1
|
Yada N, Zhang Q, Bignotti A, Gralnek SH, Sosnovske D, Hogan K, Ye Z, Zheng L, Zheng XL. Targeting neutrophil extracellular trap accumulation under flow in patients with immune-mediated thrombotic thrombocytopenic purpura. Blood Adv 2024; 8:2536-2551. [PMID: 38513079 PMCID: PMC11131081 DOI: 10.1182/bloodadvances.2023011617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/23/2024] Open
Abstract
ABSTRACT Neutrophil NETosis is a unique form of cell death, characterized by the release of decondensed chromatin and antimicrobial contents to the extracellular space, which is involved in inflammation and thrombosis. However, the role of NETosis in the pathogenesis of immune-mediated thrombotic thrombocytopenic purpura (iTTP) and how a targeted therapy affects the accumulation of neutrophil extracellular traps (NETs) under flow remain unknown. Flow cytometry demonstrated that the percentage of neutrophils undergoing NETosis in whole blood from patients with iTTP on admission was significantly increased, with a concurrent decrease in the capacity of inducible NETosis by shigatoxin. After therapy, the percentage of H3Cit+MPO+ neutrophils was significantly reduced, with an improvement in inducible NETosis in these patients. Additionally, little to no NET and thrombus formation was detected underflow in the whole blood from patients with iTTP when platelet counts were very low, but the NET and thrombus formation was dramatically increased following therapy when platelet counts rose to ≥50 × 109/L or were restored to normal with donor platelets. Similarly, there was no thrombus or NET accumulation under flow in the whole blood from vwf-/- mice, but NET accumulation was significantly higher in Adamts13-/- mice than in wild-type mice. Finally, recombinant ADAMTS13 or caplacizumab (or anfibatide) prevented NET and thrombus formation under flow in whole blood from patients with iTTP or from Adamts13-/- mice. These results indicate that neutrophil NETosis and NET formation depend on platelets and von Willebrand factor (VWF) in iTTP, and a targeted therapy such as recombinant ADAMTS13 or caplacizumab may prevent NET and thrombus formation under flow in iTTP.
Collapse
Affiliation(s)
- Noritaka Yada
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Quan Zhang
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Antonia Bignotti
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Sarah H. Gralnek
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Dennis Sosnovske
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Keenan Hogan
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Zhan Ye
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Liang Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
- Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, KS
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS
- Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, KS
| |
Collapse
|
2
|
Fujimura Y. Hereditary TTP/Upshaw-Schulman syndrome: the ductus arteriosus controls newborn survival. Int J Hematol 2024; 119:532-540. [PMID: 38536644 DOI: 10.1007/s12185-024-03731-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/01/2024] [Accepted: 02/04/2024] [Indexed: 05/05/2024]
Abstract
Hereditary TTP (hTTP), termed Upshaw-Schulman syndrome, is an ultra-rare disorder caused by a severe deficiency of plasma ADAMTS13 activity that allows circulation of ultra-large von Willebrand factor (UL-VWF) multimers. The greatest risk for hTTP is in their first days after birth, when 35-50% of patients will have severe hemolysis, jaundice, and thrombocytopenia. It is often fatal without effective treatment. In utero, fetal blood flowing from the pulmonary artery through the ductus arteriosus (DA) to the aorta is under low-shear-force. At birth, blood flow through the DA reverses to a left-to-right shunt, and the diameter of the DA begins to decrease due to hyper-oxygenated blood and decreased plasma prostaglandin E2. This causes turbulent circulation that unfolds UL-VWF, allowing platelet aggregation. If the DA closes promptly, hTTP newborns survive, but if it remains patent, turbulent circulation persists, triggering microvascular thrombosis. hTTP is commonly diagnosed as hemolytic disease of the fetus and newborn (HDFN) caused by anti-red cell antibodies and treated with exchange blood transfusion, which prevents kernicterus even when the diagnosis of hTTP is missed. The diagnosis of newborn-onset hTTP should be considered because HDFN does not cause severe thrombocytopenia, which might be effectively treated with recombinant ADAMTS13.
Collapse
Affiliation(s)
- Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyo-Cho 840, Kashihara, Nara, Japan.
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Osaka, Japan.
| |
Collapse
|
3
|
Zhang J. Identify the influences of systemic lupus erythematosus on acquired ADAMTS13-deficient thrombotic thrombocytopenic purpura using comprehensive bioinformatics analysis. Lupus 2023; 32:1501-1508. [PMID: 37846867 DOI: 10.1177/09612033231209109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
BACKGROUND The association between acquired ADAMTS13-deficient thrombotic thrombocytopenic purpura (aTTP) and systemic lupus erythematosus (SLE) has been studied; however, the underlying molecular causes remain poorly understood. This research aimed to employ bioinformatics approaches to elucidate potential molecular mechanisms contributing to the pathogenesis of SLE and aTTP. MATERIAL AND METHODS The Gene Expression Omnibus (GEO) database yielded GSE121239 and GSE36418 to get mutual different expression genes (DEGs). Subsequently, DEGs were subjected to process Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis. Then, the DEGs were used for protein-protein interaction (PPI) analysis and screened for hub genes and drugs by the DGIDB drug database. RESULTS A total of 87 DEGs between the SLE and TTP datasets were identified. In the GO and KEGG analyses, DEGs were mainly enriched in the "regulation of transcription by RNA polymerase II" and "signaling pathways regulating pluripotency of stem cells." After a PPI analysis, three hub genes (BMPR2, SMAD5, and ATF2) were identified. Finally, two drugs targeted to ATF2 were predicted by the DGIDB drug database. CONCLUSIONS Three core genes were linked to the molecular pathogenesis of SLE and aTTP, and two drugs may be viable treatments for both diseases.
Collapse
Affiliation(s)
- Jian Zhang
- Department of Hematology, Yueqing City People's Hospital, Yueqing City, China
| |
Collapse
|
4
|
Wang Z, Xu H, Gu B, Jin Y, Wang T, Ma J, Lu Y, Yu X, Zheng B, Zhang Y. Flavorubredoxin, a Candidate Trigger Related to Thrombotic Thrombocytopenic Purpura: Screening of the Complete Genome of a Salmonella enterica Serovar Typhimurium Isolate From an AIDS Case. Front Cell Infect Microbiol 2022; 12:864087. [PMID: 35755834 PMCID: PMC9226561 DOI: 10.3389/fcimb.2022.864087] [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: 01/28/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is one of the two classic thrombotic microangiopathy (TMA) diseases which could be induced by infections. To the best of our knowledge, this is the first report of an acquired immunodeficiency syndrome (AIDS) patient with acquired TTP induced by infection with Salmonella enterica serovar Typhimurium (hereafter, S. Typhimurium) isolate, S. Typhimurium_zhang, which was confirmed by serology and genetic taxonomy. The literature review identified 17 TMA-related genes encoding the candidate triggers, which were searched in the annotated genome sequence of S. Typhimurium_zhang. Anaerobic nitric oxide reductase flavorubredoxin (FlRd), encoded by norV which is related to another TMA, haemolytic uraemic syndrome (HUS), was found in S. Typhimurium_zhang. Basic local alignment search tool (BLAST) analysis revealed that norV and FlRd in S. Typhimurium_zhang, as well as eight S. Typhimurium type strains, have high identity with HUS-related Escherichia coli O157:H7 strain TW14359. Similar results were obtained from the BLAST analysis of 73 S. enterica isolates for congenital TTP which was also previously reported to be triggered by S. enterica. Phylogenetic analysis and amino acid sequence alignment revealed that FlRd was functional and highly conservative on 69 Enterobacteriaceae, including S. Typimurium_zhang and TW14359. In brief, we found norV in the genome of a S. Typhimurium clinical isolate that induced TTP in an AIDS patient. FlRd, the protein encoded by norV, probably triggered the TTP and was highly conservative, functional, and widespread in S. enterica and Enterobacteriaceae. More in vitro and in vivo studies are required to confirm our findings and determine the underlying mechanism.
Collapse
Affiliation(s)
- Zhouhan Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Beiqing Gu
- Department of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Haining, China
| | - Yanqi Jin
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Tianyuan Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jindi Ma
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yingfeng Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaopeng Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yimin Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Haining, China
| |
Collapse
|
5
|
Lee CH, Huang YC, Li SS, Hsu YT, Chen YP, Chen TY. Application of PLASMIC Score in Risk Prediction of Thrombotic Thrombocytopenic Purpura: Real-World Experience From a Tertiary Medical Center in Taiwan. Front Med (Lausanne) 2022; 9:893273. [PMID: 35615090 PMCID: PMC9124890 DOI: 10.3389/fmed.2022.893273] [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: 03/10/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder caused by severe ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) deficiency (activity <10%). Urgent intervention based on the timely evaluation of ADAMTS13 level is crucial to guide optimal therapy. The recently developed PLASMIC score based on seven items allows the rapid identification of patients at high risk for TTP due to severe ADAMTS13 deficiency. This retrospective study included 31 hospitalized patients with suspicious thrombotic microangiopathy in National Cheng Kung University Hospital from December 2016 to July 2021. Data on ADAMTS13 activity and medical and laboratory information were retrieved from medical records. The PLASMIC score could be calculated in 24 of the 31 patients with available data, and the final cohort was stratified according to the 7-point PLASMIC score. All patients with high PLASMIC score (6-7) exhibited severe ADAMTS13 deficiency (activity ≤10%). One patient with a brain tumor and a PLASMIC score of 6 did not have severe ADAMTS13 activity of ≤10%. The patients in the intermediate- and low risk groups (PLASMIC scores of 5 and 0-4, respectively) exhibited ADAMTS13 activities of above 10%. Given the role of prompt diagnosis in the timely delivery of appropriate therapy, these findings confirm and strengthen the predictive value of the PLASMIC score in patients at high risk for TTP due to severe ADAMTS13 deficiency.
Collapse
Affiliation(s)
- Chun-Hui Lee
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ching Huang
- Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sin-Syue Li
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ting Hsu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Ping Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsai-Yun Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
6
|
Borborema TS, Diniz SSL, Lima JDS, Costa FF, Murao M, Campos MK. Hereditary thrombotic thrombocytopenic purpura: a case report. Hematol Transfus Cell Ther 2022; 44:269-271. [PMID: 33028508 PMCID: PMC9123582 DOI: 10.1016/j.htct.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 06/23/2020] [Accepted: 08/02/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | | | - Mitiko Murao
- Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG), Belo Horizonte, MG, Brazil
| | - Marcia K Campos
- Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG), Belo Horizonte, MG, Brazil
| |
Collapse
|
7
|
The Efficacy and Safety of Plasma Exchange in the Treatment of Thrombotic Thrombocytopenic Purpura. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:3519937. [PMID: 35399835 PMCID: PMC8989575 DOI: 10.1155/2022/3519937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is a clinically rare thrombotic cardiovascular and microvascular disease. The purpose of this study was to observe the clinical efficacy and safety of plasma exchange in the treatment of TTP. Methods A total of 16 TTP patients who underwent plasma exchange from January 2015 to December 2020 were selected. The clinical data of all patients were collected for retrospective analysis. The effective rate of treatment, the changes of blood cell count before and after treatment, and adverse reactions during treatment were analyzed. Results A total of 50 plasma exchanges were performed in 16 TTP patients. After plasma exchange treatment, there were 4 invalid and 12 improved patients. The total effective rate of plasma exchange in patients with TTP was 75.0%. After treatment, platelet count (PLT) and hemoglobin (Hb) levels were significantly increased in TTP patients. Compared with before treatment, lactate dehydrogenase (LDH), indirect bilirubin (IBIL), total bilirubin (TBIL), and broken red blood cells were significantly reduced. In addition, 3 adverse reactions occurred in 50 plasmapheresis procedures, and the incidence of adverse reactions was 6.0%. Conclusion Plasma exchange therapy has a good therapeutic effect on TTP and can significantly improve abnormal blood cell count in patients with high safety.
Collapse
|
8
|
Hafez W, Ziade MA, Arya A, Saleh H, Ali S, Rao SR, Fdl Alla O, Ali M, Zouhbi MA, Abdelrahman A. Reduced ADAMTS13 Activity in Correlation with Pathophysiology, Severity, and Outcome of COVID-19: A Retrospective Observational Study. Int J Infect Dis 2022; 117:334-344. [PMID: 35167969 PMCID: PMC8839807 DOI: 10.1016/j.ijid.2022.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/27/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Low ADAMTS13 activity has been suggested to be an interplaying factor in the pathogenesis of COVID-19, considering that it is a thromboinflammatory disease with high risk of microthrombosis. OBJECTIVES The study aimed to explore the correlation between ADAMTS13 activity and the pathophysiological pathway of COVID-19. METHODS We carried out a retrospective observational study of 87 patients with COVID-19 in NMC Royal Hospital, Abu Dhabi, UAE. ADAMTS13 activity was measured and compared with patients' characteristics and clinical outcomes. RESULTS Low ADAMTS13 activity was associated with pneumonia (p = 0.007), severity of COVID-19 (p <0.001), and mechanical ventilation rates (p = 0.018). Death was more frequently observed among patients (5 patients) with low ADAMTS13 activity compared with normal activity (1 patient), as well as inflammatory markers. Decreased ADAMTS13 activity increased with the risk of pneumonia, severity of COVID-19, need for mechanical ventilation, and use of anticoagulants ([OR = 4.75, 95% CI 1.54-18.02, p = 0.011], [OR = 6.50, 95% CI 2.57-17.74; p <0.001], [OR = 4.10, 95% CI 1.29-15.82; p = 0.024], [OR = 8.00, 95% CI 3.13-22.16; p <0.001], respectively). The low ADAMTS13 activity group had a slightly longer time to viral clearance than the normal ADAMTS13 activity group, but it was not statistically significant (20 days, 95% CI 16-27 days vs 17 days, 95% CI 13-22 days; p = 0.08; Log rank = 3.1). CONCLUSIONS Low ADAMTS13 activity has been linked to pneumonia, COVID-19 severity, use of anticoagulants, and need for mechanical ventilation but not to mortality. We propose rADAMTS13 as a novel treatment for severe COVID-19.
Collapse
Affiliation(s)
- Wael Hafez
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates; Medical Research Division, Department of Internal Medicine, The National Research Centre, 33 El Buhouth St, Ad Doqi, Dokki, Cairo Governorate 12622, Egypt.
| | - Mohamad Azzam Ziade
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Arun Arya
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Husam Saleh
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Sara Ali
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Srinivasa Raghu Rao
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Osman Fdl Alla
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mohamed Ali
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mouhamad Al Zouhbi
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Ahmed Abdelrahman
- NMC Royal Hospital, 16th Street, Khalifa City, Abu Dhabi, United Arab Emirates; Internal Medicine Department, Zagazig School of medicine, Zagazig, Egypt
| |
Collapse
|
9
|
Annual incidence and severity of acute episodes in hereditary thrombotic thrombocytopenic purpura. Blood 2021; 137:3563-3575. [PMID: 33649760 DOI: 10.1182/blood.2020009801] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/05/2021] [Indexed: 12/15/2022] Open
Abstract
Hereditary thrombotic thrombocytopenic purpura (hTTP) is a rare thrombotic microangiopathy characterized by severe congenital ADAMTS13 deficiency and recurring acute episodes causing morbidity and premature death. Information on the annual incidence and severity of acute episodes in patients with hTTP is largely lacking. This study reports prospective data on 87 patients from the Hereditary TTP Registry (clinicaltrials.gov #NCT01257269) for survival, frequency, and severity of acute episodes from enrollment until December 2019. The 87 patients, followed up for a median of 4.2 years (range, 0.01-15 years), had a median age at overt disease onset and at clinical diagnosis of 4.6 years and 18 years (range, 0.0-70 years for both), respectively. Forty-three patients received regular plasma prophylaxis, whereas 22 did not, and treatment changed over time or was unknown in the remaining 22. Forty-three patients experienced 131 acute episodes, of which 91 (69%) occurred in patients receiving regular prophylaxis. This resulted in an annual incidence of acute episodes of 0.36 (95% confidence interval [CI], 0.29-0.44) with regular plasma treatment and of 0.41 (95% CI, 0.30-0.56) without regular plasma treatment. More than one-third of acute episodes (n = 51) were documented in children <10 years of age at enrollment and were often triggered by infections. Their annual incidence of acute episodes was significantly higher than in patients aged >40 years (1.18 [95% CI, 0.88-1.55] vs 0.14 [95% CI, 0.08-0.23]). The prophylactic plasma infusion regimens used were insufficient to prevent acute episodes in many patients. Such regimens are burdensome, and caregivers, patients, and their guardians are reluctant to start regular plasma infusions, from which children particularly would benefit.
Collapse
|
10
|
Sakai K, Fujimura Y, Miyata T, Isonishi A, Kokame K, Matsumoto M. Current prophylactic plasma infusion protocols do not adequately prevent long-term cumulative organ damage in the Japanese congenital thrombotic thrombocytopenic purpura cohort. Br J Haematol 2021; 194:444-452. [PMID: 34046888 DOI: 10.1111/bjh.17560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 01/02/2023]
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP), known as Upshaw-Schulman syndrome, is an ultrarare thrombotic disorder caused by ADAMTS13 gene mutations; however, its long-term outcomes have not been widely studied. A questionnaire survey was administered to physicians of patients in the Japanese cTTP registry to characterise these outcomes. We analysed 55 patients in remission, with 41 cases receiving prophylactic fresh frozen plasma (FFP; median dosage: 13·2 ml/kg per month) and 14 receiving on-demand FFP. Patients receiving prophylactic FFP were considered as having a more severe form of the disease and had lower platelet counts and higher serum creatinine levels than those receiving on-demand FFP (median 138 × 109 /l vs. 243 × 109 /l, P = 0·003 and 0·71 mg/dl vs 0·58 mg/dl, P = 0·009, respectively). Patients who received prophylactic FFP more commonly developed organ damage, including renal impairment, cerebral infarctions, and cardiac hypofunction, than those who did not. Adverse FFP-related events were seen in 78% of the prophylactic FFP group, with allergic reactions being most common. Since current protocols for FFP administration to the prophylactic FFP group in Japan may be insufficient for preventing cumulative organ damage, a higher dosage of ADAMTS13 supply using recombinant ADAMTS13 agent is needed in these patients.
Collapse
Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan.,Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ayami Isonishi
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| |
Collapse
|
11
|
Wendt R, Kalbitz S, Otto F, Falter T, Beige J, Rossmann H, Lämmle B. Diagnosis of Hereditary TTP Caused by Homozygosity for a Rare Complex ADAMTS13 Allele After Salmonella Infection in a 43-Year-Old Asylum Seeker. Front Med (Lausanne) 2021; 8:639441. [PMID: 33732721 PMCID: PMC7959797 DOI: 10.3389/fmed.2021.639441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/08/2021] [Indexed: 11/21/2022] Open
Abstract
A 43-year-old Armenian patient was diagnosed with salmonella infection and thrombotic microangiopathy (TMA). The clinical course was benign with resolution of all laboratory alterations after antibiotic treatment. Constantly deficient ADAMTS13 activity without ADAMTS13 inhibitors and evidence of homozygosity for a rare complex ADAMTS13 allele led to the diagnosis of congenital thrombotic thrombocytopenic purpura (cTTP). Half-life of ADAMTS13 after plasma infusion was calculated (27,6h) and double blinded plasma infusion as well as ergometric exercise with and without prior plasma infusion undertaken to investigate suspected smoldering TTP activity.
Collapse
Affiliation(s)
- Ralph Wendt
- Division of Nephrology and Kuratorium for Dialysis and Transplantation (KfH) Renal Unit, Hospital St. Georg, Leipzig, Germany.,Department of Infectious Diseases, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Sven Kalbitz
- Department of Infectious Diseases, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Felix Otto
- Institute of Applied Dermatopharmacy, Martin-Luther-University Halle/Wittenberg, Halle, Germany
| | - Tanja Falter
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| | - Joachim Beige
- Division of Nephrology and Kuratorium for Dialysis and Transplantation (KfH) Renal Unit, Hospital St. Georg, Leipzig, Germany.,Department of Infectious Diseases, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany.,Department of Nephrology und Rheumatology, Internal Medicine II, Martin-Luther-University Halle/Wittenberg, Halle, Germany
| | - Heidi Rossmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Mainz, Mainz, Germany
| | - Bernhard Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,Department of Hematology and Central Hematology Laboratory, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland.,Haemostasis Research Unit, University College London, London, United Kingdom
| |
Collapse
|
12
|
Sukumar S, Lämmle B, Cataland SR. Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med 2021; 10:536. [PMID: 33540569 PMCID: PMC7867179 DOI: 10.3390/jcm10030536] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and ischemic end organ injury due to microvascular platelet-rich thrombi. TTP results from a severe deficiency of the specific von Willebrand factor (VWF)-cleaving protease, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13). ADAMTS13 deficiency is most commonly acquired due to anti-ADAMTS13 autoantibodies. It can also be inherited in the congenital form as a result of biallelic mutations in the ADAMTS13 gene. In adults, the condition is most often immune-mediated (iTTP) whereas congenital TTP (cTTP) is often detected in childhood or during pregnancy. iTTP occurs more often in women and is potentially lethal without prompt recognition and treatment. Front-line therapy includes daily plasma exchange with fresh frozen plasma replacement and immunosuppression with corticosteroids. Immunosuppression targeting ADAMTS13 autoantibodies with the humanized anti-CD20 monoclonal antibody rituximab is frequently added to the initial therapy. If available, anti-VWF therapy with caplacizumab is also added to the front-line setting. While it is hypothesized that refractory TTP will be less common in the era of caplacizumab, in relapsed or refractory cases cyclosporine A, N-acetylcysteine, bortezomib, cyclophosphamide, vincristine, or splenectomy can be considered. Novel agents, such as recombinant ADAMTS13, are also currently under investigation and show promise for the treatment of TTP. Long-term follow-up after the acute episode is critical to monitor for relapse and to diagnose and manage chronic sequelae of this disease.
Collapse
Affiliation(s)
- Senthil Sukumar
- Division of Hematology, Department of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, CH 3010 Bern, Switzerland;
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University, 55131 Mainz, Germany
- Haemostasis Research Unit, University College London, London WC1E 6BT, UK
| | - Spero R. Cataland
- Division of Hematology, Department of Medicine, The Ohio State University, Columbus, OH 43210, USA;
| |
Collapse
|
13
|
Prevel R, Roubaud-Baudron C, Tellier E, Le Besnerais M, Kaplanski G, Veyradier A, Benhamou Y, Coppo P. [Endothelial dysfunction in thrombotic thrombocytopenic purpura: therapeutic perspectives]. Rev Med Interne 2021; 42:202-209. [PMID: 33455838 DOI: 10.1016/j.revmed.2020.12.011] [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: 05/15/2020] [Revised: 11/19/2020] [Accepted: 12/26/2020] [Indexed: 01/05/2023]
Abstract
Immune Thrombotic Thrombocytopenic Purpura (iTTP) is a rare but severe disease with a mortality rate of almost 100 % in the absence of adequate treatment. iTTP is caused by a severe deficiency in ADAMTS13 activity due to the production of inhibitory antibodies. Age has been shown to be a major prognostic factor. iTTP patients in the elderly (60yo and over) have more frequent organ involvement, especially heart and kidney failures compared with younger patients. They also have non-specific neurologic symptoms leading to a delayed diagnosis. Factors influencing this impaired survival among older patients remain unknown so far. Alteration of the functional capacity of involved organs could be part of the explanation as could be the consequences of vascular aging. In fact, severe ADAMTS13 deficiency is necessary but likely not sufficient for iTTP physiopathology. A second hit leading to endothelial activation is thought to play a central role in iTTP. Interestingly, the mechanisms involved in endothelial activation may share common features with those involved in vascular aging, potentially leading to endothelial dysfunction. It could thus be interesting to better investigate the causes of mid- and long-term mortality among older iTTP patients to confirm whether inflammation and endothelial activation really impact vascular aging and long-term mortality in those patients, in addition to their presumed role at iTTP acute phase. If so, further insights into the mechanisms involved could lead to new therapeutic targets.
Collapse
Affiliation(s)
- R Prevel
- CHU Bordeaux, Pôle de Gérontologie Clinique, 33000 Bordeaux, France; CHU Bordeaux, FHU Acronim 33000 Bordeaux, France; University Bordeaux, INSERM 1045 CRCTB 33000 Bordeaux, France
| | - C Roubaud-Baudron
- CHU Bordeaux, Pôle de Gérontologie Clinique, 33000 Bordeaux, France; University Bordeaux, INSERM UMR 1053 Bariton 33000 Bordeaux, France
| | - E Tellier
- Vascular Research Center of Marseille, Inserm, UMRS_1076, Aix-Marseille Université, Marseille, France
| | - M Le Besnerais
- Service de Médecine Interne, CHU Charles Nicolle, Rouen, France; INSERM U1096, UFR médecine pharmacie Rouen, Rouen, France
| | - G Kaplanski
- Vascular Research Center of Marseille, Inserm, UMRS_1076, Aix-Marseille Université, Marseille, France; Aix-Marseille université, 13284, Service de médecine interne, hôpital de la Conception, AP-HM, 147, boulevard Baille, 13385 Marseille cedex 05, France; Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France
| | - A Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France; Hématologie biologique, Hôpital Lariboisière, AP-HP, Université Paris Diderot, Paris, France
| | - Y Benhamou
- Service de Médecine Interne, CHU Charles Nicolle, Rouen, France; INSERM U1096, UFR médecine pharmacie Rouen, Rouen, France; Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France
| | - P Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), Paris, France; Service d'Hématologie, Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT, www.cnr-mat.fr), AP-HP.6, Paris, France.
| | | |
Collapse
|
14
|
Kremer Hovinga JA, Braschler TR, Buchkremer F, Farese S, Hengartner H, Lovey PY, Largiadèr CR, Mansouri Taleghani B, Tarasco E. Insights from the Hereditary Thrombotic Thrombocytopenic Purpura Registry: Discussion of Key Findings Based on Individual Cases from Switzerland. Hamostaseologie 2020; 40:S5-S14. [PMID: 33187004 DOI: 10.1055/a-1282-2264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The Hereditary TTP Registry is an international cohort study for patients with a confirmed or suspected diagnosis of hereditary thrombotic thrombocytopenic purpura (hTTP) and their family members. Hereditary TTP is an ultra-rare blood disorder (prevalence of ∼1-2 cases per million), the result of autosomal-recessively inherited congenital ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) deficiency (ADAMTS13 activity <10% of the normal), and associated with yet many unanswered questions. Until December 2017, the Hereditary TTP Registry had enrolled 123 confirmed hTTP patients. Their median age at disease onset was 4.5 years (range: 0-70) and at clinical diagnosis 16.7 years (range: 0-69), a difference that highlights the existing awareness gap in recognizing hTTP. The systematic collection of clinical data of individual patients revealed their substantial baseline comorbidities, as a consequence of recurring TTP episodes in the past. Most notable was the high proportion of patients having suffered from premature arterial thrombotic events, mainly transient ischemic attacks, ischemic strokes, and to a lesser extent myocardial infarctions. At 40 to 50 years of age and above, more than 50% of patients had suffered from at least one such event, and many had experienced arterial thrombotic events despite regular plasma infusions every 2 to 3 weeks that supplements the missing plasma ADAMTS13. The article by van Dorland et al. (Haematologica 2019;104(10):2107-2115) and the ongoing Hereditary TTP Registry cohort study were recognized with the Günter Landbeck Excellence Award at the 50th Hemophilia Symposium in Hamburg in November 2019, the reason to present the Hereditary TTP Registry in more detail here.
Collapse
Affiliation(s)
- Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | - Florian Buchkremer
- Division of Nephrology, Dialysis and Transplantation, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Stefan Farese
- Department of Nephrology, Burgerspital, Solothurn, Switzerland
| | - Heinz Hengartner
- Pediatric Hematology-Oncology Unit, Children's Hospital of Sankt Gallen, Sankt Gallen, Switzerland
| | - Pierre-Yves Lovey
- Service d'hématologie, Hôpital du Valais-Institut Central, Sion, Switzerland
| | - Carlo R Largiadèr
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Behrouz Mansouri Taleghani
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Erika Tarasco
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| |
Collapse
|
15
|
Scully M. Transforming the major autoantibody site on ADAMTS13: spacer domain variants retaining von Willebrand factor cleavage activity. Haematologica 2020; 105:2510-2512. [PMID: 33131242 PMCID: PMC7604561 DOI: 10.3324/haematol.2020.262154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Marie Scully
- Department of Haematology and National Institute for Health Research Cardiometabolic Programme, UCLH/UCL BRC, London, UK.
| |
Collapse
|
16
|
Alwan F, Mahdi D, Tayabali S, Cipolotti L, Lakey G, Hyare H, Scully M. Cerebral MRI findings predict the risk of cognitive impairment in thrombotic thrombocytopenic purpura. Br J Haematol 2020; 191:868-874. [DOI: 10.1111/bjh.17126] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ferras Alwan
- Department of Haematology University College London Hospital London UK
| | - Dina Mahdi
- Department of Haematology University College London Hospital London UK
| | - Sarrah Tayabali
- Department of Haematology University College London Hospital London UK
| | - Lisa Cipolotti
- Department of Neuropsychology National Hospital for Neurology and Neurosurgery UCLH NHS Trust London UK
| | - Grace Lakey
- Department of Neuropsychology National Hospital for Neurology and Neurosurgery UCLH NHS Trust London UK
| | - Harpreet Hyare
- Department of Radiology University College London Hospital London UK
| | - Marie Scully
- Department of Haematology University College London Hospital London UK
- Cardiometabolic Programme‐NIHR UCLH/UCL BRC London UK
| |
Collapse
|
17
|
Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. Good practice statements (GPS) for the clinical care of patients with thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2503-2512. [PMID: 32914535 PMCID: PMC7880820 DOI: 10.1111/jth.15009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its management. METHODS In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to both immune-mediated TTP (iTTP) and hereditary/congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations. RESULTS The panel agreed on eleven recommendations based on evidence ranging from very low to moderate certainty. For first episode and relapses of acute iTTP, the panel made a strong recommendation for the addition of corticosteroids to therapeutic plasma exchange (TPE), and a conditional recommendation for addition of rituximab and caplacizumab. For asymptomatic iTTP with low ADAMTS13, the panel made a conditional recommendation for rituximab outside of pregnancy, and for prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, but a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy. CONCLUSIONS The panel's recommendations are based on all the available evidence for the treatment effects of various approaches including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing ADAMTS13 antibody production. There was insufficient evidence for further comparison of different treatment approaches, for which future high-quality studies in iTTP (e.g., rituximab, corticosteroids, recombinant ADAMTS13, and caplacizumab) and in cTTP (eg, recombinant ADAMTS13) are needed.
Collapse
Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique, Hôpitaux de Paris, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, The University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
18
|
Patent ductus arteriosus generates neonatal hemolytic jaundice with thrombocytopenia in Upshaw-Schulman syndrome. Blood Adv 2020; 3:3191-3195. [PMID: 31698449 DOI: 10.1182/bloodadvances.2019000601] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/02/2019] [Indexed: 12/20/2022] Open
Abstract
Key Points
One third of patients with USS have a neonatal episode of severe hemolytic jaundice with thrombocytopenia induced by an unknown trigger. A USS patient with persisting PDA and recurrent neonatal hemolysis/thrombocytopenia suggests blood flow through the PDA as trigger.
Collapse
|
19
|
Upshaw-Schulman syndrome-associated ADAMTS13 variants possess proteolytic activity at the surface of endothelial cells and in simulated circulation. PLoS One 2020; 15:e0232637. [PMID: 32365113 PMCID: PMC7197795 DOI: 10.1371/journal.pone.0232637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
ADAMTS13 regulates the hemostatic activity of von Willebrand factor (VWF). Determined by static assays, proteolytic activity <10IU/dL in patient plasma, in absence of ADAMTS13 autoantibodies, indicates Upshaw-Schulman syndrome (USS); the congenital form of Thrombotic Thrombocytopenic Purpura (TTP). We have recently functionally characterized sixteen USS-associated ADAMTS13 missense variants under static conditions. Here, we used two assays under shear flow conditions to analyze the activity of those seven mutants with sufficiently high residual secretion plus two newly identified variants. One assay determines cleavage of VWF strings bound to the surface of endothelial cells. The other, light transmission aggregometry-based assay, mimics degradation of VWF-platelet complexes, which are likely to be present in the circulation during TTP bouts. We found that 100 ng/ml of all variants were able to cleave about 80–90% of VWF strings even though 5 out of 9 exhibited activity ≤1% in the state-of-the-art static assay at the same concentration. These data indicate underestimation of ADAMTS13 activity by the used static assay. In simulated circulation, two variants, with missense mutations in the vicinity of the catalytic domain, exhibited only minor residual activity while all other variants were able to effectively break down VWF-platelet complexes. In both assays, significant proteolytic activity could be observed down to 100 ng/ml ADAMTS13. It is thus intriguing to postulate that most variants would have ample activity if secretion of 10% of normal plasma levels could be achieved.
Collapse
|
20
|
Zheng L, Abdelgawwad MS, Zhang D, Xu L, Wei S, Cao W, Zheng XL. Histone-induced thrombotic thrombocytopenic purpura in adamts13 -/- zebrafish depends on von Willebrand factor. Haematologica 2020; 105:1107-1119. [PMID: 31753928 PMCID: PMC7109750 DOI: 10.3324/haematol.2019.237396] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/21/2019] [Indexed: 12/30/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is caused by severe deficiency of ADAMTS13 (A13), a plasma metalloprotease that cleaves endothelium-derived von Willebrand factor (VWF). However, severe A13 deficiency alone is often not sufficient to cause an acute TTP; additional factors may be required to trigger the disease. Using CRISPR/Cas9, we created and characterized several novel zebrafish lines carrying a null mutation in a13-/- , vwf, and both. We further used these zebrafish lines to test the hypothesis that inflammation that results in neutrophil activation and release of histone/DNA complexes may trigger TTP. As shown, a13-/- zebrafish exhibit increased levels of plasma VWF antigen, multimer size, and ability of thrombocytes to adhere to a fibrillar collagen-coated surface under flow. The a13-/- zebrafish also show an increased rate of occlusive thrombus formation in the caudal venules after FeCl3 injury. More interestingly, a13-/- zebrafish exhibit ~30% reduction in the number of total, immature, and mature thrombocytes with increased fragmentation of erythrocytes. Administration of a lysine-rich histone results in more severe and persistent thrombocytopenia and a significantly increased mortality rate in a13-/- zebrafish than in wildtype (wt) ones. However, both spontaneous and histone-induced TTP in a13-/- zebrafish are rescued by the deletion of vwf These results demonstrate a potentially mechanistic link between inflammation and the onset of TTP in light of severe A13 deficiency; the novel zebrafish models of TTP may help accelerate our understanding of pathogenic mechanisms and the discoveries of novel therapeutics for TTP and perhaps other arterial thrombotic disorders.
Collapse
Affiliation(s)
| | | | - Di Zhang
- Divisions of Laboratory Medicine
| | | | - Shi Wei
- Divisions of Anatomic Pathology, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | |
Collapse
|
21
|
Tenison E, Asif A, Sheridan M. Congenital thrombotic thrombocytopenic purpura presenting in adulthood with recurrent cerebrovascular events. BMJ Case Rep 2019; 12:12/10/e229481. [PMID: 31585956 DOI: 10.1136/bcr-2019-229481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is a rare, life-threatening disease, characterised by episodes of microangiopathic haemolytic anaemia (MAHA), thrombocytopenia and small vessel thrombosis. We describe a case of cTTP first diagnosed at age 70 years in a female presenting with an acute ischaemic stroke and thrombocytopenia, in whom A Disintegrin And Metalloproteinase with a Thrombospondin type 1 Motif, member 13 (ADAMTS13) levels were <10%, suggestive of thrombotic thrombocytopaenic purpura (TTP). The patient underwent plasma exchange and started rituximab for presumed immune TTP; however, anti-ADAMTS13 antibody titres were negative on two occasions. This, together with a history of pregnancies complicated by presumed disseminated intravascular coagulation, and two previous episodes of sepsis with MAHA, prompted investigation for cTTP, which was confirmed by genetic testing. Despite treatment with infusions of solvent/detergent-treated, virus-inactivated fresh frozen plasma, she has re-presented with further neurological deficit, associated with new infarcts on imaging. cTTP has a varied phenotype which, as demonstrated in this case, can include large vessel occlusion.
Collapse
Affiliation(s)
- Emma Tenison
- Translational Health Sciences, University of Bristol Musculoskeletal Research Unit, Bristol, UK.,Older People's Unit, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Ashar Asif
- Medical School, University of Bristol, Bristol, UK
| | - Mathew Sheridan
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
22
|
ABO blood group and procoagulant factors: the hypercoagulation hypothesis ABO and Procoagulant Factors. Pediatr Res 2019; 86:316-322. [PMID: 31158844 DOI: 10.1038/s41390-019-0445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/18/2019] [Accepted: 05/18/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND The correlation between procoagulant levels-factor VIII (FVIII), von Willebrand factor (vWF), and fibrinogen-and risk of thrombosis has been well documented in adult populations. We hypothesize that interaction of passively transferred isoagglutinins in premature neonates with a compromised immune system may trigger an immune response that can target the immature gastrointestinal tract. The objective of this study is to evaluate if there are procoagulant level differences in preterm newborns stratified by ABO blood group. METHODS VWF, FVIII, and fibrinogen levels were analyzed in neonates ≤32 weeks and/or birthweight ≤1500 g over the first 6 weeks of life. Demographic, blood type, and transfusion data were collected. RESULTS Elevations in vWF and FVIII were found to be statistically significant in the third week of life in non-O neonates vs. type O neonates. FVIII was also found to be significantly elevated in week 1. Transfused neonates also showed elevations between weeks 0 and 3. CONCLUSION There appears to be a time-dependent variation in procoagulant factor levels in preterm newborns. Although the clinical significance remains unclear, prothrombotic factors vWF and FVIII are significantly higher in non-O blood-type preterm neonates in the third week of life.
Collapse
|
23
|
Schönermarck U, Ries W, Schröppel B, Pape L, Dunaj-Kazmierowska M, Burst V, Mitzner S, Basara N, Starck M, Schmidbauer D, Mellmann A, Dittmer R, Jeglitsch M, Haas CS. Relative incidence of thrombotic thrombocytopenic purpura and haemolytic uraemic syndrome in clinically suspected cases of thrombotic microangiopathy. Clin Kidney J 2019; 13:208-216. [PMID: 32296526 PMCID: PMC7147316 DOI: 10.1093/ckj/sfz066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/29/2019] [Indexed: 12/27/2022] Open
Abstract
Background Data are lacking on the relative incidence of thrombotic thrombocytopenic purpura (TTP), haemolytic uraemic syndrome (HUS) caused by Shiga toxin–producing Escherichia coli (STEC) and atypical HUS (aHUS) in patients presenting with thrombotic microangiopathies (TMAs). Methods This was a prospective, cross-sectional, multicentre and non-interventional epidemiological study. Patients fulfilling criteria for TMAs (platelet consumption, microangiopathic haemolytic anaemia and organ dysfunction) were included in the study. The primary objective was to assess the relative incidence of TTP, STEC-HUS, aHUS and ‘other’ physician-defined diagnoses. The secondary objective was to develop an algorithm to predict a severe deficiency in ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity (≤10%) using routine laboratory parameters. A post hoc classification using the recent Kidney Disease: Improving Global Outcomes diagnostic criteria was then undertaken to further classify patient groups. Results aHUS was diagnosed with a relative incidence of 61%, whereas TTP, STEC-HUS and ‘other’ were diagnosed in 13, 6 and 20% of patients, respectively. In the post hoc analysis, 27% of patients with a TMA were classified as ‘primary aHUS’ and 53% as ‘secondary aHUS’. Multivariate analysis revealed that severe deficiency in ADAMTS13 activity (≤10%) was unlikely to underlie TMA if platelet and serum creatinine were above threshold values of 30 × 109/L and 1.8 mg/dL, respectively (negative predictive value of 92.3 and 98.1, respectively, if one or both values were above the threshold). Conclusions In this study, aHUS was the most common single diagnosis among patients presenting with a TMA. In the absence of an ADAMTS13 activity result, platelet count and serum creatinine may aid in the differential diagnosis.
Collapse
Affiliation(s)
- Ulf Schönermarck
- Medizinische Klinik IV, Klinikum der Universität, LMU, Munich, Germany
| | - Wolfgang Ries
- Internal Medicine, Diakonissenkrankenhaus, Flensburg, Germany
| | - Bernd Schröppel
- Medical Clinic I, Section of Nephrology, University of Ulm, Ulm, Germany
| | - Lars Pape
- Pediatric Nephrology, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Volker Burst
- Department II of Internal Medicine, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany.,Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Steffen Mitzner
- Division of Nephrology, Rostock University Medical Centre, Rostock, Germany.,Fraunhofer IZI Project Group 'Extracorporeal Immunomodulation', Rostock, Germany
| | - Nadezda Basara
- Medizinische Klinik I, St. Franziskus-Hospital, Flensburg, Germany
| | - Michael Starck
- Clinic for Hematology, Clinic Munich-Schwabing, Munich, Germany
| | | | | | | | | | - Christian S Haas
- Internal Medicine, Nephrology and Intensive Care Medicine, Phillips University of Marburg, Marburg, Germany
| |
Collapse
|
24
|
van Dorland HA, Taleghani MM, Sakai K, Friedman KD, George JN, Hrachovinova I, Knöbl PN, von Krogh AS, Schneppenheim R, Aebi-Huber I, Bütikofer L, Largiadèr CR, Cermakova Z, Kokame K, Miyata T, Yagi H, Terrell DR, Vesely SK, Matsumoto M, Lämmle B, Fujimura Y, Kremer Hovinga JA. The International Hereditary Thrombotic Thrombocytopenic Purpura Registry: key findings at enrollment until 2017. Haematologica 2019; 104:2107-2115. [PMID: 30792199 PMCID: PMC6886414 DOI: 10.3324/haematol.2019.216796] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
Congenital thrombotic thrombocytopenic purpura is an autosomal recessive inherited disease with a clinically heterogeneous course and an incompletely understood genotype-phenotype correlation. In 2006, the Hereditary TTP Registry started recruitment for a study which aimed to improve the understanding of this ultra-rare disease. The objective of this study is to present characteristics of the cohort until the end of 2017 and to explore the relationship between overt disease onset and ADAMTS13 activity with emphasis on the recurring ADAMTS13 c.4143_4144dupA mutation. Diagnosis of congenital thrombotic thrombocytopenic purpura was confirmed by severely deficient ADAMTS13 activity (≤10% of normal) in the absence of a functional inhibitor and the presence of ADAMTS13 mutations on both alleles. By the end of 2017, 123 confirmed patients had been enrolled from Europe (n=55), Asia (n=52, 90% from Japan), the Americas (n=14), and Africa (n=2). First recognized disease manifestation occurred from around birth up to the age of 70 years. Of the 98 different ADAMTS13 mutations detected, c.4143_4144dupA (exon 29; p.Glu1382Argfs*6) was the most frequent mutation, present on 60 of 246 alleles. We found a larger proportion of compound heterozygous than homozygous carriers of ADAMTS13 c.4143_4144dupA with overt disease onset at < 3 months of age (50% vs. 37%), despite the fact that ADAMTS13 activity was <1% in 18 of 20 homozygous, but in only 8 of 14 compound heterozygous carriers. An evaluation of overt disease onset in all patients with an available sensitive ADAMTS13 activity assay (n=97) shows that residual ADAMTS13 activity is not the only determinant of age at first disease manifestation. Registered at clinicaltrials.gov identifier NCT01257269.
Collapse
Affiliation(s)
- Hendrika A van Dorland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Magnus Mansouri Taleghani
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Kenneth D Friedman
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James N George
- Department of Biostatistics Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ingrid Hrachovinova
- NRL for Hemostasis, Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Paul N Knöbl
- Division of Hematology and Hemostasis, Department of Medicine 1, Medical University of Vienna, Austria
| | - Anne Sophie von Krogh
- Department of Hematology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Reinhard Schneppenheim
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Isabella Aebi-Huber
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | - Carlo R Largiadèr
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Zuzana Cermakova
- Blood Center, University Hospital Ostrava, Ostrava, Czech Republic
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideo Yagi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan.,Department of Hematology, Nara Prefecture General Medical Center, Nara, Japan
| | - Deirdra R Terrell
- Department of Biostatistics Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara K Vesely
- Department of Biostatistics Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan.,Japanese Red Cross Kinki Block Blood Center, Ibaraki, Osaka, Japan
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland .,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | |
Collapse
|
25
|
Oliveira DS, Lima TG, Benevides FLN, Barbosa SAT, Oliveira MA, Boris NP, Silva HF. Plasmic score applicability for the diagnosis of thrombotic microangiopathy associated with ADAMTS13-acquired deficiency in a developing country. Hematol Transfus Cell Ther 2019; 41:119-124. [PMID: 31079658 PMCID: PMC6517677 DOI: 10.1016/j.htct.2018.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/12/2018] [Accepted: 10/15/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a potentially fatal disease that requires early diagnosis and treatment that can be made possible by applying the PLASMIC score. This study aims to evaluate this score applicability for patients with suspected TTP in a developing country. METHODS This was a retrospective study performed at a tertiary hospital in the northeastern region of Brazil. Patients were analyzed in two groups: ADAMTS13 activity <10% and activity >10%. Patients were stratified according to the PLASMIC score, and the level of agreement between the PLASMIC score and the ADAMTS13 activity was evaluated. RESULTS Eight patients with thrombotic microangiopathy were included. Four patients had ADAMTS13 activity <10%, all with a PLASMIC score =6. The other four had ADAMTS13 activity >10%, all with a score <6. Based on a score =6 for presumptive diagnosis of TTP, we attained a 100% diagnostic accuracy in our sample. The PLASMIC score was also able to accurately predict response to plasma exchange and the risk of long-term unfavorable outcomes. CONCLUSIONS The reproducibility of the PLASMIC score was quite satisfactory in our sample. It accurately discriminates between patients who had ADAMTS13 deficiency and those with normal enzyme activity, precluding the need for specific laboratory evaluation, which is not always available. This score can be useful for an early diagnosis and indicates which patients will benefit from the treatment in developing countries.
Collapse
Affiliation(s)
| | - Tadeu G Lima
- Hospital Geral Dr. César Cals (HGCC), Fortaleza, CE, Brazil
| | | | | | | | | | | |
Collapse
|
26
|
Characterization and treatment of congenital thrombotic thrombocytopenic purpura. Blood 2019; 133:1644-1651. [PMID: 30770395 DOI: 10.1182/blood-2018-11-884700] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/06/2019] [Indexed: 12/15/2022] Open
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is an ultra-rare thrombomicroangiopathy caused by an inherited deficiency of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). There are limited data on genotype-phenotype correlation; there is no consensus on treatment. We reviewed the largest cohort of cTTP cases, diagnosed in the United Kingdom, over the past 15 years. Seventy-three cases of cTTP were diagnosed, confirmed by genetic analysis. Ninety-three percent were alive at the time of review. Thirty-six percent had homozygous mutations; 64% had compound heterozygous mutations. Two presentation peaks were seen: childhood (median diagnosis age, 3.5 years) and adulthood, typically related to pregnancy (median diagnosis age, 31 years). Genetic mutations differed by age of onset with prespacer mutations more likely to be associated with childhood onset (P = .0011). Sixty-nine percent of adult presentations were associated with pregnancy. Fresh-frozen plasma (FFP) and intermediate purity factor VIII concentrate were used as treatment. Eighty-eight percent of patients with normal blood counts, but with headaches, lethargy, or abdominal pain, reported symptom resolution with prophylactic therapy. The most common currently used regimen of 3-weekly FFP proved insufficient for 70% of patients and weekly or fortnightly infusions were required. Stroke incidence was significantly reduced in patients receiving prophylactic therapy (2% vs 17%; P = .04). Long-term, there is a risk of end-organ damage, seen in 75% of patients with late diagnosis of cTTP. In conclusion, prespacer mutations are associated with earlier development of cTTP symptoms. Prophylactic ADAMTS13 replacement decreases the risk of end-organ damage such as ischemic stroke and resolved previously unrecognized symptoms in patients with nonovert disease.
Collapse
|
27
|
Di Pasquale I, Budde U, Tona F, Bertomoro A, Lombardi AM, Famoso G, Bertozzi I, Dittmer R, Schneppenheim S, Fabris F. Link between von Willebrand factor multimers, relapses and coronary microcirculation in patients with thrombotic thrombocytopenic purpura in remission. Thromb Res 2019; 173:42-47. [DOI: 10.1016/j.thromres.2018.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/18/2018] [Accepted: 11/05/2018] [Indexed: 01/06/2023]
|
28
|
Kovarova P, Hrdlickova R, Blahutova S, Cermakova Z. ADAMTS13 kinetics after therapeutic plasma exchange and plasma infusion in patients with Upshaw-Schulman syndrome. J Clin Apher 2018; 34:13-20. [DOI: 10.1002/jca.21664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 06/22/2018] [Accepted: 08/23/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Petra Kovarova
- Blood Centre; University Hospital Ostrava; Ostrava Czech Republic
| | | | - Sarka Blahutova
- Blood Centre; University Hospital Ostrava; Ostrava Czech Republic
| | - Zuzana Cermakova
- Blood Centre; University Hospital Ostrava; Ostrava Czech Republic
| |
Collapse
|
29
|
Serum ADAMTS-13 Levels as an Indicator of Portal Vein Thrombosis. Gastroenterol Res Pract 2018; 2018:3287491. [PMID: 29849584 PMCID: PMC5937451 DOI: 10.1155/2018/3287491] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/21/2018] [Accepted: 02/20/2018] [Indexed: 12/15/2022] Open
Abstract
Background Coagulation disorders in patients with liver cirrhosis are a common clinical problem. Cirrhosis should be considered a state of impaired blood clotting or an imbalance of the whole coagulation system. Cirrhosis-induced coagulopathy encompasses disturbances in both the procoagulant and anticoagulant systems. This mechanism may promote the development of thrombosis with portal vein thrombosis (PVT), which is considered an obstacle to orthotopic liver transplantation (OLT). We assessed serum ADAMTS-13 levels in patients with decompensated liver cirrhosis, with and without PVT. Material and Methods Serum ADAMTS-13 levels, age, platelet count (PLT), and INR (international normalized ratio) were evaluated in (n = 64) patients with liver cirrhosis either with PVT (group 1, n = 31) or without PVT (group 2, n = 33). The results were compared with those from healthy volunteers (group 3, n = 37). Liver cirrhosis was based on Desmet's classification of chronic hepatitis in liver biopsy stage ≥ 3 or liver elastography F-score ≥ 3. Serum ADAMTS-13 levels were measured with Quantikine® ELISA Human ADAMTS13 Immunoassay, R&D Systems Inc. We used Welch's F-test, Games-Howell, one-way ANOVA, Bonferroni test, and logistic regression to determine whether ADAMTS-13 levels were a predictor that was independent of MELD and Child-Pugh scores. All results (P < 0.05) were considered statistically significant. Results The mean serum ADAMTS-13 level in patients with PVT was significantly lower than that in patients without PVT (P = 0.001) and controls (P = 0.001). The mean serum ADAMTS-13 level in patients without PVT was significantly lower than that in controls (P = 0.001). ADAMTS-13 levels were significantly associated with PVT accounting for the Child-Pugh or MELD score in the logistic regression model. Conclusions Low serum ADAMTS-13 levels can be a useful indicator of portal thrombosis in patients with decompensated liver cirrhosis irrespective of Child-Pugh or MELD scores. Further research is needed to determine whether ADAMTS-13 levels will find use in everyday clinical practice.
Collapse
|
30
|
Taleghani M, von Krogh AS, Fujimura Y, George JN, Hrachovinova I, Knöbl PN, Quist-Paulsen P, Schneppenheim R, Lämmle B, Hovinga JA. Hereditary thrombotic thrombocytopenic purpura and the hereditary TTP registry. Hamostaseologie 2018; 33:138-43. [DOI: 10.5482/hamo-13-04-0026] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 05/06/2013] [Indexed: 11/05/2022] Open
Abstract
SummaryHereditary thrombotic thrombocytopenic purpura (TTP), also known as Upshaw-Schulman syndrome, is a rare recessively inherited disease. Underlying is a severe constitutional deficiency of the von Willebrand factor-cleaving protease, ADAMTS13, due to compound heterozygous or homozygous mutations in the ADAMTS13 gene. The clinical picture is variable and more and more patients with an adult-onset are diagnosed.In the majority of countries the only available treatment is plasma, which when administered regularly can efficiently prevent acute disease bouts. The decision to initiate regular prophylaxis is often not easy, as evidence based guidelines and long term outcome data are lacking. Through the hereditary TTP registry (www.ttpregistry.net, ClinicalTrials.gov identifier: NCT01257269), which was initiated in 2006 and is open to all patients diagnosed with Upshaw-Schulman syndrome and their family members, we aim to gain further information and insights into this rare disease, which eventually will help to improve clinical management of affected patients.
Collapse
|
31
|
Pérez-Rodríguez A, Batlle-López A, Blanco R, Varela I, León J, Delgado MD, Lourés E, Rodríguez-Trillo Á, García-Rivero A, Costa-Pinto J, López-Fernández MF, Batlle J. A novel mutation in ADAMTS13 of a child with Upshaw-Schulman Syndrome. Thromb Haemost 2017; 112:1065-8. [DOI: 10.1160/th14-02-0116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/05/2014] [Indexed: 11/05/2022]
|
32
|
Taguchi F, Yagi H, Matsumoto M, Sadamura S, Isonishi A, Soejima K, Fujimura Y. The homozygous p.C1024R-ADAMTS13 gene mutation links to a late-onset phenotype of Upshaw-Schulman syndrome in Japan. Thromb Haemost 2017; 107:1003-5. [DOI: 10.1160/th11-11-0799] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 01/05/2011] [Indexed: 11/05/2022]
|
33
|
Kremer Hovinga JA, Tjønnfjord GE, Ringen IM, Lämmle B, Waage A, Quist-Paulsen P, von Krogh AS. The impact of congenital thrombotic thrombocytopenic purpura on pregnancy complications. Thromb Haemost 2017; 111:1180-3. [DOI: 10.1160/th13-08-0713] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 01/14/2014] [Indexed: 11/05/2022]
|
34
|
Yagi H, Yamaguchi N, Shida Y, Sugimoto M, Tubaki K, Fujimura Y, Matsumoto M. Highly elevated plasma level of von Willebrand factor accelerates the formation of platelet thrombus under high shear stress in plasma with deficient ADAMTS13 activity. Thromb Res 2017; 159:91-95. [PMID: 29040872 DOI: 10.1016/j.thromres.2017.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/29/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
Upshaw-Schulman syndrome (USS) is a thrombo-hemorrhagic disease caused by congenital deficiency of ADAMTS13 due to ADAMTS13 gene mutations. USS is characterized by repeated episodes of thrombocytopenia and microangiopathic hemolytic anemia that respond dramatically to infusions of fresh frozen plasma. There are two phenotypic expressions of USS: one is the early-onset type and the other, the late-onset type, is asymptomatic during childhood with the first bout of thrombotic thrombocytopenic purpura (TTP) developing after adolescence or during adulthood. We found that gravida with the latter phenotype developed thrombocytopenia and hemolytic anemia during the second or third trimesters, often followed by thrombotic microangiopathies (TMAs). These phenomena suggest that elevated plasma von Willebrand Factor (VWF) might be crucial because plasma levels of VWF antigen usually increase by 200-500% during this period of gestation. Here, we performed platelet function assays using a mixture of anti-coagulated blood from normal volunteers, human VWF, anti-ADAMTS13 monoclonal antibody A10, and purified plasma-derived ADAMTS13 to investigate the effect of plasma VWF levels on platelet thrombus formation in the context of deficient ADAMTS13. In vitro studies showed that mural thrombus formation and platelet aggregation under high shear stress were markedly augmented by increasing the amounts of exogenously added VWF when ADAMTS13 activity was deficient, as may be the case in the in vivo circulation of gravida with USS. These results suggest that highly elevated plasma VWF might accelerate platelet thrombus formation not only in the circulation but also on the surface of vascular endothelial cells in the setting of ADAMTS13 deficiency in USS.
Collapse
Affiliation(s)
- Hideo Yagi
- Department of Hematology Nara Hospital, Kinki University School of Medicine, Ikoma 630-0293, Nara, Japan; Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Nara, Japan.
| | - Naoko Yamaguchi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Nara, Japan
| | - Yasuaki Shida
- Department of Pediatrics, Nara Medical University, Kashihara 634-8522, Nara, Japan
| | - Mitsuhiko Sugimoto
- Department of Pediatrics, Nara Medical University, Kashihara 634-8522, Nara, Japan
| | - Kazuo Tubaki
- Department of Hematology Nara Hospital, Kinki University School of Medicine, Ikoma 630-0293, Nara, Japan
| | - Yoshihiro Fujimura
- Japanese Red Cross Kinki Block Blood Center, Ibaraki 567-0085, Osaka, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara 634-8522, Nara, Japan
| |
Collapse
|
35
|
Recombinant ADAMTS-13: first-in-human pharmacokinetics and safety in congenital thrombotic thrombocytopenic purpura. Blood 2017; 130:2055-2063. [PMID: 28912376 DOI: 10.1182/blood-2017-06-788026] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/07/2017] [Indexed: 02/02/2023] Open
Abstract
Safety, tolerability, and pharmacokinetics of recombinant ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13; BAX 930; SHP655) were investigated in 15 patients diagnosed with severe congenital ADAMTS-13 deficiency (plasma ADAMTS-13 activity <6%) in a prospective phase 1, first-in-human, multicenter dose escalation study. BAX 930 was well tolerated, no serious adverse events occurred, and no anti-ADAMTS-13 antibodies were observed. After single-dose administration of BAX 930 at 5, 20, or 40 U/kg body weight to adolescents and adults, there was approximate dose proportionality with respect to maximum plasma concentration (Cmax [U/mL]) and area under the concentration-time curve (AUC [h∙U/mL]). Dose-related increases of individual ADAMTS-13:Ag and activity were observed and reached a maximum within 1 hour. With escalating BAX 930 doses administered, a dose-dependent persistence of ADAMTS-13-mediated von Willebrand factor (VWF) cleavage products and reduced VWF multimeric size were observed. This study demonstrated that pharmacokinetic parameters of BAX 930 were comparable to those estimated in previous plasma infusion studies and provided evidence of pharmacodynamic activity. This study was registered at www.clinicaltrials.gov as #NCT02216084.
Collapse
|
36
|
Nieto JM, De La Fuente-Gonzalo F, González FA, Villegas A, Martínez R, Fuentes ME, Ropero P. Development and validation of a multivariable prediction rule for detecting a severe acquired ADAMTS13 activity deficiency in patients with thrombotic microangiopathies. ACTA ACUST UNITED AC 2017; 56:294-302. [DOI: 10.1515/cclm-2017-0437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/05/2017] [Indexed: 12/31/2022]
Abstract
Abstract
Background:
Thrombotic microangiopathies (TMAs) are a group of diseases that have different aetiologies and treatments, but a clinical differential diagnosis remains difficult. Among TMAs, thrombotic thrombocytopenic purpura (TTP) is characterised by a severe ADAMTS13 functional deficiency. However, assays exploring ADAMTS13 activity are limited to some specialised laboratories. Our objective was to develop and validate a diagnostic method for TTP in adult patients with TMA.
Methods:
We generated a multivariable model (four predictors) on a cohort of 174 TMA patients in order to predict an ADAMTS13 activity deficiency (AUC of 0.927). The multivariable model was simplified into a binary rule to facilitate the interpretation of the predictions. There were two scenarios for a patient: (1) Predicted ADAMTS13 deficiency; if the patient met four conditions simultaneously (platelets ≤44×109/L, creatinine ≤2 mg/dL (≤176.84 µmol/L) for males or ≤1.9 mg/dL (≤168 µmol/L) for females, age ≤68 years and no history of haematopoietic stem cell transplant [HSCT]); or (2) Predicted “normal” activity; if any of the above conditions are not met. This rule was validated on a second cohort of 86 patients and performed with sensitivity of 87.7% and specificity of 92.7%.
Results and conclusions:
This could lead to the earlier confirmation or rapid exclusion of TTP when ADAMTS13 testing is not avalilable, facilitating a more suitable therapy based on the aetiology of the TMA.
Collapse
Affiliation(s)
- Jorge M. Nieto
- Departamento de Eritropatología , Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , calle Profesor Martín Lagos sn , 28040 Madrid , Spain
| | | | - Fernando A. González
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| | - Ana Villegas
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| | - Rafael Martínez
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| | - Manuel E. Fuentes
- Unidad de Investigación, Hospital Clínico San Carlos , Madrid , Spain
| | - Paloma Ropero
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| |
Collapse
|
37
|
Pathophysiology of thrombotic thrombocytopenic purpura. Blood 2017; 130:1181-1188. [PMID: 28768626 DOI: 10.1182/blood-2017-04-636431] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/27/2017] [Indexed: 01/29/2023] Open
Abstract
The discovery of a disintegrin-like and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13) revolutionized our approach to thrombotic thrombocytopenic purpura (TTP). Inherited or acquired ADAMTS13 deficiency allows the unrestrained growth of microthrombi that are composed of von Willebrand factor and platelets, which account for the thrombocytopenia, hemolytic anemia, schistocytes, and tissue injury that characterize TTP. Most patients with acquired TTP respond to a combination of plasma exchange and rituximab, but some die or acquire irreversible neurological deficits before they can respond, and relapses can occur unpredictably. However, knowledge of the pathophysiology of TTP has inspired new ways to prevent early deaths by targeting autoantibody production, replenishing ADAMTS13, and blocking microvascular thrombosis despite persistent ADAMTS13 deficiency. In addition, monitoring ADAMTS13 has the potential to identify patients who are at risk of relapse in time for preventive therapy.
Collapse
|
38
|
Brophy TM, Ward SE, McGimsey TR, Schneppenheim S, Drakeford C, O’Sullivan JM, Chion A, Budde U, O’Donnell JS. Plasmin Cleaves Von Willebrand Factor at K1491-R1492 in the A1–A2 Linker Region in a Shear- and Glycan-Dependent Manner In Vitro. Arterioscler Thromb Vasc Biol 2017; 37:845-855. [DOI: 10.1161/atvbaha.116.308524] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/23/2017] [Indexed: 12/20/2022]
Abstract
Objective—
Previous studies have demonstrated a role for plasmin in regulating plasma von Willebrand factor (VWF) multimer composition. Moreover, emerging data have shown that plasmin-induced cleavage of VWF is of particular importance in specific pathological states. Interestingly, plasmin has been successfully used as an alternative to ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif) in a mouse model of thrombotic thrombocytopenic purpura. Consequently, elucidating the molecular mechanisms through which plasmin binds and cleaves VWF is not only of basic scientific interest but also of direct clinical importance. Our aim was to investigate factors that modulate the susceptibility of human VWF to proteolysis by plasmin.
Approach and Results—
We have adapted the VWF vortex proteolysis assay to allow for time-dependent shear exposure studies. We show that globular VWF is resistant to plasmin cleavage under static conditions, but is readily cleaved by plasmin under shear. Although both plasmin and ADAMTS13 cleave VWF in a shear-dependent manner, plasmin does not cleave at the Tyr1605-Met1606 ADAMTS13 proteolytic site in the A2 domain. Rather under shear stress conditions, or in the presence of denaturants, such as urea or ristocetin, plasmin cleaves the K1491-R1492 peptide bond within the VWF A1–A2 linker region. Finally, we demonstrate that VWF susceptibility to plasmin proteolysis at K1491-R1492 is modulated by local N-linked glycan expression within A1A2A3, and specifically inhibited by heparin binding to the A1 domain.
Conclusions—
Improved understanding of the plasmin–VWF interaction offers exciting opportunities to develop novel adjunctive therapies for the treatment of refractory thrombotic thrombocytopenic purpura.
Collapse
Affiliation(s)
- Teresa M. Brophy
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Soracha E. Ward
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Thomas R. McGimsey
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Sonja Schneppenheim
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Clive Drakeford
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Jamie M. O’Sullivan
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Alain Chion
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - Ulrich Budde
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| | - James S. O’Donnell
- From the Haemostasis Research Group, Institute of Molecular Medicine, Trinity Centre for Health Sciences, St. James’s Hospital, Trinity College Dublin, Ireland (T.M.B., S.E.W., T.R.M.G., C.D., J.M.O., A.C., J.S.O.); Medilys Laborgesellschaft mbH, Department of Hämostaseology, Hamburg, Germany (S.S., U.B.); National Centre for Hereditary Coagulation Disorders, St. James’s Hospital, Dublin, Ireland (J.S.O.); and Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin (J.S.O.)
| |
Collapse
|
39
|
Abstract
Thrombotic thrombocytopenic purpura (TTP; also known as Moschcowitz disease) is characterized by the concomitant occurrence of often severe thrombocytopenia, microangiopathic haemolytic anaemia and a variable degree of ischaemic organ damage, particularly affecting the brain, heart and kidneys. Acute TTP was almost universally fatal until the introduction of plasma therapy, which improved survival from <10% to 80-90%. However, patients who survive an acute episode are at high risk of relapse and of long-term morbidity. A timely diagnosis is vital but challenging, as TTP shares symptoms and clinical presentation with numerous conditions, including, for example, haemolytic uraemic syndrome and other thrombotic microangiopathies. The underlying pathophysiology is a severe deficiency of the activity of a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), the protease that cleaves von Willebrand factor (vWF) multimeric strings. Ultra-large vWF strings remain uncleaved after endothelial cell secretion and anchorage, bind to platelets and form microthrombi, leading to the clinical manifestations of TTP. Congenital TTP (Upshaw-Schulman syndrome) is the result of homozygous or compound heterozygous mutations in ADAMTS13, whereas acquired TTP is an autoimmune disorder caused by circulating anti-ADAMTS13 autoantibodies, which inhibit the enzyme or increase its clearance. Consequently, immunosuppressive drugs, such as corticosteroids and often rituximab, supplement plasma exchange therapy in patients with acquired TTP.
Collapse
|
40
|
Verhenne S, Vandeputte N, Pareyn I, Izsvák Z, Rottensteiner H, Deckmyn H, De Meyer SF, Vanhoorelbeke K. Long-Term Prevention of Congenital Thrombotic Thrombocytopenic Purpura in ADAMTS13 Knockout Mice by Sleeping Beauty Transposon-Mediated Gene Therapy. Arterioscler Thromb Vasc Biol 2017; 37:836-844. [PMID: 28254814 DOI: 10.1161/atvbaha.116.308680] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 02/17/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Severe deficiency in the von Willebrand factor-cleaving protease ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13) because of mutations in the ADAMTS13 gene can lead to acute episodes of congenital thrombotic thrombocytopenic purpura (TTP), requiring prompt treatment. Current treatment consists of therapeutic or prophylactic infusions of fresh frozen plasma. However, lifelong treatment with plasma products is a stressful therapy for TTP patients. Here, we describe the use of the nonviral sleeping beauty (SB) transposon system as a gene therapeutic approach to realize lifelong expression of ADAMTS13 and subsequent protection against congenital TTP. APPROACH AND RESULTS We demonstrated that hydrodynamic tail vein injection of the SB100X system expressing murine ADAMTS13 in Adamts13-/- mice resulted in long-term expression of supraphysiological levels of transgene ADAMTS13 over a period of 25 weeks. Stably expressed ADAMTS13 efficiently removed the prothrombotic ultralarge von Willebrand factor multimers present in the circulation of Adamts13-/- mice. Moreover, mice stably expressing ADAMTS13 were protected against TTP. The treated mice did not develop severe thrombocytopenia or did organ damage occur when triggered with recombinant von Willebrand factor, and this up to 20 weeks after gene transfer. CONCLUSIONS These data demonstrate the feasibility of using SB100X-mediated gene therapy to achieve sustained expression of transgene ADAMTS13 and long-term prophylaxis against TTP in Adamts13-/- mice.
Collapse
Affiliation(s)
- Sebastien Verhenne
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Nele Vandeputte
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Inge Pareyn
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Zsuzsanna Izsvák
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Hanspeter Rottensteiner
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Hans Deckmyn
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Simon F De Meyer
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.)
| | - Karen Vanhoorelbeke
- From the Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium (S.V., N.V., I.P., H.D., S.F.D.M., K.V.); Mobile DNA, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany (Z.I.); and Shire, Gene Therapy, Vienna, Austria (H.R.).
| |
Collapse
|
41
|
Scully M, Cataland S, Coppo P, de la Rubia J, Friedman KD, Kremer Hovinga J, Lämmle B, Matsumoto M, Pavenski K, Sadler E, Sarode R, Wu H. Consensus on the standardization of terminology in thrombotic thrombocytopenic purpura and related thrombotic microangiopathies. J Thromb Haemost 2017; 15:312-322. [PMID: 27868334 DOI: 10.1111/jth.13571] [Citation(s) in RCA: 294] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Indexed: 12/11/2022]
Abstract
Essentials An international collaboration provides a consensus for clinical definitions. This concerns thrombotic microangiopathies and thrombotic thrombocytopenic purpura (TTP). The consensus defines diagnosis, disease monitoring and response to treatment. Requirements for ADAMTS-13 are given. SUMMARY Background Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) are two important acute conditions to diagnose. Thrombotic microangiopathy (TMA) is a broad pathophysiologic process that leads to microangiopathic hemolytic anemia and thrombocytopenia, and involves capillary and small-vessel platelet aggregates. The most common cause is disseminated intravascular coagulation, which may be differentiated by abnormal coagulation. Clinically, a number of conditions present with microangiopathic hemolytic anemia and thrombocytopenia, including cancer, infection, transplantation, drug use, autoimmune disease, and pre-eclampsia and hemolysis, elevated liver enzymes and low platelet count syndrome in pregnancy. Despite overlapping clinical presentations, TTP and HUS have distinct pathophysiologies and treatment pathways. Objectives To present a consensus document from an International Working Group on TTP and associated thrombotic microangiopathies (TMAs). Methods The International Working Group has proposed definitions and terminology based on published information and consensus-based recommendations. Conclusion The consensus aims to aid clinical decisions, but also future studies and trials, utilizing standardized definitions. It presents a classification of the causes of TMA, and criteria for clinical response, remission and relapse of congenital and immune-mediated TTP.
Collapse
Affiliation(s)
- M Scully
- Department of Haematology, UCLH, Cardiometabolic programme-NIHR UCLH/UCL BRC, London, UK
| | - S Cataland
- Department of Internal Medicine, Ohio State University Hospital, Columbus, OH, USA
| | - P Coppo
- Department of Hematology, Saint-Antoine University Hospital, Paris, France
| | - J de la Rubia
- Department of Hematology, University Hospital Dr Peset, Valencia, Spain
| | - K D Friedman
- Division of Benign Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Kremer Hovinga
- Department of Hematology, Bern University Hospital, Bern, Switzerland
| | - B Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - M Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - K Pavenski
- Department of Laboratory medicine, St Michael's Hospital/Research Institute, Toronto, Ontario, Canada
| | - E Sadler
- Department of Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - R Sarode
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - H Wu
- Department of Pathology, Ohio State University Hospital, Columbus, OH, USA
| |
Collapse
|
42
|
Clinical importance of ADAMTS13 activity during remission in patients with acquired thrombotic thrombocytopenic purpura. Blood 2016; 128:2175-2178. [PMID: 27625362 DOI: 10.1182/blood-2016-06-724161] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
43
|
Kopić A, Benamara K, Piskernik C, Plaimauer B, Horling F, Höbarth G, Ruthsatz T, Dietrich B, Muchitsch EM, Scheiflinger F, Turecek M, Höllriegl W. Preclinical assessment of a new recombinant ADAMTS-13 drug product (BAX930) for the treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost 2016; 14:1410-9. [PMID: 27371116 DOI: 10.1111/jth.13341] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/25/2016] [Indexed: 11/26/2022]
Abstract
UNLABELLED Essentials ADAMTS-13-deficiency is a cause of thrombotic thrombocytopenic purpura (TTP). Preclinical safety of recombinant human ADAMTS-13 (BAX930) was shown in animal models. Preclinical efficacy of BAX930 was shown in a mouse model of TTP. BAX930 showed advantageous efficacy over fresh frozen plasma, the current standard of care. Click to hear Dr Cataland and Prof. Lämmle present a seminar on Thrombotic Thrombocytopenic Purpura (TTP): new Insights in Pathogenesis and Treatment Modalities. SUMMARY Background Thrombotic thrombocytopenic purpura (TTP) is a rare blood disorder characterized by microthrombosis in small blood vessels of the body, resulting in a low platelet count. Baxalta has developed a new recombinant ADAMTS-13 (rADAMTS-13) product (BAX930) for on-demand and prophylactic treatment of patients with hereditary TTP (hTTP). Objectives To evaluate the pharmacokinetics, efficacy and safety of BAX930 in different species, by use of an extensive preclinical program. Methods The prophylactic and therapeutic efficacies of BAX930 were tested in a previously established TTP mouse model. Pharmacokinetics were evaluated after single intravenous bolus injection in mice and rats, and after repeated dosing in cynomolgus monkeys. Toxicity was assessed in rats and monkeys, safety pharmacology in monkeys, and local tolerance in rabbits. Results BAX930 was shown to be efficacious, as demonstrated by a stabilized platelet count in ADAMTS-13 knockout mice that were thrombocytopenic when treated. Prophylactic efficacy was dose-dependent and comparable with that achieved by treatment with fresh frozen plasma, the mainstay of hTTP treatment. Therapeutic efficacy was treatment interval-dependent. Safety pharmacology evaluation did not show any deleterious effects of BAX930 on cardiovascular and respiratory functions in monkeys. The compound's pharmacokinetics were similar and dose-proportional in mice, rats, and monkeys. BAX930 was well tolerated in rats, monkeys, and rabbits, even at the highest doses tested. Conclusions These results demonstrate that BAX930 has a favorable preclinical profile, and support the clinical development of rADAMTS-13 for the treatment of hTTP.
Collapse
Affiliation(s)
- A Kopić
- Baxalta Innovations GmbH, Vienna, Austria
| | - K Benamara
- Baxalta Innovations GmbH, Vienna, Austria
| | | | | | - F Horling
- Baxalta Innovations GmbH, Vienna, Austria
| | - G Höbarth
- Baxalta Innovations GmbH, Vienna, Austria
| | - T Ruthsatz
- Baxalta Innovations GmbH, Vienna, Austria
| | - B Dietrich
- Baxalta Innovations GmbH, Vienna, Austria
| | | | | | - M Turecek
- Baxalta Innovations GmbH, Vienna, Austria
| | | |
Collapse
|
44
|
George JN. Evaluation and Management of Patients With Thrombotic Thrombocytopenic Purpura. J Intensive Care Med 2016; 22:82-91. [PMID: 17456728 DOI: 10.1177/0885066606297690] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) describes syndromes with multiple etiologies, some of which are rapidly fatal without plasma exchange treatment. Although there have been advances in understanding the pathogenesis of TTP, evaluation and management remain difficult because there are no specific diagnostic criteria, as TTP can be clinically similar to other acute disorders, such as sepsis, disseminated malignancy, malignant hypertension, and preeclampsia, and because urgent treatment is required. An unexpected observation of anemia and thrombocytopenia should trigger consideration of TTP; evidence that the anemia is due to microangiopathic hemolysis, suggested by the presence of red cell fragmentation on the blood smear, supports the diagnosis. When the diagnostic criteria of microangiopathic hemolytic anemia and thrombocytopenia without an apparent alternative etiology are fulfilled, plasma exchange treatment is appropriate. However, plasma exchange has risks for severe complications and death; therefore, this management decision must be balanced against the confidence in the diagnosis. With plasma exchange treatment, approximately 80% of patients survive, in contrast to only 10% in the era prior to the availability of plasma exchange. The continuing mortality from TTP, the risks of plasma exchange treatment, and the potential for recurrent episodes of TTP are clinical challenges that remain to be solved.
Collapse
Affiliation(s)
- James N George
- Hematology-Oncology Section, College of Medicine, Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190, USA.
| |
Collapse
|
45
|
Sevinc A, Kalender ME, Pehlivan Y, Sari I, Camci C. Thrombotic Thrombocytopenic Purpura and Bone Marrow Necrosis as the Initial Presentation of Lung Cancer. Clin Appl Thromb Hemost 2016; 13:449-52. [PMID: 17911200 DOI: 10.1177/1076029607303346] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a disseminated form of thrombotic microangiopathy. Although most cases are held to be idiopathic, its association with malignancy is well recognized, and it usually occurs at the terminal stage of cancer. Bone marrow necrosis (BMN) is another rare disorder defined pathologically as the necrosis of myeloid tissue and medullary stroma with preservation of bone. Although hematologic malignancy is the most common underlying disease associated with BMN, it can also be caused by solid tumors. The occurrence of TTP with BMN associated with lung cancer has not been reported in the English literature. First described is a patient with the rare association of TTP and BMN displayed as the first manifestations of a lung cancer.
Collapse
Affiliation(s)
- Alper Sevinc
- Department of Medical Oncology, Gaziantep University, School of Medicine, Gaziantep Oncology Hospital, Gaziantep, TR-27310, Turkey.
| | | | | | | | | |
Collapse
|
46
|
Genetic variations in complement factors in patients with congenital thrombotic thrombocytopenic purpura with renal insufficiency. Int J Hematol 2016; 103:283-91. [DOI: 10.1007/s12185-015-1933-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/10/2015] [Accepted: 12/28/2015] [Indexed: 12/11/2022]
|
47
|
Krogh ASV, Waage A, Quist-Paulsen P. Kongenital trombotisk trombocytopenisk purpura. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1452-7. [DOI: 10.4045/tidsskr.15.1272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|
48
|
Khodor S, Castro M, McNamara C, Chaulagain CP. Clopidogrel-induced refractory thrombotic thrombocytopenic purpura successfully treated with rituximab. Hematol Oncol Stem Cell Ther 2015; 9:76-9. [PMID: 26684918 DOI: 10.1016/j.hemonc.2015.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/15/2015] [Indexed: 01/07/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by microvascular aggregation of platelets and fibrin strands causing thrombocytopenia, microangiopathic hemolytic anemia, and organ dysfunction. TTP can develop as a result of a deficiency in ADAMTS13 enzyme activity due to either a genetic defect or, more commonly, the development of anti-ADAMTS13 autoantibodies. TTP can also be associated with pregnancy, organ transplant, lupus, infections, and drugs. Here, we present a case of TTP that developed shortly after the start of clopidogrel treatment for acute ischemic stroke and acute myocardial infarction, and describe the clinical presentation, refractory course of the disease, and successful induction of remission through the use of rituximab in a setting of pre-existing autoimmune diseases.
Collapse
Affiliation(s)
- Sara Khodor
- Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Miguel Castro
- Department of Internal Medicine, Cleveland Clinic-Florida, Weston, FL, USA
| | - Colin McNamara
- Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Chakra P Chaulagain
- Taussig Cancer Institute of the Cleveland Clinic, Maroone Cancer Center, Cleveland Clinic-Florida, Weston, FL, USA.
| |
Collapse
|
49
|
Bergmann F, Rath W. The Differential Diagnosis of Thrombocytopenia in Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:795-802. [PMID: 26634939 PMCID: PMC4678382 DOI: 10.3238/arztebl.2015.0795] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thrombocytopenia is, after anemia, the second most common abnormality of the complete blood count in pregnancy, with a reported frequency of 6.6% to 11.2%. It has many causes. Thrombocytopenia should be diagnostically evaluated as early as possible in pregnancy, so that the obstetrical management can be accordingly planned to minimize harm to the mother and child. As the various underlying diseases share clinical features and laboratory findings, the differential diagnosis is often a difficult interdisciplinary challenge. METHODS In this article, we review pertinent literature (2000-January 2015) retrieved by a selective search in PubMed. RESULTS Gestational thrombocytopenia is the most common type, accounting for 75% of cases, followed by severe pre-eclampsia/HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) in 15-22% and autoimmune thrombocytopenia (ITP) in 1-4%. Gestational thrombocytopenia and ITP differ in the bleeding history, the severity of thrombocytopenia, the frequency of neo - natal thrombocytopenia, and the rate of normalization of the platelet count after delivery. The HELLP syndrome and rarer microangiopathic hemolytic anemias (e.g., thrombotic thrombocytopenic purpura) can be differentiated on the basis of their main clinical features, such as hypertension/proteinuria and upper abdominal pain, the severity of hemolysis and thrombocytopenia, the degree of transaminase elevation, and the rapidity of postpartum remission of the clinical and laboratory findings. A stepwise diagnostic procedure should be followed to distinguish further causes, e.g., to differentiate thrombocytopenia due to infection, autoimmune disease, or drugs from thrombocytopenia due to a rare hereditary disease. CONCLUSION The early interdisciplinary evaluation of thrombocytopenia in pregnancy is a prerequisite for the optimal care of the mother and child. The development of evidence-based recommendations for interdisciplinary management should be a goal for the near future.
Collapse
Affiliation(s)
| | - Werner Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
| |
Collapse
|
50
|
Abstract
Pathogenesis of thrombotic thrombocytopenic purpura (TTP) was a mystery for over half a century until the discovery of ADAMTS13. ADAMTS13 is primarily synthesized in the liver, and its main function is to cleave von Willebrand factor (VWF) anchored on the endothelial surface, in circulation, and at the sites of vascular injury. Deficiency of plasma ADAMTS13 activity (<10%) resulting from mutations of the ADAMTS13 gene or autoantibodies against ADAMTS13 causes hereditary or acquired (idiopathic) TTP. ADAMTS13 activity is usually normal or modestly reduced (>20%) in other forms of thrombotic microangiopathy secondary to hematopoietic progenitor cell transplantation, infection, and disseminated malignancy or in hemolytic uremic syndrome. Plasma infusion or exchange remains the initial treatment of choice to date, but novel therapeutics such as recombinant ADAMTS13 and gene therapy are under development. Moreover, ADAMTS13 deficiency has been shown to be a risk factor for the development of myocardial infarction, stroke, cerebral malaria, and preeclampsia.
Collapse
Affiliation(s)
- X Long Zheng
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104;
| |
Collapse
|