1
|
Dimopoulos K, Tripodi A, Goetze JP. Laboratory investigation and diagnosis of thrombotic thrombocytopenic purpura. Crit Rev Clin Lab Sci 2023; 60:625-639. [PMID: 37452521 DOI: 10.1080/10408363.2023.2232039] [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: 12/23/2022] [Revised: 04/04/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and potentially fatal disease for which rapid diagnosis is crucial for patient outcomes. Deficient activity (< 10%) of the liver enzyme, ADAMTS13, is the pathophysiological hallmark of TTP, and measurement of the enzyme activity can establish the diagnosis of TTP with high accuracy. Thus, along with the clinical history, appropriate laboratory assessment of a suspected case of TTP is essential for diagnosis and treatment. Here, we present a review of the available laboratory tests that can assist clinicians in establishing the diagnosis of TTP, with special focus on ADAMTS13 assays, including the measurement of the antigen and activity, and detection of autoantibodies to ADAMTS13.
Collapse
Affiliation(s)
- Konstantinos Dimopoulos
- Department of Clinical Biochemistry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Armando Tripodi
- IRCCS Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| |
Collapse
|
2
|
Irsara C, Anliker M, Egger AE, Harasser L, Lhotta K, Feistritzer C, Griesmacher A, Loacker L. Evaluation of two fully automated ADAMTS13 activity assays in comparison to manual FRET assay. Int J Lab Hematol 2023; 45:758-765. [PMID: 37194625 DOI: 10.1111/ijlh.14090] [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: 12/30/2022] [Accepted: 05/03/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION The objective of the present study was to evaluate and compare the validity and utility of two fully automated ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity assays for clinical diagnostic decision-making and to compare their performance. METHODS Two automated ADAMTS13 activity assays (Werfen HemosIL® AcuStar ADAMTS13 Activity, Technoclone Technofluor ADAMTS13 Activity) were compared with a manual FRET assay (BioMedica ACTIFLUOR ADAMTS13 Activity). The following samples were used: 13 acute phase TTP (thrombotic thrombocytopenic purpura) samples from 11 different patients, one sample from a patient with congenital ADAMTS13 deficiency, 16 samples from control patients, three follow-up samples from TTP patients in long-term remission and one sample from a patient with stem cell transplantation related thrombotic microangiopathy (TMA). The WHO 1st International Standard for ADAMTS13 and several dilutions of normal plasma with ADAMTS13-depleted normal plasma were also tested. Statistical analysis included descriptive statistics, sensitivity and specificity, Passing & Bablok regression and Bland-Altman plot. RESULTS The quantitative comparison between the HemosIL® (x) and Technofluor (y) methods showed a strong correlation (Pearson r = 0.98, n = 49). When considering an ADAMTS13 activity of <10% as a hallmark for the diagnosis of TTP, two fully automated assays were both able to identify all TTP- and non-TTP-samples correctly, resulting in sensitivities and specificities of 100%. CONCLUSION Both fully automated ADAMTS13 activity assays showed a good diagnostic performance and quantitative correlation among themselves, discriminating reliably between TTP- and non-TTP-patients.
Collapse
Affiliation(s)
- Christian Irsara
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Markus Anliker
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Alexander E Egger
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Lukas Harasser
- Department of Internal Medicine IV, Nephrology and Hypertension, Innsbruck Medical University, Innsbruck, Austria
| | - Karl Lhotta
- Department of Internal Medicine III, Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Lorin Loacker
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| |
Collapse
|
3
|
Gómez-Seguí I, Pascual Izquierdo C, Mingot Castellano ME, de la Rubia Comos J. An update on the pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:17-32. [PMID: 36537217 DOI: 10.1080/17474086.2023.2159803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Severe ADAMTS13 deficiency defines thrombotic thrombocytopenic purpura (TTP). ADAMTS13 is responsible for VWF cleavage. In the absence of this enzyme, widespread thrombi formation occurs, causing microangiopathic anemia and thrombocytopenia and leading to ischemic organ injury. Understanding ADAMTS13 function is crucial to diagnose and manage TTP, both in the immune and hereditary forms. AREAS COVERED The role of ADAMTS13 in coagulation homeostasis and the consequences of its deficiency are detailed. Other factors that modulate the consequences of ADAMTS13 deficiency are explained, such as complement system activation, genetic predisposition, or the presence of an inflammatory status. Clinical suspicion of TTP is crucial to start prompt treatment and avoid mortality and sequelae. Available techniques to diagnose this deficiency and detect autoantibodies or gene mutations are presented, as they have become faster and more available in recent years. EXPERT OPINION A better knowledge of TTP pathophysiology is leading to an improvement in diagnosis and follow-up, as well as a customized treatment in patients with TTP. This scenario is necessary to define the role of new targeted therapies already available or coming soon and the need to better diagnose and monitor at the molecular level the evolution of the disease.
Collapse
Affiliation(s)
- Inés Gómez-Seguí
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio de Hematología y Hemoterapia, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón, Calle Dr. Esquerdo 46, 28007, Madrid, Spain
| | - María Eva Mingot Castellano
- Servicio de Hematología, Área de Banco de Sangre y Establecimiento de Tejidos, Hospital Universitario Virgen del Rocío, Calle Manuel Siurot s/n, 41013, Sevilla, Spain
| | - Javier de la Rubia Comos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
| |
Collapse
|
4
|
Long B, Bridwell RE, Manchanda S, Gottlieb M. Evaluation and Management of Thrombotic Thrombocytopenic Purpura in the Emergency Department. J Emerg Med 2021; 61:674-682. [PMID: 34518045 DOI: 10.1016/j.jemermed.2021.07.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a dangerous condition that can be misdiagnosed in the emergency department. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of TTP, with a focus on emergency clinicians. DISCUSSION TTP is a disorder with microangiopathic hemolytic anemia, severe thrombocytopenia, and multiorgan ischemic injury. It may be acquired or hereditary, and is caused by a reduced amount or function of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), which is an enzyme involved in cleaving von Willebrand factor. The classic presentation of TTP includes fever, neurologic abnormalities, thrombocytopenia with purpura, microangiopathic hemolytic anemia, and acute renal injury. However, < 7% of cases have all of these findings present. Testing should include a complete blood count, complete metabolic panel, blood smear, coagulation panel, fibrinogen, D-dimer, lactate dehydrogenase, ADAMTS13 level, troponin, human immunodeficiency virus assessment, urinalysis, pregnancy test as appropriate, and electrocardiogram. Management includes hematology consultation if available, plasma exchange and corticosteroids, and treatment of end-organ complications. All patients require admission for treatment and close monitoring. CONCLUSION TTP is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Rachel E Bridwell
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Shivon Manchanda
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
5
|
Beranger N, Benghezal S, Joly BS, Capdenat S, Delton A, Stepanian A, Coppo P, Veyradier A. Diagnosis and follow-up of thrombotic thrombocytopenic purpura with an automated chemiluminescent ADAMTS13 activity immunoassay. Res Pract Thromb Haemost 2021; 5:81-93. [PMID: 33537532 PMCID: PMC7845081 DOI: 10.1002/rth2.12461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/24/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy (TMA) caused by a severe functional deficiency in ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type I repeats-13), the specific von Willebrand factor (VWF) cleaving protease. ADAMTS13 activity is essential to diagnose TTP but remains challenging to assess, as reference ADAMTS13 activity assays are manual and time consuming. Current techniques also lack robustness in low detectable ADAMTS13 activity range, which could prove problematic for therapy-driven monitoring. OBJECTIVES The HemosIL AcuStar ADAMTS13 activity assay is a fast, automated chemiluminescent assay, the performance of which remains to be evaluated prospectively on very large cohorts of patients with TMA and in real-life conditions. PATIENTS AND METHODS Our study was conducted over two successive sequences: a retrospective evaluation followed by a "real-life" prospective evaluation. Overall, we evaluated the HemosIL AcuStar ADAMTS13 activity assay on 539 citrated plasma samples. We extensively studied linearity, limit of detection, contamination, intra-assay and interassay precisions with a specific focus on levels < 25 IU/dL. Diagnostic performances for the detection of < 10 IU/dL ADAMTS13 activity and overall method comparison were conducted with the fluorescence resonance energy transfer (FRETS)-VWF73 assay as the reference method. RESULTS Technical performance proved excellent. Robustness in low detectable ADAMTS13 activity range was good, potentially qualifying this assay for therapy-driven monitoring. Comparison with the FRETS-VWF73 assay was satisfactory (r 2 = .83, P < .0001) as were the diagnostic performances for acute-phase TTP (specificity, 99.7%; positive predictive value, 99.2%). CONCLUSION The HemosIL AcuStar ADAMTS13 activity assay is a fast, reliable, automated technique well adapted as a first-line ADAMTS13 activity assay for TTP diagnosis and follow-up.
Collapse
Affiliation(s)
- Nicolas Beranger
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| | - Sandrine Benghezal
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| | - Bérangère S. Joly
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| | - Sophie Capdenat
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| | - Adeline Delton
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| | - Alain Stepanian
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| | - Paul Coppo
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
- Département d’hématologie cliniqueHôpital Saint AntoineUniversité Pierre et Marie CurieParisFrance
| | - Agnès Veyradier
- Service d’hématologie BiologiqueHôpital Lariboisière, AP‐HP.Nord and EA3518Institut de Recherche Saint‐LouisUniversité de ParisParisFrance
- French National Reference Centre for Thrombotic MicroangiopathiesAssistance Publique – Hôpitaux de ParisFrance
| |
Collapse
|
6
|
Pascual C, Nieto JM, Fidalgo T, Seguí IG, Díaz-Ricart M, Docampo MF, Del Rio J, Salinas R. Multicentric evaluation of the new HemosIL Acustar ® chemiluminescence ADAMTS13 activity assay. Int J Lab Hematol 2020; 43:485-493. [PMID: 33264480 DOI: 10.1111/ijlh.13414] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a rare life-threatening thrombotic microangiopathy (TMA) characterized by the severe deficiency of ADAMTS13 activity (<10%). Rapid ADAMTS13 testing is crucial for early diagnosis and optimal management of TTP patients and other TMAs. The objective of this study was to retrospectively evaluate the performance of the recently commercialized HemosIL Acustar® ADAMTS13 activity chemiluminescent immunoassay (Instrumentation Laboratory, Bedford, Massachusetts, United States) in a multicentric study between Spain and Portugal. METHODS A comparison method was performed to compare HemosIL Acustar® with an in-house FRETS-VWF73 assay and two commercial ELISA assays: the TECHNOZYM® ADAMTS13 Activity (Technoclone GmbH, Vienna, Austria) and the DG-EIA ADAMTS-13 Activity (Diagnostic Grifols, SA, Barcelona, Spain). A set of 241 frozen plasma samples with known ADAMST13 levels was used. Agreement between methods was assessed with focus on two cut-off ADAMTS13 activity values: <10% (the clinical accepted cut-off value to confirm TTP diagnosis) and <5%. RESULTS HemosIL AcuStar® showed high agreement with the other methods in correctly classify patients with ADAMTS13 values below 10% (Kappa = 0.89) and even below 5% (Kappa = 0.94) with no false negatives and few false positives (5.40%; 95% CI: 2.20 to 8.60%). However, it also tended to underestimate ADAMTS13 levels, especially for the high assay range values (>40%) (absolute mean bias of 8.40% (95% CI: 6.53 to 10.42%)) when compared to other assays. CONCLUSIONS HemosIL AcuStar® is highly sensitive to detect ADAMTS13 values below 10% and 5%. A large prospective validation study is needed to corroborate its utility in clinical practice.
Collapse
Affiliation(s)
- Cristina Pascual
- University Hospital Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañon, Madrid, Spain
| | - Jorge M Nieto
- University Hospital Clínico San Carlos, Madrid, Spain
| | - Teresa Fidalgo
- Hospital and Universitary Center of Coimbra, Coimbra, Portugal
| | | | - Maribel Díaz-Ricart
- Hematopathology, Pathology Department, Centre de Diagnostic Biomedic (CDB), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | | | | | - Ramon Salinas
- Hospital del Sagrat Cor, Universitat Internacional de Catalunya, Banc de Sang i Teixits de Catalunya, Barcelona, Spain
| |
Collapse
|
7
|
Jacquemin M, Van Horenbeeck I, Debasse M, Toelen J, Schoeters J, Vanlinthout I, Peerlinck K, Dierickx D, Van Laer C. Optimization of the detection of inhibitory autoantibodies against the VWF-cleaving protease ADAMTS13 with an automated chemiluminescent ADAMTS13 activity immunoassay. Int J Lab Hematol 2020; 43:290-297. [PMID: 33037787 DOI: 10.1111/ijlh.13359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/03/2020] [Accepted: 09/16/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Acquired thrombotic thrombocytopenic purpura is a rare disease associated with the production of autoantibodies against the VWF-cleaving protease ADAMTS13. The detection of these antibodies is made difficult by the instability of ADAMTS13 in citrated plasma and the time-consuming ADAMTS13 assays. The aim of our study was to evaluate the optimal conditions for detecting anti-ADAMTS13 inhibitory antibodies with the novel automated chemiluminescent immunoassay HemosILR AcuStar ADAMTS13 Activity assay. METHODS The parallelism between the AcuStar ADAMTS13 calibration curve and ADAMTS13 concentrations in serially diluted citrated plasma was evaluated after 2 hours incubation at 25°C, 37°C, or 37°C after addition of Ca2+ to preserve the activity of the metalloprotease. Using Bethesda assays based on the 3 incubation procedures and the HemosILR AcuStar ADAMTS13 Activity assay, the inhibitor titers were determined in patients' samples with ADAMTS13 antibodies and compared with those determined using the TechnozymR ADAMTS13 activity ELISA. RESULTS The criterion of parallelism was respected for the 3 incubation methods over the range of ADAMTS13 concentrations relevant for the detection of ADAMTS13 inhibitor antibodies in a Bethesda assay. In agreement with this observation, all the incubation methods permitted the accurate detection and quantification of inhibitory anti-ADAMTS13 antibodies in the samples from patients with acquired thrombotic thrombocytopenic purpura. CONCLUSION Incubation of plasma samples with normal plasma at 25°C, 37°C, or 37°C after addition of Ca2+ can be used in a Bethesda assay for quantifying the inhibitory activity of antibodies interfering with ADAMTS13 in the chemiluminescent HemosILR AcuStar ADAMTS13 Activity assay.
Collapse
Affiliation(s)
- Marc Jacquemin
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium.,Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Isa Van Horenbeeck
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Mirjam Debasse
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Jelle Toelen
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Joke Schoeters
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Ingrid Vanlinthout
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Kathelijne Peerlinck
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium.,Vascular Medicine and Hemostasis, University Hospitals of Leuven, Leuven, Belgium
| | - Daan Dierickx
- Clinical Department of Hematology, University Hospitals of Leuven, Leuven, Belgium
| | - Christine Van Laer
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium.,Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Mackie I, Mancini I, Muia J, Kremer Hovinga J, Nair S, Machin S, Baker R. International Council for Standardization in Haematology (ICSH) recommendations for laboratory measurement of ADAMTS13. Int J Lab Hematol 2020; 42:685-696. [DOI: 10.1111/ijlh.13295] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Ian Mackie
- Research Haematology University College London London UK
| | - Ilaria Mancini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Università degli Studi di Milano Department of Pathophysiology and Transplantation and Fondazione Luigi Villa Milan Italy
| | - Joshua Muia
- Department of Medicine Washington University School of Medicine St Louis MO USA
| | - Johanna Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory Inselspital Bern University Hospital Bern Switzerland
| | - Sukesh Nair
- Transfusion Medicine and Immunohematology Christian Medical College Vellore India
| | - Sam Machin
- Research Haematology University College London London UK
| | - Ross Baker
- Western Australia Centre for Thrombosis and Haemostasis Perth Blood Institute Murdoch University Perth WA Australia
| |
Collapse
|
9
|
Moore GW, Meijer D, Griffiths M, Rushen L, Brown A, Budde U, Dittmer R, Schocke B, Leyte A, Geiter S, Moes A, Cutler JA, Binder NB. A multi-center evaluation of TECHNOSCREEN ® ADAMTS-13 activity assay as a screening tool for detecting deficiency of ADAMTS-13. J Thromb Haemost 2020; 18:1686-1694. [PMID: 32239643 DOI: 10.1111/jth.14815] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/26/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Quantifying A disintegrin-like and metalloprotease with thrombospondin type 1 motif, member 13 (ADAMTS-13) activity enhances thrombotic thrombocytopenic purpura (TTP) diagnosis but most assays are time consuming, technically demanding, and mainly available in reference centers. OBJECTIVE Evaluate a simple, semiquantitative ADAMTS-13 activity screening test for early identification/exclusion of TTP. PATIENTS/METHODS Plasma from 220 patients with suspected thrombotic microangiopathy at three reference centers were tested with TECHNOSCREEN® ADAMTS13 activity screening test in comparison with TECHNOZYM® ADAMTS-13 activity ELISA at two centers, and in-house fluorescence resonance energy transfer assay at the third center. The screening test indicates if ADAMTS-13 activity is at one of four level-indicator points: 0, 0.1, 0.4, or 0.8 IU/mL. RESULTS Screen results were interpreted as binary data in that ADAMTS-13 activity was above or below the 0.1 IU/mL TTP clinical threshold. Combining all sites' data, the screen exhibited 88.7% sensitivity, 90.4% specificity, 74.6% positive predictive value, and 96.2% negative predictive value, comparable to published data for quantitative assays. Five samples with quantitative results below the threshold gave screen readings of 0.1 IU/mL and seven marginally above the threshold gave screen readings of zero. All would warrant plasma exchange while the level is quantified. Nine samples with normal/near normal results gave screens of zero and confirmatory quantifications would prompt early treatment withdrawal, as is current practice. One sample generated screen/quantitative results of 0.4/0.00 IU/mL respectively and was the only clear false-negative. CONCLUSIONS The screening test provides more rapid ADAMTS-13 level evaluation than most currently available assays. Its simple operation renders it suitable for adoption in routine or specialist laboratory environments.
Collapse
Affiliation(s)
- Gary W Moore
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
- Specialist Haemostasis Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Daniëlle Meijer
- Immune Pathology and Haemostasis Laboratories, Sanquin Diagnostics BV, Amsterdam, The Netherlands
| | | | - Lucy Rushen
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Alice Brown
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Ulrich Budde
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Rita Dittmer
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Barbara Schocke
- Department of Hemostaseology, MEDILYS Laborgesellschaft mbH, Hamburg, Germany
| | - Anja Leyte
- Immune Pathology and Haemostasis Laboratories, Sanquin Diagnostics BV, Amsterdam, The Netherlands
- OLVG Lab BV, Amsterdam, The Netherlands
| | | | - Anneke Moes
- Immune Pathology and Haemostasis Laboratories, Sanquin Diagnostics BV, Amsterdam, The Netherlands
| | - Jacqueline A Cutler
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | | |
Collapse
|
10
|
Gómez-De León A, Villela-Martínez LM, Yáñez-Reyes JM, Gómez-Almaguer D. Advances in the treatment of thrombotic thrombocytopenic purpura: repurposed drugs and novel agents. Expert Rev Hematol 2020; 13:461-470. [DOI: 10.1080/17474086.2020.1750361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Andrés Gómez-De León
- Hematology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario ‘Dr. José Eleuterio González’, Monterrey, México
| | - Luis Mario Villela-Martínez
- Centro Médico “Dr. Ignacio Chavez”. ISSSTESON, Hermosillo, México
- Universidad del Valle de México. Campus Hermosillo, Hermosillo, México
| | - José Miguel Yáñez-Reyes
- Hematology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario ‘Dr. José Eleuterio González’, Monterrey, México
| | - David Gómez-Almaguer
- Hematology Department, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario ‘Dr. José Eleuterio González’, Monterrey, México
| |
Collapse
|
11
|
Chiasakul T, Cuker A. Clinical and laboratory diagnosis of TTP: an integrated approach. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:530-538. [PMID: 30504354 PMCID: PMC6246034 DOI: 10.1182/asheducation-2018.1.530] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Thrombotic thrombocytopenia purpura (TTP) is a rare, life-threatening disease with an incidence of approximately 2 persons per million per year. It is characterized by severe deficiency of the von Willebrand cleaving protease, ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13), leading to formation of platelet-rich thrombi in the microvasculature. Prompt initiation of appropriate therapy, particularly plasma exchange, may be life-saving. Diagnosis of TTP is challenging because of its diverse clinical manifestations, overlap in clinical presentation with other thrombotic microangiopathies, and limited availability of ADAMTS13 testing. Clinical prediction scores have been developed to estimate the pretest probability of severe ADAMTS13 deficiency and may be used as an adjunct to clinical judgment to guide initial management decisions. An ADAMTS13 activity level of less than 10% supports the diagnosis of TTP in appropriate clinical contexts, but many centers do not offer testing in-house and must send out the test to a reference laboratory with a turnaround time of several days. In such instances, initial management decisions must be made without the benefit of laboratory testing. In patients with TTP, inhibitor tests may be useful for distinguishing immune-mediated from congenital TTP. In this article, we review the epidemiology, natural history, and clinical presentation of TTP and laboratory assays for TTP including ADAMTS13 activity and inhibitor assays. We also describe an evidence-based approach to the evaluation of a patient with suspected TTP that integrates clinical and laboratory assessment.
Collapse
Affiliation(s)
- Thita Chiasakul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; and
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
12
|
Makris K, Haliassos A, Chondrogianni M, Tsivgoulis G. Blood biomarkers in ischemic stroke: potential role and challenges in clinical practice and research. Crit Rev Clin Lab Sci 2018; 55:294-328. [DOI: 10.1080/10408363.2018.1461190] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Konstantinos Makris
- Clinical Biochemistry Department, KAT General Hospital, Kifissia, Athens, Greece
| | | | - Maria Chondrogianni
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| |
Collapse
|
13
|
Mancini I, Valsecchi C, Lotta L, Deforche L, Pontiggia S, Bajetta M, Palla R, Vanhoorelbeke K, Peyvandi F. FRETS-VWF73 rather than CBA assay reflects ADAMTS13 proteolytic activity in acquired thrombotic thrombocytopenic purpura patients. Thromb Haemost 2017; 112:297-303. [DOI: 10.1160/th13-08-0688] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 03/13/2014] [Indexed: 01/22/2023]
Abstract
SummaryCollagen-binding activity (CBA) and FRETS-VWF73 assays are widely adopted methods for the measurement of the plasmatic activity of ADAMTS13, the von Willebrand factor (VWF) cleaving-protease. Accurately assessing the severe deficiency of ADAMTS13 is important in the management of thrombotic thrombocytopenic purpura (TTP). However, non-concordant results between the two assays have been reported in a small but relevant percentage of TTP cases. We investigated whether CBA or FRETS-VWF73 assay reflects ADAMTS13 proteolytic activity in acquired TTP patients with non-concordant measurements. Twenty plasma samples with non-concordant ADAMTS13 activity results, <10% using FRETS-VWF73 and ≥20% using CBA, and 11 samples with concordant results, <10% using either FRETS-VWF73 and CBA assays, were analysed. FRETS-VWF73 was performed in the presence of 1.5 M urea. ADAMTS13 activities were also measured under flow conditions and the VWF multimer pattern was defined in order to verify the presence of ultra-large VWF due to ADAMTS13 deficiency. In FRETS-VWF73 assay with 1.5 M urea, ADAMTS13 activity significantly increased in roughly 50% of the samples with non-concordant results, whereas it remained undetectable in all samples with concordant measurements. Under flow conditions, all tested samples showed reduced ADAMTS13 activity. Finally, samples with non-concordant results showed a ratio of high molecular weight VWF multimers higher than normal. Our results support the use of FRETS-VWF73 over CBA assay for the assessment of ADAMTS13 severe deficiency and indicate urea as one cause of the observed differences.
Collapse
|
14
|
Thouzeau S, Capdenat S, Stepanian A, Coppo P, Veyradier A. Evaluation of a commercial assay for ADAMTS13 activity measurement. Thromb Haemost 2017; 110:852-3. [DOI: 10.1160/th13-05-0393] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/07/2013] [Indexed: 11/05/2022]
|
15
|
Langley K, Fretwell R, Kitchen S, MacDonald S, Dutt T, Baker P, Singh D, McDonald V, Hughes C, Murphy P, Scully M. Multiple centre evaluation study of ADAMTS13 activity and inhibitor assays. Int J Lab Hematol 2017; 40:21-25. [DOI: 10.1111/ijlh.12718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/16/2017] [Indexed: 11/26/2022]
Affiliation(s)
- K. Langley
- Haemostasis Research Unit; University College London; London UK
| | | | - S. Kitchen
- Royal Hallamshire Hospital; Sheffield UK
| | | | - T. Dutt
- Royal Liverpool University Hospital; Liverpool UK
| | - P. Baker
- Oxford Haemophilia and Thrombosis Centre; Oxford UK
| | - D. Singh
- The Doctors Laboratory Ltd; London UK
| | - V. McDonald
- Centre for Haemostasis and Thrombosis St Thomas’ Hospital; London UK
| | - C. Hughes
- St James's University Hospital; Leeds UK
| | - P. Murphy
- Newcastle upon Tyne Hospitals Foundation Trust; Newcastle UK
| | - M. Scully
- University College London Hospitals; London UK
| |
Collapse
|
16
|
Saha M, McDaniel JK, Zheng XL. Thrombotic thrombocytopenic purpura: pathogenesis, diagnosis and potential novel therapeutics. J Thromb Haemost 2017; 15:1889-1900. [PMID: 28662310 PMCID: PMC5630501 DOI: 10.1111/jth.13764] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Indexed: 01/07/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP), a potentially fatal clinical syndrome, is primarily caused by autoantibodies against the von Willebrand factor (VWF)-cleaving metalloprotease ADAMTS-13. In general, severe deficiency of plasma ADAMTS-13 activity (< 10 IU dL-1 ) with or without detectable inhibitory autoantibodies against ADAMTS-13 supports the diagnosis of TTP. A patient usually presents with thrombocytopenia and microangiopathic hemolytic anemia (i.e. schistocytes, elevated serum lactate dehydrogenase, decreased hemoglobin and haptoglobin) without other known etiologies that cause thrombotic microangiopathy (TMA). Normal to moderately reduced plasma ADAMTS-13 activity (> 10 IU dL-1 ) in a similar clinical context supports an alternative diagnosis such as atypical hemolytic uremic syndrome (aHUS) or other types of TMA. Prompt differentiation of TTP from other causes of TMA is crucial for the initiation of an appropriate therapy to reduce morbidity and mortality. Although plasma infusion is often sufficient for prophylaxis or treatment of hereditary TTP due to ADAMTS-13 mutations, daily therapeutic plasma exchange remains the initial treatment of choice for acquired TTP with demonstrable autoantibodies. Immunomodulatory therapies, including corticosteroids, rituximab, vincristine, cyclosporine, cyclophosphamide and splenectomy, etc., should be considered to eliminate autoantibodies for a sustained remission. Other emerging therapeutic modalities, including recombinant ADAMTS-13, adeno-associated virus (AAV) 8-mediated gene therapy, platelet-delivered ADAMTS-13, and antagonists targeting the interaction between platelet glycoprotein 1b and VWF are under investigation. This review highlights the recent progress in our understanding of the pathogenesis and diagnosis of, and current and potential novel therapies for, hereditary and acquired TTP.
Collapse
Affiliation(s)
- Manish Saha
- Division of Nephrology, Departments of Medicine, The University of Alabama at Birmingham, Birmingham, AL 35249
| | - Jenny K. McDaniel
- Division of Hematology/Oncology, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL 35249
| | - X. Long Zheng
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL 35249
| |
Collapse
|
17
|
Nieto JM, De La Fuente-Gonzalo F, González FA, Villegas A, Martínez R, Fuentes ME, Ropero P. Development and validation of a multivariable prediction rule for detecting a severe acquired ADAMTS13 activity deficiency in patients with thrombotic microangiopathies. ACTA ACUST UNITED AC 2017; 56:294-302. [DOI: 10.1515/cclm-2017-0437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/05/2017] [Indexed: 12/31/2022]
Abstract
Abstract
Background:
Thrombotic microangiopathies (TMAs) are a group of diseases that have different aetiologies and treatments, but a clinical differential diagnosis remains difficult. Among TMAs, thrombotic thrombocytopenic purpura (TTP) is characterised by a severe ADAMTS13 functional deficiency. However, assays exploring ADAMTS13 activity are limited to some specialised laboratories. Our objective was to develop and validate a diagnostic method for TTP in adult patients with TMA.
Methods:
We generated a multivariable model (four predictors) on a cohort of 174 TMA patients in order to predict an ADAMTS13 activity deficiency (AUC of 0.927). The multivariable model was simplified into a binary rule to facilitate the interpretation of the predictions. There were two scenarios for a patient: (1) Predicted ADAMTS13 deficiency; if the patient met four conditions simultaneously (platelets ≤44×109/L, creatinine ≤2 mg/dL (≤176.84 µmol/L) for males or ≤1.9 mg/dL (≤168 µmol/L) for females, age ≤68 years and no history of haematopoietic stem cell transplant [HSCT]); or (2) Predicted “normal” activity; if any of the above conditions are not met. This rule was validated on a second cohort of 86 patients and performed with sensitivity of 87.7% and specificity of 92.7%.
Results and conclusions:
This could lead to the earlier confirmation or rapid exclusion of TTP when ADAMTS13 testing is not avalilable, facilitating a more suitable therapy based on the aetiology of the TMA.
Collapse
Affiliation(s)
- Jorge M. Nieto
- Departamento de Eritropatología , Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , calle Profesor Martín Lagos sn , 28040 Madrid , Spain
| | | | - Fernando A. González
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| | - Ana Villegas
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| | - Rafael Martínez
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| | - Manuel E. Fuentes
- Unidad de Investigación, Hospital Clínico San Carlos , Madrid , Spain
| | - Paloma Ropero
- Servicio de Hematología y Hemoterapia, Hospital Clínico San Carlos , Madrid , Spain
| |
Collapse
|
18
|
Abstract
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and organ ischemia linked to disseminated microvascular platelet rich-thrombi. TTP is specifically related to a severe deficiency in ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13), the specific von Willebrand factor-cleaving protease. ADAMTS13 deficiency is most frequently acquired via ADAMTS13 autoantibodies, but rarely, it is inherited via mutations of the ADAMTS13 gene. The first acute episode of TTP usually occurs during adulthood, with a predominant anti-ADAMTS13 autoimmune etiology. In rare cases, however, TTP begins as soon as childhood, with frequent inherited forms. TTP is ∼2-fold more frequent in women, and its outcome is characterized by a relapsing tendency. Rapid recognition of TTP is crucial to initiate appropriate treatment. The first-line therapy for acute TTP is based on daily therapeutic plasma exchange supplying deficient ADAMTS13, with or without steroids. Additional immune modulators targeting ADAMTS13 autoantibodies are mainly based on steroids and the humanized anti-CD20 monoclonal antibody rituximab. In refractory or unresponsive TTP, more intensive therapies including twice-daily plasma exchange; pulses of cyclophosphamide, vincristine, or cyclosporine A; or salvage splenectomy are considered. New drugs including N-acetylcysteine, bortezomib, recombinant ADAMTS13, and caplacizumab show promise in the management of TTP. Also, long-term follow-up of patients with TTP is crucial to identify the occurrence of other autoimmune diseases, to control relapses, and to evaluate psychophysical sequelae. Further development of both patients’ registries worldwide and innovative drugs is still needed to improve TTP management.
Collapse
|
19
|
Abstract
Thrombotic thrombocytopenic purpura (TTP; also known as Moschcowitz disease) is characterized by the concomitant occurrence of often severe thrombocytopenia, microangiopathic haemolytic anaemia and a variable degree of ischaemic organ damage, particularly affecting the brain, heart and kidneys. Acute TTP was almost universally fatal until the introduction of plasma therapy, which improved survival from <10% to 80-90%. However, patients who survive an acute episode are at high risk of relapse and of long-term morbidity. A timely diagnosis is vital but challenging, as TTP shares symptoms and clinical presentation with numerous conditions, including, for example, haemolytic uraemic syndrome and other thrombotic microangiopathies. The underlying pathophysiology is a severe deficiency of the activity of a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), the protease that cleaves von Willebrand factor (vWF) multimeric strings. Ultra-large vWF strings remain uncleaved after endothelial cell secretion and anchorage, bind to platelets and form microthrombi, leading to the clinical manifestations of TTP. Congenital TTP (Upshaw-Schulman syndrome) is the result of homozygous or compound heterozygous mutations in ADAMTS13, whereas acquired TTP is an autoimmune disorder caused by circulating anti-ADAMTS13 autoantibodies, which inhibit the enzyme or increase its clearance. Consequently, immunosuppressive drugs, such as corticosteroids and often rituximab, supplement plasma exchange therapy in patients with acquired TTP.
Collapse
|
20
|
Scully M, Cataland S, Coppo P, de la Rubia J, Friedman KD, Kremer Hovinga J, Lämmle B, Matsumoto M, Pavenski K, Sadler E, Sarode R, Wu H. Consensus on the standardization of terminology in thrombotic thrombocytopenic purpura and related thrombotic microangiopathies. J Thromb Haemost 2017; 15:312-322. [PMID: 27868334 DOI: 10.1111/jth.13571] [Citation(s) in RCA: 294] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Indexed: 12/11/2022]
Abstract
Essentials An international collaboration provides a consensus for clinical definitions. This concerns thrombotic microangiopathies and thrombotic thrombocytopenic purpura (TTP). The consensus defines diagnosis, disease monitoring and response to treatment. Requirements for ADAMTS-13 are given. SUMMARY Background Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) are two important acute conditions to diagnose. Thrombotic microangiopathy (TMA) is a broad pathophysiologic process that leads to microangiopathic hemolytic anemia and thrombocytopenia, and involves capillary and small-vessel platelet aggregates. The most common cause is disseminated intravascular coagulation, which may be differentiated by abnormal coagulation. Clinically, a number of conditions present with microangiopathic hemolytic anemia and thrombocytopenia, including cancer, infection, transplantation, drug use, autoimmune disease, and pre-eclampsia and hemolysis, elevated liver enzymes and low platelet count syndrome in pregnancy. Despite overlapping clinical presentations, TTP and HUS have distinct pathophysiologies and treatment pathways. Objectives To present a consensus document from an International Working Group on TTP and associated thrombotic microangiopathies (TMAs). Methods The International Working Group has proposed definitions and terminology based on published information and consensus-based recommendations. Conclusion The consensus aims to aid clinical decisions, but also future studies and trials, utilizing standardized definitions. It presents a classification of the causes of TMA, and criteria for clinical response, remission and relapse of congenital and immune-mediated TTP.
Collapse
Affiliation(s)
- M Scully
- Department of Haematology, UCLH, Cardiometabolic programme-NIHR UCLH/UCL BRC, London, UK
| | - S Cataland
- Department of Internal Medicine, Ohio State University Hospital, Columbus, OH, USA
| | - P Coppo
- Department of Hematology, Saint-Antoine University Hospital, Paris, France
| | - J de la Rubia
- Department of Hematology, University Hospital Dr Peset, Valencia, Spain
| | - K D Friedman
- Division of Benign Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Kremer Hovinga
- Department of Hematology, Bern University Hospital, Bern, Switzerland
| | - B Lämmle
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - M Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | - K Pavenski
- Department of Laboratory medicine, St Michael's Hospital/Research Institute, Toronto, Ontario, Canada
| | - E Sadler
- Department of Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - R Sarode
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - H Wu
- Department of Pathology, Ohio State University Hospital, Columbus, OH, USA
| |
Collapse
|
21
|
Underwood M, Peyvandi F, Garagiola I, Machin S, Mackie I. Degradation of two novel congenital TTP ADAMTS13 mutants by the cell proteasome prevents ADAMTS13 secretion. Thromb Res 2016; 147:16-23. [PMID: 27665541 DOI: 10.1016/j.thromres.2016.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Over 150 mutations have been identified in the ADAMTS13 gene in patients with congenital thrombotic thrombocytopenic purpura (TTP). The majority of these (86%), lead to reduced (<50%) secretion of mutant recombinant ADAMTS13. The mechanism by which this occurs has not been investigated in vitro. Two novel ADAMTS13 mutations (p.I143T and p.Y570C) identified in two congenital adolescence onset TTP patients were studied, to investigate their effects on ADAMTS13 secretion and subcellular localisation. MATERIALS AND METHODS HEK293T cells were transiently transfected with wild type or mutant ADAMTS13 cDNA. Immunofluorescence and confocal microscopy were used to study localisation within the endoplasmic reticulum (ER) and Golgi. The cell proteasome and lysosomes were inhibited in cells stably expressing ADAMTS13 to investigate degradation of ADAMTS13 by either organelle. RESULTS Both mutations severely impaired secretion and both mutants localised within the ER and Golgi. Proteasome inhibition led to the intracellular accumulation of both mutants, suggesting proteasome degradation. Lysosome inhibition on the other hand did not lead to increased intracellular accumulation of the mutants. CONCLUSIONS Proteasome degradation of these ADAMTS13 mutants contributed to their reduced secretion.
Collapse
Affiliation(s)
- Mary Underwood
- Haemostasis Research Unit, University College London, London, England; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Flora Peyvandi
- Haemostasis Research Unit, University College London, London, England; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Samuel Machin
- Haemostasis Research Unit, University College London, London, England
| | - Ian Mackie
- Haemostasis Research Unit, University College London, London, England
| |
Collapse
|
22
|
Nakashima MO, Zhang X, Rogers HJ, Vengal L, Gibson B, Daly TM, Kottke-Marchant K. Validation of a panel of ADAMTS13 assays for diagnosis of thrombotic thrombocytopenic purpura: activity, functional inhibitor, and autoantibody test. Int J Lab Hematol 2016; 38:550-9. [DOI: 10.1111/ijlh.12542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- M. O. Nakashima
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - X. Zhang
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - H. J. Rogers
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - L. Vengal
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - B. Gibson
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - T. M. Daly
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| | - K. Kottke-Marchant
- Robert J. Tomsich Pathology and Laboratory Medicine Institute; Cleveland Clinic; Cleveland OH USA
| |
Collapse
|
23
|
Pépin M, Kleinjan A, Hajage D, Büller HR, Di Nisio M, Kamphuisen PW, Salomon L, Veyradier A, Stepanian A, Mahé I. ADAMTS-13 and von Willebrand factor predict venous thromboembolism in patients with cancer. J Thromb Haemost 2016; 14:306-15. [PMID: 26589836 DOI: 10.1111/jth.13205] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 10/16/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED ESSENTIALS: Cancer patients are at high risk of venous thromboembolism (VTE). In this study, cases and controls were cancer patients who did or did not develop VTE. von Willebrand factor (VWF) levels were higher if compared with controls and correlated with cancer stage. VWF and ADAMTS-13 are associated with the occurrence of VTE in cancer. BACKGROUND Patients with cancer are at high risk of venous thromboembolism (VTE). ADAMTS-13 regulates von Willebrand factor (VWF) activity, which plays a role in the development of cancer and in VTE. OBJECTIVES The aim of this study was to search for an association between the levels of VWF and ADAMTS-13 and VTE in patients with cancer and to compare current scoring systems for prediction of VTE before and after addition of these parameters. PATIENTS/METHODS In a case-control study, in which patients with recently diagnosed cancer were followed-up for 6 months, we compared 20 patients who developed VTE (cases) and 140 patients with cancer without VTE (controls), matched for sex, age, and type and stage of cancer. We measured VWF, ADAMTS-13 (activity and antigen), P-selectin, D-dimer and F1 + 2 levels at baseline, and calculated both the Khorana score and the Khorana score expanded after addition of P-selectin and D-dimer levels. RESULTS VWF levels were significantly higher in cases when compared with controls (326 ± 185% vs. 242 ± 158%) and correlated with advanced stage of cancer: localized, 185 [142; 222]; locally advanced, 240 [146; 257]; metastatic, 267 [153; 324] (mean [interquartile range]). The addition of two biomarkers, ADAMTS-13 activity and F1 + 2 levels, to the Khorana score improved receiver operating curves. CONCLUSIONS von Willebrand factor and ADAMTS-13 are associated with the occurrence of VTE in patients with cancer. Moreover, addition of ADAMTS-13 and F1 + 2 levels to the Khorana score considerably increases the predictive value for VTE.
Collapse
Affiliation(s)
- M Pépin
- Service de Médecine Interne, Hôpital Louis Mourier (AP-HP), Colombes, France
- Unité 1176, INSERM, Le Kremlin-Bicêtre, France
| | - A Kleinjan
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - D Hajage
- Département d'Epidémiologie et Recherche Clinique, URC Paris-Nord, Hôpital Bichat-Claude Bernard (AP-HP), Paris, France
- INSERM, CIC 1425-EC, UMR1123, Paris, France
| | - H R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M Di Nisio
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
- Department of Medical, Oral and Biotechnological Sciences, University G. D'Annunzio, Chieti, Italy
| | - P W Kamphuisen
- Department of Vascular Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - L Salomon
- Département de Recherche, Centre Ophtalmologique Rothschild, Paris, France
| | - A Veyradier
- Service d'Hématologie biologique, Hôpital Lariboisière (AP-HP), Paris, France
- Universitaire Paris Diderot, EA 7334 REMES Sorbonne Paris Cité, Paris, France
- Université Paris Diderot, Institut Universitaire d'Hématologie, EA3518, Paris, France
| | - A Stepanian
- Service d'Hématologie biologique, Hôpital Lariboisière (AP-HP), Paris, France
- Université Paris Diderot, Institut Universitaire d'Hématologie, EA3518, Paris, France
| | - I Mahé
- Service de Médecine Interne, Hôpital Louis Mourier (AP-HP), Colombes, France
- Universitaire Paris Diderot, EA 7334 REMES Sorbonne Paris Cité, Paris, France
- Université Paris Diderot, Institut Universitaire d'Hématologie, EA3518, Paris, France
| |
Collapse
|
24
|
An international consensus approach to the management of atypical hemolytic uremic syndrome in children. Pediatr Nephrol 2016; 31:15-39. [PMID: 25859752 DOI: 10.1007/s00467-015-3076-8] [Citation(s) in RCA: 338] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 01/26/2015] [Accepted: 02/16/2015] [Indexed: 12/19/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) emerged during the last decade as a disease largely of complement dysregulation. This advance facilitated the development of novel, rational treatment options targeting terminal complement activation, e.g., using an anti-C5 antibody (eculizumab). We review treatment and patient management issues related to this therapeutic approach. We present consensus clinical practice recommendations generated by HUS International, an international expert group of clinicians and basic scientists with a focused interest in HUS. We aim to address the following questions of high relevance to daily clinical practice: Which complement investigations should be done and when? What is the importance of anti-factor H antibody detection? Who should be treated with eculizumab? Is plasma exchange therapy still needed? When should eculizumab therapy be initiated? How and when should complement blockade be monitored? Can the approved treatment schedule be modified? What approach should be taken to kidney and/or combined liver-kidney transplantation? How should we limit the risk of meningococcal infection under complement blockade therapy? A pressing question today regards the treatment duration. We discuss the need for prospective studies to establish evidence-based criteria for the continuation or cessation of anticomplement therapy in patients with and without identified complement mutations.
Collapse
|
25
|
Krogh ASV, Waage A, Quist-Paulsen P. Kongenital trombotisk trombocytopenisk purpura. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1452-7. [DOI: 10.4045/tidsskr.15.1272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|
26
|
|
27
|
Connell NT, Cheves T, Sweeney JD. Effect of ADAMTS13 activity turnaround time on plasma utilization for suspected thrombotic thrombocytopenic purpura. Transfusion 2015; 56:354-9. [DOI: 10.1111/trf.13359] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/22/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Nathan T. Connell
- Hematology Division; Brigham and Women's Hospital; Boston Massachusetts
| | - Tracey Cheves
- Department of Pathology & Laboratory Medicine; Rhode Island Hospital; Providence Rhode Island
| | - Joseph D. Sweeney
- Department of Pathology & Laboratory Medicine; Rhode Island Hospital; Providence Rhode Island
| |
Collapse
|
28
|
Abstract
Pathogenesis of thrombotic thrombocytopenic purpura (TTP) was a mystery for over half a century until the discovery of ADAMTS13. ADAMTS13 is primarily synthesized in the liver, and its main function is to cleave von Willebrand factor (VWF) anchored on the endothelial surface, in circulation, and at the sites of vascular injury. Deficiency of plasma ADAMTS13 activity (<10%) resulting from mutations of the ADAMTS13 gene or autoantibodies against ADAMTS13 causes hereditary or acquired (idiopathic) TTP. ADAMTS13 activity is usually normal or modestly reduced (>20%) in other forms of thrombotic microangiopathy secondary to hematopoietic progenitor cell transplantation, infection, and disseminated malignancy or in hemolytic uremic syndrome. Plasma infusion or exchange remains the initial treatment of choice to date, but novel therapeutics such as recombinant ADAMTS13 and gene therapy are under development. Moreover, ADAMTS13 deficiency has been shown to be a risk factor for the development of myocardial infarction, stroke, cerebral malaria, and preeclampsia.
Collapse
Affiliation(s)
- X Long Zheng
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 19104;
| |
Collapse
|
29
|
Massively parallel enzyme kinetics reveals the substrate recognition landscape of the metalloprotease ADAMTS13. Proc Natl Acad Sci U S A 2015; 112:9328-33. [PMID: 26170332 DOI: 10.1073/pnas.1511328112] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Proteases play important roles in many biologic processes and are key mediators of cancer, inflammation, and thrombosis. However, comprehensive and quantitative techniques to define the substrate specificity profile of proteases are lacking. The metalloprotease ADAMTS13 regulates blood coagulation by cleaving von Willebrand factor (VWF), reducing its procoagulant activity. A mutagenized substrate phage display library based on a 73-amino acid fragment of VWF was constructed, and the ADAMTS13-dependent change in library complexity was evaluated over reaction time points, using high-throughput sequencing. Reaction rate constants (kcat/KM) were calculated for nearly every possible single amino acid substitution within this fragment. This massively parallel enzyme kinetics analysis detailed the specificity of ADAMTS13 and demonstrated the critical importance of the P1-P1' substrate residues while defining exosite binding domains. These data provided empirical evidence for the propensity for epistasis within VWF and showed strong correlation to conservation across orthologs, highlighting evolutionary selective pressures for VWF.
Collapse
|
30
|
Evaluation of a chromogenic commercial assay using VWF-73 peptide for ADAMTS13 activity measurement. Thromb Res 2014; 134:1074-80. [DOI: 10.1016/j.thromres.2014.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 08/14/2014] [Accepted: 09/04/2014] [Indexed: 11/23/2022]
|
31
|
Hanby HA, Zheng XL. Current status in diagnosis and treatment of hereditary thrombotic thrombocytopenic purpura. ACTA ACUST UNITED AC 2014; 3. [PMID: 25343060 DOI: 10.4172/2161-1041.1000e108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hayley A Hanby
- The Cell and Molecular Biology Graduate Group and Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, Tel. 215-590-3565; Fax. 267-426-5165
| | - X Long Zheng
- The Cell and Molecular Biology Graduate Group and Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, Tel. 215-590-3565; Fax. 267-426-5165
| |
Collapse
|
32
|
Pandey S, Nakagawa M, Rosenbaum ER, Arnaoutakis K, Hutchins LF, Makhoul I, Milojkovic N, Cottler-Fox M. Rituximab and intermediate-purity plasma-derived factor VIII concentrate (Koate®) as adjuncts to therapeutic plasma exchange for thrombotic thrombocytopenic purpura in patients with an ADAMTS13 inhibitor. J Clin Apher 2014; 30:50-4. [DOI: 10.1002/jca.21348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 06/29/2014] [Accepted: 07/01/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Soumya Pandey
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Mayumi Nakagawa
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Eric R. Rosenbaum
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Konstantinos Arnaoutakis
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Laura F. Hutchins
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Issam Makhoul
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Natasha Milojkovic
- Department of Medicine (Division of Hematology/Oncology); University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Michele Cottler-Fox
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| |
Collapse
|
33
|
ADAMTS13 deficiency, despite well-compensated liver functions in patients with noncirrhotic portal hypertension. Indian J Gastroenterol 2014; 33:355-63. [PMID: 24756423 DOI: 10.1007/s12664-014-0460-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 03/30/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND We have reported A disintegrin and metalloprotease with thrombospondin type 1 motif, member 13 (ADAMTS13) deficiency in noncirrhotic intrahepatic portal hypertension (NCIPH) patients of European origin with preserved liver function. We aimed to study ADAMTS13-von Willebrand factor (vWF) imbalance in Indian patients with NCIPH. METHODS Twenty-nine cases with NCIPH [22 males; 29 years (13-58); Child's A, 23; B, 6], 22 disease controls with cryptogenic chronic liver disease [15 males; 46 years (18-74); Child's A, 9; B, 9; C, 4] and 17 healthy controls [14 males; 32 years (27-45)] were enrolled in the study. We measured ADAMTS13 antigen and activity (by collagen binding assay (CBA) and by fluorescence resonance energy transfer [FRET] assay), and vWF antigen levels in plasma of study patients. RESULTS ADAMTS13 activity by CBA in NCIPH patients (32 %, 5 % to 100 %; median, range; p-value <0.001) and disease controls (36 %, 5 % to 144 %; p = 0.001) was significantly lower than in healthy controls (87 %; 60 % to 148 %). ADAMTS13 antigen and activity by FRET assay were also lower in cases and disease controls. ADAMTS13 activity (by CBA) to antigen ratio was lower in NCIPH and disease controls than in healthy controls. Of 29 NCIPH patients, 3 (all in Child's A) had severe ADAMTS13 deficiency (<10 % ADAMTS13 activity), and 8 (Child's A, 7; B, 1) had moderate ADAMTS13 deficiency (10 % to 25 % activity). Conversely, vWF antigen and vWF:ADAMTS13 ratio were higher in patients with NCIPH and in disease controls than in healthy controls. CONCLUSIONS This study validates the finding of ADAMTS13 deficiency in NCIPH despite preserved liver functions in an Indian population suggesting its involvement in pathogenesis of NCIPH.
Collapse
|
34
|
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening thrombotic microangiopathy which causes significant morbidity and mortality unless promptly recognized and treated. The underlying pathogenesis of TTP is a severe deficiency in ADAMTS13 activity, a metalloprotease that cleaves ultralarge von Willebrand factor multimers. This deficiency is either autoantibody mediated (acquired TTP) or due to deleterious mutations in the gene encoding ADAMTS13 (congenital TTP). The elucidation of this disease mechanism has reinforced the rationale and place of current therapies (eg, plasma exchange) as well as providing a basis for the prospective evaluation of immunotherapy with rituximab in addition to classic immunosuppression (eg, corticosteroid) in autoantibody-mediated TTP. This review discusses the current evidence base for therapeutic interventions in acquired and congenital TTP as well as providing a practical approach to the other aspects of investigation and management for which a firm evidence base is lacking. Novel agents that are currently being evaluated in prospective trials and future directions of therapy are also discussed which are expected to make an important contribution to improving outcomes in patients with TTP.
Collapse
Affiliation(s)
- Piers Blombery
- Department of Haematology, University College London Hospital, London,
UK
| | - Marie Scully
- Department of Haematology, University College London Hospital, London,
UK
| |
Collapse
|