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Tsakiris DA, Gavriilaki E, Chanou I, Meyer SC. Hemostasis and complement in allogeneic hematopoietic stem cell transplantation: clinical significance of two interactive systems. Bone Marrow Transplant 2024:10.1038/s41409-024-02362-8. [PMID: 39004655 DOI: 10.1038/s41409-024-02362-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024]
Abstract
Hematopoietic stem cell transplantation (HCT) represents a curative treatment option for certain malignant and nonmalignant hematological diseases. Conditioning regimens before HCT, the development of graft-versus-host disease (GVHD) in the allogeneic setting, and delayed immune reconstitution contribute to early and late complications by inducing tissue damage or humoral alterations. Hemostasis and/or the complement system are biological regulatory defense systems involving humoral and cellular reactions and are variably involved in these complications after allogeneic HCT. The hemostasis and complement systems have multiple interactions, which have been described both under physiological and pathological conditions. They share common tissue targets, such as the endothelium, which suggests interactions in the pathogenesis of several serious complications in the early or late phase after HCT. Complications in which both systems interfere with each other and thus contribute to disease pathogenesis include transplant-associated thrombotic microangiopathy (HSCT-TMA), sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), and GVHD. Here, we review the current knowledge on changes in hemostasis and complement after allogeneic HCT and how these changes may define clinical impact.
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Affiliation(s)
| | - Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioanna Chanou
- Department of Biomedical Sciences, School of Health Sciences, International Hellenic University, Thessaloniki, Greece
| | - Sara C Meyer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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2
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Kafa K, Hoell JI. Transplant-associated thrombotic microangiopathy in pediatrics: incidence, risk factors, therapeutic options, and outcome based on data from a single center. Front Oncol 2024; 14:1399696. [PMID: 39050576 PMCID: PMC11266128 DOI: 10.3389/fonc.2024.1399696] [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: 03/12/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Background Transplant-associated thrombotic microangiopathy (TA-TMA) is a critical complication of hematopoietic stem cell transplantation. Awareness about TA-TMA has increased in recent years, resulting in the implementation of TA-TMA screening in most centers. Methods Retrospective analysis of children who underwent autologous or allogeneic hematopoietic stem cell transplantation at our center between January 2018 and December 2022 was conducted to evaluate the incidence, clinical features, and outcomes of TA-TMA following the administration of different therapeutic options. Results A total of 45 patients comprised the study cohort, of whom 10 developed TA-TMA with a cumulative incidence of 22% by 100 days after transplantation. Patients with and without TA-TMA in our cohort displayed an overall survival of 80% and 88%, respectively (p = 0.48), and a non-relapse mortality of 0% and 5.7%, respectively (p = 0.12), at 1 year after transplantation. Risk factors for TA-TMA development included allogeneic transplantation and total body irradiation-based conditioning regime. Among the 10 patients with TA-TMA, 7 did not meet the high-risk criteria described by Jodele and colleagues. Of these seven patients, two responded to calcineurin-inhibitor withdrawal without further therapy and five developed multiorgan dysfunction syndrome and were treated with anti-inflammatory steroids (prednisone), and all responded to therapy. The three patients with high-risk TA-TMA were treated with complement blockade or prednisone, and all responded to therapy. Conclusion TA-TMA is a multifactorial complication with high morbidity rates. Patients with high-risk TA-TMA may benefit from complement blockade using eculizumab. No consensus has been reached regarding therapy for patients who do not meet high-risk criteria. Our analysis showed that these patients may respond to anti-inflammatory treatment with prednisone.
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Affiliation(s)
- Kinan Kafa
- Department of Pediatric Hematology and Oncology, University Hospital Halle (Saale), Halle, Germany
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Nusrat S, Davis H, MacDougall K, George JN, Nakamura R, Borogovac A. Thrombotic Microangiopathy After Hematopoietic Stem Cell and Solid Organ Transplantation: A Review for Intensive Care Physicians. J Intensive Care Med 2024; 39:406-419. [PMID: 37990516 DOI: 10.1177/08850666231200193] [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: 11/23/2023]
Abstract
Intensive care physicians may assume the primary care of patients with transplant-associated thrombotic microangiopathy (TA-TMA), an uncommon but potentially critical complication of hematopoietic stem cell transplants (HSCTs) and solid organ transplants. TA-TMA can have a dramatic presentation with multiple organ dysfunction syndrome (MODS) associated with high morbidity and mortality. The typical presenting clinical features are hemolytic anemia, thrombocytopenia, refractory hypertension, proteinuria and worsening renal failure. Intestinal involvement, with abdominal pain, nausea and vomiting, gastrointestinal bleeding, and ascites are also common. Cardiopulmonary involvement may develop from various causes including pulmonary arteriolar hypertension, pleural and pericardial effusions, and diffuse alveolar hemorrhage. Due to other often concurrent complications after HSCT, early diagnosis and effective management of TA-TMA may be challenging. Close collaboration between ICU and transplant physicians, along with other relevant specialists, is needed to best manage these patients. There are currently no approved therapies for the treatment of TA-TMA. Plasma exchange and rituximab are not recommended unless circulating factor H (CFH) antibodies or thrombotic thrombocytopenic purpura (TTP; ADAMTS activity < 10%) are diagnosed or highly suspected. The role of the complement pathway activation in the pathophysiology of TA-TMA has led to the successful use of targeted complement inhibitors, such as eculizumab. However, the relatively larger studies using eculizumab have been mostly conducted in the pediatric population with limited data on the adult population. This review is focused on the role of intensive care physicians to emphasize the clinical approach to patients with suspected TA-TMA and to discuss diagnosis and treatment strategies.
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Affiliation(s)
- Sanober Nusrat
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hugh Davis
- Division of Pulmonary and Critical Care Medicine, City of Hope, Duarte, CA, USA
| | - Kira MacDougall
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James N George
- Department of Medicine, Division of Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Azra Borogovac
- Department of Hematology and Hematopoietic Cell Transplantation, Lennar Foundation Cancer Center, City of Hope, Irvine, CA, USA
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Gavriilaki E, Bousiou Z, Batsis I, Vardi A, Mallouri D, Koravou EE, Konstantinidou G, Spyridis N, Karavalakis G, Noli F, Patriarcheas V, Masmanidou M, Touloumenidou T, Papalexandri A, Poziopoulos C, Yannaki E, Sakellari I, Politou M, Papassotiriou I. Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) and Growth Differentiation Factor-15 (GDF-15) Levels Are Significantly Associated with Endothelial Injury Indices in Adult Allogeneic Hematopoietic Cell Transplantation Recipients. Int J Mol Sci 2023; 25:231. [PMID: 38203404 PMCID: PMC10778584 DOI: 10.3390/ijms25010231] [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: 11/21/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GvHD) represent life-threatening syndromes after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In both conditions, endothelial dysfunction is a common denominator, and development of relevant biomarkers is of high importance for both diagnosis and prognosis. Despite the fact that soluble urokinase plasminogen activator receptor (suPAR) and growth differentiation factor-15 (GDF-15) have been determined as endothelial injury indices in various clinical settings, their role in HSCT-related complications remains unexplored. In this context, we used immunoenzymatic methods to measure suPAR and GDF-15 levels in HSCT-TMA, acute and/or chronic GVHD, control HSCT recipients, and apparently healthy individuals of similar age and gender. We found considerably greater SuPAR and GDF-15 levels in HSCT-TMA and GVHD patients compared to allo-HSCT and healthy patients. Both GDF-15 and suPAR concentrations were linked to EASIX at day 100 and last follow-up. SuPAR was associated with creatinine and platelets at day 100 and last follow-up, while GDF-15 was associated only with platelets, suggesting that laboratory values do not drive EASIX. SuPAR, but not GDF-15, was related to soluble C5b-9 levels, a sign of increased HSCT-TMA risk. Our study shows for the first time that suPAR and GDF-15 indicate endothelial damage in allo-HSCT recipients. Rigorous validation of these biomarkers in many cohorts may provide utility for their usefulness in identifying and stratifying allo-HSCT recipients with endothelial cell impairment.
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Affiliation(s)
- Eleni Gavriilaki
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Zoi Bousiou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioannis Batsis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Anna Vardi
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Despina Mallouri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Evaggelia-Evdoxia Koravou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgia Konstantinidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Nikolaos Spyridis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Georgios Karavalakis
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Foteini Noli
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Vasileios Patriarcheas
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Masmanidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Tasoula Touloumenidou
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Apostolia Papalexandri
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Christos Poziopoulos
- Department of Hematology, Metropolitan Hospital, Neo Faliro, 18547 Athens, Greece;
| | - Evangelia Yannaki
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Ioanna Sakellari
- BMT Unit, Hematology Department, George Papanicolaou General Hospital, 57010 Thessaloniki, Greece; (Z.B.); (I.B.); (A.V.); (D.M.); (E.-E.K.); (G.K.); (N.S.); (G.K.); (F.N.); (V.P.); (M.M.); (T.T.); (A.P.); (E.Y.); (I.S.)
| | - Marianna Politou
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ioannis Papassotiriou
- First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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Radnay Z, Illés Á, Udvardy M, Prohászka Z, Sinkovits G, Csányi MC, Kellermayer M, Kiss A, Hársfalvi J. Von Willebrand Factor and Platelet Levels before Conditioning Chemotherapy Indicate Bone Marrow Regeneration following Autologous Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2022; 28:830.e1-830.e7. [PMID: 36058547 DOI: 10.1016/j.jtct.2022.08.028] [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: 12/07/2021] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 12/24/2022]
Abstract
Autologous hematopoietic stem cell transplantation (HSCT) is often complicated by hemostatic and thrombotic events associated with endothelial cell injury. Thrombotic complications are affected by a disturbed balance between platelets, circulating von Willebrand factor (VWF), and its specific protease, ADAMTS13. HSCT-associated endothelial dysfunction, impaired hemostasis, and inflammation are interrelated processes, and research on the complex interplay of conditioning regimens from engraftment to bone marrow regeneration remains intensive. This prospective observational study comparing lymphoma and multiple myeloma (MM) patients who underwent autologous HSCT explored how platelet count, VWF level, ADAMTS13 activity, and C-reactive protein (CRP) level as potential markers (1) vary in response to therapy, (2) differ between the 2 groups, and (3) correlate with the remission state at 100 days after HSCT. We correlated the quantitative changes in platelet count and levels of VWF, ADAMTS13, and CRP with one another during HSCT and in the remission state in 45 patients with lymphoma and 59 patients with MM who underwent autologous HSCT between 2010 and 2013 at the University of Debrecen. Samples were collected at the start of conditioning chemotherapy, on the day of stem cell transplantation, and at 5, 11, and 100 days following HSCT. CRP levels peaked when platelet counts dropped to a minimum, and these changes were much more pronounced in the lymphoma group. VWF level was the highest, with lower ADAMTS13 activity, at platelet engraftment in both patient groups equally. Diagnostic evidence indicative of thrombotic complications was not found. In the lymphoma group, VWF level prior to conditioning had statistically significant correlations with platelet count, CRP level, and hemoglobin concentration at the time of bone marrow regeneration (P < .001) and during the remission state (P = .034). In the MM group, platelet count before conditioning was correlated with platelet count (P < .001) and white blood cell count (P = .012) at the time of bone marrow regeneration. The statistically significant correlation of the markers at the time of bone marrow regeneration with the preconditioning VWF levels in lymphoma and with the preconditioning platelet counts in MM might indicate the clinical significance of the bone marrow niches of arterioles and megakaryocytes, respectively, where the stem cells are located and regulated. Because preconditioning VWF levels are associated with remission after HSCT in lymphoma patients, VWF should be screened before conditioning, along with the markers used in HSCT protocols, to optimize personalized treatment and reduce therapeutic risks.
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Affiliation(s)
- Zita Radnay
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Árpád Illés
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklós Udvardy
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - György Sinkovits
- Research Laboratory, 3rd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Mária Csilla Csányi
- Department of Biophysics and Radiation Biology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Miklós Kellermayer
- Department of Biophysics and Radiation Biology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Attila Kiss
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Jolán Hársfalvi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Hungary; Department of Biophysics and Radiation Biology, Faculty of Medicine, Semmelweis University, Budapest, Hungary.
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Zheng L, Cao L, Zheng XL. ADAMTS13 protease or lack of von Willebrand factor protects irradiation and melanoma-induced thrombotic microangiopathy in zebrafish. J Thromb Haemost 2022; 20:2270-2283. [PMID: 35894519 PMCID: PMC9641623 DOI: 10.1111/jth.15820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe deficiency of plasma ADAMTS13 activity may result in potentially fatal thrombotic thrombocytopenic purpura and relative deficiency of plasma ADAMTS13 activity may be associated with adverse outcomes of certain malignancies. Here, we report the role of ADAMTS13 or lack of von Willebrand factor (VWF) in reducing irradiation and melanoma-induced thrombotic microangiopathy (TMA) and mortality in zebrafish. METHODS Zebrafish melanoma cell line (ZMEL) was injected subcutaneously into wild-type (wt), adamts13-/- (a13-/- ), von Willebrand factor (vwf-/- ), and a13-/- vwf-/- zebrafish following total body irradiation; the tumor growth, its gene expression pattern, the resulting thrombocytopenia, and the mortality were determined. RESULTS Total body irradiation at 30 Gy alone resulted in a transient thrombocytopenia in both wt and a13-/- zebrafish. However, thrombocytopenia occurred earlier and more profound in a13-/- than in wt zebrafish, which was resolved 2 weeks following irradiation alone. An inoculation of ZMEL following the irradiation resulted in more severe and persistent thrombocytopenia, as well as earlier death in a13-/- than in wt zebrafish. The vwf-/- or a13-/- vwf-/- zebrafish were protected from developing severe thrombocytopenia following the same maneuvers. RNA-sequencing revealed significant differentially expressed genes associated with oxidation-reduction, metabolism, lipid, fatty acid and cholesterol metabolic processes, steroid synthesis, and phospholipid efflux in the melanoma explanted from a13-/- zebrafish compared with that from the wt controls. CONCLUSIONS Our results indicated that plasma ADAMTS13 or lack of VWF may offer a significant protection against the development of irradiation- and/or melanoma-induced TMA. Such a microenvironment may directly affect melanoma cell phenotypes via alternation in the oxidation-reduction and lipid metabolic pathways.
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Affiliation(s)
- Liang Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Institute of Reproductive and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Liyun Cao
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Institute of Reproductive and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
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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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A review of thrombotic microangiopathies in multiple myeloma. Leuk Res 2019; 85:106195. [DOI: 10.1016/j.leukres.2019.106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
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Kishimoto K, Hasegawa D, Kawasaki K, Tamura A, Yamamoto N, Saito A, Kozaki A, Ishida T, Kosaka Y. Early posttransplant plasma ADAMTS13 activity reduction in stem cell transplantation: a prospective study of 46 pediatric patients. Bone Marrow Transplant 2019; 54:1926-1929. [PMID: 30890772 DOI: 10.1038/s41409-019-0506-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/25/2019] [Accepted: 03/01/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Kenji Kishimoto
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan.
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Keiichiro Kawasaki
- Department of Pediatrics, Kita-Harima Medical Center, Ichibacho, Ono, Japan
| | - Akihiro Tamura
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Nobuyuki Yamamoto
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Atsuro Saito
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Aiko Kozaki
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Toshiaki Ishida
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
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Gavriilaki E, Anagnostopoulos A, Mastellos DC. Complement in Thrombotic Microangiopathies: Unraveling Ariadne's Thread Into the Labyrinth of Complement Therapeutics. Front Immunol 2019; 10:337. [PMID: 30891033 PMCID: PMC6413705 DOI: 10.3389/fimmu.2019.00337] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/08/2019] [Indexed: 12/20/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are a heterogeneous group of syndromes presenting with a distinct clinical triad: microangiopathic hemolytic anemia, thrombocytopenia, and organ damage. We currently recognize two major entities with distinct pathophysiology: thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Beyond them, differential diagnosis also includes TMAs associated with underlying conditions, such as drugs, malignancy, infections, scleroderma-associated renal crisis, systemic lupus erythematosus (SLE), malignant hypertension, transplantation, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), and disseminated intravascular coagulation (DIC). Since clinical presentation alone is not sufficient to differentiate between these entities, robust pathophysiological features need to be used for early diagnosis and appropriate treatment. Over the last decades, our understanding of the complement system has evolved rapidly leading to the characterization of diseases which are fueled by complement dysregulation. Among TMAs, complement-mediated HUS (CM-HUS) has long served as a disease model, in which mutations of complement-related genes represent the first hit of the disease and complement inhibition is an effective and safe strategy. Based on this knowledge, clinical conditions resembling CM-HUS in terms of phenotype and genotype have been recognized. As a result, the role of complement in TMAs is rapidly expanding in recent years based on genetic and functional studies. Herein we provide an updated overview of key pathophysiological processes underpinning complement activation and dysregulation in TMAs. We also discuss emerging clinical challenges in streamlining diagnostic algorithms and stratifying TMA patients that could benefit more from complement modulation. With the advent of next-generation complement therapeutics and suitable disease models, these translational perspectives could guide a more comprehensive, disease- and target-tailored complement intervention in these disorders.
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Affiliation(s)
- Eleni Gavriilaki
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Dimitrios C Mastellos
- Division of Biodiagnostic Sciences and Technologies, INRASTES, National Center for Scientific Research Demokritos, Athens, Greece
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11
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Dvorak CC, Higham C, Shimano KA. Transplant-Associated Thrombotic Microangiopathy in Pediatric Hematopoietic Cell Transplant Recipients: A Practical Approach to Diagnosis and Management. Front Pediatr 2019; 7:133. [PMID: 31024873 PMCID: PMC6465621 DOI: 10.3389/fped.2019.00133] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/21/2019] [Indexed: 01/04/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an endothelial damage syndrome that is increasingly identified as a complication of both autologous and allogeneic hematopoietic cell transplantation (HCT) in children. If not promptly diagnosed and treated, TA-TMA can lead to significant morbidity (e.g., permanent renal injury) or mortality. However, as the recognition of the early stages of TA-TMA may be difficult, we propose a TA-TMA "triad" of hypertension, thrombocytopenia (or platelet transfusion refractoriness), and elevated lactate dehydrogenase (LDH). While not diagnostic, this triad should prompt further evaluation for TA-TMA. There is increased understanding of the risk factors for the development of TA-TMA, including those which are inherent (e.g., race, genetics), transplant approach-related (e.g., second HCT, use of HLA-mismatched donors), and related to post-transplant events (e.g., receipt of calcineurin inhibitors, development of graft-vs. -host-disease, or certain infections). This understanding should lead to enhanced screening for TA-TMA signs and symptoms in high-risk patients. The pathophysiology of TA-TMA is complex, resulting from a cycle of activation of endothelial cells to produce a pro-coagulant state, along with activation of antigen-presenting cells and lymphocytes, as well as activation of the complement cascade and microthrombi formation. This has led to the formulation of a "Three-Hit Hypothesis" in which patients with either an underlying predisposition to complement activation or pre-existing endothelial injury (Hit 1) undergo a toxic conditioning regimen causing endothelial injury (Hit 2), and then additional insults are triggered by medications, alloreactivity, infections, and/or antibodies (Hit 3). Understanding this cycle of injury permits the development of a specific TA-TMA treatment algorithm designed to treat both the triggers and the drivers of the endothelial injury. Finally, several intriguing approaches to TA-TMA prophylaxis have been identified. Future work on the development of a single diagnostic test with high specificity and sensitivity, and the development of a robust risk-scoring system, will further improve the management of this serious post-transplant complication.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Christine Higham
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
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12
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Jia C, Qin M, Wang B, Zhu G, Yan Y. Variable clinical manifestations of hematopoietic stem cell transplant-associated thrombotic microangiopathy. Pediatr Investig 2018; 2:253-256. [PMID: 32851275 PMCID: PMC7331427 DOI: 10.1002/ped4.12100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Chenguang Jia
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Department of Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Maoquan Qin
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Department of Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Bin Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Department of Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Guanghua Zhu
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Department of Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Yan Yan
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Department of Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
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13
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Studt JD, Voorberg J, Hovinga JA, Schaller M. Acquired thrombotic thrombocytopenic purpura. Hamostaseologie 2018; 33:121-30. [DOI: 10.5482/hamo-12-12-0023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 01/17/2013] [Indexed: 01/16/2023] Open
Abstract
SummaryThe von Willebrand factor (VWF)-cleaving metalloprotease, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motifs-13) is the only known target of the dysregulated immune response in acquired TTP. Autoantibodies to ADAMTS13 either neutralize its activity or accelerate its clearance, thereby causing a severe deficiency of ADAMTS13 in plasma. As a consequence, size regulation of VWF is impaired and the persistence of ultra-large VWF (ULVWF) multimers facilitates micro vascular platelet aggregation causing microangiopathic haemolytic anaemia and ischaemic organ damage. Autoimmune TTP although a rare disease with an annual incidence of 1.72 cases has a mortality rate of 20% even with adequate therapy.We describe the mechanisms involved in ADAMTS13 autoimmunity with a focus on the role of B- and T-cells in the pathogenesis of this disorder. We discuss the potential translation of recent experimental findings into future therapeutic concepts for the treatment of acquired TTP.
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14
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Li WY, Li XL, He XF, Ma X, Han Y, Wu DP, Sun AN. [Thrombotic microangiopathy with lack of ADAMT13 activity after allogeneic hematopoietic stem cell transplantation: a case report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:1072-1074. [PMID: 29365405 PMCID: PMC7342184 DOI: 10.3760/cma.j.issn.0253-2727.2017.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | | | | | - A N Sun
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou 215006, China
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15
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Qi J, Wang J, Chen J, Su J, Tang Y, Wu X, Ma X, Chen F, Ruan C, Zheng XL, Wu D, Han Y. Plasma levels of complement activation fragments C3b and sC5b-9 significantly increased in patients with thrombotic microangiopathy after allogeneic stem cell transplantation. Ann Hematol 2017; 96:1849-1855. [PMID: 28801815 PMCID: PMC6225065 DOI: 10.1007/s00277-017-3092-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 08/04/2017] [Indexed: 12/30/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an uncommon but severe complication in patients undergoing allogeneic stem cell transplantation (allo-SCT). However, the mechanism is unclear. From 2011 to 2014, 20 patients with TA-TMA, 20 patients without, and 54 patients with various other complications, including veno occlusive disease (VOD), graft-versus-host disease (GVHD), and infection, were recruited in the study. Plasma vWF antigen (vWFAg), vWF activity (vWFAc), and ADAMTS13 activity were determined in these patients by ELISAs and FRETS-vWF73 assay, respectively. Plasma C3b, sC5b-9, and CH50 were also determined by ELISAs. Plasma levels of C3b were significantly increased in patients with either TA-TMA (p < 0.0001) or GVHD (p < 0.01). Plasma sC5b-9 and CH50 levels in patients with TA-TMA were also significantly increased (p < 0.001). Plasma ADAMTS13 activity was lower in patients with VOD, but normal with other complications. Both plasma vWFAg and vWFAc levels were not elevated in patients with TA-TMA or VOD compared with those of other groups. Complement activation likely via an alternative pathway (increased C3b, sC5b-9, and CH50) may play a role in the pathogenesis of TA-TMA. ADAMTS13 activity is reduced in VOD, but the ADAMTS13/vWF axis appears to be unaffected in patients with TA-TMA.
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Affiliation(s)
- Jiaqian Qi
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jie Wang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jia Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jian Su
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Yaqiong Tang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Xiaojin Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Xiao Ma
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Feng Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Changgeng Ruan
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - X Long Zheng
- Divsion of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, 35243, USA
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China.
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China.
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.
| | - Yue Han
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Haematology, Suzhou, China.
- Soochow University, Collaborative Innovation Centre of Haematology, Suzhou, China.
- Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.
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16
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Zeisbrich M, Becker N, Benner A, Radujkovic A, Schmitt K, Beimler J, Ho AD, Zeier M, Dreger P, Luft T. Transplant-associated thrombotic microangiopathy is an endothelial complication associated with refractoriness of acute GvHD. Bone Marrow Transplant 2017. [PMID: 28650448 DOI: 10.1038/bmt.2017.119] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There is increasing evidence that endothelial dysfunction is involved in refractoriness of acute GvHD (aGvHD). Here we investigated the hypothesis that another endothelial complication, transplant-associated thrombotic microangiopathy (TMA), contributes to the pathogenesis of aGvHD refractoriness. TMA was retrospectively assessed in 771 patients after allogeneic stem cell transplantation (alloSCT). Incidences of TMA and refractory aGvHD were correlated with biomarkers of endothelial damage obtained before alloSCT for patients receiving or not receiving statin-based endothelial prophylaxis (SEP). Diagnostic criteria for TMA and refractory aGvHD were met by 41 (5.3%) and 76 (10%) patients, respectively. TMA was overrepresented in patients with refractory aGvHD (45.0 vs 2.3% in all other patients, P<0.001). TMA independently increased mortality. Elevated pretransplant suppressor of tumorigenicity-2 and nitrates along with high-risk variants of the thrombomodulin gene were associated with increased risk of TMA. In contrast, SEP abolished the unfavorable outcome predicted by pretransplant biomarkers on TMA risk. Patients on SEP had a significantly lower risk of TMA (P=0.001) and refractory aGvHD (P=0.055) in a multivariate multistate model. Our data provide evidence that TMA contributes to the pathogenesis of aGvHD refractoriness. Patients with an increased TMA risk can be identified pretransplant and may benefit from pharmacological endothelium protection.
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Affiliation(s)
- M Zeisbrich
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - N Becker
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - A Benner
- Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - A Radujkovic
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - K Schmitt
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - J Beimler
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - A D Ho
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - M Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - P Dreger
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - T Luft
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
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17
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Gavriilaki E, Sakellari I, Anagnostopoulos A, Brodsky RA. Transplant-associated thrombotic microangiopathy: opening Pandora's box. Bone Marrow Transplant 2017; 52:1355-1360. [PMID: 28287636 DOI: 10.1038/bmt.2017.39] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/01/2017] [Accepted: 02/05/2017] [Indexed: 12/20/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is an early complication of hematopoietic cell transplantation (HCT). A high mortality rate is documented in patients who are refractory to calcineurin inhibitor cessation. Estimates of TA-TMA prevalence vary significantly and are higher in allogeneic compared with autologous HCT. Furthermore, our understanding of the pathophysiology that is strongly related to diagnosis and treatment options is limited. Recent evidence has linked TA-TMA with atypical hemolytic uremic syndrome, a disease of excessive activation of the alternative pathway of complement, opening the Pandora's box in treatment options. As conventional treatment management is highly inefficient, detection of complement activation may allow for early recognition of patients who will benefit from complement inhibition. Preliminary clinical results showing successful eculizumab administration in children and adults with TA-TMA need to be carefully evaluated. Therefore, realizing the unmet needs of better understanding TA-TMA in this complex setting, we aimed to summarize current knowledge focusing on (1) critical evaluation of diagnostic criteria, (2) epidemiology and prognosis, (3) recent evidence of complement activation and endothelial damage and (4) treatment options.
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Affiliation(s)
- E Gavriilaki
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece.,Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - I Sakellari
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - A Anagnostopoulos
- Hematology Department-Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - R A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Jodele S, Laskin BL, Dandoy CE, Myers KC, El-Bietar J, Davies SM, Goebel J, Dixon BP. A new paradigm: Diagnosis and management of HSCT-associated thrombotic microangiopathy as multi-system endothelial injury. Blood Rev 2014; 29:191-204. [PMID: 25483393 DOI: 10.1016/j.blre.2014.11.001] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/18/2014] [Accepted: 11/20/2014] [Indexed: 01/03/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is now a well-recognized and potentially severe complication of HSCT that carries a high risk of death. In those who survive, TA-TMA may be associated with long-term morbidity and chronic organ injury. Recently, there have been new insights into the incidence, pathophysiology, and management of TA-TMA. Specifically, TA-TMA can manifest as a multi-system disease occurring after various triggers of small vessel endothelial injury, leading to subsequent tissue damage in different organs. While the kidney is most commonly affected, TA-TMA involving organs such as the lung, bowel, heart, and brain is now known to have specific clinical presentations. We now review the most up-to-date research on TA-TMA, focusing on the pathogenesis of endothelial injury, the diagnosis of TA-TMA affecting the kidney and other organs, and new clinical approaches to the management of this complication after HSCT.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, USA.
| | - Benjamin L Laskin
- Division of Nephrology, The Children's Hospital of Philadelphia, USA
| | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, USA
| | - Javier El-Bietar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, USA
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, USA
| | - Jens Goebel
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, USA
| | - Bradley P Dixon
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, USA
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19
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The clinical implications of ADAMTS13 function: the perspectives of haemostaseologists. Thromb Res 2013; 132:403-7. [PMID: 24050828 DOI: 10.1016/j.thromres.2013.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 07/17/2013] [Accepted: 07/21/2013] [Indexed: 02/08/2023]
Abstract
Apart from TTP, ADAMTS13 may be an important player in those conditions where Von Willebrand Factor and the Platelet Glycoprotein GP Ib axis have a part to play in the pathogenesis. This includes stroke, myocardial infarction, sepsis and inflammatory condition. This article reviews the literature in these conditions.
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20
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Singh N, McNeely J, Parikh S, Bhinder A, Rovin BH, Shidham G. Kidney complications of hematopoietic stem cell transplantation. Am J Kidney Dis 2013; 61:809-21. [PMID: 23291149 DOI: 10.1053/j.ajkd.2012.09.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 09/08/2012] [Indexed: 12/25/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) exposes a patient's kidneys to a unique combination of challenges, including high-dose radiation, anemia, chemotherapeutic agents, graft-versus-host disease, opportunistic infections, attenuated and altered immunologic responses, fluid and electrolyte imbalances, and extensive courses of antimicrobial agents. Since the inception of HSCT in the 1950s, there has been increasing interest in defining, determining, and managing the kidney complications that accompany this procedure. In this article, we review the common causes of acute kidney injury and chronic kidney disease that occur with HSCT, including HSCT-associated thrombotic microangiopathy, a distinct cause of chronic kidney disease with a multifactorial cause previously known as bone marrow transplant nephropathy or radiation nephropathy. Additionally, we review other kidney complications, including calcineurin inhibitor nephrotoxicity and chronic graft-versus-host disease-associated glomerulonephritis, that develop post-HSCT. Critically, due to its grave prognosis, it is important to identify HSCT-associated thrombotic microangiopathy early, as well as distinguish it from the other causes of chronic kidney disease.
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Affiliation(s)
- Neeraj Singh
- Department of Internal Medicine, Division of Nephrology, The Ohio State University College of Medicine and Public Health, Columbus, OH, USA.
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21
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Hershko K, Simhadri VL, Blaisdell A, Hunt RC, Newell J, Tseng SC, Hershko AY, Choi JW, Sauna ZE, Wu A, Bram RJ, Komar AA, Kimchi-Sarfaty C. Cyclosporin A impairs the secretion and activity of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeat). J Biol Chem 2012; 287:44361-71. [PMID: 23144461 DOI: 10.1074/jbc.m112.383968] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The protease ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeat) cleaves multimers of von Willebrand factor, thus regulating platelet aggregation. ADAMTS13 deficiency leads to the fatal disorder thrombotic thrombocytopenic purpura (TTP). It has been observed that cyclosporin A (CsA) treatment, particularly in transplant patients, may sometimes be linked to the development of TTP. Until now, the reason for such a link was unclear. Here we provide evidence demonstrating that cyclophilin B (CypB) activity plays an important role in the secretion of active ADAMTS13. We found that CsA, an inhibitor of CypB, reduces the secretion of ADAMTS13 and leads to conformational changes in the protein resulting in diminished ADAMTS13 proteolytic activity. A direct, functional interaction between CypB (which possesses peptidyl-prolyl cis-trans isomerase (PPIase) and chaperone functions) and ADAMTS13 is demonstrated using immunoprecipitation and siRNA knockdown of CypB. Finally, CypB knock-out mice were found to have reduced ADAMTS13 levels. Taken together, our findings indicate that cyclophilin-mediated activity is an important factor affecting secretion and activity of ADAMTS13. The large number of proline residues in ADAMTS13 is consistent with the important role of cis-trans isomerization in the proper folding of this protein. These results altogether provide a novel mechanistic explanation for CsA-induced TTP in transplant patients.
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Affiliation(s)
- Klilah Hershko
- Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, Maryland 20982, USA
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22
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Munchel A, Chen A, Symons H. Emergent Complications in the Pediatric Hematopoietic Stem Cell Transplant Patient. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011; 12:233-244. [PMID: 25411564 PMCID: PMC4234095 DOI: 10.1016/j.cpem.2011.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hematopoietic cell transplantation is the only potentially curative option for a variety of pediatric malignant and nonmalignant disorders. Despite advances in transplantation biology and immunology as well as in posttransplant management that have contributed to improved survival and decreased transplant-related mortality, hematopoietic cell transplantation does not come without significant risk of complications. When patients who have undergone hematopoietic cell transplantation present to the emergency department, it is important to consider a variety of therapy-related complications to optimize management and outcome. In this article, we use clinical cases to highlight some of the more common emergent complications after hematopoietic cell transplantation.
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Affiliation(s)
- Ashley Munchel
- Pediatric Hematology/Oncology, The Johns Hopkins Hospital, Baltimore, MD
- Pediatric Oncology Branch at the National Institutes of Health, Bethesda, MD
| | - Allen Chen
- Division of Oncology, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
- Division of Pediatrics, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
| | - Heather Symons
- Division of Oncology, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
- Division of Pediatrics, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
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23
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Thrombotic microangiopathy in haematopoietic cell transplantation: an update. Mediterr J Hematol Infect Dis 2010; 2:e2010033. [PMID: 21776339 PMCID: PMC3134219 DOI: 10.4084/mjhid.2010.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 10/29/2010] [Indexed: 12/17/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) represents a vital procedure for patients with various hematologic conditions. Despite advances in the field, HCT carries significant morbidity and mortality. A rare but potentially devastating complication is transplantation-associated thrombotic microangiopathy (TA-TMA). In contrast to idiopathic TTP, whose etiology is attributed to deficient activity of ADAMTS13, (a member of the A Disintegrin And Metalloprotease with Thrombospondin 1 repeats family of metalloproteases), patients with TA-TMA have > 5% ADAMTS13 activity. Pathophysiologic mechanisms associated with TA-TMA, include loss of endothelial cell integrity induced by intensive conditioning regimens, immunosuppressive therapy, irradiation, infections and graft-versus-host (GVHD) disease. The reported incidence of TA-TMA ranges from 0.5% to 75%, reflecting the difficulty of accurate diagnosis in these patients. Two different groups have proposed consensus definitions for TA-TMA, yet they fail to distinguish the primary syndrome from secondary causes such as infections or medication exposure. Despite treatment, mortality rate in TA-TMA ranges between 60% to 90%. The treatment strategies for TA-TMA remain challenging. Calcineurin inhibitors should be discontinued and replaced with alternative immunosuppressive agents. Daclizumab, a humanized monoclonal anti-CD25 antibody, has shown promising results in the treatment of TA-TMA. Rituximab or the addition of defibrotide, have been reported to induce remission in this patient population. In general, plasma exchange is not recommended.
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24
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Palomo M, Diaz-Ricart M, Carbo C, Rovira M, Fernandez-Aviles F, Martine C, Ghita G, Escolar G, Carreras E. Endothelial Dysfunction after Hematopoietic Stem Cell Transplantation: Role of the Conditioning Regimen and the Type of Transplantation. Biol Blood Marrow Transplant 2010; 16:985-93. [DOI: 10.1016/j.bbmt.2010.02.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 02/04/2010] [Indexed: 10/19/2022]
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Abstract
Hemolytic uremic syndrome (HUS) is related to a renal thrombotic microangiopathy, inducing hypertension and acute renal failure (ARF). Its pathogenesis involves an activation/lesion of microvascular endothelial cells, mainly in the renal vasculature, secondary to bacterial toxins, drugs, or autoantibodies. An overactivation of the complement alternate pathway secondary to a heterozygote deficiency of regulatory proteins (factor H, factor I or MCP) or to an activating mutation of factor B or C3 can also result in HUS. Less frequently, renal microthrombi are due to an acquired or a constitutional deficiency in ADAMTS-13, the protease cleaving von Wilebrand factor. Hemolytic anemia with schistocytes, thrombocytopenia without evidence of disseminated intravascular coagulation, and renal failure are consistently found. In typical HUS, a prodromal diarrhea, with blood in the stools, is observed, related to pathogenic enterobacteria, most frequently E. Coli O157:H7. HUS may also occur in the post partum period, and is then related to a factor H or factor I deficiency. HUS may also occur after various treatments such as mitomycin C, gemcitabine, ciclosporin A, or tacrolimus, and as reported more recently bevacizumab, an anti VEGF antibody. Atypical HUS are not associated with diarrhea, may be sporadic or familial, and can be related to an overactivation of the complement alternate pathway. More recently, some of them have been related to a mutation of thrombomodulin, which also regulates the alternate pathway of complement. In adults, several HUS are encountered in the course of chronic nephropathies: nephroangiosclerosis, chronic glomerulonephritis, post irradiation nephropathy, scleroderma, disseminated lupus erythematosus, antiphospholipid syndrome. Overall the prognosis of HUS has improved, with a patient survival greater than 85% at 1 year. Chronic renal failure is observed as a sequella in 20 to 65% of the cases. Plasma infusions and plasma exchanges are effective in most of the cases to treat hemolysis and thrombocytopenia. Steroid therapy is debated, as well as immunosuppressive drugs, including rituximab, in autoimmune forms. A new monoclonal anti-C5 antibody is tested, and seems to be effective in atypical HUS with abnormal complement alternate pathway activation. If terminal renal failure occurs, renal transplantation can be performed but the risk of recurrence, which very low in post infectious forms of HUS, is about 70 to 80% in genetic forms of complement regulatory protein deficiency.
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Affiliation(s)
- Alexandre Hertig
- Service des urgences néphrologiques et transplantation rénale, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
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Abstract
Patients with solid and hematologic malignancies presenting with major bleeding or thrombotic complications, potentially life-ending events in a cancer patient's clinical course, usually require admission to an intensive care unit (ICU), making their diagnosis and management even more important for the intensivist. Given the significant advances in the diagnosis and treatment of almost all types of cancers in recent years, the intensivist is likely to encounter an ever-increasing number of cancer patients in the ICU setting with these complications. Abnormal hemostasis can occur as a consequence of both the pathology and treatment of cancer. Because cancer can have multiple effects on hemostatic equilibrium, treatment of these complications can be more complex than in the general population. This article reviews the physiology of coagulation and fibrinolysis, with special attention to those aspects that are most frequently altered in the setting of malignancy. The pathophysiology of bleeding and thrombotic complications specific to critically ill cancer patients are then detailed, and the diagnostic and therapeutic strategies are discussed. Special emphasis is placed on new cancer medications that have an effect on hemostasis, and on novel clotting and anticoagulant agents that are available to the intensivist for the management of these patients.
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Affiliation(s)
- Karen S Carlson
- Department of Medicine, New York Presbyterian Hospital of Weill Cornell Medical College, 525 E 68th Street, Payson 3, New York, NY 10065, USA
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Follow-up of ADAMTS13 enzyme and its relationship with clinical events after allogeneic hematopoietic stem cell transplantation. Blood Coagul Fibrinolysis 2009; 20:165-9. [PMID: 19657314 DOI: 10.1097/mbc.0b013e3283177b30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We aimed to evaluate the ADAMTS13 activity weekly after the hematopoietic stem cell transplantation and its relationship with clinical outcome. We studied 30 patients undergoing allogeneic hematopoietic stem cell transplantation with different conditioning regimens and 15 healthy controls. Plasmas were collected from patients 10 days before transplantation, the day of transplantation and 7th, 14th, 21st and 28th days after transplantation. Patients were followed for median period of 13 months (6-24 months). Patient plasmas were further collected when graft versus host disease (GVHD) developed. Enzyme activities of patients did not show a significant change through weeks [87% (39-145), 82% (16-110), 80% (36-134), 80% (36-134), 86% (47-127), 89% (11-127) and 90% (10-127)]. None of our patients had enzyme activity lower than 5% and had thrombotic microangiopathy, thromboembolism or hepatic veno-occlusive disease. Enzyme activity on the day of acute GVHD was not significantly different from the pretransplantation period (73 +/- 32 versus 87 +/- 20%, P = 0.231), but significantly lower than healthy controls (73 +/- 32 versus 97 +/- 16%, P = 0.02). Moreover, by the 28th day after transplantation, patients with acute GVHD had lower enzyme activity than the patients without acute GVHD (62 +/- 36 versus 95 +/- 22%, P = 0.009). ADAMTS13 activity was lower in samples taken from patients with chronic GVHD compared with baseline level (67 +/- 13 versus 91 +/- 30%, P = 0.15) and healthy controls (67 +/- 13 versus 97 +/- 16%, P = 0002). According to our data, transplantation does not have significant effect on ADAMTS13 activity. Acute or chronic GVHD causes a slight decrease of the enzyme that may indicate the possible cytokine effect.
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Transplantation-associated thrombotic microangiopathy: effect of concomitant GVHD on efficacy of therapeutic plasma exchange. Bone Marrow Transplant 2009; 45:699-704. [DOI: 10.1038/bmt.2009.233] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kennedy GA, Bleakley S, Butler J, Mudie K, Kearey N, Durrant S. Posttransplant thrombotic microangiopathy: sensitivity of proposed new diagnostic criteria. Transfusion 2009; 49:1884-9. [PMID: 19453982 DOI: 10.1111/j.1537-2995.2009.02217.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Objective diagnosis of transplantation-associated thrombotic microangiopathy (TA-TMA) has traditionally been difficult due to the multiple potential etiologies of thrombocytopenia and red blood cell fragmentation occurring after allogeneic hematopoietic stem cell transplantation (SCT). To attempt to address this issue of diagnostic uncertainty, two new diagnostic criteria for TA-TMA have recently been proposed: the Bone Marrow Transplant Clinical Trials Network (BMT-CTN) and the International Working Group (IWG) criteria. However, both newly proposed criteria are yet to be clinically validated. STUDY DESIGN AND METHODS All 15 cases of TA-TMA previously diagnosed at the authors' institution between December 2001 and March 2008 were retrospectively reclassified under the newly proposed BMT-CTN and IWG criteria. RESULTS Potential diagnostic pitfalls were identified in both the BMT-CTN and the IWG TA-TMA criteria. The main limitation of the BMT-CTN criteria appeared to be need for concurrent renal and/or neurologic dysfunction to be manifest at TA-TMA diagnosis, which was present in only 73% of our patient cohort. For the IWG criteria, the main limitation to TA-TMA diagnosis appeared to be the requirement for schistocytosis of more than 4%, which was present in only 27% of these patients. CONCLUSION Our experience suggests that potentially significant diagnostic pitfalls remain with both recently proposed TA-TMA diagnostic criteria, pitfalls that are likely to limit the diagnostic sensitivity of both. It is recommended that further clinical correlation of both the BMT-CTN and the IWG criteria be undertaken before either is routinely adapted into SCT practice.
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Affiliation(s)
- Glen A Kennedy
- Department of Haematology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
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31
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Choi CM, Schmaier AH, Snell MR, Lazarus HM. Thrombotic microangiopathy in haematopoietic stem cell transplantation: diagnosis and treatment. Drugs 2009; 69:183-98. [PMID: 19228075 DOI: 10.2165/00003495-200969020-00004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Each year in the US, more than 10 000 patients benefit from allogeneic haematopoietic stem cell transplantation (HSCT), a modality that offers an excellent chance of eradicating malignancy but confers a higher risk of treatment-related mortality. An uncommon but devastating consequence of HSCT is transplantation-associated thrombotic microangiopathy (TA-TMA). The incidence of TA-TMA ranges from 0.5% to 76%, with a mortality rate of 60-90% despite treatment. Although there appears to be a consistent treatment approach to idiopathic thrombotic thrombocytopenic purpura (TTP) using plasma exchange, corticosteroids and rituximab, the treatment strategies for TA-TMA are perplexing, in part, because the literature regarding this complex condition does not provide true consensus for incidence, aetiology, diagnostic criteria, classification and optimal therapy. The classic definition of idiopathic TTP includes schistocytes on the peripheral blood smear, thrombocytopenia and increased serum lactate dehydrogenase. Classic idiopathic TTP has been attributed to deficient activity of the metalloproteinase responsible for cleaving ultra-large von Willebrand factor multimers. This protease is a member of the 'a disintegrin and metalloprotease with thrombospondin type 1 motif' family and is subsequently named ADAMTS-13. Severely deficient ADAMTS-13 activity (<5% of normal) is associated with idiopathic TTP in 33-100% of patients. In constrast to the pathophysiology of idiopathic TTP, patients with TA-TMA have >5% ADAMTS-13 serum activity. These data may explain why plasma exchange, a standard treatment modality for idiopathic TTP that restores ADAMTS-13 activity, is not effective in TA-TMA. TA-TMA has a multifactorial aetiology of endothelial damage induced by intensive conditioning therapy, irradiation, immunosuppressants, infection and graft-versus-host disease. Treatment consists of substituting calcineurin inhibitors with an alternative immunosuppressive agent that possesses another mode of action. One candidate may be daclizumab, especially in those with mild to moderate TMA. Rituximab therapy or the addition of defibrotide may also be beneficial. In general, plasma exchange is not recommended.
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Affiliation(s)
- Cecilia M Choi
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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32
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Affiliation(s)
- Anaadriana Zakarija
- Division of Hematology/Oncology, Northwestern University, 676 N. St. Clair, Suite 850, Chicago, IL 60611, USA.
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Ushigome H, Sakai K, Suzuki T, Nobori S, Yoshizawa A, Kaihara S, Okamoto M, Urasaki K, Yoshimura N. Successful treatment of de novo thrombotic microangiopathy after minor ABO-mismatched living donor kidney transplantation. Clin Transplant 2008. [DOI: 10.1111/j.1399-0012.2008.00844.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Brandão LR, Kletzel M, Boulad F, Kurtzberg J, Maloney K, Fligman I, Sison CP, Dimichele D. A prospective longitudinal multicenter study of coagulation in pediatric patients undergoing allogeneic stem cell transplantation. Pediatr Blood Cancer 2008; 50:1240-6. [PMID: 18273869 DOI: 10.1002/pbc.21473] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Thrombotic complications occur in adult patients undergoing stem cell transplantation (SCT), especially following high dose chemo-radiotherapy. There is little published information in children on the impact of SCT on coagulation, as well as potential correlations between altered coagulation and SCT-associated thrombosis and organ failure. PROCEDURE Forty three pediatric subjects who underwent allogeneic SCT were prospectively evaluated for congenital thrombophilia, anticoagulant levels, coagulation activation, and fibrinolysis at pre-established set points encompassing the period from the 2 to 4 weeks prior to conditioning to 28 days post-transplantation. RESULTS A significant decrease of protein C and antithrombin levels was found in 39% and 31% of subjects respectively, between SCT days +6 and +7. A peak in plasminogen activator inhibitor-1 levels in 31% of subjects was noted between days +9 and +10. No subject experienced a thrombotic event or other SCT-related organ failure. Antithrombin deficiency correlated with underlying malignancy, donor HLA-mismatch, and TBI, whereas decreased PC activity demonstrated a trend of association with lack of T-cell depletion and TBI. Prophylactic heparin did not influence the pattern of acquired hemostatic abnormalities observed in this cohort. CONCLUSIONS Children undergoing allogeneic SCT develop a state of acquired thrombophilia in the early post-transplantation period. Although no SCT-related thromboembolic events were observed, our results provide new information about the hemostatic changes in children undergoing allogeneic SCT and their potential clinical triggers. The significance of these findings requires further prospective evaluation in a larger cohort of patients.
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Affiliation(s)
- Leonardo R Brandão
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.
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35
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Thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation: an autopsy study. Transplantation 2008; 85:22-8. [PMID: 18192907 DOI: 10.1097/01.tp.0000297998.33418.7e] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posttransplantation thrombotic microangiopathy (PTMA) is a complication of allogeneic hematopoietic stem cell transplantation (HSCT). However, limited autopsy data are available, and it remains unclear whether PTMA is a discrete clinical and pathologic entity. The aims of this autopsy study were to determine the correlation between clinical and pathologic diagnosis of PTMA, to define the precise morphologic spectrum of PTMA, and to seek for potential etiologic factors. METHODS The study included 20 consecutive patients with HSCT autopsied at the University of Oklahoma, between 1994 and 2005. Applying strict clinical-laboratory criteria, 6 patients were diagnosed clinically with PTMA and treated with plasma exchange. Clinical variables, including underlying disease, conditioning regimen, stem cell donor status, duration and serum level of cyclosporine, infections, and acute graft versus host disease were compared statistically in patients with histologic signs of PTMA (n=8) with those without PTMA (n=12). RESULTS PTMA was verified histologically in all 6 patients with a clinical diagnosis of PTMA but only 2 of the 14 patients who were not clinically diagnosed had histologic evidence of PTMA (P<0.0001). Kidneys were affected in all 8 patients with PTMA, and limited extrarenal involvement by PTMA was observed in 3 of these 8 patients. No statistically significant differences in relevant clinical and morphologic variables were identified between the PTMA and non-PTMA groups. CONCLUSIONS This study documents a strong correlation between the clinical and morphologic diagnosis of PTMA. The kidney is the primary target of PTMA, with dominant glomerular and arteriolar involvement. The etiology is likely to be multifactorial.
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36
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Castagna L, Todisco E, Sarina B, Santoro A. Rituximab in thrombotic microangiopathy. Br J Haematol 2007; 139:166; author reply 166-7. [PMID: 17854324 DOI: 10.1111/j.1365-2141.2007.06767.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Batts ED, Lazarus HM. Diagnosis and treatment of transplantation-associated thrombotic microangiopathy: real progress or are we still waiting? Bone Marrow Transplant 2007; 40:709-19. [PMID: 17603513 DOI: 10.1038/sj.bmt.1705758] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an infrequent but devastating syndrome that occurs in allogeneic hematopoietic stem cell transplant recipients, and is associated with a variety of transplantation-related factors, including conditioning regimens, immunosuppressive agents, GVHD and opportunistic infections. Progress in managing this condition has been hampered by lack of a consensus definition and poor understanding of the pathophysiology of the disorder. Two different groups recently have proposed consensus definitions, yet they fail to distinguish the primary syndrome from the secondary causes, such as a variety of infections, medication exposure or other conditions. Increasing evidence suggests that TA-TMA is a multifactorial disorder that is distinct from thrombotic thrombocytopenic purpura (TTP), and likely represents the final common pathway of a number of endothelial cell insults. TA-TMA responds poorly to conventional treatment for TTP, including plasma exchange, but newer agents, including daclizumab and defibrotide show promise. In addition, other agents known to modify endothelial responses to injury, including statins, prostacyclin analogues, endothelin-receptor antagonists and free radical scavengers, may lead to improved outcomes for patients affected by this disorder.
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Affiliation(s)
- E D Batts
- Department of Medicine, Case Medical Center, University Hospitals of Cleveland, Cleveland, OH 44106, USA
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Nangaku M, Nishi H, Fujita T. Pathogenesis and prognosis of thrombotic microangiopathy. Clin Exp Nephrol 2007; 11:107-114. [PMID: 17593509 DOI: 10.1007/s10157-007-0466-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 02/01/2007] [Indexed: 12/25/2022]
Abstract
Thrombotic microangiopathy (TMA) is a clinicopathological syndrome characterized by thrombosis formation in the microvasculature of various organs. Included in the broad category of TMA are the hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). Typical HUS is caused by Escherichia coli O157:H7, which produces the Shiga-like toxins; Stx-1 and Stx-2. In addition to damaging endothelial cells via the inhibition of protein synthesis, Shiga-like toxins also activate endothelial cells to produce inflammatory mediators, amplifying the prothrombogenic state. Although most patients with typical HUS recover renal functions, recent analysis has shown that typical HUS is not a benign disease in the long term. Genetic abnormalities of complement regulatory proteins predispose patients to atypical HUS. Mutations in factor H, membrane cofactor protein, and factor I are known to be associated with atypical HUS. Atypical HUS forms have a poor outcome and show recurrent and progressive courses. Autoimmune IgG inhibitors of a disintegrin and metalloprotease, with thrombospodin-1-like domains (ADAMTS) 13 and mutations of the ADAMTS13 gene lead to the development of TTP. Without treatment, TTP is associated with a very high mortality rate. As it is for atypical HUS, plasma exchange is currently the most feasible treatment for TTP. Etiological diagnosis at the bedside and the development of disease-specific therapeutic modalities will enable us to optimize the management of patients with TMA and improve their prognosis in the future.
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Affiliation(s)
- Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hiroshi Nishi
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiro Fujita
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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40
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Au WY, Ma ES, Lee TL, Ha SY, Fung AT, Lie AKW, Kwong YL. Successful treatment of thrombotic microangiopathy after haematopoietic stem cell transplantation with rituximab. Br J Haematol 2007; 137:475-8. [PMID: 17433026 DOI: 10.1111/j.1365-2141.2007.06588.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Thrombotic microangiopathy (TMA) is a grave complication after haematopoietic stem cell transplantation (HSCT) and effective treatment is undefined. Five patients with postHSCT TMA, which was refractory to at least 1 week of plasma exchange and prednisolone, were treated with rituximab (375 mg/m(2)/week x 4). Remission was achieved in four patients, of whom three remained in remission and one had died of sepsis at a median follow-up of 10 months. ADAMTS13 levels were low in all evaluable patients, and only one patient showed significant anti-ADAMTS13 antibody. The levels of ADAMTS13 and anti-ADAMTS13 antibody did not change significantly with rituximab-induced remission.
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Affiliation(s)
- Wing-Yan Au
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
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41
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Kojouri K, George JN. Thrombotic microangiopathy following allogeneic hematopoietic stem cell transplantation. Curr Opin Oncol 2007; 19:148-54. [PMID: 17272988 DOI: 10.1097/cco.0b013e3280148a2f] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this article is to assess the current understanding and uncertainties about the evaluation and management of thrombotic microangiopathy that occurs following allogeneic hematopoietic stem cell transplantation. RECENT FINDINGS Current data may not be sufficient to establish posttransplantation thrombotic microangiopathy as a discrete clinical or pathologic entity, distinct from other well recognized transplant-related complications. Analysis of case series of posttransplantation thrombotic microangiopathy illustrates uncertainties regarding incidence, risk factors, diagnosis, treatment, and survival. These studies have suggested the lack of efficacy of plasma exchange treatment and have identified other transplant-related complications, such as acute graft-versus-host disease and opportunistic infections, as the predominant causes of death in patients who had been diagnosed with posttransplantation thrombotic microangiopathy. Recently consensus diagnostic criteria were proposed by two independent groups to provide more uniform identification of patients with posttransplantation thrombotic microangiopathy; these criteria may result in a clearer definition of this syndrome. SUMMARY Posttransplantation thrombotic microangiopathy remains a diagnostic and therapeutic challenge. Further studies are required to determine if it is a specific entity and to define its relation to other transplant-related complications.
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Affiliation(s)
- Kiarash Kojouri
- Hematology-Oncology Section, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA
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Cataland SR, Jin M, Smith E, Stanek M, Wu HM. Full evaluation of an acquired case of thrombotic thrombocytopenic purpura following the surgical resection of glioblastoma multiforme. J Thromb Haemost 2006; 4:2733-7. [PMID: 16972936 DOI: 10.1111/j.1538-7836.2006.02217.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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