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Kar S, Kumar CGD, Kar R, Basavarajegowda A. Autoimmune Hemolytic Anemia in Children: Clinical Profile and Outcome. Indian J Pediatr 2024; 91:143-148. [PMID: 36787020 DOI: 10.1007/s12098-022-04469-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/18/2022] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To discover the common triggers for AIHA in children, their clinical profile, treatment response, and outcome. METHODS This was an ambispective descriptive study conducted between 2013 and 2020. Children aged 1 mo to 14 y with hemolytic anemia and a positive direct antiglobulin test (DAT) were included. Children with a positive DAT but without any clinicolaboratory evidence of hemolysis were excluded. Data were collected from a structured pro forma with particulars comprising clinicolaboratory profile, treatment administered, and disease outcome. RESULTS A total of 46 children (aged between 1 mo and 14 y) were enrolled in the study. The mean age of onset was 8.7 (± 4.34) y, and 24 (52.8%) were males. Secondary causes were observed in 29 (63%) cases, while the primary cause was found in 17 (37%). Systemic lupus erythematosus (SLE) was the common trigger in 13 (45%) cases, followed by malignancy in 4 (14%) cases. Pallor (98%), hepatomegaly (72%), and splenomegaly (48%) were the most commonly observed clinical signs. The mixed immunophenotype was observed in 27 (59%) cases, followed by warm type in 12 (26%) and cold agglutinin type in 7 (15%) cases. All children received glucocorticoid therapy, and mycophenolate mofetil was commonly used as second-line therapy in 15 (33%) cases. 13 cases (71%) of primary AIHA and only 4 (14%) cases of secondary anemia achieved complete remission. Overall, 7 children (15%) died, all belonging to secondary AIHA. CONCLUSION Secondary AIHA was more common than primary in the present study, and SLE was the standard trigger. Primary AIHA carries a better prognosis than secondary.
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Affiliation(s)
- Shrutiprajna Kar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - C G Delhi Kumar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Rakhee Kar
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Abhishekh Basavarajegowda
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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2
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Hlavackova E, Krenova Z, Kerekes A, Slanina P, Vlkova M. B cell subsets reconstitution and immunoglobulin levels in children and adolescents with B non-Hodgkin lymphoma after treatment with single anti CD20 agent dose included in chemotherapeutic protocols: single center experience and review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023. [PMID: 37227099 DOI: 10.5507/bp.2023.021] [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: 05/26/2023] Open
Abstract
BACKGROUND RTX, an anti-CD20 monoclonal antibody, added to chemotherapy has proven to be effective in children and adolescents with high-grade, high-risk and matured non-Hodgkin lymphoma. RTX leads to prompt CD19+ B lymphocyte depletion. However, despite preserved immunoglobulin production by long-lived plasmablasts after treatment, patients remain at risk of prolonged hypogammaglobulinemia. Further, there are few general guidelines for immunology laboratories and clinical feature monitoring after B cell-targeted therapies. The aim of this paper is to describe B cell reconstitution and immunoglobulin levels after pediatric B-NHL protocols, that included a single RTX dose and to review the literature. METHODS A retrospective single-center study on the impact of a single RTX dose included in a chemotherapeutic pediatric B Non-Hodgkin Lymphoma (B-NHL) treatment protocols. Immunology laboratory and clinical features were evaluated over an eight hundred days follow-up (FU) period, after completing B-NHL treatment. RESULTS Nineteen patients (fifteen Burkitt lymphoma, three Diffuse large B cell lymphoma, and one Marginal zone B cell lymphoma) fulfilled the inclusion criteria. Initiation of B cell subset reconstitution occurred a median of three months after B-NHL treatment. Naïve and transitional B cells declined over the FU in contrast to the marginal zone and the switched memory B cell increase. The percentage of patients with IgG, IgA, and IgM hypogammaglobulinemia declined consistently over the FU. Prolonged IgG hypogammaglobulinemia was detectable in 9%, IgM in 13%, and IgA in 25%. All revaccinated patients responded to protein-based vaccines by specific IgG antibody production increase. Following antibiotic prophylaxes, none of the patients with hypogammaglobulinemia manifested with either a severe or opportunistic infection course. CONCLUSION The addition of a single RTX dose to the chemotherapeutic treatment protocols was not shown to increase the risk of developing secondary antibody deficiency in B-NHL pediatric patients. Observed prolonged hypogammaglobulinemia remained clinically silent. However interdisciplinary agreement on regular long-term immunology FU after anti-CD20 agent treatment is required.
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Affiliation(s)
- Eva Hlavackova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Zdenka Krenova
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Arpad Kerekes
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Peter Slanina
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marcela Vlkova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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3
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Ibrahim L, Dong SX, O'Hearn K, Grimes AB, Kaicker S, FritchLilla S, Breakey VR, Grace RF, Lebensburger JD, Klaassen RJ, Lambert M. Pediatric refractory immune thrombocytopenia: A systematic review. Pediatr Blood Cancer 2023; 70:e30173. [PMID: 36579787 DOI: 10.1002/pbc.30173] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/30/2022]
Abstract
Pediatric immune thrombocytopenia (ITP) is an acquired disorder associated with autoimmune destruction and impairment of platelet production in children. Some children exhibit poor or transient response to ITP-directed treatments and are referred to as having refractory ITP (rITP). There is currently no consensus on the definition of rITP, nor evidence-based treatment guidelines for patients with rITP. After a survey of pediatric ITP experts demonstrated lack of consensus on pediatric rITP, we pursued a systematic review to examine the reported clinical phenotypes and treatment outcomes in pediatric rITP. The search identified 253 relevant manuscripts; following review, 11 studies proposed a definition for pediatric rITP with no consensus amongst them. Most definitions included suboptimal response to medical management, while some outlined specific platelet thresholds to define this suboptimal response. Common attributes identified in this study should be used to propose a comprehensive definition, which will facilitate outcome comparisons of future rITP studies.
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Affiliation(s)
- Layan Ibrahim
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Selina X Dong
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Katie O'Hearn
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Amanda B Grimes
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hematology Center, Houston, Texas, USA
| | - Shipra Kaicker
- Division of Pediatric Hematology and Oncology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Stephanie FritchLilla
- Cancer and Blood Disorders Program, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Vicky R Breakey
- Division of Pediatric Hematology/Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Robert J Klaassen
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Michele Lambert
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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4
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Calhoun B, Moore A, Dickey A, Shoemaker DM. Systemic loxoscelism induced warm autoimmune hemolytic anemia: clinical series and review. Hematology 2022; 27:543-554. [PMID: 35544675 DOI: 10.1080/16078454.2022.2065086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Describe the development of warm autoimmune hemolytic anemia warm (AIHA) secondary to a brown recluse spider (Loxosceles reclusa) bite is known as systemic loxoscelism; and review epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. METHODS Cases series of two cases of warm AIHA due to systemic loxoscelism and a review of the current literature: epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. RESULTS Presented here are two cases of warm AIHA due to systemic loxoscelism. Each patient was generally healthy appearing and presented with symptomatic anemia in the setting of brown recluse spider bites. Both patients were eventually found to have warm AIHA. Upon recognition of the diagnosis, the patients were started on corticosteroids and aggressive intravenous fluid hydration. In addition, they received transfusions of packed red blood cells. Their clinical courses improved, and they recovered to eventually be discharged home. CONCLUSION Envenomation by a brown recluse spider, Loxosceles reclusa, can result in systemic loxoscelism which can cause warm AIHA. The diagnosis of warm AIHA is confirmed by the direct antiglobulin/Coomb's test. Warm AIHA can be a life-threatening disease process. Hemodynamic support with intravenous fluids and RBC transfusion is the initial step in the management of these patients. Corticosteroids are the mainstay of current management. Second line treatments include rituximab. Rarely patients require splenectomy for refractory disease. Corticosteroids should be tapered over a three-month period.
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Affiliation(s)
- Brandon Calhoun
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Andrew Moore
- SEHealth Cancer Center, SEHealth, Cape Girardeau, MO, USA
| | - Andrew Dickey
- SEHealth Cancer Center, SEHealth, Cape Girardeau, MO, USA
| | - D Matthew Shoemaker
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
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5
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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6
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Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
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Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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Luterbacher F, Bernard F, Baleydier F, Ranza E, Jandus P, Blanchard-Rohner G. Case Report: Persistent Hypogammaglobulinemia More Than 10 Years After Rituximab Given Post-HSCT. Front Immunol 2021; 12:773853. [PMID: 35003091 PMCID: PMC8727997 DOI: 10.3389/fimmu.2021.773853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/26/2021] [Indexed: 12/14/2022] Open
Abstract
Rituximab (RTX) is an anti-CD20 monoclonal antibody that targets B cells-from the immature pre-B-cell stage in the bone marrow to mature circulating B cells-while preserving stem cells and plasma cells. It is used to treat autoimmune diseases, hematological malignancies, or complications after hematopoietic stem cell transplantation (HSCT). Its safety profile is acceptable; however, a subset of patients can develop persistent hypogammaglobulinemia and associated severe complications, especially in pediatric populations. We report the unrelated cases of two young men aged 17 and 22, presenting with persistent hypogammaglobulinemia more than 7 and 10 years after treatment with RTX, respectively, and administered after HSCT for hemolytic anemia and Epstein-Barr virus reactivation, respectively. Both patients' immunological workups showed low levels of total immunoglobulin, vaccine antibodies, and class switched-memory B cells but an increase in naive B cells, which can also be observed in primary immunodeficiencies such as those making up common variable immunodeficiency. Whole exome sequencing for one of the patients failed to detect a pathogenic variant causing a Mendelian immunological disorder. Annual assessments involving interruption of immunoglobulin replacement therapy each summer failed to demonstrate the recovery of endogenous immunoglobulin production or normal numbers of class switched-memory B cells 7 and 10 years after the patients' respective treatments with RTX. Although the factors that may lead to prolonged hypogammaglobulinemia after rituximab treatment (if necessary) remain unclear, a comprehensive immunological workup before treatment and long-term follow-up are mandatory to assess long-term complications, especially in children.
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Affiliation(s)
- Fanny Luterbacher
- The Children’s Hospital, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Fanette Bernard
- Pediatric Hematology/Oncology Unit, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Frédéric Baleydier
- Pediatric Hematology/Oncology Unit, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Emmanuelle Ranza
- Genetic Medicine Division, Geneva University Hospitals, Geneva, Switzerland
- Medigenome, Swiss Institute of Genomic Medicine, Geneva, Switzerland
| | - Peter Jandus
- Immunology and Allergology Division, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Geraldine Blanchard-Rohner
- Pediatric Immunology and Vaccinology Unit, General Pediatrics Division, Department for Women, Children, and Teenagers, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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9
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Ong MS, Rothman D, Barmettler S, Son MB, Lo M, Roberts J, Natter M. New-onset Hypogammaglobulinemia and Infectious Complications Associated with Rituximab Use in Childhood-onset Rheumatic Diseases. Rheumatology (Oxford) 2021; 61:1610-1620. [PMID: 34329428 DOI: 10.1093/rheumatology/keab626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the incidence and risk factors for hypogammaglobulinemia and infectious complications associated with rituximab treatment in childhood-onset rheumatic diseases. METHODS We performed a single-center retrospective study of patients (n = 85) treated at Boston Children's Hospital (BCH) from 2009 to 2019. Study subjects included patients (ages 6 to 24) who received rituximab for the treatment of a childhood-onset rheumatic disease. RESULTS New-onset hypogammaglobulinemia developed in 23 (27.1%) patients within 18 months of rituximab induction treatment. 22 patients (25.9%) developed at least one infectious complication in the 18 months following the first rituximab infusion; of these, 11 (50%) had serious infections requiring inpatient treatment. After adjusting for potential confounders, exposure to pulse corticosteroid therapy in the month prior to rituximab use was a significant predictor of both new-onset hypogammaglobulinemia (OR 3.94; 95% CI 1.07-16.0; p = 0.044) and infectious complications (OR 15.3; 95% CI 3.04-126.8; p = 0.003). Post-rituximab hypogammaglobulinemia was the strongest predictor of serious infectious complications (OR 7.89; 95% CI 1.41-65.6; p = 0.028). Younger age at rituximab use was also a significant predictor of new-onset hypogammaglobulinemia (OR 0.83; 95% CI 0.70-0.97; p = 0.021). Compared with other rheumatic diseases, patients with vasculitis had a higher likelihood of developing infectious complications, including serious infections. CONCLUSION Although rituximab was well tolerated in terms of infectious complications in the majority of patients with childhood-onset rheumatic diseases, a substantial proportion developed new-onset hypogammaglobulinemia and infectious complications following treatment. Our study highlights a role for heightened vigilance of rituximab-associated hypogammaglobulinemia and infections in pediatric patients with rheumatic conditions.
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Affiliation(s)
- Mei Sing Ong
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston MA, United States
| | - Deborah Rothman
- Pediatric Rheumatology, Massachusetts General Hospital, Boston MA, United States
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston MA, United States
| | - Mary Beth Son
- Pediatric Rheumatology, Boston Children's Hospital, Boston MA, United States
| | - Mindy Lo
- Pediatric Rheumatology, Boston Children's Hospital, Boston MA, United States
| | - Jordan Roberts
- Pediatric Rheumatology, Boston Children's Hospital, Boston MA, United States
| | - Marc Natter
- Pediatric Rheumatology, Massachusetts General Hospital, Boston MA, United States.,Computational Health Informatics Program, Boston Children's Hospital, Boston MA, United States.,Department of Pediatrics, Harvard Medical School, Boston MA, United States
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10
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Rituximab-induced hypogammaglobulinemia and infection risk in pediatric patients. J Allergy Clin Immunol 2021; 148:523-532.e8. [PMID: 33862010 DOI: 10.1016/j.jaci.2021.03.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Rituximab is a B-cell depleting agent used in B-cell malignancies and autoimmune diseases. A subset of adult patients may develop prolonged and symptomatic hypogammaglobulinemia following rituximab treatment. However, this phenomenon has not been well delineated in the pediatric population. OBJECTIVES This study sought to determine the prevalence, risk factors, and clinical significance of hypogammaglobulinemia following rituximab therapy in children. METHODS This was a multicenter, retrospective cohort study that extracted clinical and immunological data from pediatric patients who received rituximab. RESULTS The cohort comprised 207 patients (median age, 12.0 years). Compared to baseline values, there was a significant increase in hypogammaglobulinemia post-rituximab therapy, with an increase in prevalence of hypo-IgG (28.7%-42.6%; P = .009), hypo-IgA (11.1%-20.4%; P = .02), and hypo-IgM (20.0%-62.0%; P < .0001). Additionally, low IgG levels at any time post-rituximab therapy were associated with a higher risk of serious infections (34.4% vs 18.9%; odds ratio, 2.3; 95% CI, 1.1-4.8; P = .03). Persistent IgG hypogammaglobulinemia was observed in 27 of 101 evaluable patients (26.7%). Significant risk factors for persistent IgG hypogammaglobulinemia included low IgG and IgA levels pre-rituximab therapy. Nine patients (4.3%) within the study were subsequently diagnosed with a primary immunodeficiency, 7 of which received rituximab for autoimmune cytopenias. CONCLUSIONS Hypogammaglobulinemia post-rituximab treatment is frequently diagnosed within the pediatric population. Low IgG levels are associated with a significant increase in serious infections, and underlying primary immunodeficiencies are relatively common in children receiving rituximab, thus highlighting the importance of immunologic monitoring both before and after rituximab therapy.
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11
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Desai AK, Baloh CH, Sleasman JW, Rosenberg AS, Kishnani PS. Benefits of Prophylactic Short-Course Immune Tolerance Induction in Patients With Infantile Pompe Disease: Demonstration of Long-Term Safety and Efficacy in an Expanded Cohort. Front Immunol 2020; 11:1727. [PMID: 32849613 PMCID: PMC7424004 DOI: 10.3389/fimmu.2020.01727] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/29/2020] [Indexed: 01/19/2023] Open
Abstract
Immune tolerance induction (ITI) with a short-course of rituximab, methotrexate, and/or IVIG in the enzyme replacement therapy (ERT)-naïve setting has prolonged survival and improved clinical outcomes in patients with infantile Pompe disease (IPD) lacking endogenous acid-alpha glucosidase (GAA), known as cross-reactive immunologic material (CRIM)-negative. In the context of cancer therapy, rituximab administration results in sustained B-cell depletion in 83% of patients for up to 26–39 weeks with B-cell reconstitution beginning at approximately 26 weeks post-treatment. The impact of rituximab on serum immunoglobulin levels is not well studied, available data suggest that rituximab can cause persistently low immunoglobulin levels and adversely impact vaccine responses. Data on a cohort of IPD patients who received a short-course of ITI with rituximab, methotrexate, and IVIG in the ERT-naïve setting and had ≥6 months of follow-up were retrospectively studied. B-cell quantitation, ANC, AST, ALT, immunization history, and vaccine titers after B-cell reconstitution were reviewed. Data were collected for 34 IPD patients (25 CRIM-negative and 9 CRIM-positive) with a median age at ERT initiation of 3.5 months (0.1–11.0 months). B-cell reconstitution, as measured by normalization of CD19%, was seen in all patients (n = 33) at a median time of 17 weeks range (11–55 weeks) post-rituximab. All maintained normal CD19% with the longest follow-up being 248 weeks post-rituximab. 30/34 (88%) maintained negative/low anti-rhGAA antibody titers, even with complete B-cell reconstitution. Infections during immunosuppression were reported in five CRIM-negative IPD patients, all resolved satisfactorily on antibiotics. There were no serious sequelae or deaths. Of the 31 evaluable patients, 27 were up to date on age-appropriate immunizations. Vaccine titers were available for 12 patients after B-cell reconstitution and adequate humoral response was observed in all except an inadequate response to the Pneumococcal vaccine (n = 2). These data show the benefits of short-course prophylactic ITI in IPD both in terms of safety and efficacy. Data presented here are from the youngest cohort of patients treated with rituximab and expands the evidence of its safety in the pediatric population.
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Affiliation(s)
- Ankit K Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - Carolyn H Baloh
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - John W Sleasman
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - Amy S Rosenberg
- Division of Biologics Review and Research 3, Office of Biotechnology Products, Center for Drug Evaluation and Research, US FDA, Bethesda, MD, United States
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, United States
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Deyà-Martínez A, Gordón Y, Molina-Anguita C, Vlagea A, Piquer M, Juan M, Esteve-Solé A, Antón J, Madrid Á, García-García A, Plaza AM, Armangue T, Alsina L. Single-cycle rituximab-induced immunologic changes in children: Enhanced in neuroimmunologic disease? NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e724. [PMID: 32376706 PMCID: PMC7217658 DOI: 10.1212/nxi.0000000000000724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/17/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To investigate the immunologic impact of a single cycle of rituximab (RTX) in children and adolescents with immune-mediated disorders, we evaluated B cells and immunoglobulin levels of 20 patients with neuroimmunologic, nephrologic, dermatologic, and rheumatologic disorders treated under recommended guidelines. METHODS Retrospective study of immunologic changes in children (aged ≤18 years) diagnosed with immune-mediated disorders in which RTX was prescribed between June 2014 and February 2019. Patients were excluded if they had prior diagnosis of malignant disease or primary immunodeficiency. Patients were clinically and immunologically followed up every 3 months. Only patients having received a single cycle of RTX and with a follow-up greater than 12 months were included in the analysis of persistent dysgammaglobulinemia. RESULTS Twenty children were included. Median age at RTX treatment was 12.8 years (interquartile range [IQR] 6.6-15.5 years). Median follow-up was 12.6 months (IQR 10.2-24 months). Of the 14 patients eligible for persistent dysgammaglobulinemia analysis (3 had received RTX retreatment, 2 had <12 months post-RTX follow-up, and in 1 data for this time point was missing), 2/14 (14%) remained with complete B-cell depletion, and 5/14 (36%) had dysgammaglobulinemia. Patients with dysgammaglobulinemia were younger (7.8 vs 15.6 years, p = 0.072), had more underlying neuroimmunologic diseases (5/5 vs 0/9, p < 0.001), and had received more frequently concentrated doses of RTX (3/5 vs 1/9, p = 0.05) than patients without dysgammaglobulinemia. Kinetics of immunoglobulins in the 20 patients revealed a decrease as early as 3 months after RTX in patients with neuroimmunologic disorders. CONCLUSION In our cohort, single-cycle RTX-induced dysgammaglobulinemia was enhanced in patients with neuroimmunologic diseases. Further studies are needed to confirm this observation.
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Affiliation(s)
- Angela Deyà-Martínez
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Yadira Gordón
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Cristina Molina-Anguita
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Alexandru Vlagea
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Monica Piquer
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Manel Juan
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Ana Esteve-Solé
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jordi Antón
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Álvaro Madrid
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Ana García-García
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Ana M Plaza
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain
| | - Thaís Armangue
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain.
| | - Laia Alsina
- From the Clinical Immunology and Primary Immunodeficiencies Unit (A.D.-M., A.E.-S., A.G.-G., L.A.), Pediatric Allergy and Clinical Immunology Department (A.D.-M., Y.G., M.P., A.E.-S., A.G.-G., A.M.P., L.A.), Hospital Sant Joan de Déu, Barcelona, Spain; Institut de Recerca Sant Joan de Déu (A.D.-M., Y.G., M.P., A.E.-S., J.A., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic (A.D.-M., A.V., M.P., M.J., A.E.-S., A.G.-G., A.M.P., L.A.), Barcelona, Spain; Universitat de Barcelona (J.A., L.A., M.J.), Spain; Immunology Department (A.V., M.J.), Biomedical Diagnostics Center, Hospital Clinic-IDIBAPS, Barcelona, Spain; Pediatric Neuroimmunology Unit (C.M.-A., T.A.), Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Neuroimmunology Program (T.A.), Institut D'Investigacions Biomèdiques (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain; Pediatric Rheumatology Division (J.A.), Hospital Sant Joan de Déu, Barcelona, Spain; and Pediatric Nephrology Department (Á.M.), Hospital Sant Joan de Déu, Barcelona, Spain.
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Ottaviano G, Marinoni M, Graziani S, Sibson K, Barzaghi F, Bertolini P, Chini L, Corti P, Cancrini C, D'Alba I, Gabelli M, Gallo V, Giancotta C, Giordano P, Lassandro G, Martire B, Angarano R, Mastrodicasa E, Bava C, Miano M, Naviglio S, Verzegnassi F, Saracco P, Trizzino A, Biondi A, Pignata C, Moschese V. Rituximab Unveils Hypogammaglobulinemia and Immunodeficiency in Children with Autoimmune Cytopenia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:273-282. [PMID: 31377437 DOI: 10.1016/j.jaip.2019.07.032] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Rituximab (RTX; anti-CD20 mAb) is a treatment option in children with refractory immune thrombocytopenia, autoimmune hemolytic anemia (AHA), and Evans syndrome (ES). Prevalence and clinical course of RTX-induced hypogammaglobulinemia in these patients are poorly known. OBJECTIVE To evaluate the prevalence and risk factors for persistent hypogammaglobulinemia (PH) after RTX use. METHODS Clinical and immunologic data from children treated with RTX for immune thrombocytopenia, AHA, and ES were collected from 16 Italian centers and 1 UK center at pre-RTX time point (0), +6 months, and yearly, up to 4 years post-RTX. Patients with previously diagnosed malignancy or primary immune deficiency (PID) were excluded. RESULTS We analyzed 53 children treated with RTX for immune thrombocytopenia (n = 36), AHA (n = 13), and ES (n = 4). Median follow-up was 30 months (range, 12-48). Thirty-two percent of patients (17 of 53) experienced PH, defined as IgG levels less than 2 SD for age at last follow-up (>12 months after RTX). Significantly delayed B-cell recovery was observed in children experiencing PH (hazard ratio, 0.55; P < .05), and 6 of 17 (35%) patients had unresolved B-cell lymphopenia at last follow-up. PH was associated with IgA and IgM deficiency, younger age at RTX use (51 vs 116 months; P < .01), a diagnosis of AHA/ES, and better response to RTX. Nine patients with PH (9 of 17 [53%]) were eventually diagnosed with a PID. CONCLUSIONS Post-RTX PH is a frequent condition in children with autoimmune cytopenia; a sizable proportion of patients with post-RTX PH were eventually diagnosed with a PID. In-depth investigation for PID is therefore recommended in these patients.
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Affiliation(s)
| | - Maddalena Marinoni
- Paediatric Department, ASST-Sette Laghi, "F. Del Ponte" Hospital, Varese, Italy
| | - Simona Graziani
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy
| | - Keith Sibson
- Department of Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - Federica Barzaghi
- Paediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Bertolini
- Paediatric Hematology Oncology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Loredana Chini
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy
| | - Paola Corti
- Paediatric Haematology, Fondazione MBBM, Monza, Italy
| | - Caterina Cancrini
- University Department of Pediatrics, Unit of Immune and Infectious Diseases, Childrens' Hospital Bambino Gesù, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Irene D'Alba
- Paediatric Haematology-Oncology, Maternal Infant Hospital "G. Salesi", Ancona, Italy
| | - Maria Gabelli
- Department of Women's and Children's Health, Pediatric Onco-Hematology Unit, University of Padova, Padova, Italy
| | - Vera Gallo
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy
| | - Carmela Giancotta
- University Department of Pediatrics, Unit of Immune and Infectious Diseases, Childrens' Hospital Bambino Gesù, Rome, Italy
| | - Paola Giordano
- Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Giuseppe Lassandro
- Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Baldassare Martire
- Paediatric Hematology Oncology Unit, "Policlinico-Giovanni XXII" Hospital, University of Bari, Bari, Italy
| | - Rosa Angarano
- Paediatric Hematology Oncology Unit, "Policlinico-Giovanni XXII" Hospital, University of Bari, Bari, Italy
| | | | - Cecilia Bava
- Haematology Unit, IRCCS Istituto "G. Gaslini", Genova, Italy
| | - Maurizio Miano
- Haematology Unit, IRCCS Istituto "G. Gaslini", Genova, Italy
| | - Samuele Naviglio
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Federico Verzegnassi
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Paola Saracco
- Paediatric Haematology, Department of Paediatrics, University Hospital Città della Salute e della Scienza di Torino, Torino, Italy
| | - Antonino Trizzino
- Department of Pediatric Hematology and Oncology, ARNAS Civico Di Cristina and Benfratelli Hospital, Palermo, Italy
| | - Andrea Biondi
- Paediatric Haematology, Milano-Bicocca University, Monza, Italy
| | - Claudio Pignata
- Department of Women's and Children's Health, Pediatric Onco-Hematology Unit, University of Padova, Padova, Italy
| | - Viviana Moschese
- Paediatric Immunopathology and Allergology Unit, Tor Vergata University Hospital, University of Roma Tor Vergata, Rome, Italy
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Primary and Secondary Immune Cytopenias: Evaluation and Treatment Approach in Children. Hematol Oncol Clin North Am 2019; 33:489-506. [PMID: 31030815 DOI: 10.1016/j.hoc.2019.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This review summarizes the evaluation and management of the autoimmune cytopenias, a heterogeneous group of conditions including, but not limited to, autoimmune hemolytic anemia, immune thrombocytopenia, and multilineage disorders in Evans syndrome. These diseases can be challenging to treat and there are limited data comparing second-line therapeutics. The understanding of the molecular cause of these conditions is improving with the goal of advancing therapies and making them more targeted.
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15
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Recommendations on RBC Transfusion Support in Children With Hematologic and Oncologic Diagnoses From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S149-S156. [PMID: 30161070 PMCID: PMC6126910 DOI: 10.1097/pcc.0000000000001610] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and supporting evidence for RBC transfusions in critically ill children with hematologic and oncologic disease from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The hematologic/oncologic subgroup included seven experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS The hematologic/oncologic subgroup developed 14 recommendations (seven clinical, seven research); all achieved greater than 80% agreement. In patients with sickle cell disease, Transfusion and Anemia Expertise Initiative recommends: 1) RBC transfusion to achieve a target hemoglobin concentration of 10 g/dL rather than hemoglobin of less than 30% prior to surgical procedures requiring general anesthesia and 2) exchange transfusion over simple (nonexchange) transfusion if the child's condition is deteriorating (based on clinical judgment), otherwise a simple, nonexchange RBC transfusion is recommended. There is insufficient evidence to make recommendations on transfusion thresholds for patients with sickle cell disease prior to minor procedures, with acute stroke or with pulmonary hypertension. For patients with oncologic disease or undergoing hematopoietic stem cell transplant, a hemoglobin concentration of 7-8 g/dL is recommended. Due to lack of evidence, research is needed to clarify the appropriate transfusion thresholds in these patients. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed specific pediatric recommendations regarding RBC transfusion management in critically ill children with sickle cell disease, oncologic disease, and hematopoietic stem cell transplant and recommendations to help guide future research priorities.
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Anti-CD20 Treatment of Autoimmune Hemolytic Anemia Refractory to Corticosteroids and Azathioprine: A Pediatric Case Report and Mini Review. Case Rep Hematol 2018; 2018:8471073. [PMID: 30225153 PMCID: PMC6129358 DOI: 10.1155/2018/8471073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/30/2018] [Indexed: 12/18/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon hematological entity in children and sometimes is characterized by a severe course requiring more than one line course therapy. Treatment decisions depend on the severity and chronicity of the anemia and the characteristics of the autoantibodies. Immunosuppression with corticosteroids is the first-line treatment, especially in warm-reactive AIHA. Refractory cases are treated with immunosuppressive drugs, cytotoxic agents, androgens, or splenectomy, with various side effects and questionable efficacy. Another second-line option is rituximab, an anti-CD20 monoclonal antibody, which has been used as an off-label agent with encouraging results from small limited studies or case reports. Herein, we add our experience on the safety and clinical efficacy of rituximab by presenting the case of a boy with warm-type AIHA resistant to corticosteroids and azathioprine, successfully treated with rituximab. We also offer a review of the relevant literature.
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Second-line therapy in paediatric warm autoimmune haemolytic anaemia. Guidelines from the Associazione Italiana Onco-Ematologia Pediatrica (AIEOP). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:352-357. [PMID: 29757134 DOI: 10.2450/2018.0024-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 02/08/2023]
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18
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Ghrenassia E, Mariotte E, Azoulay E. Rituximab-related Severe Toxicity. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7176228 DOI: 10.1007/978-3-319-73670-9_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Abstract
Primary Evans syndrome (ES) is defined by the concurrent or sequential occurrence of immune thrombocytopenia and autoimmune hemolytic anemia in the absence of an underlying etiology. The syndrome is characterized by a chronic, relapsing, and potentially fatal course requiring long-term immunosuppressive therapy. Treatment of ES is hardly evidence-based. Corticosteroids are the mainstay of therapy. Rituximab has emerged as the most widely used second-line treatment, as it can safely achieve high response rates and postpone splenectomy. An increasing number of new genetic defects involving critical pathways of immune regulation identify specific disorders, which explain cases of ES previously reported as "idiopathic".
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20
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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21
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Ducassou S, Leverger G, Fernandes H, Chambost H, Bertrand Y, Armari-Alla C, Nelken B, Monpoux F, Guitton C, Leblanc T, Fisher A, Lejars O, Jeziorski E, Fouissac F, Lutz P, Pasquet M, Pellier I, Piguet C, Vic P, Bayart S, Marie-Cardine A, Michel M, Perel Y, Aladjidi N. Benefits of rituximab as a second-line treatment for autoimmune haemolytic anaemia in children: a prospective French cohort study. Br J Haematol 2017; 177:751-758. [PMID: 28444729 DOI: 10.1111/bjh.14627] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/31/2016] [Indexed: 11/28/2022]
Abstract
Childhood autoimmune haemolytic anaemia (AIHA) requires second-line immunosuppressive therapy in 30-50% of cases. It appears that rituximab is indicated in such circumstances. This prospective national study reports the practice, efficacy and tolerance of rituximab in children with isolated AIHA and AIHA in the setting of Evans syndrome (ES). Sixty-one children were given rituximab between 2000 and 2014. The median interval from diagnosis to rituximab was 9·9 [interquartile range (IQR) 1·6-28·5] months. Forty-six patients responded (75%) and the 6-year relapse-free survival (RFS) was 48%. Twenty patients relapsed at a median interval of 10·8 (IQR 3·9-18·7) months, rituximab allowed steroid withdrawal in 44/61 (72%) of children. In isolated AIHA, complete response and 6-year RFS were significantly higher than in ES (P < 0·05). Ten out of 61 patients were infants, seven of who responded with a 6-year RFS of 71%. Among patients without immunoglobulin substitution before rituximab, 4 are still receiving substitutions. Five patients died, including one potentially attributable to rituximab. This large observational series of childhood AIHA established the rituximab benefit-risk ratio, allowing steroid withdrawal, with 37% of long-term responders, mainly in isolated AIHA. All subgroups of patients drew benefit. Our long-term results indicate the baseline to be challenged by new treatment approaches.
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Affiliation(s)
- Stéphane Ducassou
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Guy Leverger
- Paediatric Onco-Haematology Unit, Hôpital Trousseau, APHP, Paris, France
| | - Helder Fernandes
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Hervé Chambost
- Paediatric Haematology Unit, Hôpital La Timone Enfants - APHM, Marseille, France
| | - Yves Bertrand
- Paediatric Immuno-Haematology Unit, Institut d'Hématologie et d'Oncologie Pédiatrique (IHOP), Lyon, France
| | | | - Brigitte Nelken
- Paediatrics Unit, University Hospital of Lille, Lille, France
| | - Fabrice Monpoux
- Paediatric Onco-Haematology Unit, University Hospital of Nice, Nice, France
| | - Corinne Guitton
- Paediatrics Unit, University Hospital Bicêtre - APHP, Le Kremlin-Bicêtre, France
| | - Thierry Leblanc
- Haematology Unit, Hôpital Robert Debré - APHP, Paris, France
| | - Alain Fisher
- Immuno-Haematology Unit, Hôpital Necker - APHP, Paris, France
| | - Odile Lejars
- Paediatric Onco-Haematology Unit, University Hospital of Tours, Tours, France
| | - Eric Jeziorski
- Paediatric Onco-Haematology Unit, University Hospital of Montpellier, Montpellier, France
| | - Fanny Fouissac
- Paediatric Onco-Haematology Unit, University Hospital of Nancy, Nancy, France
| | - Patrick Lutz
- Paediatric Onco-Haematology Unit, University Hospital of Strasbourg, Strasbourg, France
| | - Marlène Pasquet
- Paediatric Onco-Haematology Unit, University Hospital of Toulouse, Toulouse, France
| | - Isabelle Pellier
- Paediatric Onco-Haematology Unit, University Hospital of Angers, Angers, France
| | - Christophe Piguet
- Paediatric Onco-Haematology Unit, University Hospital of Limoges, Limoges, France
| | - Philippe Vic
- Paediatric Unit, General Hospital of Quimper, Quimper, France
| | - Sophie Bayart
- Paediatric Onco-Haematology Unit, University Hospital of Rennes, Rennes, France
| | - Aude Marie-Cardine
- Paediatric Onco-Haematology Unit, University Hospital of Rouen, Rouen, France
| | - Marc Michel
- Department of Internal Medicine, Henri Mondor University Hospital, APHP, Université Paris-Est Créteil, Créteil, France
| | - Yves Perel
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Nathalie Aladjidi
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
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Panigrahi A, Clark A, Myers J, Raj A. A novel immunomodulatory treatment involving mycophenolate mofetil and corticosteroids for pediatric autoimmune cytopenias. Pediatr Blood Cancer 2017; 64:287-293. [PMID: 27615037 DOI: 10.1002/pbc.26210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/11/2016] [Accepted: 07/22/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Successful treatment of both pediatric autoimmune hemolytic anemia (AIHA) and immune thrombocytopenic purpura (ITP), specifically those that are refractory to first-line therapies, remains unsatisfactory in terms of long-term remission and medication side effects. Here, we propose a novel combination therapy of mycophenolate mofetil (MMF), an adjunct immunosuppressive, and short-term corticosteroids for the treatment of persistent or chronic autoimmune cytopenias in children. This combination may allow for rapid decrease of steroid usage as well as prolonged count stabilization with minimal toxicity to the patient. PROCEDURE Prospective case series of nine patients, six with persistent or chronic ITP and three with persistent or chronic AIHA, between the ages of 5 and 19 years who are being treated with combination therapy consisting of corticosteroids and MMF. RESULTS All patients with ITP (Patients 4-9) and AIHA (Patients 1-3) met complete response (CR) criteria, as they all initially achieved platelet counts 100 × 109 l-1 or more or hemoglobin level greater than or equal to 10 g/dl, respectively, while on combination therapy and then maintained this level or higher while on MMF alone after steroids were discontinued. CONCLUSIONS Our results are very promising, as MMF appears to be an effective and well-tolerated adjunct immunosuppressant that allows for rapid weaning of steroid usage, minimal adverse side effects to the patients, and long-term stabilization of counts, a goal that has not been achieved successfully with other secondary treatment modalities. Therefore, this novel combination therapy may be an excellent alternative for the treatment of persistent or chronic autoimmune cytopenias in the pediatric population.
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Affiliation(s)
- Arun Panigrahi
- Division of Pediatric Hematology-Oncology, University of Louisville, Louisville, Kentucky
| | - Amy Clark
- University of Louisville School of Medicine, Louisville, Kentucky
| | - John Myers
- University of Louisville School of Medicine, Louisville, Kentucky.,Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Ashok Raj
- Division of Pediatric Hematology-Oncology, University of Louisville, Louisville, Kentucky
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23
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Consolini R, Costagliola G, Spatafora D. The Centenary of Immune Thrombocytopenia-Part 2: Revising Diagnostic and Therapeutic Approach. Front Pediatr 2017; 5:179. [PMID: 28871277 PMCID: PMC5566994 DOI: 10.3389/fped.2017.00179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/07/2017] [Indexed: 01/19/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children and adolescents and can be considered as a paradigmatic model of autoimmune disease. This second part of our review describes the clinical presentation of ITP, the diagnostic approach and overviews the current therapeutic strategies. Interestingly, it suggests an algorithm useful for differential diagnosis, a crucial process to exclude secondary forms of immune thrombocytopenia (IT) and non-immune thrombocytopenia (non-IT), which require a different therapeutic management. Advances in understanding the pathogenesis led to new therapeutic targets, as thrombopoietin receptor agonists, whose role in treatment of ITP will be discussed in this work.
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Affiliation(s)
- Rita Consolini
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Giorgio Costagliola
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Davide Spatafora
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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24
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Ito K, Okamoto M, Inaguma Y, Okamoto A, Ando M, Ando Y, Tsuge M, Tomono A, Kakumae Y, Hayashi T, Yamada S, Emi N. Influence of R-CHOP Therapy on Immune System Restoration in Patients with B-Cell Lymphoma. Oncology 2016; 91:302-310. [PMID: 27682623 DOI: 10.1159/000449251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/18/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the immunosuppressive effect of R-CHOP in patients with B-cell lymphoma at 2 years. METHODS Parameters of humoral and cell-mediated immunity were assessed in 89 patients with diffuse large B-cell lymphoma or follicular lymphoma before and after 6-8 cycles of R-CHOP-14 or R-CHOP-21 regimen. RESULTS Data on pre- and posttreatment serum IgG (sIgG) levels were available for all 89 patients, while the corresponding data on serum CD20+, CD3+, CD4+, and CD8+ lymphocyte counts were available in only 43. Median sIgG levels significantly decreased from 1,221 mg/dl (baseline) to 733 mg/dl (after chemotherapy) (p < 0.001). Although CD20+ and CD4+ cell counts decreased (p < 0.001), no significant effect of chemotherapy on CD3+ and CD8+ cell counts was observed. CD20+ cell counts were restored to baseline levels at the 12-month follow-up. sIgG levels and CD4+ cell counts were not completely restored at 24 months, indicating a sustained immunosuppressive effect of R-CHOP in these patients. The incidence of infections over the 2-year period was 16.3-23.6%. CONCLUSION The immunosuppressive effect of R-CHOP in newly diagnosed cases of B-cell lymphoma tends to persist for >2 years, although sIgG levels were restored more quickly than CD4+ cell counts.
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Affiliation(s)
- Kaori Ito
- Department of Pharmacy, Fujita Health University Hospital, Aichi, Japan
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25
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Abstract
Autoimmune lymphoproliferative syndrome (ALPS) is a disorder of abnormal lymphocyte homeostasis, resulting from mutations in the Fas apoptotic pathway. Clinical manifestations include noninfectious and nonmalignant lymphadenopathy, splenomegaly, and autoimmune pathology-most commonly, autoimmune cytopenias. Rarely, and in association with specific genetic mutations, patients with ALPS may go on to develop secondary lymphoid malignancies. Though ALPS is a rare disorder, it should be suspected and ruled out in children presenting with chronic and refractory multilineage cytopenias associated with nonmalignant lymphoproliferation. Revised diagnostic criteria and insights into disease biology have improved both diagnosis and treatment. Sirolimus and mycophenolate mofetil are the best-studied and most effective corticosteroid-sparing therapies for ALPS, and they should be considered first-line therapy for patients who need chronic treatment. This review highlights practical clinical considerations for diagnosis and management of ALPS.
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26
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Cheng DR, Barton R, Greenway A, Crawford NW. Rituximab and protection from vaccine preventable diseases: applying the evidence to pediatric patients. Expert Rev Vaccines 2016; 15:1567-1574. [PMID: 27216827 DOI: 10.1080/14760584.2016.1193438] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION This article analyses and highlights the challenge of immunization and preventing vaccine preventable diseases in pediatric patients on rituximab. Rituximab is a chimeric anti-CD 20 monoclonal antibody that is an immunosuppressant affecting both cellular and humoral immunity. Children and adolescents on rituximab are at increased risk of infection and vaccine preventable diseases, and require additional strategies to optimize and maximize their protection against such illnesses. Areas covered: This article provides a comprehensive MEDLINE and Pubmed review of existing literature regarding vaccine immunogenicity and safety in patients on rituximab, and assists in providing an evidence base to develop immunization guidelines. Of particular note, the use of live-attenuated vaccines and optimum timing of vaccines post rituximab is considered and discussed. Expert commentary: The increasing use of rituximab in a variety of novel areas within pediatrics must be accompanied by informed discussion around mitigating the risks. These include immunosuppression, and potential susceptibility to infection. Optimizing vaccine status by establishing adequate antibody titers prior to commencement remains the best preventative strategy.
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Affiliation(s)
- Daryl R Cheng
- a General Medicine , The Royal Children's Hospital , Melbourne , VIC , Australia.,b Department of Paediatrics , The University of Melbourne , Melbourne , VIC , Australia.,c SAEFVIC , Murdoch Children's Research Institute , Melbourne , VIC , Australia
| | - Rebecca Barton
- d Haematology Department , The Royal Children's Hospital , Melbourne , VIC , Australia
| | - Anthea Greenway
- d Haematology Department , The Royal Children's Hospital , Melbourne , VIC , Australia.,e Haematology Research Group , Murdoch Children's Research Institute , Melbourne , VIC , Australia
| | - Nigel W Crawford
- a General Medicine , The Royal Children's Hospital , Melbourne , VIC , Australia.,b Department of Paediatrics , The University of Melbourne , Melbourne , VIC , Australia.,c SAEFVIC , Murdoch Children's Research Institute , Melbourne , VIC , Australia
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27
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Rituximab salvage therapy in adults with immune thrombocytopenia: retrospective study on efficacy and safety profiles. Int J Hematol 2016; 104:85-91. [PMID: 27040278 DOI: 10.1007/s12185-016-1992-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/10/2016] [Accepted: 03/15/2016] [Indexed: 01/19/2023]
Abstract
Splenectomy remains the preferred treatment for chronic immune thrombocytopenia (ITP) after corticosteroid failure, despite the risks of despite surgical complications and infection. The aim of this study was to assess the efficacy of and tolerance to rituximab through a retrospective analysis of 35 refractory/relapsing ITP patients treated from 2004 to 2013. The median age of subjects was 46 years (14-80). Rituximab was given at a weekly dose of 375 mg/m(2) for 4 weeks. Median time from diagnosis to first infusion was 17 months (1-362) and follow-up was 47 months (2-133). The overall response rates at 1 and 2 years after the first infusion were 47 and 38 %, with complete response rates of 24 and 25 %, respectively. Median duration of response was 38 months (1-123), with 37 % of patients maintaining a durable response (>1 year). Twenty-nine percent of patients had undergone splenectomy. A durable response after rituximab was more frequently observed in patients undergoing second-line therapy than those in third or later (83 versus 35 %, P = 0.01). Forty-four percent of patients experienced mild hypogammaglobulinaemia after rituximab, and no clinical infection occurred. To conclude, rituximab should be considered as an alternative treatment to splenectomy. Its efficacy and safety profile should lead us to choose this medical option therapy before surgery for ITP patients.
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28
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Abstract
Evans syndrome is an underdiagnosed condition consisting of simultaneous or sequential combination of autoimmune hemolytic anemia and immune-mediated thrombocytopenia. We report a case of severe Evans syndrome presenting as altered mental status, a rare presenting sign of the disease. This case highlights the difficulty in diagnosing Evans syndrome and provides a review of the literature and management strategies for treating the disorder.
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29
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Laribi K, Bolle D, Ghnaya H, Sandu A, Besançon A, Denizon N, Truong C, Pineau-Vincent F, de Materre AB. Rituximab is an effective and safe treatment of relapse in elderly patients with resistant warm AIHA. Ann Hematol 2016; 95:765-9. [PMID: 26858026 DOI: 10.1007/s00277-016-2605-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
Abstract
We evaluated the efficacy and safety of rituximab for the treatment of 23 elderly patients (median age 78 years) with warm autoimmune haemolytic anaemia (AIHA). The median follow-up was 31 months. Patients had received one to five previous treatments. Rituximab was administered by intravenous infusion at a dose of 375 mg/m(2) once weekly for 4 weeks. The OR rate was 86.9 % (CR = 39.1 %, PR = 47.8 %). Median OS was 87 months. The median OS of patients who reached CR could not be calculated, and that of patients with PR was 67 months. At last follow-up, eight of the 20 responding patients, including one patient in CR and seven in PR, had relapsed after a median of 6 months. Failure to achieve CR was a risk factor for relapse (p = 0.028). We did not identify any pretreatment characteristics predictive of response to rituximab. In conclusion, rituximab is an effective treatment for elderly patients with refractory warm AIHA.
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Affiliation(s)
- Kamel Laribi
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France.
| | - Delphine Bolle
- Pharmacy Department, Centre hospitalier, Le Mans, France
| | - Habib Ghnaya
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Andrea Sandu
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Anne Besançon
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Nathalie Denizon
- Department of Haematology, Centre Hospitalier, 194 Avenue Rubillard, 72000, Le Mans, France
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30
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Wallace G, Myers KC, Davies SM, Teusink A, Jodele S. Rapid rituximab infusion is safe in paediatric and young adult patients with non-malignant indications. Br J Haematol 2015. [PMID: 26205134 DOI: 10.1111/bjh.13604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Gregory Wallace
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ashley Teusink
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon disorder caused by autoantibodies directed against self red blood cells. It can be idiopathic or secondary, and classified as warm, cold (cold hemagglutinin disease (CAD) and paroxysmal cold hemoglobinuria) or mixed, according to the thermal range of the autoantibody. AIHA may develop gradually, or have a fulminant onset with life-threatening anemia. The treatment of AIHA is still not evidence-based. The first-line therapy for warm AIHA are corticosteroids, which are effective in 70-85% of patients and should be slowly tapered over a time period of 6-12 months. For refractory/relapsed cases, the current sequence of second-line therapy is splenectomy (effective approx. in 2 out of 3 cases but with a presumed cure rate of up to 20%), rituximab (effective in approx. 80-90% of cases), and thereafter any of the immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporin, mycophenolate mofetil). Additional therapies are intravenous immunoglobulins, danazol, plasma-exchange, and alemtuzumab and high-dose cyclophosphamide as last resort option. As the experience with rituximab evolves, it is likely that this drug will be located at an earlier point in therapy of warm AIHA, before more toxic immunosuppressants, and in place of splenectomy in some cases. In CAD, rituximab is now recommended as first-line treatment.
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Affiliation(s)
- Alberto Zanella
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Reynaud Q, Durieu I, Dutertre M, Ledochowski S, Durupt S, Michallet AS, Vital-Durand D, Lega JC. Efficacy and safety of rituximab in auto-immune hemolytic anemia: A meta-analysis of 21 studies. Autoimmun Rev 2015; 14:304-13. [DOI: 10.1016/j.autrev.2014.11.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/26/2014] [Indexed: 12/21/2022]
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Worch J, Makarova O, Burkhardt B. Immunreconstitution and infectious complications after rituximab treatment in children and adolescents: what do we know and what can we learn from adults? Cancers (Basel) 2015; 7:305-28. [PMID: 25643241 PMCID: PMC4381260 DOI: 10.3390/cancers7010305] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 01/19/2023] Open
Abstract
Rituximab, an anti CD20 monoclonal antibody, is widely used in the treatment of B-cell malignancies in adults and increasingly in pediatric patients. By depleting B-cells, rituximab interferes with humoral immunity. This review provides a comprehensive overview of immune reconstitution and infectious complications after rituximab treatment in children and adolescents. Immune reconstitution starts usually after six months with recovery to normal between nine to twelve months. Extended rituximab treatment results in a prolonged recovery of B-cells without an increase of clinically relevant infections. The kinetic of B-cell recovery is influenced by the concomitant chemotherapy and the underlying disease. Intensive B-NHL treatment such as high-dose chemotherapy followed by rituximab bears a risk for prolonged hypogammaglobulinemia. Overall transient alteration of immune reconstitution and infections after rituximab treatment are acceptable for children and adolescent without significant differences compared to adults. However, age related disparities in the kinetic of immune reconstitution and the definitive role of rituximab in the treatment for children and adolescents with B-cell malignancies need to be evaluated in prospective controlled clinical trials.
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Affiliation(s)
- Jennifer Worch
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, 48149, Germany.
| | - Olga Makarova
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, 48149, Germany.
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, 48149, Germany.
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Vagace JM, Bajo R, Gervasini G. Diagnostic and therapeutic challenges of primary autoimmune haemolytic anaemia in children. Arch Dis Child 2014; 99:668-73. [PMID: 24599068 DOI: 10.1136/archdischild-2013-305748] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Autoimmune haemolytic anaemias (AIHAs) are extracorpuscular haemolytic anaemias produced by antierythrocyte autoantibodies which cause a shortened red blood cell life span. There are several reasons why the diagnosis and treatment of AIHAs in children represent a bigger challenge than in adult patients, including the presence of particular AIHA types, the uncertainty of serological tests and the limited clinical experience. All these facts have added up to a poor understanding and management of some topics in childhood AIHA. We discuss some of these questions, for example, the occurrence of AIHA with negative direct antiglobulin (Coombs) test, the correct diagnosis and actual incidence of paroxysmal cold haemoglobinuria, the most appropriate second-line therapy of AIHA in childhood or the management of transfusion procedures in these patients. This review takes a practical point of view, providing with some ground rules on how to identify and deal with these paediatric patients.
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Matsubara K, Takahashi Y, Hayakawa A, Tanaka F, Nakadate H, Sakai M, Maeda N, Oka T, Ishii E, Bessho F, Morimoto T, Goto H, Hashii Y, Hatakeyama N, Shirahata A, Imaizumi M. Long-term follow-up of children with refractory immune thrombocytopenia treated with rituximab. Int J Hematol 2014; 99:429-36. [PMID: 24609717 DOI: 10.1007/s12185-014-1541-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 01/19/2023]
Abstract
Data on long-term outcomes of children with refractory immune thrombocytopenia (ITP) treated with rituximab are limited. We retrospectively analyzed the long-term effect of rituximab on 22 pediatric ITP patients (11 boys and 11 girls). Compete response (CR) (platelet count ≥100 × 10(9)/L) and partial response (PR) (platelet count 30-99 × 10(9)/L) were achieved in nine (41 %) and two (9 %) patients, respectively. Of the 11 responders, eight subsequently relapsed 2-26 months after initial rituximab treatment. The 5-year relapse-free rate was 14 % (3/22, 95 % confidence interval: 0-27 %) with a median follow-up period of 6.4 years. Five initial responders with subsequent relapse and one non-responder received multiple rituximab treatments of nine courses; all patients responded to the second rituximab therapy without any significant toxicity. All eight patients who relapsed after an initial response and six of 11 non-responders achieved CR or PR with subsequent treatment, including repeated courses of rituximab, splenectomy, steroids, and other immunomodulating agents. Our findings indicated that the sustained effect of rituximab on children with refractory ITP is low, but that the long-term outcome of ITP itself is not poor. Furthermore, repeated rituximab administration may be a promising therapy for those who relapse after an initial response.
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MESH Headings
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antibodies, Monoclonal, Murine-Derived/adverse effects
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Child
- Child, Preschool
- Female
- Follow-Up Studies
- Humans
- Immunologic Factors/administration & dosage
- Immunologic Factors/adverse effects
- Immunologic Factors/therapeutic use
- Infant
- Male
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Recurrence
- Retreatment
- Retrospective Studies
- Rituximab
- Treatment Outcome
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Affiliation(s)
- Kousaku Matsubara
- Department of Pediatrics, Nishi-Kobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, 651-2273, Japan,
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B-Cell Targeted Therapies in Autoimmune Cytopenias and Thrombosis. MILESTONES IN DRUG THERAPY 2014. [PMCID: PMC7123699 DOI: 10.1007/978-3-0348-0706-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ever since the advent of Rituximab and subsequently the emergence of other compounds targeting B cells, a cornucopia of medical applications have been found for this family of compounds. After their establishment as standard of care in many conditions such as rituximab in lymphoma and rheumatoid arthritis, they have been progressively found to aid in the treatment of many other conditions. This area constituted a fertile area of research in the past 12 years. Physicians have investigated the B-cell depleting agents use in cases of autoimmune hematologic cytopenias such as immune thrombocytopenia, Evans syndrome, cold and warm autoimmune hemolytic anemia, and other thrombophilic disorders such as the antiphospholipid syndrome and thrombocytopenic purpura. This chapter presents a historical perspective reviewing the various studies that have been published in this field. In addition, it offers a current assessment of the evidence regarding the use of B-cell depleting agents in the aforementioned conditions.
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Abstract
The diagnosis and management of children with autoimmune cytopenias can be challenging. Children can present with immune-mediated destruction of a single-cell lineage or multiple cell lineages, including platelets (immune thrombocytopenia [ITP]), erythrocytes (autoimmune hemolytic anemia), and neutrophils (autoimmune neutropenia). Immune-mediated destruction can be primary or secondary to a comorbid immunodeficiency, malignancy, rheumatologic condition, or lymphoproliferative disorder. Treatment options generally consist of nonspecific immune suppression or modulation. This nonspecific approach is changing as recent insights into disease biology have led to targeted therapies, including the use of thrombopoietin mimetics in ITP and sirolimus for cytopenias associated with autoimmune lymphoproliferative syndrome.
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Birgens H, Frederiksen H, Hasselbalch HC, Rasmussen IH, Nielsen OJ, Kjeldsen L, Larsen H, Mourits-Andersen T, Plesner T, Rønnov-Jessen D, Vestergaard H, Klausen TW, Schöllkopf C. A phase III randomized trial comparing glucocorticoid monotherapyversusglucocorticoid and rituximab in patients with autoimmune haemolytic anaemia. Br J Haematol 2013; 163:393-9. [DOI: 10.1111/bjh.12541] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/27/2013] [Indexed: 12/17/2022]
Affiliation(s)
- Henrik Birgens
- Department of Haematology; Copenhagen University Hospital; Herlev; Denmark
| | | | | | - Inge H. Rasmussen
- Department of Haematology; Aalborg University Hospital; Århus University; Aalborg; Denmark
| | - Ove J. Nielsen
- Department of Haematology; Copenhagen University Hospital; Rigshospitalet; Copenhagen; Denmark
| | - Lars Kjeldsen
- Department of Haematology; Copenhagen University Hospital; Rigshospitalet; Copenhagen; Denmark
| | - Herdis Larsen
- Department of Internal Medicine; Haematology section; Viborg Hospital; Viborg; Denmark
| | | | - Torben Plesner
- Department of Haematology; Vejle Hospital; Vejle; Denmark
| | - Dorthe Rønnov-Jessen
- Department of Internal Medicine; Haematology section; Viborg Hospital; Viborg; Denmark
| | | | - Tobias W. Klausen
- Department of Haematology; Copenhagen University Hospital; Herlev; Denmark
| | - Claudia Schöllkopf
- Department of Haematology; Roskilde University Hospital; Roskilde; Denmark
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Losa Frías V, García Sánchez A, Ortiz Valentín I, González Vicent M, Velasco Arribas M, Madero López L, Sevilla Navarro J. Rituximab en el tratamiento de citopenias autoinmunitarias refractarias a tratamientos convencionales. An Pediatr (Barc) 2013; 78:398-404. [DOI: 10.1016/j.anpedi.2012.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 11/03/2012] [Accepted: 11/05/2012] [Indexed: 01/19/2023] Open
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Transient effect of anti-CD20 therapy in a child with 22q11.2 deletion syndrome and severe steroid refractory cytopenias: a case report. J Pediatr Hematol Oncol 2013; 35:311-4. [PMID: 23612383 DOI: 10.1097/mph.0b013e31828be602] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We report on the development of steroid-refractory recurrent cytopenias in a child with 22q11.2 deletion syndrome. His first hematological complication was autoimmune hemolytic anemia at 3 months of age. Thereafter, he developed severe autoimmune cytopenias of all 3 hematological lineages with poor response to steroids and intravenous immunoglobulin. At the age of 2½ years, a course of anti-CD20 therapy (Rituximab) was given with transient hematological recovery. Because of persistent symptoms, bone marrow transplantation from a matched unrelated donor was performed. Although the data in the use of anti-CD20 therapy in children with 22q11.2 deletion syndrome and autoimmune cytopenias are limited, our experience suggests its potential benefit.
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Kim W, Kim SH, Huh SY, Kong SY, Choi YJ, Cheong HJ, Kim HJ. Reduced antibody formation after influenza vaccination in patients with neuromyelitis optica spectrum disorder treated with rituximab. Eur J Neurol 2013; 20:975-80. [PMID: 23521577 DOI: 10.1111/ene.12132] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 02/04/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Vaccination against infection becomes important in patients with neuromyelitis optica spectrum disorder (NMOSD) because they are at an increased risk of infection due to long-term immunosuppressive therapy. However, it is unclear whether NMOSD patients under immunosuppression therapy show proper antibody formation after vaccination. Thus the antibody formation after influenza A (H1N1) vaccination in patients with NMOSD receiving rituximab was evaluated. METHODS The study enrolled 26 patients with NMOSD, nine with multiple sclerosis and eight healthy controls. The enrolled patients had been treated with rituximab (n = 16), mycophenolate mofetil (n = 5), azathioprine (n = 6) and interferon-β (IFN-β) (n = 8). Antibodies against the H1N1 influenza virus were measured in the serum drawn just before (T0) and between 3 and 5 weeks after (T1) vaccination. The immunization states for hepatitis B virus surface antigen, measles and tetanus during the treatment period were also tested. RESULTS The rituximab group showed significantly lower geometric mean titer, seroprotection rate and mean fold increase than the azathioprine group, IFN-β group and healthy controls, and a lower seroconversion rate than the IFN-β group. This decrease in vaccination efficacy was also shown in patients receiving mycophenolate mofetil. The immunization state for hepatitis B virus surface antigen, measles and tetanus remained the same during the treatment period with each drug, suggesting that these treatments do not affect previously formed immunity. CONCLUSION This study shows a severely hampered humoral immune response to H1N1 influenza vaccine in patients with NMOSD treated with rituximab, although the vaccination itself is safe in these patients.
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Affiliation(s)
- W Kim
- Department of Neurology, The Catholic University of Korea, Seoul, Korea.
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Gokcebay DG, Tavil B, Fettah A, Yarali N, Azik FM, Tunc B. Evaluation of children with chronic immune thrombocytopenic purpura and Evans syndrome treated with rituximab. Clin Appl Thromb Hemost 2012; 19:663-7. [PMID: 22815318 DOI: 10.1177/1076029612451649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The primary objective was to evaluate the response rate of rituximab therapy for children with chronic immune thrombocytopenic purpura (ITP) and Evans syndrome (ES) and immune reconstitution of these children after rituximab therapy. Eleven patients with chronic ITP and 2 with ES between 6 and 18 years of age and platelet count less than 20 × 10(9)/L received rituximab. Overall response (OR) was defined as an increase in platelet count above 50 × 10(9)/L. The mean age of 13 children (9 girls, 4 boys) was 11.2 ± 3.8 years (6-18). One of the patients with ES had been splenectomized; others were not. The patients mean follow-up time was 10.3 ± 9.3 months after rituximab therapy. Two patients achieved complete response, 4 patients achieved partial response, and OR rate was 46% (6 of 13) after therapy. Seven patients have no response. In conclusion, rituximab may be considered prior to splenectomy in children with chronic ITP and ES with an acceptable toxicity profile.
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Affiliation(s)
- D G Gokcebay
- 1Department of Pediatric Hematology, Ankara Children's Hematology and Oncology Hospital, Diskapi, Ankara, Turkey
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Pranzatelli MR, Tate ED, Shenoy S, Travelstead AL. Ofatumumab for a rituximab-allergic child with chronic-relapsing paraneoplastic opsoclonus-myoclonus. Pediatr Blood Cancer 2012; 58:988-91. [PMID: 21618414 DOI: 10.1002/pbc.23187] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/08/2011] [Indexed: 12/25/2022]
Abstract
Ofatumumab is a fully human anti-CD20 monoclonal antibody in phase II-III trials for various autoimmune and lymphoreticular diseases. We used it to treat a rituximab-allergic child with severe, chronic-relapsing, opsoclonus-myoclonus syndrome (OMS), characterized by persistent cerebrospinal fluid (CSF) B-cell expansion and T-cell dysregulation. He had relapsed despite chemotherapy, plasma exchange with immunoadsorption, and resection of ganglioneuroblastoma, detected 3 years after OMS onset. The four ofatumumab infusions (1,195 mg/m(2) total dose) were well tolerated, and CSF B-cell expansion was eliminated. No further relapses have occurred in 3 years, but he remains on low-dose ACTH with neuropsychiatric residuals of OMS.
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44
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Rituximab in steroid refractory autoimmune hemolytic anemia. Indian J Pediatr 2012; 79:803-5. [PMID: 21830023 DOI: 10.1007/s12098-011-0544-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 07/15/2011] [Indexed: 01/19/2023]
Abstract
Autoimmune hemolytic anemia is rare in children and infants and steroids are the corner stone of therapy. Management of the patients with steroid refractory/dependent disease is difficult .Rituximab is being used in the treatment of a variety of autoimmune diseases including Autoimmune hemolytic anemia (AIHA),especially in adults but there is scarce data regarding the use of this agent in pediatric AIHA patients.The authors report two cases of steroid refractory AIHA, who responded to rituximab with review the literature of its use in pediatrics.
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45
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Rituximab for children with immune thrombocytopenia: a systematic review. PLoS One 2012; 7:e36698. [PMID: 22666325 PMCID: PMC3364261 DOI: 10.1371/journal.pone.0036698] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 04/05/2012] [Indexed: 01/19/2023] Open
Abstract
Background Rituximab has been widely used off-label as a second line treatment for children with immune thrombocytopenia (ITP). However, its role in the management of pediatric ITP requires clarification. To understand and interpret the available evidence, we conducted a systematic review to assess the efficacy and safety of rituximab for children with ITP. Methodology/Principal Findings We searched MEDLINE, EMBASE, Cochrane Library, CBM, CNKI, abstract databases of American Society of Hematology, American Society of Clinical Oncology and Pediatric Academic Society. Clinical studies published in full text or abstract only in any language that met predefined inclusion criteria were eligible. Efficacy analysis was restricted to studies enrolling 5 or more patients. Safety was evaluated from all studies that reported data of toxicity. 14 studies (323 patients) were included for efficacy assessment in children with primary ITP. The pooled complete response (platelet count ≥100×109/L) and response (platelet count ≥30×109/L) rate after rituximab treatment were 39% (95% CI, 30% to 49%) and 68% (95%CI, 58% to 77%), respectively, with median response duration of 12.8 month. 4 studies (29 patients) were included for efficacy assessment in children with secondary ITP. 11 (64.7%) of 17 patients associated with Evans syndrome achieved response. All 6 patients with systemic lupus erythematosus associated ITP and all 6 patients with autoimmune lymphoproliferative syndrome associated ITP achieved response. 91 patients experienced 108 adverse events associated with rituximab, among that, 91 (84.3%) were mild to moderate, and no death was reported. Conclusions/Significance Randomized controlled studies on effect of rituximab for children with ITP are urgently needed, although a series of uncontrolled studies found that rituximab resulted in a good platelet count response both in children with primary and children secondary ITP. Most adverse events associated with rituximab were mild to moderate, and no death was reported.
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46
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Outcomes 5 years after response to rituximab therapy in children and adults with immune thrombocytopenia. Blood 2012; 119:5989-95. [PMID: 22566601 DOI: 10.1182/blood-2011-11-393975] [Citation(s) in RCA: 242] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Treatments for immune thrombocytopenic purpura (ITP) providing durable platelet responses without continued dosing are limited. Whereas complete responses (CRs) to B-cell depletion in ITP usually last for 1 year in adults, partial responses (PRs) are less durable. Comparable data do not exist for children and 5-year outcomes are unavailable. Patients with ITP treated with rituximab who achieved CRs and PRs (platelets > 150 × 10(9)/L or 50-150 × 10(9)/L, respectively) were selected to be assessed for duration of their response; 72 adults whose response lasted at least 1 year and 66 children with response of any duration were included. Patients had baseline platelet counts < 30 × 10(9)/L; 95% had ITP of > 6 months in duration. Adults and children each had initial overall response rates of 57% and similar 5-year estimates of persisting response (21% and 26%, respectively). Children did not relapse after 2 years from initial treatment whereas adults did. Initial CR and prolonged B-cell depletion predicted sustained responses whereas prior splenectomy, age, sex, and duration of ITP did not. No novel or substantial long-term clinical toxicity was observed. In summary, 21% to 26% of adults and children with chronic ITP treated with standard-dose rituximab maintained a treatment-free response for at least 5 years without major toxicity. These results can inform clinical decision-making.
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Atay D, Oztürk G, Anak S, Devecioğlu O, Unüvar A, Karakaş Z, Ağaoğlu L. Rituximab therapy for refractory autoimmune thrombocytopenia in patients with systemic lupus erythematosus. Turk J Haematol 2012; 29:92-3. [PMID: 24744634 PMCID: PMC3986779 DOI: 10.5505/tjh.2012.26539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 09/19/2011] [Indexed: 01/19/2023] Open
Affiliation(s)
- Didem Atay
- Okmeydani Education and Research Hospital, Department of Pediatric Hematology and Oncology, İstanbul, Turkey
| | - Gülyüz Oztürk
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Sema Anak
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Omer Devecioğlu
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Ayşegül Unüvar
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Zeynep Karakaş
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Leyla Ağaoğlu
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
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48
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Nabhan C, Smith SM, Kahl BS. Maintenance rituximab in follicular non-Hodgkin lymphoma: facts and controversies. Leuk Lymphoma 2011; 53:770-8. [PMID: 21958083 DOI: 10.3109/10428194.2011.628061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The advent of rituximab, a chimeric monoclonal antibody against CD20, has arguably improved and changed the natural history of non-Hodgkin lymphoma and has become an essential component of front-line and relapsed disease treatment strategies. Given its tolerability and long half-life, rituximab has been investigated in the maintenance setting in follicular lymphoma. Several landmark studies have demonstrated improvement in progression-free survival in patients receiving maintenance rituximab compared to those observed. These favorable results were witnessed in front-line and in the relapsed setting using a variety of induction programs such as rituximab monotherapy or chemoimmunotherapy. Importantly, toxicities were predictable and manageable. Despite these encouraging results, many vital and practical questions remain unanswered. In this review, we critically analyze the data that led to the widespread use of maintenance rituximab in follicular lymphoma and attempt to answer the most important questions facing practicing oncologists when deciding on using this approach in their patients.
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Affiliation(s)
- Chadi Nabhan
- Department of Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, USA.
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49
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Pescovitz MD, Torgerson TR, Ochs HD, Ocheltree E, McGee P, Krause-Steinrauf H, Lachin JM, Canniff J, Greenbaum C, Herold KC, Skyler JS, Weinberg A. Effect of rituximab on human in vivo antibody immune responses. J Allergy Clin Immunol 2011; 128:1295-1302.e5. [PMID: 21908031 DOI: 10.1016/j.jaci.2011.08.008] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 07/30/2011] [Accepted: 08/01/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND B-lymphocyte depletion with rituximab has been shown to benefit patients with various autoimmune diseases. We have previously demonstrated that this benefit is also apparent in patients with newly diagnosed type 1 diabetes. OBJECTIVES The effect of rituximab on in vivo antibody responses, particularly during the period of B-lymphocyte depletion, is incompletely determined. This study was designed to assess this knowledge void. METHODS In patients with recent-onset type 1 diabetes treated with rituximab (n = 46) or placebo (n = 29), antibody responses to neoantigen phiX174 during B-lymphocyte depletion and with hepatitis A (as a second neoantigen) and tetanus/diphtheria (as recall antigens) after B-lymphocyte recovery were studied. Anti- tetanus, diphtheria, mumps, measles, and rubella titers were measured before and after treatment by means of ELISA. Antibody titers and percentage IgM versus percentage IgG to phiX174 were measured by means of phage neutralization. B-lymphocyte subsets were determined by means of flow cytometry. RESULTS No change occurred in preexisting antibody titers. Tetanus/diphtheria and hepatitis A immunization responses were protective in the rituximab-treated subjects, although significantly blunted compared with those seen in the controls subjects, when immunized at the time of B-lymphocyte recovery. Anti-phiX174 responses were severely reduced during the period of B-lymphocyte depletion, but with B-lymphocyte recovery, anti-phiX174 responses were within the normal range. CONCLUSIONS During the time of B-lymphocyte depletion, rituximab recipients had a decreased antibody response to neoantigens and significantly lower titers after recall immunization with diphtheria and tetanus toxoid. With recovery, immune responses return toward normal. Immunization during the time of B-lymphocyte depletion, although ineffective, does not preclude a subsequent response to the antigen.
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Affiliation(s)
- Mark D Pescovitz
- Department of Surgery, Indiana University, Indianapolis, IN, USA
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50
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Abstract
Autoimmune lymphoproliferative syndrome (ALPS) represents a failure of apoptotic mechanisms to maintain lymphocyte homeostasis, permitting accumulation of lymphoid mass and persistence of autoreactive cells that often manifest in childhood with chronic nonmalignant lymphadenopathy, hepatosplenomegaly, and recurring multilineage cytopenias. Cytopenias in these patients can be the result of splenic sequestration as well as autoimmune complications manifesting as autoimmune hemolytic anemia, immune-mediated thrombocytopenia, and autoimmune neutropenia. More than 300 families with hereditary ALPS have now been described; nearly 500 patients from these families have been studied and followed worldwide over the last 20 years by our colleagues and ourselves. Some of these patients with FAS mutations affecting the intracellular portion of the FAS protein also have an increased risk of B-cell lymphoma. The best approaches to diagnosis, follow-up, and management of ALPS, its associated cytopenias, and other complications resulting from infiltrative lymphoproliferation and autoimmunity are presented.
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