, 19%) for chronic granulocytic leukemia, 2.8 years (n=71, 29%) for lymphoma, 1.5 years (n=23, 9%) for myeloma, 1.43 years (n=10, 4%) for aplasia, and 1.4 years (n=38, 15%) for a miscellaneous group comprising less than 10 examples each. Multivariate analysis showed that only diagnosis and age had a significant impact on survival, but these two variables might be interrelated. There was no significant difference in outcome by source of graft. CONCLUSION The results confirm that procedures carried out in a properly constituted and dedicated unit, which meets established criteria and strictly observes treatment protocols, generate results comparable to those in a First World referral center. Low rates of transplant-related mortality, rejection and graft-versus-host disease are confirmed, but the benefits cannot be extrapolated outside of academically oriented and supervised facilities.
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Borowitz MJ, Craig FE, Digiuseppe JA, Illingworth AJ, Rosse W, Sutherland DR, Wittwer CT, Richards SJ. Guidelines for the diagnosis and monitoring of paroxysmal nocturnal hemoglobinuria and related disorders by flow cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2010; 78:211-30. [PMID: 20533382 DOI: 10.1002/cyto.b.20525] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematopoietic stem cell disorder characterized by a somatic mutation in the PIGA gene, leading to a deficiency of proteins linked to the cell membrane via glycophosphatidylinositol (GPI) anchors. While flow cytometry is the method of choice for identifying cells deficient in GPI-linked proteins and is, therefore, necessary for the diagnosis of PNH, to date there has not been an attempt to standardize the methodology used to identify these cells. METHODS In this document, we present a consensus effort that describes flow cytometric procedures for detecting PNH cells. RESULTS We discuss clinical indications and offer recommendations on data interpretation and reporting but mostly focus on analytical procedures important for analysis. We distinguish between routine analysis (defined as identifying an abnormal population of 1% or more) and high-sensitivity analysis (in which as few as 0.01% PNH cells are detected). Antibody panels and gating strategies necessary for both procedures are presented in detail. We discuss methods for assessing PNH populations in both white blood cells and red blood cells and the relative advantages of measuring each. We present steps needed to validate the more elaborate high-sensitivity techniques, including the need for careful titration of reagents and determination of background rates in normal populations, and discuss technical pitfalls that might affect interpretation. CONCLUSIONS This document should both enable laboratories interested in beginning PNH testing to establish a valid procedure and allow experienced laboratories to improve their techniques.
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Affiliation(s)
- Michael J Borowitz
- Department of Pathology and Oncology, Johns Hopkins Medical Institutions, Baltimore, Maryland 21231, USA.
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Torres J, De Vroey B, Noël MP, Notteghem B, Colombel JF. Recurrent small bowel ischemia in a patient with paroxysmal nocturnal hemoglobinuria. Nat Rev Gastroenterol Hepatol 2010; 7:410-4. [PMID: 20440280 DOI: 10.1038/nrgastro.2010.59] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND A 33-year-old female presented with a history of recurrent epigastric pain and vomiting of bile, accompanied by duodenal wall thickening seen on an abdominal CT scan and a congestive, bluish and ischemic-looking duodenal mucosa as visualized by endoscopy. The patient's medical history was notable for paroxysmal nocturnal hemoglobinuria diagnosed 15 years before. The patient was usually treated with danazol and warfarin and she received regular blood transfusions for hemolytic anemia. INVESTIGATIONS Medical history and physical examination. Blood tests, coagulation study, search for thrombophilic disorders and small vessel vasculitis. Stool culture and virology. Test for autoantibodies. Abdominal CT scan. Upper gastrointestinal endoscopy with duodenal biopsies. DIAGNOSIS Small bowel ischemia complicating paroxysmal nocturnal hemoglobinuria. MANAGEMENT Treatment with warfarin was started but ischemic episodes recurred despite appropriate anticoagulation. Treatment with the complement inhibitor eculizumab was then proposed.
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Affiliation(s)
- Joana Torres
- Clinique des Maladies de l'Appareil Digestif et de la Nutrition, Hôpital Claude Huriez, Rue Michel Polonovski, 59037 Lille Cedex, France
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Hemoglobinuria paroxística nocturna: nuevos tratamientos y recomendaciones generales para su diagnóstico. Med Clin (Barc) 2010; 134:369-74. [DOI: 10.1016/j.medcli.2009.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 09/04/2009] [Accepted: 09/10/2009] [Indexed: 11/20/2022]
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Madkaikar M, Gupta M, Jijina F, Ghosh K. Paroxysmal nocturnal haemoglobinuria: diagnostic tests, advantages, & limitations. Eur J Haematol 2009; 83:503-11. [DOI: 10.1111/j.1600-0609.2009.01338.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Loken MR, Chu SC, Fritschle W, Kalnoski M, Wells DA. Normalization of bone marrow aspirates for hemodilution in flow cytometric analyses. CYTOMETRY PART B-CLINICAL CYTOMETRY 2009; 76:27-36. [DOI: 10.1002/cyto.b.20429] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 02/19/2008] [Accepted: 04/21/2008] [Indexed: 11/11/2022]
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Hernández-Campo PM, Almeida J, Orfao A. Hemoglobinuria paroxística nocturna. Med Clin (Barc) 2008; 131:617-30. [DOI: 10.1157/13127921] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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