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Seguí IG, Mingot Castellano ME, Izquierdo CP, de la Rubia J. Should we consider caplacizumab as routine treatment for acute thrombotic thrombocytopenic purpura? An expert perspective on the pros and cons. Expert Rev Hematol 2024; 17:9-25. [PMID: 38353182 DOI: 10.1080/17474086.2024.2318347] [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: 11/15/2023] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening disorder. Caplacizumab has been the latest drug incorporated into the initial treatment of acute episodes, allowing for faster platelet recovery and a decrease in refractoriness, exacerbation, thromboembolic events, and mortality. However, caplacizumab is also associated with a bleeding risk and higher treatment costs, which prevent many centers from using it universally. AREAS COVERED Studies that included iTTP and/or caplacizumab to date were selected for this review using PubMed and MEDLINE platforms. We describe outcomes in the pre-caplacizumab era and after it, highlighting the benefits and risks of its use early in frontline, and also pointing out special situations that require careful management. EXPERT OPINION It is clear that the availability of caplacizumab has significantly and favorably impacted the management of iTTP patients. Whether this improvement is cost-effective still remains uncertain, and data on long-term sequelae and different healthcare systems will help to clarify this point. In addition, evidence of the bleeding/thrombotic risk of iTTP patients under this drug needs to be better addressed in future studies.
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Affiliation(s)
- Inés Gómez Seguí
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
| | | | | | - Javier de la Rubia
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
- Internal Medicine, Universidad Católica "San Vicente Mártir", Valencia, Spain
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2
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Neuman L, Joseph A, Bouzid R, Lescroart M, Mariotte E, Ederhy S, Tuffet S, Baudel JL, Benhamou Y, Galicier L, Grangé S, Provôt F, Neel A, Pène F, Delmas Y, Presne C, Poullin P, Wynckel A, Perez P, Barbet C, Halimi JM, Chatelet V, Rebibou JM, Ojeda-Uribe M, Vigneau C, Mesnard L, Veyradier A, Azoulay E, Coppo P, Chabriat H. Predictors of acute ischemic cerebral lesions in immune-mediated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. J Neurol 2023; 270:5023-5033. [PMID: 37392208 DOI: 10.1007/s00415-023-11830-y] [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: 05/19/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND The immune form of thrombotic thrombocytopenic purpura (iTTP) and the hemolytic and uremic syndrome (HUS) are two major forms of thrombotic microangiopathy (TMA). Their treatment has been recently greatly improved. In this new era, both the prevalence and predictors of cerebral lesions occurring during the acute phase of these severe conditions remain poorly known. AIM The prevalence and predictors of cerebral lesions appearing during the acute phase of iTTP and Shiga toxin-producing Escherichia coli-HUS or atypical HUS were evaluated in a prospective multicenter study. METHODS Univariate analysis was performed to report the main differences between patients with iTTP and those with HUS or between patients with acute cerebral lesions and the others. Multivariable logistic regression analysis was used to identify the potential predictors of these lesions. RESULTS Among 73 TMA cases (mean age 46.9 ± 16 years (range 21-87 years) with iTTP (n = 57) or HUS (n = 16), one-third presented with acute ischemic cerebral lesions on magnetic resonance imagery (MRI); two individuals also had hemorrhagic lesions. One in ten patients had acute ischemic lesions without any neurological symptom. The neurological manifestations did not differ between iTTP and HUS. In multivariable analysis, three factors predicted the occurrence of acute ischemic lesions on cerebral MRI: (1) the presence of old infarcts on cerebral MRI, (2) the level of blood pulse pressure, (3) the diagnosis of iTTP. CONCLUSION At the acute phase of iTTP or HUS, both symptomatic and covert ischemic lesions are detected in one third of cases on MRI. Diagnosis of iTTP and the presence of old infarcts on MRI are associated with the occurrence of such acute lesions as well as increased blood pulse pressure, that may represent a potential target to further improve the therapeutic management of these conditions.
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Affiliation(s)
- Lisa Neuman
- Centre NeuroVasculaire Translationnel, Centre de Référence CERVCO, Département de Neurologie, Hôpital Lariboisière, GHU AP-HP Nord, Université de Paris, Paris, France
| | - Adrien Joseph
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Raïda Bouzid
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
| | - Mickael Lescroart
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Eric Mariotte
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Stéphane Ederhy
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Department of Cardiology, Saint-Antoine Hospital, GRC N° 27, Sorbonne Université, AP-HP, 75012, Paris, France
| | - Sophie Tuffet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Department of Clinical Pharmacology, Clinical Research Platform of East of Paris (Unité de Recherche Clinique (URCEST), Centre de Recherche Clinique (CRCEST), Centre de Ressources Biologiques (CRB.APHP-SU), Hôpital Saint Antoine, AP-HP, Paris, France
| | - Jean-Luc Baudel
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Département de Médecine Interne, Hôpital Universitaire de Rouen, Université de Normandie, Rouen, France
- Service de Réanimation Médicale, CHU Charles Nicolle, Rouen, France
| | - Lionel Galicier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service d'Immunologie Clinique, CHU Saint-Louis, Université de Paris, Paris, France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Réanimation Médicale, CHU Charles Nicolle, Rouen, France
| | - François Provôt
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, Hôpital Albert-Calmette, Lille, France
| | - Antoine Neel
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Réanimation Médicale, CHU Hôtel-Dieu, Nantes, France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de médecine intensive-réanimationHôpital Cochin, APHP Centre &, Université de Paris, Paris, France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, Hôpital Nord, Amiens, France
| | - Pascale Poullin
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service d'hémaphérèse et d'autotransfusion, Hôpital la Conception, Marseille, France
| | - Alain Wynckel
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, Hôpital Maison Blanche, Reims, France
| | - Pierre Perez
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Réanimation Polyvalente, CHU de Nancy, Nancy, France
| | - Christelle Barbet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Hôpitaux Bretonneau et Clocheville, Tours, France
| | - Jean-Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Hôpitaux Bretonneau et Clocheville, Tours, France
| | - Valérie Chatelet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Centre Universitaire des Maladies Rénales, UNICAEN, CHU de Caen Normandie, Normandie Université, Caen, France
| | - Jean-Michel Rebibou
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service de Néphrologie, CHU de Dijon, Dijon, France
| | - Mario Ojeda-Uribe
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Service d'Hématologie et de Thérapie Cellulaire, Groupe Hospitalier Region Mulhouse-Sud-Alsace (GHRMSA), Mulhouse, France
| | - Cécile Vigneau
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Inserm, EHESP, Irset (Institut de Recherche en SantéEnvironnement et Travail)-UMR_S 1085, Université de Rennes, CHU Rennes, 35000, Rennes, France
| | - Laurent Mesnard
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Biochimie, Hôpital Saint-Antoine, 75571, Paris Cedex 12, France
| | - Elie Azoulay
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France
- Médecine Intensive Réanimation, Hôpital Saint Louis, AP-HP, Paris, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), AP-HP, Paris, France.
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France.
- Service d'Hématologie, Centre National de Référence des Microangiopathies Thrombotiques, AP-HP.6 and Sorbonne-Université, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.
- Centre de Recherche Des Cordeliers, INSERM UMRS 1138, Paris, France.
| | - Hugues Chabriat
- Centre NeuroVasculaire Translationnel, Centre de Référence CERVCO, Département de Neurologie, Hôpital Lariboisière, GHU AP-HP Nord, Université de Paris, Paris, France
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Joseph A, Joly BS, Picod A, Veyradier A, Coppo P. The Specificities of Thrombotic Thrombocytopenic Purpura at Extreme Ages: A Narrative Review. J Clin Med 2023; 12:jcm12093068. [PMID: 37176509 PMCID: PMC10179719 DOI: 10.3390/jcm12093068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy (TMA) related to a severe ADAMTS13 deficiency, the specific von Willebrand factor (VWF)-cleaving protease. This deficiency is often immune-mediated (iTTP) and related to the presence of anti-ADAMTS13 autoantibodies that enhance its clearance or inhibit its VWF processing activity. iTTP management may be challenging at extreme ages of life. International cohorts of people with TTP report delayed diagnoses and misdiagnoses in children and elderly people. Child-onset iTTP shares many features with adult-onset iTTP: a female predominance, an idiopathic presentation, and the presence of neurological disorders and therapeutic strategies. Long-term follow-ups and a transition from childhood to adulthood are crucial to preventing iTTP relapses, in order to identify the occurrence of other autoimmune disorders and psychosocial sequelae. In contrast, older iTTP patients have an atypical clinical presentation, with delirium, an atypical neurological presentation, and severe renal and cardiac damages. They also have a poorer response to treatment and prognosis. Long-term sequelae are highly prevalent in older patients. Prediction scores for iTTP diagnoses are not used for children and have a lower sensitivity and specificity in patients over 60 years old. ADAMTS13 remains the unique biological marker that is able to definitely confirm or rule out the diagnosis of iTTP and predict relapses during follow-ups.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Bérangère S Joly
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Adrien Picod
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Department, Saint-Antoine hospital, Public Assistance Hospitals of Paris, 75571 Paris, France
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Karsenty CL, Kirk SE, Helber HL, Esquilin JM, Despotovic JM, Grimes AB. Molecular Diagnosis Is Vital to the Accurate Classification and Management of Thrombotic Thrombocytopenic Purpura in Children. Front Immunol 2022; 13:836960. [PMID: 35479064 PMCID: PMC9038040 DOI: 10.3389/fimmu.2022.836960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening hematologic disease, presenting a myriad of diagnostic and management challenges in children. Here, we provide a review of this disorder and discuss 2 exemplary cases of TTP occurring in adolescents, emphasizing the need for consideration of late-onset congenital TTP (cTTP). We demonstrate the importance of early confirmation of ADAMTS13 enzyme deficiency and the presence or absence of ADAMTS13 inhibitor in order to rapidly initiate the appropriate life-saving therapies. Ultimately, molecular testing is paramount to distinguishing between congenital and acquired immune-mediated TTP.
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Affiliation(s)
- Cecile L. Karsenty
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
- *Correspondence: Cecile L. Karsenty,
| | - Susan E. Kirk
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Hannah L. Helber
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Jose M. Esquilin
- Methodist Children’s Hospital, San Antonio, TX, United States
- Methodist Physicians Pediatric Specialists of Texas, San Antonio, TX, United States
| | - Jenny M. Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
| | - Amanda B. Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
- Texas Children’s Cancer and Hematology Centers, Texas Children's Hospital, Houston, TX, United States
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