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Sawyer J, Elliott T, Orton L, Sowell H, Gatwood K, Shultes K. Prevention and management of acute toxicities from conditioning regimens during hematopoietic stem cell transplantation. Clin Hematol Int 2024; 6:1-10. [PMID: 38817311 PMCID: PMC11087001 DOI: 10.46989/001c.94952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/13/2023] [Indexed: 06/01/2024] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) remains the only curative option for several hematological malignancies. Its use has continued to grow, with an estimated 23,500 transplants performed annually in the United States alone. The acute toxicities that occur from conditioning chemotherapy can impact the peri-transplant period and have substantial implications on patients' tolerability and outcomes, irrespective of the treatment of their disease. Chemotherapy-induced nausea vomiting (CINV), mucositis, transplant-associated thrombotic microangiopathy (TA-TMA), and sinusoidal obstruction syndrome, also known as a veno-occlusive disease (SOS/VOD) can all have significant implications for patients. These acute complications begin with the start of conditioning chemotherapy and add to potential toxicity for patients throughout the early post-transplant period, from Day +30 for CINV, mucositis, and SOS, and which can continue through at least Day +100 with the onset of TA-TMA. These toxicities must be prevented and managed appropriately. This review will summarize the literature surrounding them and guide their management.
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Affiliation(s)
- Jana Sawyer
- PharmacyVA Tennessee Valley Healthcare System
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2
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Collotta D, Bertocchi I, Chiapello E, Collino M. Antisense oligonucleotides: a novel Frontier in pharmacological strategy. Front Pharmacol 2023; 14:1304342. [PMID: 38044945 PMCID: PMC10690781 DOI: 10.3389/fphar.2023.1304342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Antisense oligonucleotides (ASOs) are short single stranded synthetic RNA or DNA molecules, whereas double-stranded RNA nucleotide sequences are called small interfering RNA (siRNA). ASOs bind to complementary nucleic acid sequences impacting the associated functions of the targeted nucleic acids. They represent an emerging class of drugs that, through a revolutionary mechanism of action, aim to directly regulate disease-causing genes and their variants, providing an alternative tool to traditional "protein-specific" therapies. The majority of the ASOs are designed to treat orphan genetic disorders that in most of the cases are seriously disabling and still lacking an adequate therapy. In order to translate ASOs into clinical success, constant technological advances have been instrumental in overcoming several pharmacological, toxicological and formulation limitations. Accordingly, chemical structures have been recently implemented and new bio-conjugation and nanocarriers formulation strategies explored. The aim of this work is to offer an overview of the antisense technology with a comparative analysis of the oligonucleotides approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA).
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Affiliation(s)
- D. Collotta
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - I. Bertocchi
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
- Neuroscience Institute Cavalieri Ottolenghi (NICO), University of Turin, Turin, Italy
| | - E. Chiapello
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - M. Collino
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
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3
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Kashyap R, Anwer F, Iqbal MA, Khalid F, Khan A, Ali MA, Anwar MY, Chaudhary A, Jaan A. Efficacy and Safety of Recombinant Thrombomodulin for the Prophylaxis of Veno-Occlusive Complication in Allogeneiccit Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis. Hematol Oncol Stem Cell Ther 2023; 16:93-101. [PMID: 34655527 DOI: 10.1016/j.hemonc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/08/2021] [Accepted: 09/22/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hepatic veno-occlusive disease (VOD), also termed as sinusoidal obstruction syndrome (SOS), is a lethal complication after hematopoietic stem cell transplantation (HSCT). Various factors put patients undergoing allogeneic HSCT at an increased risk for VOD. Thrombomodulin (TM) is an important factor which has a wide range of effects, including anticoagulant, anti-inflammatory, angiogenic, and protective effect, on endothelial cells. It plays a role in preventing excessive coagulation and thrombosis by binding with thrombin and inhibiting the coagulation cascade. There are a limited number of options for the prevention of this fatal complication. Recombinant thrombomodulin (rTM), an endothelial anticoagulant co-factor, as prophylactic therapy might be able to prevent veno-occlusive complications after stem cell transplantation. METHODS A literature search was performed on PubMed, Embase, and Web of Science. We used the following Mesh terms and Emtree terms, "Hepatic Veno-Occlusive Diseases" OR "Sinusoidal Obstruction" OR "Stem Cell Transplantations " AND "Thrombomodulin" from the inception of data up to April 1, 2021. The PICO (Patient/Population, Intervention, Comparison and Outcomes) framework was used for the literature search. RESULTS For the VOD incidence after HSCTstem cell transplantation, the result was in favor of rTM with a risk ratio (RR) of 0.53 (I2 = 0%, 95% confidence interval [CI] = 0.32-0.89). The incidence of transplant-associated thrombotic microangiopathy (TA-TMA) after HSCT was reduced in rTM group. The RR for incidence of TA-TMA was 0.48 (I2 = 62%, 95% CI = 0.20-1.17) favoring rTM. The RR for incidence of graft-versus-host disease (GvHD) was also lower in rTM group, 0.48 (I2 = 64%, 95% CI = 0.32-0.72). CONCLUSION In our meta-analysis, we evaluate the efficacy and safety of rTM in the prevention of SOS after HSCT. According to our results, rTM use led to a significant reduction in SOS episodes, TA-TMA, and GvHD after HSCT.
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Affiliation(s)
| | - Faiz Anwer
- Associate Professor of Medicine Hematology, Oncology, Stem Cell Transplantation, Multiple Myeloma Program, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Ave, Cleveland, OH 44195, USA
| | | | | | - Anam Khan
- All India Institutes of Medical Sciences (AIIMS), New Delhi, India
| | | | | | | | - Ali Jaan
- Rochester General Hospital, Rochester, NY, USA
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4
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A case of percutaneous transhepatic stomal varices embolization and partial splenic artery embolization for rectal cancer after CAPOX/BEV chemotherapy: the summary of the stomal varices related to oxaliplatin administration. Clin J Gastroenterol 2023; 16:54-62. [PMID: 36266604 PMCID: PMC9889487 DOI: 10.1007/s12328-022-01720-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 02/04/2023]
Abstract
Capecitabine and oxaliplatin (CAPOX) plus bevacizumab (BEV) therapy (CAPOX/BEV) is a standard treatment recommended as the first-line treatment for colorectal cancer recurrence. Recently, sinusoidal obstruction syndrome (SOS) and resulting portal hypertension have been reported as important side effects of oxaliplatin. We herein report a rectal cancer patient who underwent percutaneous transhepatic stoma variceal embolization (PTO) and partial splenic artery embolization (PSE) for stomal variceal bleeding and splenomegaly due to portal hypertension caused by SOS after CAPOX therapy. A 43-year-old man who underwent robot-assisted laparoscopic abdominoperineal resection for advanced lower rectal cancer was started on CAPOX/BEV therapy for early recurrence 1 month after surgery. In the sixth course, splenomegaly rapidly worsened, stomal varices appeared, and the stoma began bleeding. At 5 months after the appearance of stomal varices, the splenomegaly worsened, the frequency of stomal bleeding increased, and PTO was performed. Five months later, PSE was performed for splenomegaly and thrombocytopenia. At 5 months since the PSE, the stoma bleeding has not recurred, and the thrombocytopenia has been corrected. The patient has been able to continue chemotherapy. We suggest that staged treatment by PTO and PSE be considered an important treatment option for stomal varices and splenomegaly associated with SOS.
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Frame D, Scappaticci GB, Braun TM, Maliarik M, Sisson TH, Pipe SW, Lawrence DA, Richardson PG, Holinstat M, Hyzy RC, Kaul DR, Gregg KS, Lama VN, Yanik GA. Defibrotide Therapy for SARS-CoV-2 ARDS. Chest 2022; 162:346-355. [PMID: 35413279 PMCID: PMC8993696 DOI: 10.1016/j.chest.2022.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND SARS-CoV-2-related ARDS is associated with endothelial dysfunction and profound dysregulation of the thrombotic-fibrinolytic pathway. Defibrotide is a polyanionic compound with fibrinolytic, antithrombotic, and antiinflammatory properties. RESEARCH QUESTION What is the safety and tolerability of defibrotide in patients with severe SARS-CoV-2 infections? STUDY DESIGN AND METHODS We report a prospective, open-label, single-center safety trial of defibrotide for the management of SARS-CoV-2-related ARDS. Eligible participants were 18 years of age or older with clinical and radiographic signs of ARDS, no signs of active bleeding, a serum D-dimer of more than twice upper limit of normal, and positive polymerase chain reaction-based results for SARS-CoV-2. Defibrotide (6.25 mg/kg/dose IV q6h) was administered for a planned 7-day course, with serum D-dimer levels and respiratory function monitored daily during therapy. RESULTS Twelve patients (median age, 63 years) were treated, with 10 patients receiving mechanical ventilation and 6 receiving vasopressor support at study entry. The median D-dimer was 3.25 μg/ml (range, 1.33-12.3) at study entry. The median duration of therapy was 7 days. No hemorrhagic or thrombotic complications occurred during therapy. No other adverse events attributable to defibrotide were noted. Four patients met the day 7 pulmonary response parameter, all four showing a decrease in serum D-dimer levels within the initial 72 h of defibrotide therapy. Three patients died of progressive pulmonary disease 11, 17, and 34 days after study entry. Nine patients (75%) remain alive 64 to 174 days after initiation of defibrotide. Day 30 all-cause mortality was 17% (95% CI, 0%-35%). All patients with a baseline Pao2 to Fio2 ratio of ≥ 125 mm Hg survived, whereas the three patients with a baseline Pao2 to Fio2 ratio of < 125 mm Hg died. INTERPRETATION The use of defibrotide for management of SARS-CoV-2-related ARDS proved safe and tolerable. No hemorrhagic or thrombotic complications were reported during therapy, with promising outcomes in a patient population with a historically high mortality rate. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04530604; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- David Frame
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Department of Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Gianni B. Scappaticci
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Department of Clinical Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Thomas M. Braun
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Mary Maliarik
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Thomas H. Sisson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Steven W. Pipe
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI
| | - Daniel A. Lawrence
- Department of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Paul G. Richardson
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Michael Holinstat
- Division of Pharmacology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Daniel R. Kaul
- Division of Infectious Disease, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Kevin S. Gregg
- Division of Infectious Disease, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Gregory A. Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI,CORRESPONDENCE TO: Gregory A. Yanik, MD
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6
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Alhamadani F, Zhang K, Parikh R, Wu H, Rasmussen TP, Bahal R, Zhong XB, Manautou JE. Adverse Drug Reactions and Toxicity of the Food and Drug Administration-Approved Antisense Oligonucleotide Drugs. Drug Metab Dispos 2022; 50:879-887. [PMID: 35221289 PMCID: PMC11022857 DOI: 10.1124/dmd.121.000418] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/14/2022] [Indexed: 04/19/2024] Open
Abstract
The market for large molecule biologic drugs has grown rapidly, including antisense oligonucleotide (ASO) drugs. ASO drugs work as single-stranded synthetic oligonucleotides that reduce production or alter functions of disease-causing proteins through various mechanisms, such as mRNA degradation, exon skipping, and ASO-protein interactions. Since the first ASO drug, fomivirsen, was approved in 1998, the U.S. Food and Drug Administration (FDA) has approved 10 ASO drugs to date. Although ASO drugs are efficacious in treating some diseases that are untargetable by small-molecule chemical drugs, concerns on adverse drug reactions (ADRs) and toxicity cannot be ignored. Illustrative of this, mipomersen was recently taken off the market due to its hepatotoxicity risk. This paper reviews ADRs and toxicity from FDA drug labeling, preclinical studies, clinical trials, and postmarketing real-world studies on the 10 FDA-approved ASO drugs, including fomivirsen and pegaptanib, mipomersen, nusinersen, inotersen, defibrotide, eteplirsen, golodirsen, viltolarsen, and casimersen. Unique and common ADRs and toxicity for each ASO drug are summarized here. The risk of developing hepatotoxicity, kidney toxicity, and hypersensitivity reactions co-exists for multiple ASO drugs. Special precautions need to be in place when certain ASO drugs are administrated. Further discussion is extended on studying the mechanisms of ADRs and toxicity of these drugs, evaluating the existing physiologic and pathologic states of patients, optimizing the dose and route of administration, and formulating personalized treatment plans to improve the clinical utility of FDA-approved ASO drugs and discovery and development of new ASO drugs with reduced ADRs. SIGNIFICANCE STATEMENT: The current review provides a comprehensive analysis of unique and common ADRs and the toxicity of FDA-approved ASO drugs. The information can help better manage the risk of severe hepatotoxicity, kidney toxicity, and hypersensitivity reactions in the usage of currently approved ASO drugs and the discovery and development of new and safer ASO drugs.
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Affiliation(s)
- Feryal Alhamadani
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - Kristy Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - Rajvi Parikh
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - Hangyu Wu
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - Theodore P Rasmussen
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - Raman Bahal
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - Xiao-Bo Zhong
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
| | - José E Manautou
- Department of Pharmaceutical Sciences, School of Pharmacy (F.A., K.Z., H.W., T.P.R., R.B., X.Z., J.E.M.), and Department of Physiology and Neurobiology (R.P.), University of Connecticut, Storrs, Connecticut
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7
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Hepatic veno-occlusive disease (sinusoidal obstruction syndrome) after hematopoietic stem cell transplantation in adult patients: diagnosis, incidence, prophylaxis, and treatment. Transfus Apher Sci 2022; 61:103372. [DOI: 10.1016/j.transci.2022.103372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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8
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Fernández S, Palomo M, Molina P, Díaz-Ricart M, Escolar G, Téllez A, Seguí F, Ventosa H, Torramade-Moix S, Rovira M, Carreras E, Nicolás JM, Castro P. Progressive endothelial cell damage in correlation with sepsis severity. Defibrotide as a contender. J Thromb Haemost 2021; 19:1948-1958. [PMID: 33872468 DOI: 10.1111/jth.15343] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/03/2021] [Accepted: 04/13/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The vascular endothelium plays a key role in sepsis pathophysiology and the associated organ dysfunction. METHODS We evaluated endothelial function in an experimental in vitro model of sepsis, using endothelial cells grown in the presence of serum from patients with septic syndromes (sepsis, severe sepsis, and septic shock), noninfectious systemic inflammatory response syndrome (NI-SIRS) and healthy volunteers. Experiments were performed in the absence and presence of defibrotide (DF) (100 µg/ml) to evaluate its potential protective effect. RESULTS After exposure to patients' sera, there was a progressive endothelial cell activation in correlation with sepsis severity, with a proinflammatory and prothrombotic phenotype, exhibiting significantly increased expression of adhesion receptors at the surface (intercellular adhesion molecule-1, p < .05 and vascular cell adhesion molecule-1, p < .05); higher production and release to the extracellular matrix (ECM) of von Willebrand factor (p < .001); augmented thrombogenicity of the ECM toward platelets (p < .001); and increased phosphorylation of intracellular p38MAPK. DF prevented these changes in all groups. CONCLUSIONS Markers of endothelial damage increased progressively in association with the severity of septic syndromes. The endothelium is therefore an important therapeutic target to prevent complications of sepsis. DF shows promising potential to modulate the endothelial damage associated with sepsis and may constitute a pharmacological tool to decrease its sequelae including multiorgan failure.
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Affiliation(s)
- Sara Fernández
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Patricia Molina
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Maribel Díaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Ginés Escolar
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Adrián Téllez
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Ferran Seguí
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Helena Ventosa
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Sergi Torramade-Moix
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Montserrat Rovira
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
- Stem Cell Transplantation Unit, Department of Haematology, Institute of Haematology and Oncology, Hospital Clinic, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Josep M Nicolás
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
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9
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Shi H, Gandhi AA, Smith SA, Wang Q, Chiang D, Yalavarthi S, Ali RA, Liu C, Sule G, Tsou PS, Zuo Y, Kanthi Y, Farkash EA, Lin JD, Morrissey JH, Knight JS. Endothelium-protective, histone-neutralizing properties of the polyanionic agent defibrotide. JCI Insight 2021; 6:e149149. [PMID: 34264868 PMCID: PMC8492316 DOI: 10.1172/jci.insight.149149] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022] Open
Abstract
Neutrophil-mediated activation and injury of the endothelium play roles in the pathogenesis of diverse disease states ranging from autoimmunity to cancer to COVID-19. Neutralization of cationic proteins (such as neutrophil extracellular trap–derived [NET-derived] histones) with polyanionic compounds has been suggested as a potential strategy for protecting the endothelium from such insults. Here, we report that the US Food and Drug Administration–approved polyanionic agent defibrotide (a pleiotropic mixture of oligonucleotides) directly engages histones and thereby blocks their pathological effects on endothelium. In vitro, defibrotide counteracted endothelial cell activation and pyroptosis-mediated cell death, whether triggered by purified NETs or recombinant histone H4. In vivo, defibrotide stabilized the endothelium and protected against histone-accelerated inferior vena cava thrombosis in mice. Mechanistically, defibrotide demonstrated direct and tight binding to histone H4 as detected by both electrophoretic mobility shift assay and surface plasmon resonance. Taken together, these data provide insights into the potential role of polyanionic compounds in protecting the endothelium from thromboinflammation with potential implications for myriad NET- and histone-accelerated disease states.
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Affiliation(s)
- Hui Shi
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Alex A Gandhi
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan, Ann Arbor, United States of America
| | - Qiuyu Wang
- Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, United States of America
| | - Diane Chiang
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Srilakshmi Yalavarthi
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Ramadan A Ali
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Chao Liu
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Gautam Sule
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Pei-Suen Tsou
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Yu Zuo
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Yogendra Kanthi
- Division of Intramural Research National Heart, Lung and Blood Institute, Bethesda, United States of America
| | - Evan A Farkash
- Department of Pathology, University of Michigan, Ann Arbor, United States of America
| | - Jiandie D Lin
- University of Michigan, Ann Arbor, United States of America
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan, Ann Arbor, United States of America
| | - Jason S Knight
- Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
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10
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Shi H, Gandhi AA, Smith SA, Wang Q, Chiang D, Yalavarthi S, Ali RA, Liu C, Sule G, Tsou PS, Zuo Y, Kanthi Y, Farkash EA, Lin JD, Morrissey JH, Knight JS. Endothelium-protective, histone-neutralizing properties of the polyanionic agent defibrotide. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 33655266 DOI: 10.1101/2021.02.21.21252160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neutrophil-mediated activation and injury of the endothelium play a role in the pathogenesis of diverse disease states ranging from autoimmunity to cancer to COVID-19. Neutralization of cationic proteins (such as neutrophil extracellular trap/NET-derived histones) with polyanionic compounds has been suggested as a potential strategy for protecting the endothelium from such insults. Here, we report that the FDA-approved polyanionic agent defibrotide (a pleiotropic mixture of oligonucleotides) directly engages histones and thereby blocks their pathological effects on endothelium. In vitro , defibrotide counteracted endothelial cell activation and pyroptosis-mediated cell death, whether triggered by purified NETs or recombinant histone H4. In vivo , defibrotide stabilized the endothelium and protected against histone-accelerated inferior vena cava thrombosis in mice. Mechanistically, defibrotide demonstrated direct and tight binding to histone H4 as detected by both electrophoretic mobility shift assay and surface plasmon resonance. Taken together, these data provide insights into the potential role of polyanionic compounds in protecting the endothelium from thromboinflammation with potential implications for myriad NET- and histone-accelerated disease states.
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11
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Tappe W, Aggarwal S, Topaloglu O, Iacobelli M. A Meta-Analysis Evaluating the Incidence of Bleeding Events With Intravenous Defibrotide Treatment Outside the Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome Setting. Clin Appl Thromb Hemost 2021; 26:1076029620935202. [PMID: 32687402 PMCID: PMC7372611 DOI: 10.1177/1076029620935202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Defibrotide is approved to treat hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) with renal/pulmonary dysfunction following hematopoietic cell transplantation (HCT) in adult and pediatric patients in the United States, and to treat severe hepatic VOD/SOS post-HCT in adult and pediatric patients aged >1 month in the European Union. The defibrotide prescribing information warns that defibrotide may increase bleeding risk in VOD/SOS patients. To broaden our understanding of the incidence of bleeding with defibrotide, we performed a meta-analysis of the published literature of defibrotide use outside of the post-HCT VOD/SOS setting. Of 1857 records identified, 125 reported on defibrotide; 23 contained data on bleeding events. The estimated overall incidence of bleeding events was 1% (95% confidence interval [CI]: 0%-2%) and 8% (95% CI: 3%-14%) in studies using intravenous defibrotide and studies with controls, respectively. The risk ratio for bleeding events with intravenous defibrotide versus controls was 0.36 (95% CI: 0.24-0.52; P < .00001) among studies with data on intravenous defibrotide and controls. This meta-analysis of defibrotide use outside of the post-HCT VOD/SOS setting suggests that the incidence of bleeding with defibrotide is lower than controls.
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Transplant-associated thrombotic microangiopathy: theoretical considerations and a practical approach to an unrefined diagnosis. Bone Marrow Transplant 2021; 56:1805-1817. [PMID: 33875812 PMCID: PMC8338557 DOI: 10.1038/s41409-021-01283-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 02/07/2023]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic stem cell transplant (HSCT) with high morbidity and mortality. The triad of endothelial cell activation, complement dysregulation, and microvascular hemolytic anemia has the potential to cause end organ dysfunction, multiple organ dysfunction syndrome and death, but clinical features mimic other disorders following HSCT, delaying diagnosis. Recent advances have implicated complement as a major contributor and the therapeutic potential of complement inhibition has been explored. Eculizumab has emerged as an effective therapy and narsoplimab (OMS721) has been granted priority review by the FDA. Large studies performed mostly in pediatric patients suggest that earlier recognition and treatment may lead to improved outcomes. Here we present a clinically focused summary of recently published literature and propose a diagnostic and treatment algorithm.
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Analysis of Time to Complete Response after Defibrotide Initiation in Patients with Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome after Hematopoietic Cell Transplantation. Transplant Cell Ther 2020; 27:88.e1-88.e6. [PMID: 32950693 PMCID: PMC8549529 DOI: 10.1016/j.bbmt.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/21/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially life-threatening complication that occurs after hematopoietic cell transplantation (HCT). The mortality associated with untreated VOD/SOS with multiorgan dysfunction (MOD) has been reported to be >80%. The recommended dose of defibrotide is 6.25 mg/kg every 6 hours, administered as a 2-hour i.v. infusion, for a minimum of 21 days or until resolution of VOD/SOS signs and symptoms. The objective of this analysis was to evaluate the time to complete response (CR) in patients with post-HCT VOD/SOS treated with defibrotide. The time to defibrotide discontinuation due to a CR served as a surrogate for time to CR in an expanded access study (T-IND; ClinicalTrials.govNCT00628498; n = 1000), and was analyzed separately from the time to CR data pooled from a phase 2 randomized dose-finding study (NCT00003966; n = 74 patients who received 25 mg/kg/day) and a phase 3 historically controlled study (NCT00358501; n = 102). For all studies, a CR was defined as total serum bilirubin <2 mg/dL with resolution of VOD/SOS-related MOD (renal and/or pulmonary dysfunction); the phase 2 study also required resolution of central nervous system dysfunction. In the T-IND, 390 patients discontinued treatment due to a CR and had sufficient data for analysis. The median time to discontinuation was 22 days (range, 2 to 64 days). Discontinuation due to CR occurred beyond 21 days in 235 patients (60%) and beyond 28 days in 57 patients (15%). The pooled phase 2 and 3 studies included 60 patients who achieved a CR, with a median time to CR of 24.5 days (range, 7 to 123 days). A CR was achieved beyond 21 days in 32 patients (53%) and beyond 28 days in 24 patients (40%). The Kaplan-Meier estimate of day +100 survival rate was substantially higher in patients who discontinued due to a CR compared with those who did not (92.5% versus 37.3%). Treatment-emergent adverse events occurred in 185 of 390 patients (47%) who discontinued due to a CR in the T-IND and in 55 of 60 patients (92%) who achieved a CR in the pooled phase 2 and 3 studies, and rates did not differ according to duration of treatment (≤21 days versus >21 days). Taken together, these results highlight the importance of continued defibrotide therapy until resolution of VOD/SOS signs and symptoms, as currently indicated in the approved product labels, which may occur beyond the recommended minimum of 21 days.
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Use of defibrotide to treat adult patients with transplant-associated thrombotic microangiopathy. Bone Marrow Transplant 2018; 54:142-145. [PMID: 29899573 DOI: 10.1038/s41409-018-0256-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/04/2023]
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15
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Abstract
Drug molecules transformed into nanoparticles or endowed with nanostructures with or without the aid of carrier materials are referred to as "nanomedicines" and can overcome some inherent drawbacks of free drugs, such as poor water solubility, high drug dosage, and short drug half-life in vivo. However, most of the existing nanomedicines possess the drawback of low drug-loading (generally less than 10%) associated with more carrier materials. For intravenous administration, the extensive use of carrier materials might cause systemic toxicity and impose an extra burden of degradation, metabolism, and excretion of the materials for patients. Therefore, on the premise of guaranteeing therapeutic effect and function, reducing or avoiding the use of carrier materials is a promising alternative approach to solve these problems. Recently, high drug-loading nanomedicines, which have a drug-loading content higher than 10%, are attracting increasing interest. According to the fabrication strategies of nanomedicines, high drug-loading nanomedicines are divided into four main classes: nanomedicines with inert porous material as carrier, nanomedicines with drug as part of carrier, carrier-free nanomedicines, and nanomedicines following niche and complex strategies. To date, most of the existing high drug-loading nanomedicines belong to the first class, and few research studies have focused on other classes. In this review, we investigate the research status of high drug-loading nanomedicines and discuss the features of their fabrication strategies and optimum proposal in detail. We also point out deficiencies and developing direction of high drug-loading nanomedicines. We envision that high drug-loading nanomedicines will occupy an important position in the field of drug-delivery systems, and hope that novel perspectives will be proposed for the development of high drug-loading nanomedicines.
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Affiliation(s)
- Shihong Shen
- Key Laboratory of Biomedical Information Engineering of Education Ministry, School of Life Science and Technology, Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Youshen Wu
- Key Laboratory of Biomedical Information Engineering of Education Ministry, School of Life Science and Technology, Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Yongchun Liu
- Key Laboratory of Biomedical Information Engineering of Education Ministry, School of Life Science and Technology, Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Daocheng Wu
- Key Laboratory of Biomedical Information Engineering of Education Ministry, School of Life Science and Technology, Xi’an Jiaotong University, Xi’an, People’s Republic of China
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An Analysis of Responses to Defibrotide in the Pulmonary Vascular Bed of the Cat. Am J Ther 2017; 23:e757-65. [PMID: 24368612 DOI: 10.1097/mjt.0000000000000010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Defibrotide is a polydisperse mixture of single-stranded oligonucleotides with many pharmacologic properties and multiple actions on the vascular endothelium. Responses to defibrotide and other vasodepressor agents were evaluated in the pulmonary vascular bed of the cat under conditions of controlled pulmonary blood flow and constant left atrial pressure. Lobar arterial pressure was increased to a high steady level with the thromboxane A2 analog U-46619. Under increased-tone conditions, defibrotide caused dose-dependent decreases in lobar arterial pressure without altering systemic arterial and left atrial pressures. Responses to defibrotide were significantly attenuated after the administration of the cyclooxygenase inhibitor sodium meclofenamate. Responses to defibrotide were also significantly attenuated after the administration of both the adenosine 1 and 2 receptor antagonists 8-cyclopentyl-1,3-dimethylxanthine and 8-(3-chlorostyryl)caffeine. Responses to defibrotide were not altered after the administration of the vascular selective adenosine triphosphate-sensitive potassium channel blocker U-37883A, or after the administration of the nitric oxide synthase inhibitor L-N-(1-iminoethyl)-ornithine. These data show that defibrotide has significant vasodepressor activity in the pulmonary vascular bed of the cat. They also suggest that pulmonary vasodilator responses to defibrotide are partially dependent on both the activation of the cyclooxygenase enzyme and adenosine 1 and 2 receptor pathways and independent of the activation of adenosine triphosphate-sensitive potassium channels or the synthesis of nitric oxide in the pulmonary vascular bed of the cat.
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17
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Use of defibrotide to treat transplant-associated thrombotic microangiopathy: a retrospective study of the Paediatric Diseases and Inborn Errors Working Parties of the European Society of Blood and Marrow Transplantation. Bone Marrow Transplant 2017; 52:762-764. [PMID: 28092354 DOI: 10.1038/bmt.2016.351] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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18
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Delicque J, Boulin M, Guiu B, Pelage JP, Escal L, Schembri V, Assenat E, Fohlen A. Interventional oncology for hepatocellular carcinoma. Clin Res Hepatol Gastroenterol 2016; 40:530-537. [PMID: 27055387 DOI: 10.1016/j.clinre.2016.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/17/2016] [Indexed: 02/04/2023]
Abstract
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and is increasing in incidence. The overall prognosis of patients with liver cancer is poor. The Barcelona Clinic Liver Cancer (BCLC) classification in 5 stages is endorsed by European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Disease (AASLD). This classification is recommended for treatment allocation. Because a small proportion of patients are suitable for curative surgical treatment, various locoregional therapies are widely used to manage patients with HCC. The image-guided therapies, also called interventional radiology or interventional oncology (IO) techniques consisted in percutaneous or endovascular approach. This article reviews the different IO treatments available in HCC patients and the strength of the data.
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Affiliation(s)
- Julien Delicque
- St-Eloi University Hospital, Department of Radiology, 34000 Montpellier, France
| | - Mathieu Boulin
- Dijon University Hospital, Department of Pharmacy, 21000 Dijon, France
| | - Boris Guiu
- St-Eloi University Hospital, Department of Radiology, 34000 Montpellier, France.
| | - Jean-Pierre Pelage
- St-Eloi University Hospital, Department of Radiology, 34000 Montpellier, France
| | - Laure Escal
- St-Eloi University Hospital, Department of Radiology, 34000 Montpellier, France
| | - Valentina Schembri
- St-Eloi University Hospital, Department of Radiology, 34000 Montpellier, France
| | - Eric Assenat
- St-Eloi University Hospital, Department of Oncology, 34000 Montpellier, France
| | - Audrey Fohlen
- University and Medical Center of Caen, 14033 Caen cedex, France.
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Stein C, Castanotto D, Krishnan A, Nikolaenko L. Defibrotide (Defitelio): A New Addition to the Stockpile of Food and Drug Administration-approved Oligonucleotide Drugs. MOLECULAR THERAPY. NUCLEIC ACIDS 2016; 5:e346. [PMID: 28131276 PMCID: PMC5023395 DOI: 10.1038/mtna.2016.42] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 05/16/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Cy Stein
- Department of Medical Oncology and Experimental Therapeutics, City of Hope, Duarte, California, USA; Department of Molecular and Cellular Biology, City of Hope, Duarte, California, USA.
| | - Daniela Castanotto
- Department of Medical Oncology and Experimental Therapeutics, City of Hope, Duarte, California, USA; Department of Molecular and Cellular Biology, City of Hope, Duarte, California, USA
| | - Amrita Krishnan
- Department of Hematologic Oncology, City of Hope, Duarte, California, USA
| | - Liana Nikolaenko
- Department of Hematologic Oncology, City of Hope, Duarte, California, USA
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Dalle JH, Giralt SA. Hepatic Veno-Occlusive Disease after Hematopoietic Stem Cell Transplantation: Risk Factors and Stratification, Prophylaxis, and Treatment. Biol Blood Marrow Transplant 2015; 22:400-9. [PMID: 26431626 DOI: 10.1016/j.bbmt.2015.09.024] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/24/2015] [Indexed: 12/13/2022]
Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), can develop in a subset of patients, primarily after myeloablative hematopoietic stem cell transplantation, but it also may occur after reduced-intensity conditioning. Severe VOD/SOS, typically characterized by multiorgan failure, has been associated with a mortality rate greater than 80%. Therefore, an accurate and prompt diagnosis of VOD/SOS is essential for early initiation of appropriate therapy to improve clinical outcomes. Moreover, some studies have support the use of prophylaxis for patients who are at high risk of developing VOD/SOS. This review summarizes risk factors associated with development of VOD/SOS, including pretransplantation patient characteristics and factors related to stem cell transplantation, that can facilitate patient stratification according to risk. The incidence of VOD/SOS, clinical features, and diagnostic criteria are reviewed. Data on emerging treatment strategies for patients with VOD/SOS are discussed in the context of recent treatment guidelines. Additionally, options for prophylaxis in individuals who are at increased risk are presented. Although historically only those patients with moderate to severe VOD/SOS have been treated, early therapy and prophylaxis may be appropriate for many patients and may have the potential to improve patients' outcomes and survival, including for those with nonsevere disease.
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Affiliation(s)
- Jean-Hugues Dalle
- Department of Paediatric Haematology, Paris Diderot University, Sorbonne Paris Cité, Hôpital Robert Debré, APHP, Paris, France
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York.
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Defibrotide: a review of its use in severe hepatic veno-occlusive disease following haematopoietic stem cell transplantation. Clin Drug Investig 2015; 34:895-904. [PMID: 25351934 DOI: 10.1007/s40261-014-0242-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Defibrotide (Defitelio(®)) was recently approved in the EU for the treatment of severe hepatic veno-occlusive disease (VOD), also known as sinusoidal obstructive syndrome, in haematopoietic stem cell transplantation (HSCT) therapy. It is indicated in adults, adolescents, children and infants over 1 month of age. Defibrotide is also available in the US via an expanded-access protocol. Defibrotide is thought to protect endothelial cells and restore the thrombo-fibrinolytic balance in VOD. In a multicentre, phase III trial, the complete response rate by day +100 (primary endpoint) was significantly higher, and mortality at day +100 was significantly lower, in patients with severe hepatic VOD and multiorgan failure following HSCT who received intravenous defibrotide 6.25 mg/kg every 6 h than in a group of historical controls. The efficacy of defibrotide in severe hepatic VOD following HSCT was also supported by findings from a phase II dose-finding study, compassionate-use data and information provided from an independent transplant registry. Intravenous defibrotide was generally well tolerated in patients with severe hepatic VOD following HSCT, and was not associated with an increased risk of haemorrhagic adverse events. In conclusion, defibrotide is the only agent approved (in the EU) for use in severe hepatic VOD following HSCT and represents a useful advance in the treatment of this condition.
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Young JAH, Weisdorf DJ. Infections in Recipients of Hematopoietic Stem Cell Transplants. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7152282 DOI: 10.1016/b978-1-4557-4801-3.00312-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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23
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Carmona A, Díaz-Ricart M, Palomo M, Molina P, Pino M, Rovira M, Escolar G, Carreras E. Distinct deleterious effects of cyclosporine and tacrolimus and combined tacrolimus-sirolimus on endothelial cells: protective effect of defibrotide. Biol Blood Marrow Transplant 2013; 19:1439-45. [PMID: 23845694 DOI: 10.1016/j.bbmt.2013.07.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/01/2013] [Indexed: 11/19/2022]
Abstract
Endothelial dysfunction seems to be a key factor in the development of several complications observed early after hematopoietic stem cell transplantation (HSCT). The conditioning regimen and many other factors associated with the procedure are responsible for this endothelial damage. The effects of immunosuppressive agents on endothelial function have not been explored in detail. We evaluated the effects of 3 drugs commonly used in HSCT: 2 calcineurin inhibitors, cyclosporine A (CSA) and tacrolimus (TAC), and an inhibitor of mTOR, sirolimus (SIR). We also evaluated the effect of the combination of TAC and SIR (TAC+SIR), which is used increasingly in clinical practice. Microvascular endothelial cells (HMEC-1) were exposed to these drugs to evaluate changes in (1) intercellular adhesion molecule (ICAM)-1 expression on the cell surface, assessed by immunofluorescence labeling and expressed as the mean gray value (MGV); (2) reactivity of the extracellular matrix (ECM) toward platelets, upon exposure of the ECM to circulating blood; and (3) whole-blood clot formation, assessed by thromboelastometry. Studies were conducted in the absence and presence of defibrotide (DF) to assess its possible protective effect. The exposure of HMEC-1 to CSA and TAC+SIR significantly increased the expression of ICAM-1 (157.5 ± 11.6 and 153.4 ± 9.5 MGV, respectively, versus 105.7 ± 6.5 MGV in controls [both P < .05]). TAC applied alone increased ICAM-1 slightly (120.3 ± 8.2 MGV), and SIR had no effect (108.9 ± 7.4 MGV). ECM reactivity increased significantly only in response to CSA (surface covered by platelets of 41.2% ± 5.4% versus 30.1% ± 2.0%, P < .05). DF attenuated all these changes. No significant changes in the viscoelastic properties of clot formation were observed in any condition with blood samples incubated in vitro. In conclusion, CSA and TAC+SIR had a proinflammatory effect, but only CSA exhibited an additional prothrombotic effect. Interestingly, DF exerted clear protective anti-inflammatory and antithrombotic effects on the endothelium.
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Affiliation(s)
- Alba Carmona
- Hemotherapy-Hemostasis Department, Centre de Diagnòstic Biomèdic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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Richardson PG, Corbacioglu S, Ho VTV, Kernan NA, Lehmann L, Maguire C, Maglio M, Hoyle M, Sardella M, Giralt S, Holler E, Carreras E, Niederwieser D, Soiffer R. Drug safety evaluation of defibrotide. Expert Opin Drug Saf 2012; 12:123-36. [PMID: 23228043 DOI: 10.1517/14740338.2012.749855] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), is a potentially life-threatening complication of chemotherapeutic conditioning used in preparation for hematopoietic stem-cell transplantation (SCT). Defibrotide (DF) has been shown in Phase II and III trials to improve complete response in patients with severe VOD (sVOD). None of the articles, to date, provide a comprehensive review of the safety of DF in VOD and/or a range of other conditions. AREAS COVERED This article reviews current clinical findings on DF, primarily in terms of safety for use in treatment and prophylaxis of VOD, and relevant safety data for its use in other diseases. The literature review was conducted using a PubMed search with the fixed term 'defibrotide' in combination with ≥ 1 of 'safety', 'veno-occlusive disease' (with and without 'treatment', 'prevention'), 'oncology', 'myeloma', 'microangiopathy', 'anti-thrombotic' and 'peripheral vascular disorder'. Related articles from the EBMT and ASH conference websites were also included. EXPERT OPINION DF was well tolerated in majority of the studies. The safety profile of DF is largely favourable with toxicities comparable to control populations in the setting of SCT complicated by sVOD.
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Affiliation(s)
- Paul G Richardson
- Dana-Farber Cancer Institute, Medical Oncology, 450 Brookline Avenue, Mayer 232, Boston 02215, USA.
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Moore JM, Avery JW. Defibrotide: a Swiss Army knife intervention in the battle against cerebral malaria. Arterioscler Thromb Vasc Biol 2012; 32:541-4. [PMID: 22345588 DOI: 10.1161/atvbaha.111.242776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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26
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Francischetti IMB, Oliveira CJ, Ostera GR, Yager SB, Debierre-Grockiego F, Carregaro V, Jaramillo-Gutierrez G, Hume JCC, Jiang L, Moretz SE, Lin CK, Ribeiro JMC, Long CA, Vickers BK, Schwarz RT, Seydel KB, Iacobelli M, Ackerman HC, Srinivasan P, Gomes RB, Wang X, Monteiro RQ, Kotsyfakis M, Sá-Nunes A, Waisberg M. Defibrotide interferes with several steps of the coagulation-inflammation cycle and exhibits therapeutic potential to treat severe malaria. Arterioscler Thromb Vasc Biol 2012; 32:786-98. [PMID: 22116094 PMCID: PMC3288196 DOI: 10.1161/atvbaha.111.240291] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 11/05/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The coagulation-inflammation cycle has been implicated as a critical component in malaria pathogenesis. Defibrotide (DF), a mixture of DNA aptamers, displays anticoagulant, anti-inflammatory, and endothelial cell (EC)-protective activities and has been successfully used to treat comatose children with veno-occlusive disease. DF was investigated here as a drug to treat cerebral malaria. METHODS AND RESULTS DF blocks tissue factor expression by ECs incubated with parasitized red blood cells and attenuates prothrombinase activity, platelet aggregation, and complement activation. In contrast, it does not affect nitric oxide bioavailability. We also demonstrated that Plasmodium falciparum glycosylphosphatidylinositol (Pf-GPI) induces tissue factor expression in ECs and cytokine production by dendritic cells. Notably, dendritic cells, known to modulate coagulation and inflammation systemically, were identified as a novel target for DF. Accordingly, DF inhibits Toll-like receptor ligand-dependent dendritic cells activation by a mechanism that is blocked by adenosine receptor antagonist (8-p-sulfophenyltheophylline) but not reproduced by synthetic poly-A, -C, -T, and -G. These results imply that aptameric sequences and adenosine receptor mediate dendritic cells responses to the drug. DF also prevents rosetting formation, red blood cells invasion by P. falciparum and abolishes oocysts development in Anopheles gambiae. In a murine model of cerebral malaria, DF affected parasitemia, decreased IFN-γ levels, and ameliorated clinical score (day 5) with a trend for increased survival. CONCLUSION Therapeutic use of DF in malaria is proposed.
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MESH Headings
- Animals
- Anti-Inflammatory Agents/pharmacology
- Anticoagulants/pharmacology
- Antimalarials/pharmacology
- Blood Coagulation/drug effects
- Cells, Cultured
- Complement Activation/drug effects
- Cytokines/blood
- Dendritic Cells/drug effects
- Dendritic Cells/immunology
- Dendritic Cells/parasitology
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Endothelial Cells/drug effects
- Endothelial Cells/immunology
- Endothelial Cells/metabolism
- Endothelial Cells/parasitology
- Female
- Glycosylphosphatidylinositols/metabolism
- Hemoglobins/metabolism
- Humans
- Inflammation Mediators/blood
- Malaria, Cerebral/blood
- Malaria, Cerebral/drug therapy
- Malaria, Cerebral/immunology
- Malaria, Cerebral/parasitology
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Nitric Oxide/metabolism
- Plasmodium berghei/drug effects
- Plasmodium berghei/pathogenicity
- Plasmodium falciparum/drug effects
- Plasmodium falciparum/growth & development
- Plasmodium falciparum/metabolism
- Plasmodium falciparum/pathogenicity
- Platelet Aggregation/drug effects
- Polydeoxyribonucleotides/pharmacology
- Receptors, Purinergic P1/drug effects
- Receptors, Purinergic P1/metabolism
- Severity of Illness Index
- Thromboplastin/metabolism
- Time Factors
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Affiliation(s)
- Ivo M B Francischetti
- Section of Vector Biology, Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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27
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Avery JW, Smith GM, Owino SO, Sarr D, Nagy T, Mwalimu S, Matthias J, Kelly LF, Poovassery JS, Middii JD, Abramowsky C, Moore JM. Maternal malaria induces a procoagulant and antifibrinolytic state that is embryotoxic but responsive to anticoagulant therapy. PLoS One 2012; 7:e31090. [PMID: 22347435 PMCID: PMC3274552 DOI: 10.1371/journal.pone.0031090] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 01/02/2012] [Indexed: 01/06/2023] Open
Abstract
Low birth weight and fetal loss are commonly attributed to malaria in endemic areas, but the cellular and molecular mechanisms that underlie these poor birth outcomes are incompletely understood. Increasing evidence suggests that dysregulated hemostasis is important in malaria pathogenesis, but its role in placental malaria (PM), characterized by intervillous sequestration of Plasmodium falciparum, proinflammatory responses, and excessive fibrin deposition is not known. To address this question, markers of coagulation and fibrinolysis were assessed in placentae from malaria-exposed primigravid women. PM was associated with significantly elevated placental monocyte and proinflammatory marker levels, enhanced perivillous fibrin deposition, and increased markers of activated coagulation and suppressed fibrinolysis in placental plasma. Submicroscopic PM was not proinflammatory but tended to be procoagulant and antifibrinolytic. Birth weight trended downward in association with placental parasitemia and high fibrin score. To directly assess the importance of coagulation in malaria-induced compromise of pregnancy, Plasmodium chabaudi AS-infected pregnant C57BL/6 mice were treated with the anticoagulant, low molecular weight heparin. Treatment rescued pregnancy at midgestation, with substantially decreased rates of active abortion and reduced placental and embryonic hemorrhage and necrosis relative to untreated animals. Together, the results suggest that dysregulated hemostasis may represent a novel therapeutic target in malaria-compromised pregnancies.
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Affiliation(s)
- John W. Avery
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
| | - Geoffrey M. Smith
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
| | - Simon O. Owino
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Demba Sarr
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
| | - Tamas Nagy
- Department of Veterinary Pathology, University of Georgia, Athens, Georgia, United States of America
| | - Stephen Mwalimu
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - James Matthias
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, United States of America
| | - Lauren F. Kelly
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
| | - Jayakumar S. Poovassery
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
| | - Joab D. Middii
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Carlos Abramowsky
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Julie M. Moore
- Department of Infectious Diseases and Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
- * E-mail:
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Abstract
INTRODUCTION Defibrotide is a polydisperse oligonucleotide obtained from porcine intestinal mucosa and prepared by controlled depolymerization of DNA. It is a nucleic acid polymer, predominantly single-stranded, which has anti-ischemic and anti-thrombotic properties. AREAS COVERED The efficacy and safety of defibrotide in the treatment of veno-occlusive disease (VOD) occurring after high-dose chemotherapy and hematopoietic stem-cell transplantation is now well established in Phase II - III trials. A recent randomized, Phase III trial in pediatric patients has also demonstrated its role in the prevention of VOD. Preclinical studies reported the inhibitory effects of defibrotide on myeloma cells' growth through an antiangiogenic action and a regulation of the tumor-microenvironment interactions. A recent Phase II trial underlines the efficacy and safety of defibrotide-thalidomide-melphalan combination in the treatment of relapsed/refractory multiple myeloma. EXPERT OPINION Defibrotide may be effective in the prophylaxis and the treatment of veno-occlusive disease. Recent experimental results suggest that defibrotide may belong to the new generation of anti-cancer drugs that can prevent tumor angiogenesis. In multiple myeloma, defibrotide may overcome the prothrombotic effect of thalidomide on endothelial cells. Further preclinical and clinical investigations are needed to assess the precise role of defibrotide in the treatment of patients with multiple myeloma.
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Richardson P, Linden E, Revta C, Ho V. Use of defibrotide in the treatment and prevention of veno-occlusive disease. Expert Rev Hematol 2011; 2:365-76. [PMID: 21082942 DOI: 10.1586/ehm.09.30] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is one of the most important complications of high-dose chemotherapy and stem cell transplantation. VOD is a clinical syndrome characterized by jaundice, hepatic enlargement and fluid retention typically seen by day +30 after transplantation. Severe VOD is complicated by multiorgan failure and a high mortality rate approaching 100%. Defibrotide (DF) is a novel agent with both antithrombotic and fibrinolytic properties that has emerged as an effective therapy for severe VOD. In Phase II studies, treatment of severe VOD has resulted in complete responses of 30-60% and survival past day 100 ranging between 32-50%. A Phase III, historically controlled study of DF for treatment of severe VOD has recently been completed and results are awaited with interest. In addition, DF may be effective prophylaxis for VOD in high-risk patients. This review will focus on a summary of the pharmacology of DF and the clinical evidence for its use in VOD.
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Affiliation(s)
- Paul Richardson
- Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA.
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30
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Defibrotide prevents the activation of macrovascular and microvascular endothelia caused by soluble factors released to blood by autologous hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2010; 17:497-506. [PMID: 21126597 DOI: 10.1016/j.bbmt.2010.11.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/22/2010] [Indexed: 11/20/2022]
Abstract
Endothelial activation and damage occur in association with autologous hematopoietic stem cell transplantation (HSCT). Several of the early complications associated with HSCT seem to have a microvascular location. Through the present study, we have characterized the activation and damage of endothelial cells of both macro (HUVEC) and microvascular (HMEC) origin, occurring early after autologous HSCT, and the potential protective effect of defibrotide (DF). Sera samples from patients were collected before conditioning (Pre), at the time of transplantation (day 0), and at days 7, 14, and 21 after autologous HSCT. Changes in the expression of endothelial cell receptors at the surface, presence and reactivity of extracellular adhesive proteins, and the signaling pathways involved were analyzed. The expression of ICAM-1 at the cell surface increased progressively in both HUVEC and HMEC. However, a more prothrombotic profile was denoted for HMEC, in particular at the time of transplantation (day 0), reflecting the deleterious effect of the conditioning treatment on the endothelium, especially at a microvascular location. Interestingly, this observation correlated with a higher increase in the expression of both tissue factor and von Willebrand factor on the extracellular matrix, together with activation of intracellular p38 MAPK and Akt. Previous exposure and continuous incubation of cells with DF prevented the signs of activation and damage induced by the autologous sera. These observations corroborate that conditioning treatment in autologous HSCT induces a proinflammatory and a prothrombotic phenotype, especially at a microvascular location, and indicate that DF has protective antiinflammatory and antithrombotic effects in this setting.
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Successful treatment of severe sinusoidal obstruction syndrome despite multiple organ failure with defibrotide after allogeneic stem cell transplantation: a case report. J Med Case Rep 2009; 3:6164. [PMID: 19830097 PMCID: PMC2726490 DOI: 10.4076/1752-1947-3-6164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 02/24/2009] [Indexed: 11/17/2022] Open
Abstract
Introduction We report a case of sinusoidal obstruction syndrome, a typical and life-threatening complication after allogeneic stem-cell transplantation, successfully treated with defibrotide despite massive multiple organ failure. Case presentation A 64-year-old Caucasian woman underwent allogeneic peripheral blood stem-cell transplantation from her human leukocyte antigen-identical sister against aggressive lymphoplasmocytoid immunocytoma. Seven days later, the patient developed severe sinusoidal obstruction syndrome according to the modified Seattle criteria. We initiated treatment with defibrotide. Despite early treatment, multiple organ failure with kidney failure requiring dialysis and ventilator-dependent lung failure aggravated the clinical course. Furthermore, central nervous dysfunction occurred as well as transfusion refractory thrombocytopenia. Conclusion As highlighted in our report, defibrotide is the most promising drug in the treatment of the formerly, almost lethal, severe sinusoidal obstruction syndrome to date. This is demonstrated very clearly in our patient. She improved completely, even after renal, cerebral and respiratory failure.
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Angiogenesis alteration by defibrotide: implications for its mechanism of action in severe hepatic veno-occlusive disease. Blood 2008; 112:4343-52. [DOI: 10.1182/blood-2008-04-149682] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Abstract
Defibrotide (DF) is a mixture of porcine-derived single-stranded phosphodiester oligonucleotides (9-80-mer; average, 50-mer) that has been successfully used to treat severe hepatic veno-occlusive disease (sVOD) with multiorgan failure (MOF) in patients who have received cytotoxic chemotherapy in preparation for bone marrow transplantation. However, its mechanism of action is unknown. Herein, we show that DF and phosphodiester oligonucleotides can bind to heparin-binding proteins (eg, basic fibroblast growth factor [bFGF] but not vascular endothelial growth factor [VEGF] 165) with low nanomolar affinity. This binding occurred in a length- and concentration-dependent manner. DF can mobilize proangiogenic factors such as bFGF from their depot or storage sites on bovine corneal endothelial matrix. However, these molecules do not interfere with high-affinity binding of bFGF to FGFR1 IIIc but can replace heparin as a required cofactor for binding and hence cellular mitogenesis. DF also protects bFGF against digestion by trypsin and chymotrypsin and from air oxidation. In addition, DF binds to collagen I with low nanomolar affinity and can promote human microvascular endothelial cell-1 (HMEC-1) cell mitogenesis and tubular morphogenesis in three-dimensional collagen I gels. Thus, our data suggest that DF may provide a stimulus to the sinusoidal endothelium of a liver that has suffered a severe angiotoxic event, thus helping to ameliorate the clinical sVOD/MOF syndrome.
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Sangro B, Gil-Alzugaray B, Rodriguez J, Sola I, Martinez-Cuesta A, Viudez A, Chopitea A, Iñarrairaegui M, Arbizu J, Bilbao JI. Liver disease induced by radioembolization of liver tumors. Cancer 2008; 112:1538-46. [PMID: 18260156 DOI: 10.1002/cncr.23339] [Citation(s) in RCA: 256] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Bruno Sangro
- Liver Unit, Department of Internal Medicine, University Clinic and CIBERHD, Pamplona, Spain.
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Tay J, Tinmouth A, Fergusson D, Huebsch L, Allan DS. Systematic review of controlled clinical trials on the use of ursodeoxycholic acid for the prevention of hepatic veno-occlusive disease in hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2007; 13:206-17. [PMID: 17241926 DOI: 10.1016/j.bbmt.2006.09.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 09/27/2006] [Indexed: 12/12/2022]
Abstract
Hepatic veno-occlusive disease (HVOD) is a serious life-threatening complication of hematopoietic stem cell transplantation (HSCT). Currently, there is no optimal therapeutic strategy and preventive measures are ill-defined. Ursodeoxycholic acid (UA) is well-tolerated oral medication that has been associated with possible benefit as a prophylactic agent. We sought to summarize and quantify the clinical effects of prophylactic UA in the context of HSCT. We undertook a systematic review of studies addressing the use of UA as monotherapy or in combination with other agents in patients undergoing HSCT. The Search Strategy included MEDLINE (1966 to fourth week of March 2006), EMBASE (1980 to fourth week of March 2006), all EBM Reviews (fourth quarter of 2005), Ovid Healthstar (1966 to fourth week of March 2006), and Google Scholar on March 20, 2006. Six studies, 4 randomized clinical trials and 2 historically controlled studies, representing 824 patients were included in the review. Three randomized clinical trials comparing prophylactic UA with no treatment demonstrated reduced proportion of HVOD (relative risk [RR], 0.34; 95% confidence interval [CI], 0.17-0.66). When the analysis was limited to higher-quality studies, the beneficial effect of UA remained significant (RR, 0.36; 95% CI, 0.15-0.90). Transplant-related mortality was also reduced with the prophylactic use of UA (RR, 0.58; 95% CI, 0.35-0.95). UA did not significantly attenuate the outcomes of acute graft-versus-host disease (RR, 0.76; 95% CI, 0.53-1.09), relapse (RR, 0.77; 95% CI, 0.46-1.31), or overall survival (RR, 1.22; 95 % CI, 0.96-1.54). UA appears effective for HVOD prophylaxis in patients undergoing HSCT and should be considered as a prevention strategy by HSCT centers to reduce HVOD.
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Affiliation(s)
- Jason Tay
- Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa, Ontario, Canada
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35
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Abstract
Hepatic veno-occlusive disease (HVOD) is rarely encountered and easily misjudged as Budd-Chiari syndrome. It is often related to stem cell transplantation in recent years. We report a case of HVOD that is related to ingestion of some palatable local dishes. The diagnosis was confirmed by liver biopsy pathology with specific observation of inflammatory changes and fibrosis of venules intima, dilated sinusoids and central veins. Chronic diarrhea is unique for this case as a result of ingesting harmful stuffs. This case demonstrated that supervision and instruction of food recipe and traditional medicine are crucial, and prompt diagnosis, supportive care and specific treatment are essential to decreasing the morbidity and mortality of HVOD.
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Affiliation(s)
- Yong-Song Guan
- Department of Radiology, West China Hospital, Sichuan University, 37 Guoxuexiang, Chengdu 610041, Sichuan Province, China.
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