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Sakurai K, Saito K, Hatta S, Katsuoka Y, Meguro K, Yokoyama H, Izumi T. Successful haploidentical hematopoietic stem cell transplantation for paroxysmal nocturnal hemoglobinuria with severe pancytopenia developed after long-term aplastic anemia treatment. Clin Case Rep 2024; 12:e8832. [PMID: 38681032 PMCID: PMC11053247 DOI: 10.1002/ccr3.8832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/22/2024] [Accepted: 04/15/2024] [Indexed: 05/01/2024] Open
Abstract
Haploidentical hematopoietic stem cell transplantation (HSCT) with posttransplant cyclophosphamide is an alternative treatment for aplastic anemia-paroxysmal nocturnal hemoglobinuria (PNH) syndrome with poor prognostic factors. Ravulizumab treatment for PNH before HSCT might have a beneficial effect.
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Affiliation(s)
- Kazuki Sakurai
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
- Department of HematologyTohoku University HospitalSendaiJapan
| | - Kei Saito
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
| | - Shunsuke Hatta
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
| | - Yuna Katsuoka
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
| | - Kuniaki Meguro
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
| | - Hisayuki Yokoyama
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
- Department of HematologyTohoku University HospitalSendaiJapan
| | - Toru Izumi
- Department of HematologyNational Hospital Organization Sendai Medical CenterSendaiJapan
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Bodó I, Amine I, Boban A, Bumbea H, Kulagin A, Lukina E, Piekarska A, Zupan IP, Sokol J, Windyga J, Cermak J. Complement Inhibition in Paroxysmal Nocturnal Hemoglobinuria (PNH): A Systematic Review and Expert Opinion from Central Europe on Special Patient Populations. Adv Ther 2023; 40:2752-2772. [PMID: 37072660 PMCID: PMC10112829 DOI: 10.1007/s12325-023-02510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/28/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Hemolysis in paroxysmal nocturnal hemoglobinuria (PNH) is complement-mediated due to the lack of complement inhibitors in the hemopoietic cell membranes, making complement inhibition the best approach to manage PNH. Three complement inhibitors are approved by the European Medicines Agency as targeted therapy for PNH: eculizumab and ravulizumab, two humanized monoclonal antibodies targeting the same complement 5 (C5) epitope, approved in 2007 and 2019, respectively, and the more recently approved cyclic peptide, the complement 3 (C3) inhibitor pegcetacoplan. Although national and international PNH treatment guidelines exist, they do not take into consideration the latest clinical trial evidence. Given the lack of evidence-based data for some clinical situations encountered in real life, we identified specific populations of patients who may benefit from switching to proximal C3 from terminal C5 inhibition. METHODS The expert recommendations presented here were created using a Delphi-like process by a group of expert PNH specialists across Central Europe. Based on an initial advisory board meeting discussion, recommendations were prepared and reviewed as part of a Delphi survey to test agreement. RESULTS Using a systematic approach, literature databases were searched for relevant studies, and 50 articles were reviewed by the experts and included as supporting evidence. CONCLUSION Implementation of these recommendations uniformly across healthcare institutions will promote the best use of complement inhibition in managing PNH, and has the potential to positively impact patient outcomes in Central Europe and worldwide.
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Affiliation(s)
- Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi u., Budapest, 1088, Hungary.
| | - Ismail Amine
- Department of Hematology, Tokuda Hospital Sofia, Sofia, Bulgaria
| | - Ana Boban
- Division of Haematology, Department of Internal Medicine, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Horia Bumbea
- Bone Marrow Transplant Unit, Department of Hematology, Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Alexander Kulagin
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russia
| | - Elena Lukina
- Department of Orphan Diseases, National Research Medical Center for Hematology, Moscow, Russia
| | - Agnieszka Piekarska
- Department of Hematology and Transplantology Medical, University of Gdansk, Gdansk, Poland
| | - Irena Preloznik Zupan
- Department of Hematology, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Juraj Sokol
- Department of Hematology and Transfusion Medicine, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jaroslav Cermak
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
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3
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Panse J. Paroxysmal nocturnal hemoglobinuria: Where we stand. Am J Hematol 2023; 98 Suppl 4:S20-S32. [PMID: 36594182 DOI: 10.1002/ajh.26832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
For the last 20 years, therapy of paroxysmal nocturnal hemoglobinuria (PNH) relied-up until recently-on antibody based terminal complement inhibitionon. PNH pathophysiology-a mutational defect leading to partial or complete absence of complement-regulatory proteins on blood cells-leads to intravascular hemolysis and consequences such as thrombosis and other sequelae. A plethora of new drugs interfering with the proximal and terminal complement cascade are under recent development and the first "proof-of-pinciple" proximal complement inhibitor targeting C3 has been approved in 2021. "PNH: where we stand" will try to give a brief account on where we came from and where we stand focusing on approved therapeutic options. The associated improvements as well as potential consequences of actual and future treatments as well as their impact on the disease will continue to necessitate academic and scientific focus on improving treatment options as well as on side effects and outcomes relevant to individual patient lives and circumstances in order to develop effective, safe, and available treatment for all hemolytic PNH patients globally.
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Affiliation(s)
- Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen Bonn Cologne Düsseldorf (ABCD), Aachen, Germany
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Gavriilaki E, Tragiannidis A, Papathanasiou M, Besikli S, Karvouni P, Douka V, Paphianou E, Hatzipantelis E, Papaioannou G, Athanasiadou A, Marvaki A, Panteliadou AK, Vardi A, Batsis I, Syrigou A, Mallouri D, Lalayanni C, Sakellari I. Aplastic anemia and paroxysmal nocturnal hemoglobinuria in children and adults in two centers of Northern Greece. Front Oncol 2022; 12:947410. [PMID: 36439498 PMCID: PMC9684709 DOI: 10.3389/fonc.2022.947410] [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] [Received: 05/18/2022] [Accepted: 10/17/2022] [Indexed: 09/14/2023] Open
Abstract
Bone marrow failure (BMF) syndromes are a group of various hematological diseases with cytopenia as a main common characteristic. Given their rarity and continuous progress in the field, we aim to provide data considering the efficiency and safety of the therapeutic methods, focusing on the treatment of aplastic anemia(AA) and paroxysmal nocturnal hemoglobinuria (PNH). We enrolled consecutive patients diagnosed with BMF in two referral centers of Northern Greece from 2008 to 2020. We studied 43 patients with AA (37 adults and 6 children/adolescents) and 6 with classical PNH. Regarding classical PNH, 4 patients have received eculizumab treatment with 1/4 presenting extravascular hemolysis. Among 43 patients with aplastic anemia, PNH clones were detected in 11. Regarding patients that did not receive alloHCT (n=15), 14/15 were treated with ATG and cyclosporine as first line, with the addition of eltrombopag in patients treated after its approval (n=9). With a median follow-up of 16.7 (1.8-56.2) months from diagnosis, 12/14 (85.7%) are alive (4-year OS: 85.1%). AlloHCT was performed in 28 patients. Five patients developed TA-TMA which did not resolve in 3/5 (all with a pre-transplant PNH clone). With the follow-up among survivors reaching 86.3 (6.3-262.4) months, 10-year OS was 56.9%, independently associated with PNH clones after adjusting for age (p=0.024). In conclusion, our real-world experience confirms that novel treatments are changing the field of BMF syndromes. Nevertheless, there is still an unmet need to personalize algorithms in this field.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Athanasios Tragiannidis
- 2Paediatric Department, American Hellenic Educational Progressive Association (AHEPA) Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Papathanasiou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Sotiria Besikli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Vassiliki Douka
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Eleni Paphianou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Emmanuel Hatzipantelis
- 2Paediatric Department, American Hellenic Educational Progressive Association (AHEPA) Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Giorgos Papaioannou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anastasia Athanasiadou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anastasia Marvaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Alkistis-Kira Panteliadou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anna Vardi
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioannis Batsis
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Antonia Syrigou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Despina Mallouri
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Chrysavgi Lalayanni
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioanna Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G Papanicolaou Hospital, Thessaloniki, Greece
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Yoo JJ, Chonat S. Evaluating ravulizumab for the treatment of children and adolescents with paroxysmal nocturnal hemoglobinuria. Expert Rev Hematol 2022; 15:385-392. [PMID: 35502699 DOI: 10.1080/17474086.2022.2073215] [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: 11/04/2022]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired clonal stem cell disease harvesting a somatic mutation in the phosphatidylinositol glycan class A (PIG-A) gene. This mutation results in a deficiency in cell membrane complement regulators leading to activation of the terminal complement pathway, clinically presenting as hemolytic anemia and thrombosis, and frequently associated with bone marrow failure. This condition was historically managed with supportive care and bone marrow transplant. AREAS COVERED This paper will review primary data on the pharmacology, efficacy, and safety of ravulizumab in the pediatric/adolescent population gathered from literature search from PubMed, abstracts from annual meetings, and medication package inserts. Eligible clinical trials identified on the clinicaltrials.gov website are also briefly discussed. EXPERT OPINION : The discovery of eculizumab, a monoclonal antibody against complement protein 5, has revolutionized the PNH landscape, with decreased hemolysis and risk of thrombosis, improved quality-of-life, and has become the standard of care. Ravulizumab, a longer-acting C5-inhibitor with 4 times the half-life of eculizumab, was recently approved for pediatric patients with PNH. Ravulizumab is effective, safe, and has the potential to improve quality of life further. In addition, ongoing clinical trials using second-generation complement inhibitors may provide promising new interventions in PNH.
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Affiliation(s)
- Justin J Yoo
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Li L, Liu H, Wang H, Liu Z, Chen Y, Liu C, Zhao X, Li L, Wang H, Shao Z, Fu R. Clinical observation of low-dose combination chemotherapy in refractory/recurrent paroxysmal nocturnal hemoglobinuria patients: A single-center retrospective analysis. J Clin Lab Anal 2022; 36:e24239. [PMID: 35028973 PMCID: PMC8841174 DOI: 10.1002/jcla.24239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We performed a retrospective analysis to investigate the clinical characteristics and therapeutic strategies of 20 refractory/recurrent PNH patients, including the clinical efficacy of chemotherapy treatment, safety, and survival. METHODS The clinical data of 20 classic PNH patients who were refractory/recurrent or had glucocorticoid dependence in our hospital were analyzed, including clinical manifestations, laboratory examinations, treatment efficacy, and survival. RESULTS Seventeen patients had a marked improvement in anemia after chemotherapy, 14 patients acquired blood transfusion independence, and the Hb of 3 patients increased to normal levels. Although 6 patients still needed blood transfusion, the transfusion interval was significantly prolonged. The percentages of LDH, TBIL, and RET, which are indicators of hemolysis, were significantly lower than those before chemotherapy. The dosage of adrenal glucocorticoids was reduced by more than half compared with that before chemotherapy. CONCLUSIONS Chemotherapy can reduce PNH clones, promote normal hematopoiesis, and control hemolytic attack. It is a promising and widely used therapeutic method.
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Affiliation(s)
- Liyan Li
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Hui Liu
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Honglei Wang
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Zhaoyun Liu
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Yingying Chen
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Chunyan Liu
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Xiaoyu Zhao
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Lijuan Li
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Huaquan Wang
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Zonghong Shao
- Department of HematologyTianjin Medical University General HospitalTianjinChina
| | - Rong Fu
- Department of HematologyTianjin Medical University General HospitalTianjinChina
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Garg A, Khanikar D, Shah S, Patel K, Shah K, Raj A, Panchal H, Patel A, Parikh S. Hematopoietic stem cell transplantation in paroxysmal nocturnal hemoglobinuria: Experience from a tertiary care center. JOURNAL OF APPLIED HEMATOLOGY 2022. [DOI: 10.4103/joah.joah_15_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Szlendak U, Krzymieniewska B, Mendek-Czajkowska E, Rogatko-Koroś M, Witkowska A, Włodarska J, Drozd-Sokołowska J, Spychalska J, Budziszewska B, Patkowska E, Woźniak J, Krzywdzińska A, Jurek S, Juszczyński P, Jaworska M, Rosłon M, Gruber-Bzura B, Wasilewski R, Baran B, Windyga J, Nowak J. Persistent imbalance, anti-apoptotic, and anti-inflammatory signature of circulating C-C chemokines and cytokines in patients with paroxysmal nocturnal hemoglobinuria. Cytokine 2021; 150:155780. [PMID: 34896730 DOI: 10.1016/j.cyto.2021.155780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal non-malignant disease in which hematopoietic cell apoptosis may play an important pathophysiological role. Previous studies of the content of phosphatidylinositol (3,4,5)-trisphosphate (PI(3,4,5)P3) indicated the possibility of remote transmission of anti-apoptotic signals between pathological and normal hematopoietic progenitors. METHODS The study determined the plasma levels of beta chemokines and cytokines in N = 19 patients with PNH and 31 healthy controls. The research material was peripheral blood plasma (EDTA) stored at -80 °C until the test. Beta chemokine and cytokine concentrations were tested in duplicate with Bio-Plex Pro Human Cytokine Assay (Bio-Rad, Hercules, CA, USA) using a Luminex 200 flow cytometer and xPONENT software (Luminex Corporation, Austin, TX, USA). In peripheral blood CD34+ cells we tested the proportions of PI(3,4,5)P3+ and Annexin binding apoptotic phenotype using FC and phosflow. RESULTS Compared to the control group, the PNH group showed a significant increase in the plasma concentration of some beta chemokines and cytokines, including MIP-1alpha/CCL3, eotaxin/CCL11, MCP1/CCL2, IL4 and G-CSF. In the group of PNH patients, a significant decrease in the concentration of some cytokines was also observed: RANTES/CCL5, MIP-1beta/CCL4, PDGF-BB and IL9. At the same time, the plasma concentrations of the chemokine IP-10/CXCL10 and the cytokines IFN-gamma, TNF, IL6 and IL10 showed no significant deviations from the values for the control group. Anti-apoptotic phenotype and phosphatidylinositol (3,4,5)-trisphosphate content in PNH clone of CD34+ cells were associated with the level of CCL3 and negatively associated with CCL5, CCL4, PDGF-BB and IL9. CONCLUSIONS This data suggest the existence of apoptotic and PI(3,4,5)P3 imbalance in PNH CD34+ cells driven by anti-apoptotic cytokine biosignature in PNH. Plasma cytokines and intracellular enzymes that regulate the phosphoinositide pathways may become a therapeutic target in PNH.
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Affiliation(s)
- Urszula Szlendak
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Beata Krzymieniewska
- Laboratory of Immunophenotyping, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Ewa Mendek-Czajkowska
- Specialist Outpatient Clinic, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Marta Rogatko-Koroś
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Witkowska
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Joanna Włodarska
- Day Treatment Department, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantology and Internal Medicine, University Clinical Center, Medical University of Warsaw, Warsaw, Poland
| | - Justyna Spychalska
- Department of Hematological and Transfusion Immunology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Bożena Budziszewska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Elżbieta Patkowska
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jolanta Woźniak
- Laboratory of Immunophenotyping, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Krzywdzińska
- Laboratory of Immunophenotyping, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Sławomir Jurek
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Przemysław Juszczyński
- Department of Experimental Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Małgorzata Jaworska
- Department of Biochemistry and Biopharmaceuticals, National Medicines Institute, Warsaw, Poland
| | - Magdalena Rosłon
- Department of Biochemistry and Biopharmaceuticals, National Medicines Institute, Warsaw, Poland
| | - Beata Gruber-Bzura
- Department of Biochemistry and Biopharmaceuticals, National Medicines Institute, Warsaw, Poland
| | - Robert Wasilewski
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Beata Baran
- Department of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jacek Nowak
- Department of Immunogenetics, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.
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Giannotta JA, Fattizzo B, Barcellini W. Paroxysmal Nocturnal Hemoglobinuria in the Context of a Myeloproliferative Neoplasm: A Case Report and Review of the Literature. Front Oncol 2021; 11:756589. [PMID: 34858830 PMCID: PMC8632248 DOI: 10.3389/fonc.2021.756589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by intravascular hemolytic anemia and thrombosis and is notoriously associated with aplastic anemia and myelodysplastic syndromes. Rarer associations include myeloproliferative neoplasms (MPNs), which are also burdened by increased thrombotic tendency. The therapeutic management of this rare combination has not been defined so far. Here, we describe a 62-year-old man who developed a highly hemolytic PNH more than 10 years after the diagnosis of MPN. The patient started eculizumab, obtaining good control of intravascular hemolysis but without amelioration of transfusion-dependent anemia. Moreover, we performed a review of the literature regarding the clinical and pathogenetic significance of the association of PNH and MPN. The prevalence of PNH clones in MPN patients is about 10%, mostly in association with JAK2V617F-positive myelofibrosis. Thrombotic events were a common clinical presentation (35% of subjects), sometimes refractory to combined treatment with cytoreductive agents, anticoagulants, and complement inhibitors. The latter showed only partial effectiveness in controlling hemolytic anemia and, due to the paucity of data, should be taken in consideration after a careful risk/benefit evaluation in this peculiar setting.
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Affiliation(s)
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Graft rejection markers in children undergoing hematopoietic cell transplant for bone marrow failure. Blood Adv 2021; 5:4594-4604. [PMID: 34614507 PMCID: PMC8759133 DOI: 10.1182/bloodadvances.2021005231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022] Open
Abstract
CXCL9, BAFF, and sC5b-9 are potential biomarkers and therapeutic targets for graft rejection after transplant. Fever monitoring is a widely available and informative predictor of graft rejection after transplant.
Graft rejection (GR) is a poorly understood complication of hematopoietic cell transplant (HCT). GR risk factors are well published, but there are no reliable biomarkers or therapies known. Fever is the most common symptom of GR, but no study has evaluated fever kinetics as a diagnostic marker of GR. The objectives of this study were to identify mechanisms, biomarkers, and potential therapies for GR after HCT. Chemokine ligand 9 (CXCL9), B-cell activating factor (BAFF), and complement markers (sC5b-9, C3a, and C5a) were measured in 7 patients with GR and compared with 15 HCT controls. All patients had a diagnosis of aplastic anemia, Fanconi anemia, or genetically undefined chromosomal fragility syndrome. All patients with GR were febrile during GR; therefore, control patients who underwent HCT were matched for diagnosis and early fevers after HCT. Patients withh GR had significantly higher CXCL9, BAFF, and sC5b-9 at the time of fever and GR compared with control patients who underwent HCT at the time of fever. The maximum fever was significantly higher and occurred significantly later in the transplant course in patients with GR compared with febrile HCT controls. These data support the use of CXCL9, BAFF, sC5b-9, and fever kinetics as GR markers. Two patients with GR underwent a second HCT that was complicated by high fevers. Both patients received interferon and complement blockers during their second HCT, and both preserved their graft. These laboratory and clinical findings support larger studies to evaluate the safety and efficacy of interferon, complement, and BAFF inhibitors for the prevention and treatment of GR after HCT.
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Cheng WY, Sarda SP, Mody-Patel N, Krishnan S, Yenikomshian M, Mahendran M, Lejeune D, Yu LH, Duh MS. Real-World Healthcare Resource Utilization (HRU) and Costs of Patients with Paroxysmal Nocturnal Hemoglobinuria (PNH) Receiving Eculizumab in a US Population. Adv Ther 2021; 38:4461-4479. [PMID: 34275086 PMCID: PMC8342328 DOI: 10.1007/s12325-021-01825-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/10/2021] [Indexed: 10/30/2022]
Abstract
INTRODUCTION To evaluate the economic burden and treatment patterns of patients with paroxysmal nocturnal hemoglobinuria (PNH) treated with eculizumab, a C5 inhibitor, who were defined as blood transfusion-dependent (TD) versus blood transfusion-free (TF) in the US population. METHODS Patients aged at least 12 years with at least two claims for eculizumab infusion (first claim was the index date) were identified from the IBM® MarketScan® Research Databases (April 1, 2014-September 30, 2019). The overall PNH eculizumab user cohort was stratified into the TD cohort (i.e., at least one claim for blood transfusion within 6 months following any eculizumab infusion, including on the infusion date) or the TF cohort (i.e., all non-TD patients). Treatment patterns, healthcare resource utilization (HRU), and costs were evaluated and compared during follow-up (i.e., index date to end of enrollment or data availability). RESULTS Of 151 patients in the overall cohort (mean age 36.7 years; 55.6% female), 55 were TD (mean age 35.1 years; 67.3% female) and 96 were TF (mean age 37.6 years; 49.0% female). A total of 61% of patients (TD, 66%; TF, 58%) discontinued eculizumab, with TD patients having a shorter median time to discontinuation (TD, 0.5 years; TF, 0.9 years). TD patients had more all-cause hospitalizations than TF patients (p < 0.05). TD patients incurred higher all-cause direct medical costs (adjusted cost difference = $247,848) and medical-related absenteeism costs (adjusted cost difference = $4186) than TF patients (all p < 0.05), largely driven by hospitalizations. Similar trends were observed for PNH-related HRU and costs. CONCLUSIONS The economic burden of patients with PNH treated with eculizumab is greater among those dependent on blood transfusions.
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Affiliation(s)
- Wendy Y Cheng
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199-7668, USA.
| | - Sujata P Sarda
- Apellis Pharmaceuticals, Inc., 100 5th Avenue, Waltham, MA, 02451, USA
| | - Nikita Mody-Patel
- Apellis Pharmaceuticals, Inc., 100 5th Avenue, Waltham, MA, 02451, USA
| | - Sangeeta Krishnan
- Apellis Pharmaceuticals, Inc., 100 5th Avenue, Waltham, MA, 02451, USA
| | - Mihran Yenikomshian
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199-7668, USA
| | - Malena Mahendran
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Montréal, QC, H3B 0G7, Canada
| | - Dominique Lejeune
- Groupe d'analyse, Ltée, 1190 avenue des Canadiens-de-Montréal, Montréal, QC, H3B 0G7, Canada
| | - Louise H Yu
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199-7668, USA
| | - Mei Sheng Duh
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199-7668, USA
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12
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Du Y, Han B. Advances in Hematopoietic Stem Cell Transplantation for Patients with Paroxysmal Nocturnal Hemoglobinuria. Transplant Cell Ther 2020; 27:301-307. [PMID: 33840442 DOI: 10.1016/j.jtct.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 01/29/2023]
Abstract
In the era of eculizumab, the number of patients with paroxysmal nocturnal hemoglobinuria (PNH) who undergo hematopoietic stem cell transplantation (HSCT) has decreased significantly. However, owing to the possibility of severe aplastic anemia (AA) or a suboptimal response to eculizumab, HSCT still plays an important role in the treatment of patients with PNH combined with AA or recurrent hemolysis-related symptoms despite its high level of risk. Here we review studies involving patients with PNH who underwent HSCT over the past 15 years and conclude that patients with refractory AA/PNH and patients with severe classical PNH are candidates for HSCT in countries where eculizumab is unavailable. The major causes of death from transplantation include graft-versus-host disease (GVHD), infection, and thrombotic microangiopathy. A haploidentical donor is a potential choice for patients without an HLA-matched donor. In addition, the use of eculizumab in combination with HSCT may help prevent GVHD.
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Affiliation(s)
- Yali Du
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences.
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Outcome of allogeneic hematopoietic stem cell transplantation in adult patients with paroxysmal nocturnal hemoglobinuria. Int J Hematol 2020; 113:122-127. [PMID: 32889696 DOI: 10.1007/s12185-020-02982-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/25/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
The safety and efficacy of allogeneic hematopoietic stem cell transplantation (HSCT) for paroxysmal nocturnal hemoglobinuria (PNH) remain unclear. Therefore, we retrospectively analyzed the outcomes of 42 adult patients with PNH who underwent allogeneic HSCT using the registry database of the Japan Society for Hematopoietic Cell Transplantation. The median patient age was 32.5 years. The number of packed red cell (PRC) transfusions was < 20 times in 19 patients and ≥ 20 times in 16; 7 patients had missing data. Stem cell sources were bone marrow (N = 15) or peripheral blood (N = 13) from a related donor or bone marrow (N = 11) and cord blood (N = 3) from an unrelated donor. The cumulative incidence of neutrophil engraftment at day 40 was 81%. Six patients died before engraftment, and the 6-year overall survival (OS) was 74%. The OS of patients with < 20 pretransplant PRC transfusions was significantly higher than that of patients with ≥ 20 pretransplant PRC transfusions (95% vs. 63%; P < 0.05). Moreover, the OS of patients aged < 30 years was significantly higher than that of patients aged ≥ 30 years (90% vs. 59%; P < 0.05). Allogeneic HSCT for PNH could provide favorable survival; however, pretransplant transfusion burden and patient age should be considered when deciding the timing of allogeneic HSCT.
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Allogeneic Hematopoietic Stem Cell Transplantation for Paroxysmal Nocturnal Hemoglobinuria: Multicenter Analysis by the Polish Adult Leukemia Group. Biol Blood Marrow Transplant 2020; 26:1833-1839. [PMID: 32512214 DOI: 10.1016/j.bbmt.2020.05.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/23/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the sole potential cure for paroxysmal nocturnal hemoglobinuria (PNH); however, the data on its utility in PNH are limited. This retrospective analysis of patients with PNH who underwent allo-HSCT in 11 Polish centers between 2002 and 2016 comprised 78 patients with PHN, including 27 with classic PNH (cPNH) and 51 with bone marrow failure-associated PNH (BMF/PNH). The cohort was 59% male, with a median age of 29 years (range, 12 to 65 years). There was a history of thrombosis in 12% and a history of hemolysis in 81%, and 92% required erythrocyte transfusions before undergoing allo-HSCT. No patient received eculizumab, and 26% received immunosuppressive treatment. The median time from diagnosis to allo-HSCT was 12 months (range, 1 to 127 months). Almost all patients (94%) received reduced-toxicity conditioning, 66% with treosulfan. The stem cell source was peripheral blood in 72% and an identical sibling donor in 24%. Engraftment occurred in 96% of the patients. With a median follow-up of 5.1 years in patients with cPNH and 3.2 years in patients with BMF/PNH, 3-year overall survival (OS) was 88.9% in the former and 85.1% in the latter (P = not significant [NS]). The 3-year OS for patients with/without thrombosis was 50%/92% (P = NS) in the cPNH group and 83.3%/85.3% (P = NS) in the BMF/PNH group. The 3-year OS for in the BMF/PNH patients with/without hemolysis was 93.9%/62.9% (hazard ratio, .13; P = .016). No other factors impacted OS. After allo-HSCT, the frequency of the PNH clone was reduced to 0%, <1%, and <2.4% in 48%, 48%, and 4% of cPNH patients and in 84%, 11%, and 5% of BMF/PNH patients, respectively. The frequency of acute graft-versus-host disease (GVHD) grade II-IV was 23%, and the cumulative 1-year incidence of extensive chronic GVHD was 10.8% in the BMF/PNH group and 3.7% in the cPNH group. Allo-HSCT is a valid option for PNH patients, effectively eliminating the PNH clone with satisfactory overall survival and acceptable toxicity. Reduced-toxicity conditioning with treosulfan is effective and safe in patients with cPNH and BMF/PNH.
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Allogeneic Hematopoietic Cell Transplantation in Patients With Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria Clones: Time for a Change. Hemasphere 2020; 4:e345. [PMID: 32309782 PMCID: PMC7162086 DOI: 10.1097/hs9.0000000000000345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/21/2019] [Accepted: 02/03/2020] [Indexed: 11/26/2022] Open
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Successful cord blood transplantation for a paroxysmal nocturnal hemoglobinuria complicated with Budd-Chiari syndrome and myelodysplastic syndrome. Ann Hematol 2019; 98:2427-2428. [PMID: 31399806 DOI: 10.1007/s00277-019-03781-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
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