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Favaloro EJ. The Role of the von Willebrand Factor Collagen-Binding Assay (VWF:CB) in the Diagnosis and Treatment of von Willebrand Disease (VWD) and Way Beyond: A Comprehensive 36-Year History. Semin Thromb Hemost 2024; 50:43-80. [PMID: 36807283 DOI: 10.1055/s-0043-1763259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The von Willebrand factor (VWF) collagen binding (VWF:CB) assay was first reported for use in von Willebrand diagnostics in 1986, by Brown and Bosak. Since then, the VWF:CB has continued to be used to help diagnose von Willebrand disease (VWD) (correctly) and also to help assign the correct subtype, as well as to assist in the monitoring of VWD therapy, especially desmopressin (DDAVP). However, it is important to recognize that the specific value of any VWF:CB is predicated on the use of an optimized VWF:CB, and that not all VWF:CB assays are so optimized. There are some good commercial assays available, but there are also some "not-so-good" commercial assays available, and these may continue to give the VWF:CB "a bad reputation." In addition to VWD diagnosis and management, the VWF:CB found purpose in a variety of other applications, from assessing ADAMTS13 activity, to investigation into acquired von Willebrand syndrome (especially as associated with use of mechanical circulatory support or cardiac assist devices), to assessment of VWF activity in disease states in where an excess of high-molecular-weight VWF may accumulate, and lead to increased (micro)thrombosis risk (e.g., coronavirus disease 2019, thrombotic thrombocytopenic purpura). The VWF:CB turns 37 in 2023. This review is a celebration of the utility of the VWF:CB over this nearly 40-year history.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
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Emirova KM, Orlova OM, Chichuga EM, Muzurov AL, Avdonin PP, Avdonin PV. A Moderate Decrease in ADAMTS13 Activity Correlates with the Severity of STEC-HUS. Biomolecules 2023; 13:1671. [PMID: 38002352 PMCID: PMC10669222 DOI: 10.3390/biom13111671] [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: 09/19/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 11/26/2023] Open
Abstract
Atypical hemolytic uremic syndrome (HUS) develops as a result of damage to the endothelium of microvasculature vessels by Shiga toxin produced by enterohemorrhagic Escherichia coli (STEC-HUS). STEC-HUS remains the leading cause of acute kidney injury (AKI) in children aged 6 months to 5 years. The pathomorphological essence of the disease is the development of thrombotic microangiopathy (TMA). One of the key causes of TMA is an imbalance in the ADAMTS13-von Willebrand factor (vWF)-platelet system. The goal of the work was to clarify the role of a moderate decrease in ADAMTS13 activity in the pathogenesis of STEC-HUS. The activity of ADAMTS13 was determined in 138 children (4 months-14.7 years) in the acute period of STEC-HUS and the features of the course of the disease in these patients were analyzed. The study revealed a decrease in the activity and concentration of ADAMTS13 in 79.8% and 90.6% of patients, respectively. Measurements of von Willebrand factor antigen content and the activity of von Willebrand factor in the blood plasma of part of these patients were carried out. In 48.6% and 34.4% of cases, there was an increase in the antigen concentration and the activity of the Willebrand factor, respectively. Thrombocytopenia was diagnosed in 97.8% of children. We have demonstrated that moderately reduced ADAMTS13 activity correlates with the risk of severe manifestations of STEC-HUS in children; the rate of developing multiple organ failure, cerebral disorders, pulmonary edema, and acute kidney injury with the need for dialysis increases. It is assumed that reduction in ADAMTS13 activity may serve as a predictor of disease severity.
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Affiliation(s)
- Khadizha M. Emirova
- Department of Pediatrics, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia; (K.M.E.); (O.M.O.)
- St. Vladimir Children’s City Clinical Hospital, Moscow 107014, Russia;
| | - Olga M. Orlova
- Department of Pediatrics, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia; (K.M.E.); (O.M.O.)
- St. Vladimir Children’s City Clinical Hospital, Moscow 107014, Russia;
| | - Ekaterina M. Chichuga
- Department of Hospital Pediatrics, N.N. Burdenko Voronezh State Medical University, Voronezh 394036, Russia;
| | - Alexander L. Muzurov
- St. Vladimir Children’s City Clinical Hospital, Moscow 107014, Russia;
- Russian Medical Academy of Continuous Professional Education, Moscow 123995, Russia
| | - Piotr P. Avdonin
- Koltsov Institute of Developmental Biology, Moscow 119334, Russia;
| | - Pavel V. Avdonin
- Koltsov Institute of Developmental Biology, Moscow 119334, Russia;
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Donadelli R, Sinha A, Bagga A, Noris M, Remuzzi G. HUS and TTP: traversing the disease and the age spectrum. Semin Nephrol 2023; 43:151436. [PMID: 37949684 DOI: 10.1016/j.semnephrol.2023.151436] [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: 11/12/2023]
Abstract
Hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenia purpura (TTP) are rare diseases sharing a common pathological feature, thrombotic microangiopathy (TMA). TMA is characterized by microvascular thrombosis with consequent thrombocytopenia, microangiopathic hemolytic anemia and/or multiorgan dysfunction. In the past, the distinction between HUS and TTP was predominantly based on clinical grounds. However, clinical presentation of the two syndromes often overlaps and, the differential diagnosis is broad. Identification of underlying pathogenic mechanisms has enabled the classification of these syndromes on a molecular basis: typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS); atypical HUS or complement-mediated TMA (aHUS/CM-TMA) associated with genetic or acquired defects leading to dysregulation of the alternative pathway (AP) of complement; and TTP that results from a severe deficiency of the von Willebrand Factor (VWF)-cleaving protease, ADAMTS13. The etiology of TMA differs between pediatric and adult patients. Childhood TMA is chiefly caused by STEC-HUS, followed by CM-TMA and pneumococcal HUS (Sp-HUS). Rare conditions such as congenital TTP (cTTP), vitamin B12 metabolism defects, and coagulation disorders (diacylglycerol epsilon mutation) present as TMA chiefly in children under 2 years of age. In contrast secondary causes and acquired ADAMT13 deficiency are more common in adults. In adults, compared to children, diagnostic delays are more frequent due to the wide range of differential diagnoses. In this review we focus on the three major forms of TMA, STEC-HUS, aHUS and TTP, outlining the clinical presentation, diagnosis and management of the affected patients, to help highlight the salient features and the differences between adult and pediatric patients which are relevant for management.
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Affiliation(s)
- Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Aditi Sinha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy.
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Turner NA, Moake JL. Heat-inactivated Factor B inhibits alternative pathway fluid-phase activation and convertase formation on endothelial cell-secreted ultra-large von Willebrand factor strings. Sci Rep 2023; 13:5764. [PMID: 37031266 PMCID: PMC10082794 DOI: 10.1038/s41598-023-33007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 04/10/2023] Open
Abstract
Defective regulation of the alternative complement pathway (AP) causes excessive activation and promotes the inflammation and renal injury observed in atypical hemolytic-uremic syndrome (aHUS). The usefulness of heat-inactivated Factor B (HFB) in reducing AP activation was evaluated in: fluid-phase reactions, using purified complement proteins and Factor H (FH)-depleted serum; and in surface-activated reactions using human endothelial cells (ECs). C3a and Ba levels, measured by quantitative Western blots, determined the extent of fluid-phase activation. In reactions using C3, FB, and Factor D proteins, HFB addition (2.5-fold FB levels), reduced C3a levels by 60% and Ba levels by 45%. In reactions using FH-depleted serum (supplemented with FH at 12.5% normal levels), Ba levels were reduced by 40% with HFB added at 3.5-fold FB levels. The effectiveness of HFB in limiting AP convertase formation on activated surfaces was evaluated using stimulated ECs. Fluorescent microscopy was used to quantify endogenously released C3, FB, and C5 attached to EC-secreted ultra-large VWF strings. HFB addition reduced attachment of C3b by 2.7-fold, FB by 1.5-fold and C5 by fourfold. Our data indicate that HFB may be of therapeutic value in preventing AP-mediated generation of C3a and C5a, and the associated inflammation caused by an overactive AP.
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Affiliation(s)
- Nancy A Turner
- Department of Bioengineering, Rice University, Houston, TX, USA.
| | - Joel L Moake
- Department of Bioengineering, Rice University, Houston, TX, USA
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Delayed diagnosis of congenital thrombotic thrombocytopenic purpura in a patient with recurrent strokes. J Thromb Thrombolysis 2022; 53:734-738. [PMID: 35022991 PMCID: PMC8754194 DOI: 10.1007/s11239-021-02629-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 10/26/2022]
Abstract
Congenital thrombotic thrombocytopenic purpura (cTTP) is caused by ADAMTS13 mutations and associated with high risk of microvascular thrombosis. A 58 year old female had an ischemic stroke during hormonal fertility, and a TIA a year after. She suffered another stroke 18 years later while on warfarin. Four months after she developed severe thrombocytopenia, mild anemia, and increased LDH. Blood film showed schistocytes. She was hospitalized with presumptive TTP. ADAMTS 13 activity was undetectable without inhibitor. She developed another stroke and received plasma exchange. A homozygote ADAMTS 13 mutation was identified. Despite plasma, the ADAMTS13 activity remained < 10% and she had another stroke. Recombinant ADAMTS13 therapy was obtained through compassionate use. She receives weekly infusions maintaining ADAMTS13 trough levels above 10% without thrombotic recurrences. This case underscores the need to recognize cTTP as a cause of cryptogenic strokes, and the diagnostic value of the peripheral blood film. rADAMTS13 replacement may prevent recurrences.
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Schrezenmeier E, Kremerskothen E, Halleck F, Staeck O, Liefeldt L, Choi M, Schüler M, Weber U, Bachmann N, Grohmann M, Wagner T, Budde K, Bergmann C. The underestimated burden of monogenic kidney disease in adults waitlisted for kidney transplantation. Genet Med 2021; 23:1219-1224. [PMID: 33712733 PMCID: PMC8257480 DOI: 10.1038/s41436-021-01127-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Chronic kidney disease (CKD) is a major health-care burden. Increasing evidence suggests that a considerable proportion of patients are affected by a monogenic kidney disorder. Methods In this study, the kidney transplantation waiting list at the Charité was screened for patients with undetermined cause of CKD. By next-generation sequencing (NGS) we targeted all 600 genes described and associated with kidney disease or allied disorders. Results In total, 635 patients were investigated. Of these, 245 individuals had a known cause of CKD (38.5%) of which 119 had a proven genetic disease (e.g., ADPKD, Alport). The other 340 patients (53.5%) were classified as undetermined diagnosis, of whom 87 had kidney failure (KF) onset <40 years. To this latter group genetic testing was offered as well as to those patients (n = 29) with focal segmental glomerulosclerosis (FSGS) and all individuals (n = 21) suspicious for thrombotic microangiopathy (TMA) in kidney biopsy. We detected diagnostic variants in 26 of 126 patients (20.6%) of which 14 of 126 (11.1%) were pathogenic or likely pathogenic. In another 12 of 126 (9.5%) patients, variants of unknown significance (VUS) were detected. Conclusion Our study demonstrates the diagnostic value of comprehensive genetic testing among patients with undetermined CKD.
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Affiliation(s)
- Eva Schrezenmeier
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany.
| | - Elisa Kremerskothen
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Fabian Halleck
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | | | - Lutz Liefeldt
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Mira Choi
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Markus Schüler
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Ulrike Weber
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Nadine Bachmann
- Medizinische Genetik Mainz, Limbach Genetics GmbH, Mainz, Germany
| | - Maik Grohmann
- Medizinische Genetik Mainz, Limbach Genetics GmbH, Mainz, Germany
| | - Timo Wagner
- Medizinische Genetik Mainz, Limbach Genetics GmbH, Mainz, Germany
| | - Klemens Budde
- Charité-Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Carsten Bergmann
- Medizinische Genetik Mainz, Limbach Genetics GmbH, Mainz, Germany. .,Department of Medicine, Nephrology, University Hospital Freiburg, Freiburg, Germany.
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7
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Reddy RL. Therapeutic Apheresis. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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8
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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.
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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
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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.
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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
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van Dorland HA, Taleghani MM, Sakai K, Friedman KD, George JN, Hrachovinova I, Knöbl PN, von Krogh AS, Schneppenheim R, Aebi-Huber I, Bütikofer L, Largiadèr CR, Cermakova Z, Kokame K, Miyata T, Yagi H, Terrell DR, Vesely SK, Matsumoto M, Lämmle B, Fujimura Y, Kremer Hovinga JA. The International Hereditary Thrombotic Thrombocytopenic Purpura Registry: key findings at enrollment until 2017. Haematologica 2019; 104:2107-2115. [PMID: 30792199 PMCID: PMC6886414 DOI: 10.3324/haematol.2019.216796] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
Congenital thrombotic thrombocytopenic purpura is an autosomal recessive inherited disease with a clinically heterogeneous course and an incompletely understood genotype-phenotype correlation. In 2006, the Hereditary TTP Registry started recruitment for a study which aimed to improve the understanding of this ultra-rare disease. The objective of this study is to present characteristics of the cohort until the end of 2017 and to explore the relationship between overt disease onset and ADAMTS13 activity with emphasis on the recurring ADAMTS13 c.4143_4144dupA mutation. Diagnosis of congenital thrombotic thrombocytopenic purpura was confirmed by severely deficient ADAMTS13 activity (≤10% of normal) in the absence of a functional inhibitor and the presence of ADAMTS13 mutations on both alleles. By the end of 2017, 123 confirmed patients had been enrolled from Europe (n=55), Asia (n=52, 90% from Japan), the Americas (n=14), and Africa (n=2). First recognized disease manifestation occurred from around birth up to the age of 70 years. Of the 98 different ADAMTS13 mutations detected, c.4143_4144dupA (exon 29; p.Glu1382Argfs*6) was the most frequent mutation, present on 60 of 246 alleles. We found a larger proportion of compound heterozygous than homozygous carriers of ADAMTS13 c.4143_4144dupA with overt disease onset at < 3 months of age (50% vs. 37%), despite the fact that ADAMTS13 activity was <1% in 18 of 20 homozygous, but in only 8 of 14 compound heterozygous carriers. An evaluation of overt disease onset in all patients with an available sensitive ADAMTS13 activity assay (n=97) shows that residual ADAMTS13 activity is not the only determinant of age at first disease manifestation. Registered at clinicaltrials.gov identifier NCT01257269.
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Affiliation(s)
- Hendrika A van Dorland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Magnus Mansouri Taleghani
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Kenneth D Friedman
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James N George
- Department of Biostatistics Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ingrid Hrachovinova
- NRL for Hemostasis, Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Paul N Knöbl
- Division of Hematology and Hemostasis, Department of Medicine 1, Medical University of Vienna, Austria
| | - Anne Sophie von Krogh
- Department of Hematology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Reinhard Schneppenheim
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Isabella Aebi-Huber
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | - Carlo R Largiadèr
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Zuzana Cermakova
- Blood Center, University Hospital Ostrava, Ostrava, Czech Republic
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideo Yagi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan.,Department of Hematology, Nara Prefecture General Medical Center, Nara, Japan
| | - Deirdra R Terrell
- Department of Biostatistics Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara K Vesely
- Department of Biostatistics Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan.,Japanese Red Cross Kinki Block Blood Center, Ibaraki, Osaka, Japan
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland .,Department for BioMedical Research, University of Bern, Bern, Switzerland
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11
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Bechtel-Walz W, Walz G, Neumann-Haefelin E. Long-Term Therapeutic Plasma Exchange Therapy as Effective Approach to Refractory Primary Acquired Pregnancy-Related Thrombocytopenic Purpura. Ther Apher Dial 2018; 23:99-100. [PMID: 30125471 DOI: 10.1111/1744-9987.12748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Wibke Bechtel-Walz
- Department of Medicine IV, Faculty of Medicine, University of Freiburg, Germany
| | - Gerd Walz
- Department of Medicine IV, Faculty of Medicine, University of Freiburg, Germany
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12
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Attar RZ, Ramel EI, Safdar OY, Desoky S. A case of patient with renal lupus with an initial presentation of hemolytic uremic syndrome triggered by streptococcal infection. Clin Case Rep 2018; 6:712-718. [PMID: 29636946 PMCID: PMC5889269 DOI: 10.1002/ccr3.1425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/30/2017] [Accepted: 01/05/2018] [Indexed: 11/23/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a systemic disease that is presented in a myriad of ways. Renal involvement is common in SLE and usually presents clinically as glomerulonephritis. We describe patients with SLE presented initially with hemolytic uremic syndrome which is a distinctive initial presentation.
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Affiliation(s)
- Rahaf Z. Attar
- College of medicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Enas I. Ramel
- College of medicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Osama Y. Safdar
- Faculty of MedicinePediatric Nephrology Center of ExcellenceKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Sherif Desoky
- Faculty of MedicinePediatric Nephrology Center of ExcellenceKing Abdulaziz UniversityJeddahSaudi Arabia
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13
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Complement factor H in AMD: Bridging genetic associations and pathobiology. Prog Retin Eye Res 2017; 62:38-57. [PMID: 28928087 DOI: 10.1016/j.preteyeres.2017.09.001] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/08/2017] [Accepted: 09/13/2017] [Indexed: 01/28/2023]
Abstract
Age-Related Macular Degeneration (AMD) is a complex multifactorial disease characterized in its early stages by lipoprotein accumulations in Bruch's Membrane (BrM), seen on fundoscopic exam as drusen, and in its late forms by neovascularization ("wet") or geographic atrophy of the Retinal Pigmented Epithelial (RPE) cell layer ("dry"). Genetic studies have strongly supported a relationship between the alternative complement cascade, in particular the common H402 variant in Complement Factor H (CFH) and development of AMD. However, the functional significance of the CFH Y402H polymorphism remains elusive. In this article, we critically review the literature surrounding the functional significance of this polymorphism. Furthermore, based on our group's studies we propose a model in which CFH H402 affects CFH binding to heparan sulfate proteoglycans leading to accelerated lipoprotein accumulation in BrM and drusen progression. We also review the literature on the role of other complement components in AMD pathobiologies, including C3a, C5a and the membrane attack complex (MAC), and on transgenic mouse models developed to interrogate in vivo the effects of the CFH Y402H polymorphism.
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14
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Fidalgo T, Martinho P, Pinto CS, Oliveira AC, Salvado R, Borràs N, Coucelo M, Manco L, Maia T, Mendes MJ, Del Orbe Barreto R, Corrales I, Vidal F, Ribeiro ML. Combined study of ADAMTS13 and complement genes in the diagnosis of thrombotic microangiopathies using next-generation sequencing. Res Pract Thromb Haemost 2017; 1:69-80. [PMID: 30046676 PMCID: PMC6058207 DOI: 10.1002/rth2.12016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/15/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The 2 main forms of thrombotic microangiopathy (TMA) are thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). Deficiency of ADAMTS13 and dysregulation of the complement pathway result in TTP and aHUS, respectively; however, overlap of their clinical characteristics makes differential diagnosis challenging. OBJECTIVES AND METHODS We aimed to develop a TMA diagnosis workflow based on ADAMTS13 activity and screening of ADAMTS13 and complement genes using a custom next-generation sequencing (NGS) gene panel. PATIENTS For this, from a cohort of 154 Portuguese patients with acute TMA, the genotype-phenotype correlations were analyzed in 7 hereditary TTP (ADAMTS13 activity <10%, no inhibitor), 36 acquired TTP (ADAMTS13 activity <10%, presence of an inhibitor), and in 34 presumable aHUS. RESULTS In total, 37 different rare variants, 8 of which novel (in ADAMTS13,CFH, and CD46), were identified across 7 genes. Thirteen TTP patients were homozygous (n=6), compound heterozygous (n=2), and heterozygous (n=5) for 11 ADAMTS13 variants (6 pathogenic mutations). Among the 34 aHUS patients, 17 were heterozygous for 23 variants in the different complement genes with distinct consequences, ranging from single pathogenic mutations associated with complete disease penetrance to benign variants that cause aHUS only when combined with other variants and/or CFH and CD46 risk haplotypes or CFHR1-3 deletion. CONCLUSIONS Our study provides evidence of the usefulness of the NGS panel as an excellent technology that enables more rapid diagnosis of TMA, and is a valuable asset in clinical practice to discriminate between TTP and aHUS.
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Affiliation(s)
- Teresa Fidalgo
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Patrícia Martinho
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Catarina S. Pinto
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Ana C. Oliveira
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Ramon Salvado
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Nina Borràs
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - Margarida Coucelo
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Licínio Manco
- Research Centre for Anthropology and Health (CIAS), Department of Life SciencesUniversity of CoimbraCoimbraPortugal
| | - Tabita Maia
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - M. João Mendes
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | | | - Irene Corrales
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - Francisco Vidal
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - M. Letícia Ribeiro
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
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15
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Bettoni S, Galbusera M, Gastoldi S, Donadelli R, Tentori C, Spartà G, Bresin E, Mele C, Alberti M, Tortajada A, Yebenes H, Remuzzi G, Noris M. Interaction between Multimeric von Willebrand Factor and Complement: A Fresh Look to the Pathophysiology of Microvascular Thrombosis. THE JOURNAL OF IMMUNOLOGY 2017; 199:1021-1040. [PMID: 28652401 DOI: 10.4049/jimmunol.1601121] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 05/23/2017] [Indexed: 12/18/2022]
Abstract
von Willebrand factor (VWF), a multimeric protein with a central role in hemostasis, has been shown to interact with complement components. However, results are contrasting and inconclusive. By studying 20 patients with congenital thrombotic thrombocytopenic purpura (cTTP) who cannot cleave VWF multimers because of genetic ADAMTS13 deficiency, we investigated the mechanism through which VWF modulates complement and its pathophysiological implications for human diseases. Using assays of ex vivo serum-induced C3 and C5b-9 deposits on endothelial cells, we documented that in cTTP, complement is activated via the alternative pathway (AP) on the cell surface. This abnormality was corrected by restoring ADAMTS13 activity in cTTP serum, which prevented VWF multimer accumulation on endothelial cells, or by an anti-VWF Ab. In mechanistic studies we found that VWF interacts with C3b through its three type A domains and initiates AP activation, although assembly of active C5 convertase and formation of the terminal complement products C5a and C5b-9 occur only on the VWF-A2 domain. Finally, we documented that in the condition of ADAMTS13 deficiency, VWF-mediated formation of terminal complement products, particularly C5a, alters the endothelial antithrombogenic properties and induces microvascular thrombosis in a perfusion system. Altogether, the results demonstrated that VWF provides a platform for the activation of the AP of complement, which profoundly alters the phenotype of microvascular endothelial cells. These findings link hemostasis-thrombosis with the AP of complement and open new therapeutic perspectives in cTTP and in general in thrombotic and inflammatory disorders associated with endothelium perturbation, VWF release, and complement activation.
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Affiliation(s)
- Serena Bettoni
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Miriam Galbusera
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Sara Gastoldi
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Roberta Donadelli
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Chiara Tentori
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Giuseppina Spartà
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Elena Bresin
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Caterina Mele
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Marta Alberti
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
| | - Agustin Tortajada
- Department of Immunology, Complutense University, Research Institute Hospital 12 de Octubre, 28040 Madrid, Spain
| | - Hugo Yebenes
- Departamento de Medicina Celular y Molecular, Centro de Investigaciones Biologicas, 28040 Madrid, Spain
| | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy; .,Unità di Nefrologia e Dialisi, Azienda Ospedaliera Papa Giovanni XXIII, 24127 Bergamo, Italy; and.,Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Marina Noris
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Centro di Ricerche Cliniche per le Malattie Rare "Aldo e Cele Daccò," 24020 Ranica Bergamo, Italy
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16
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Åkesson A, Zetterberg E, Klintman J. At the Cross Section of Thrombotic Microangiopathy and Atypical Hemolytic Uremic Syndrome: A Narrative Review of Differential Diagnostics and a Problematization of Nomenclature. Ther Apher Dial 2017; 21:304-319. [DOI: 10.1111/1744-9987.12535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Alexander Åkesson
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
| | - Eva Zetterberg
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
| | - Jenny Klintman
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
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17
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Murine systemic thrombophilia and hemolytic uremic syndrome from a factor H point mutation. Blood 2017; 129:1184-1196. [PMID: 28057640 DOI: 10.1182/blood-2016-07-728253] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/22/2016] [Indexed: 01/07/2023] Open
Abstract
Complement plays a key role in host defense, but its dysregulation can cause autologous tissue injury. Complement activation is normally controlled by regulatory proteins, including factor H (FH) in plasma and membrane cofactor protein (MCP) on the cell surface. Mutations in FH and MCP are linked to atypical hemolytic uremic syndrome, a type of thrombotic microangiopathy (TMA) that causes renal failure. We describe here that disruption of FH function on the cell surface can also lead to disseminated complement-dependent macrovascular thrombosis. By gene targeting, we introduced a point mutation (W1206R) into murine FH that impaired its interaction with host cells but did not affect its plasma complement-regulating activity. Homozygous mutant mice carrying this mutation developed renal TMA as well as systemic thrombophilia involving large blood vessels in multiple organs, including liver, lung, spleen, and kidney. Approximately 30% of mutant mice displayed symptoms of stroke and ischemic retinopathy, and 48% died prematurely. Genetic deficiency of complement C3 and factor D prevented both the systemic thrombophilia and renal TMA phenotypes. These results demonstrate a causal relationship between complement dysregulation and systemic angiopathy and suggest that complement activation may contribute to various human thrombotic disorders involving both the micro- and macrovasculature.
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18
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Mancini I, Ricaño-Ponce I, Pappalardo E, Cairo A, Gorski MM, Casoli G, Ferrari B, Alberti M, Mikovic D, Noris M, Wijmenga C, Peyvandi F. Immunochip analysis identifies novel susceptibility loci in the human leukocyte antigen region for acquired thrombotic thrombocytopenic purpura. J Thromb Haemost 2016; 14:2356-2367. [PMID: 27762046 DOI: 10.1111/jth.13548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/28/2016] [Indexed: 12/11/2022]
Abstract
Essentials Genetic predisposition to acquired thrombotic thrombocytopenic purpura (aTTP) is mainly unknown. Genetic risk factors for aTTP were studied by Immunochip analysis and replication study. Human leukocyte antigen (HLA) variant rs6903608 conferred a 2.5-fold higher risk of developing aTTP. rs6903608 and HLA-DQB1*05:03 may explain most of the HLA association signal in aTTP. Click to hear Dr Cataland's presentation on acquired thrombotic thrombocytopenic purpura SUMMARY: Background Acquired thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening thrombotic microangiopathy associated with the development of autoantibodies against the von Willebrand factor-cleaving protease ADAMTS-13. Similarly to what has been found for other autoimmune disorders, there is evidence of a genetic contribution, including the association of the human leukocyte antigen (HLA) class II complex with disease risk. Objective To identify novel genetic risk factors in acquired TTP. Patients/Methods We undertook a case-control genetic association study in 190 European-origin TTP patients and 1255 Italian healthy controls by using the Illumina Immunochip. Replication analysis in 88 Italian cases and 456 controls was performed with single-nucleotide polymorphism (SNP) TaqMan assays. Results and conclusion We identified one common variant (rs6903608) located within the HLA class II locus that was independently associated with acquired TTP at genome-wide significance and conferred a 2.6-fold increased risk of developing a TTP episode (95% confidence interval [CI] 2.02-3.27, P = 1.64 × 10-14 ). We also found five non-HLA variants mapping to chromosomes 2, 6, 8 and X that were suggestively associated with the disease: rs9490550, rs115265285, rs5927472, rs7823314, and rs1334768 (nominal P-values ranging from 1.59 × 10-5 to 7.60 × 10-5 ). Replication analysis confirmed the association of HLA variant rs6903608 with acquired TTP (pooled P = 3.95 × 10-19 ). Imputation of classic HLA genes followed by stepwise conditional analysis revealed that the combination of rs6903608 and HLA-DQB1*05:03 may explain most of the HLA association signal in acquired TTP. Our results refined the association of the HLA class II locus with acquired TTP, confirming its importance in the etiology of this autoimmune disease.
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Affiliation(s)
- I Mancini
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, and Fondazione Luigi Villa, Milan, Italy
| | - I Ricaño-Ponce
- Genetics Department, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - E Pappalardo
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, and Fondazione Luigi Villa, Milan, Italy
| | - A Cairo
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M M Gorski
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, and Fondazione Luigi Villa, Milan, Italy
| | - G Casoli
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - B Ferrari
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Alberti
- IRCCS - Istituto di Ricerche Farmacologiche 'Mario Negri', Clinical Research Center for Rare Diseases, Aldo e Cele Daccò, Bergamo, Italy
| | - D Mikovic
- Hemostasis Department and Hemophilia Center, Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - M Noris
- IRCCS - Istituto di Ricerche Farmacologiche 'Mario Negri', Clinical Research Center for Rare Diseases, Aldo e Cele Daccò, Bergamo, Italy
| | - C Wijmenga
- Genetics Department, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - F Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, and Fondazione Luigi Villa, Milan, Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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19
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Therapeutic Apheresis. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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20
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Cheong HI, Jo SK, Yoon SS, Cho H, Kim JS, Kim YO, Koo JR, Park Y, Park YS, Shin JI, Yoo KH, Oh D. Clinical Practice Guidelines for the Management of Atypical Hemolytic Uremic Syndrome in Korea. J Korean Med Sci 2016; 31:1516-28. [PMID: 27550478 PMCID: PMC4999392 DOI: 10.3346/jkms.2016.31.10.1516] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/10/2016] [Indexed: 12/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare syndrome characterized by micro-angiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. The major pathogenesis of aHUS involves dysregulation of the complement system. Eculizumab, which blocks complement C5 activation, has recently been proven as an effective agent. Delayed diagnosis and treatment of aHUS can cause death or end-stage renal disease. Therefore, a diagnosis that differentiates aHUS from other forms of thrombotic microangiopathy is very important for appropriate management. These guidelines aim to offer recommendations for the diagnosis and treatment of patients with aHUS in Korea. The guidelines have largely been adopted from the current guidelines due to the lack of evidence concerning the Korean population.
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Affiliation(s)
- Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Sung Soo Yoon
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Young Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Ja Ryong Koo
- Division of Nephrology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong, Korea
| | - Yong Park
- Division of Hematology, Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, School of Medicine, CHA University, Seongnam, Korea.
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21
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Ueda Y, Gullipalli D, Song WC. Modeling complement-driven diseases in transgenic mice: Values and limitations. Immunobiology 2016; 221:1080-90. [PMID: 27371974 DOI: 10.1016/j.imbio.2016.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/07/2016] [Accepted: 06/09/2016] [Indexed: 12/15/2022]
Abstract
Remarkable advances have been made over past decades in understanding the pathogenesis of complement-mediated diseases. This has led to development of new therapies for, and in some cases re-classification of, complement-driven diseases. This success is due to not only insight from human patients but also studies using transgenic animal models. Animal models that mimic human diseases are useful tools to understand the mechanism of disease and develop new therapies but there are also limitations due to species differences in their complement systems. This review provides a summary of transgenic animal models for three human diseases that are at the forefront of anti-complement therapy, paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy (C3G). They are discussed here as examples to highlight the values and limitations of animal modeling in complement-driven diseases.
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Affiliation(s)
- Yoshiyasu Ueda
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States
| | - Damodar Gullipalli
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States.
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22
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Coppo R, Bonaudo R, Peruzzi RL, Amore A, Brunati A, Romagnoli R, Salizzoni M, Galbusera M, Gotti E, Daina E, Noris M, Remuzzi G. Liver transplantation for aHUS: still needed in the eculizumab era? Pediatr Nephrol 2016; 31:759-68. [PMID: 26604087 DOI: 10.1007/s00467-015-3278-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/28/2015] [Accepted: 10/28/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND The risk of disease recurrence after a kidney transplant is high in patients with atypical hemolytic uremic syndrome (aHUS) and mutations in the complement factor H (FH) gene (CFH). Since FH is mostly produced by the liver, a kidney transplant does not correct the genetic defect. The anti-C5 antibody eculizumab prevents post-transplant aHUS recurrence, but it does not cure the disease. Combined liver-kidney transplantation has been performed in few patients with CFH mutations based on the rationale that liver replacement provides a source of normal FH. METHODS We report the 9-year follow-up of a child with aHUS and a CFH mutation, including clinical data, extensive genetic characterization, and complement profile in the circulation and at endothelial level. The outcome of kidney and liver transplants performed separately 3 years apart are reported. RESULTS The patient showed incomplete response to plasma, with relapsing episodes, progression to end-stage renal disease, and endothelial-restricted complement dysregulation. Eculizumab prophylaxis post-kidney transplant did not achieve sustained remission, leaving the child at risk of disease recurrence. A liver graft given 3 years after the kidney transplant completely abrogated endothelial complement activation and allowed eculizumab withdrawal. CONCLUSIONS Liver transplant may definitely cure aHUS and represents an option for patients with suboptimal response to eculizumab.
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Affiliation(s)
- Rosanna Coppo
- Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino, Turin and Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Roberto Bonaudo
- Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino, Turin and Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - R Licia Peruzzi
- Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino, Turin and Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Alessandro Amore
- Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino, Turin and Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Andrea Brunati
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin , Turin, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin , Turin, Italy
| | - Mauro Salizzoni
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin , Turin, Italy
| | - Miriam Galbusera
- Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Villa Camozzi, 3-24020, Ranica (Bergamo), Italy.,Centro Anna Maria Astori, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Eliana Gotti
- Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Erica Daina
- Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Villa Camozzi, 3-24020, Ranica (Bergamo), Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Villa Camozzi, 3-24020, Ranica (Bergamo), Italy.
| | - Giuseppe Remuzzi
- Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Villa Camozzi, 3-24020, Ranica (Bergamo), Italy.,Centro Anna Maria Astori, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Science and Technology Park Kilometro Rosso, Bergamo, Italy.,Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.,Department of Biomedical Sciences of Health, University of Milan, Milan, Italy
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Peyvandi F, Rossio R, Ferrari B, Lotta LA, Pontiggia S, Ghiringhelli Borsa N, Pizzuti M, Donadelli R, Piras R, Cugno M, Noris M. Thrombotic microangiopathy without renal involvement: two novel mutations in complement-regulator genes. J Thromb Haemost 2016; 14:340-5. [PMID: 26613809 DOI: 10.1111/jth.13210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 01/01/2023]
Abstract
UNLABELLED ESSENTIALS: The differential diagnosis among thrombotic microangiopathies (TMAs) is challenging. We studied a case of TMA with neurologic symptoms, no renal impairment and normal ADAMTS-13 levels. Two novel mutations in complement factor I and thrombomodulin genes were identified. Complement-regulator genes can be involved in TMAs with normal ADAMTS-13 regardless of renal damage. BACKGROUND Thrombotic microangiopathies (TMAs) often represent a challenge for clinicians, because clinical, laboratory, and even genetic features are not always sufficient to distinguish among different TMAs. OBJECTIVES The aim of this study was to investigate the pathogenetic mechanisms underlying an acute case of TMA with features of both thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). PATIENTS/METHODS We report the case of a 49-year-old woman who developed an acute TMA with neurologic involvement and no renal impairment. ADAMTS-13, von Willebrand factor, and complement-system biochemical characterization was performed on acute phase samples. Exome sequencing and direct Sanger sequencing of previously aHUS-associated genes were performed. The functional consequences of the thrombomodulin (THBD) mutation were investigated by in vitro expression studies. RESULTS Despite a clinical diagnosis of TTP, the patient had normal ADAMTS-13 levels and increased VWF antigen levels with ultra-large von Willebrand factor multimers. C3, C4, and complement factors H and I (CFI) were normal. Molecular analysis confirmed two novel heterozygous mutations in CFI (c.805G>A, p.G269S) and THBD (c.1103C>T, p.P368L), and in vitro expression studies showed a reduction in the generation of activated thrombin-activatable fibrinolysis inhibitor (TAFIa) caused by mutated THBD. This proinflammatory condition, associated with the p.G269S mutation in CFI, probably leads to a complement-mediated endothelial activation, with a relevant prothrombotic potential in case of transient environmental triggers. CONCLUSIONS This study identified the first case of acute TMA without renal involvement but with neurological damage carrying two novel mutations in complement-regulator genes, highlighting the possible role of the complement system as a common pathogenetic mechanism in TMAs.
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Affiliation(s)
- F Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - R Rossio
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | - B Ferrari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | - L A Lotta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | - S Pontiggia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
| | - N Ghiringhelli Borsa
- Molecular Otolaryngology and Renal Research Laboratories, University of Iowa, Iowa City, IA, USA
| | - M Pizzuti
- Unit of Hematology, San Carlo Hospital, Potenza, Italy
| | - R Donadelli
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Ranica, Bergamo, Italy
| | - R Piras
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Ranica, Bergamo, Italy
| | - M Cugno
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - M Noris
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Ranica, Bergamo, Italy
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24
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Rurali E, Banterla F, Donadelli R, Bresin E, Galbusera M, Gastoldi S, Peyvandi F, Underwood M, Remuzzi G, Noris M. ADAMTS13 Secretion and Residual Activity among Patients with Congenital Thrombotic Thrombocytopenic Purpura with and without Renal Impairment. Clin J Am Soc Nephrol 2015; 10:2002-12. [PMID: 26342041 DOI: 10.2215/cjn.01700215] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/27/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Acute renal impairment is observed in 11%-23% of patients with congenital thrombotic thrombocytopenic purpura (TTP) and deficiency of a disintegrin and metalloprotease with thrombospondin motifs 13 (ADAMTS13, a metalloprotease that cleaves von Willebrand factor [VWF] multimers), a substantial percentage of whom develop CKD during follow-up. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Here we investigated whether, in 18 patients with congenital recruited from 1996 to 2013 who fulfilled inclusion criteria, acute renal involvement occurred during bouts segregated with lower secretion and activity levels of ADAMTS13 mutants. We performed expression studies and a sensitive recombinant VWF (rVWF) A1-A2-A3 cleavage test (detection limit, 0.78% of normal ADAMTS13 activity). RESULTS A higher risk of acute renal impairment during bouts was observed in patients with childhood (<18 years) onset (odds ratio [OR], 24.6 [95% confidence interval (CI), 1.11 to 542.44]) or a relapsing (≥1 episode per year) disease (OR, 54.6 [95% CI, 2.25 to 1326.28]) than in patients with adulthood onset or long-lasting remission, respectively. Whatever the age at onset, patients with acute renal impairment had mutations different from those in patients without renal involvement. Moreover, mutations in patients with acute renal impairment compared with those in patients without renal involvement caused lower in vitro rADAMTS13 secretion (1.33% versus 12.5%; P<0.001) and residual activity (0.11% versus 3.47%; P=0.003). rADAMTS13 secretion ≤3.75% and residual activity ≤0.4% best discriminated patients with renal impairment (receiver-operating characteristic curve sensitivity, 100% and 100%; specificity, 100% and 83.3%, respectively; logistic regression OR, 325 [95% CI, 6 to 18339] and 91.7 [95% CI, 3.2 to 2623.5], respectively). All mutations found in patients with childhood onset or relapsing disease were associated with acute renal impairment during bouts, confirming the link between acute renal impairment and early onset or a relapsing course. ADAMTS13 activity levels in vivo, measured in patients' serum by rVWF A1-A2-A3 cleavage test, correlated with in vitro rADAMTS13 mutant activity (r=0.95; P<0.001). CONCLUSIONS In congenital TTP, renal impairment and relapsing disease might be predicted by measurements of in vitro rADAMTS13 secretion and activity levels and in vivo serum ADAMTS13 activity.
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Affiliation(s)
- Erica Rurali
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Federica Banterla
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Roberta Donadelli
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Elena Bresin
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Miriam Galbusera
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Sara Gastoldi
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano and Luigi Villa Foundation, Milan, Italy
| | - Mary Underwood
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano and Luigi Villa Foundation, Milan, Italy
| | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; and Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Marina Noris
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri," Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
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26
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Re-examination of 30-day survival and relapse rates in patients with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. PLoS One 2015; 10:e0127744. [PMID: 26000799 PMCID: PMC4441419 DOI: 10.1371/journal.pone.0127744] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are characterized by microangiopathic hemolytic anemia and thrombocytopenia. Interestingly, markedly different survival rates have been reported despite increases in survivability. We studied TTP-HUS 30-day mortality and relapse rates of patients who received TPE at our institution and compared them to published data. PATIENTS AND METHODS Retrospective study analyzed 30-day mortality and relapse rates attributed to TTP-HUS from 01/01/2008 to 12/31/2012 and compared them to comparable literature reporting mortality and survival. Studies describing other etiologies for TPE and different mortality time interval were excluded. RESULTS Fifty-nine patients were analyzed and all were initially treated with TPE and corticosteroids. Eleven patients were classified as not having TTP-HUS due to testing or clinical reassessment which ruled in other etiologies, and 18/59 patients had ADAMTS13 activity <10%. Of remaining patients, 36/48 (75%) were diagnosed as idiopathic and 12/48 (25%) as secondary TTP-HUS. Patients received a mean of 12 TPEs (range 1-42); 42/48 (87.5%) patients had ADAMTS13 activity measured; complete response obtained in 39/48 (81.2%) patients (platelet count >100 x 10(9)/L); partial response in 4/48 (8%); and 5/48 (10.4%) did not have increases in platelet counts (2/5 of these patients died within the study period). Forty percent of patients obtained platelet counts >150 x 10(9)/L. Overall 30-day mortality for our patient cohort was 6.7% (4/59). Comparison of our mortality rate to combined data of five published studies of 16% (92/571) showed a significant difference, p = 0.04. Our relapse rate was 18.6% (11/59) similar to previous reports. CONCLUSIONS Wide differences in mortality may be due to grouping of two distinct pathologic entities under TTP-HUS; and presence of confounding factors in the patient populations under study such as co-morbidities, promptness of TPE initiation, delay in diagnosis and therapeutic practice.
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27
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Ardalan M, Rezaeifar P. Von Willebrand factor-cleaving protease activity in thrombotic microangiopathy: first report from iran. Nephrourol Mon 2014; 6:e18900. [PMID: 25738110 PMCID: PMC4330667 DOI: 10.5812/numonthly.18900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/10/2014] [Accepted: 05/13/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a rare but devastating small vessels disorder that is characterized by intravascular platelet thrombi, thrombocytopenia, and various degrees of organ ischemia and anemia, which is due to erythrocyte fragmentation in microcirculation. OBJECTIVES The Aim of this study was to determine the von Willebrand factor-cleaving protease (ADAMTS13) activity during the acute phase of TMA. We also investigated inhibiting antibodies against ADAMTS13 in these patients. PATIENTS AND METHODS In a collaborative work with Mario-Negro institute of pharmacological research in Bergamo-Italy, we registered the clinical and laboratory data, collected the serum samples, and transferred the samples to the laboratories. Serum samples were taken before the start of plasmapheresis or at least 15 days after the final exchange. RESULTS We recruited 40 patients (14 males and 26 females) with the mean age of 46.12 ± 17.26 years. The mean activity of ADAMTS13 was 34.58% ± 21.83%. Two patients had inhibitory antibodies against ADAMTS13 with profound deficiency of ADAMTS13 activity (< 6%). Infectious diseases were the most common underlying condition, followed by systemic lupus erythematous. CONCLUSIONS Majority of patients had an underlying condition and had various ADAMTS13 activity. The presence of inhibiting antibodies and accompanied complete deficiency of ADAMTS13 activity is an indicator of severity.
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Affiliation(s)
- Mohammadreza Ardalan
- Chronic Kidney Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding author: Mohammadreza Ardalan, Chronic Kidney Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel: +98-9141168518, Fax: +98-4113366579, E-mail:
| | - Parisa Rezaeifar
- Chronic Kidney Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
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28
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Rossio R, Lotta LA, Pontiggia S, Borsa NG, Garagiola I, Ardissino G, Mikovic D, Cugno M, Peyvandi F. A novel CD46 mutation in a patient with microangiopathy clinically resembling thrombotic thrombocytopenic purpura and normal ADAMTS13 activity. Haematologica 2014; 100:e87-9. [PMID: 25381125 DOI: 10.3324/haematol.2014.111062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Raffaella Rossio
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan and Luigi Villa Foundation, Milan, Italy
| | - Luca Andrea Lotta
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan and Luigi Villa Foundation, Milan, Italy
| | - Silvia Pontiggia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan and Luigi Villa Foundation, Milan, Italy
| | - Nicolò Ghiringhelli Borsa
- Laboratory of Medical Genetics, Center for HUS Control Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan and Luigi Villa Foundation, Milan, Italy
| | - Gianluigi Ardissino
- Center for HUS Control, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Danijela Mikovic
- Blood Transfusion Institute of Serbia, Svetog Save 39, Belgrade, Serbia
| | - Massimo Cugno
- Internal Medicine, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan and Luigi Villa Foundation, Milan, Italy
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29
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Hong H, Xiao W, Stempak LM, Sandhaus LM, Maitta RW. Absolute immature platelet count dynamics in diagnosing and monitoring the clinical course of thrombotic thrombocytopenic purpura. Transfusion 2014; 55:756-65. [PMID: 25370931 DOI: 10.1111/trf.12912] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/21/2014] [Accepted: 09/08/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a life-threatening diagnosis requiring prompt initiation of therapeutic plasma exchange (TPE). Measurement of immature platelet (PLT) fraction (%-IPF) differentiates PLT consumption or destruction from hypoproduction. STUDY DESIGN AND METHOD Our study evaluated %-IPF changes over the course of TTP treated with TPE and as a measure of treatment efficacy. Eleven idiopathic TTP patients, two human immunodeficiency virus (HIV)-associated TTP patients, and five non-TTP patients with thrombocytopenia were enrolled into our study. All patients were treated with TPE and had ADAMTS13 activity measured. RESULTS All idiopathic TTP patients had a significantly increased %-IPF and decreased absolute immature PLT count (A-IPC) and PLT count at presentation. An A-IPC value of less than 5 × 10(9) /L at presentation has 84.6% sensitivity, 80% specificity, and 91.7% positive predictive value for diagnosing TTP. A concurrent steady decline in %-IPF and increased PLT counts toward normal was observed in TTP patients undergoing TPE. The A-IPC, however, showed an increase and decrease curve that was not seen in the two HIV-associated TTP patients with no response to TPE and the five non-TTP patients. More importantly, reaching an A-IPC ratio of 3 compared to baseline value during TPE can readily differentiate idiopathic TTP from the other two groups and is correlated with good clinical responses to TPE. An abrupt increase of A-IPC during TPE was also noted in a TTP patient who relapsed 3 days before PLT count decrease. A-IPC is positively correlated with ADAMTS13 activity at presentation but negatively correlated with ADAMTS13 activity during recovery. CONCLUSION A-IPC should be routinely analyzed for diagnosing and monitoring TTP patients.
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Affiliation(s)
- Hong Hong
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Wenbin Xiao
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Lisa M Stempak
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Linda M Sandhaus
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert W Maitta
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
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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.
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Uğur Bilgin A, Karaselek MA, Çamlı K. Successful management of thrombotic thrombocytopenic purpura associated with pregnancy. Transfus Apher Sci 2014; 50:433-7. [DOI: 10.1016/j.transci.2014.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/20/2014] [Accepted: 02/24/2014] [Indexed: 11/27/2022]
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How I treat: the clinical differentiation and initial treatment of adult patients with atypical hemolytic uremic syndrome. Blood 2014; 123:2478-84. [PMID: 24599547 DOI: 10.1182/blood-2013-11-516237] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Published data demonstrating the efficacy of complement inhibition therapy in patients with atypical hemolytic uremic syndrome (aHUS) are remarkable in contrast to the historically poor long-term prognosis for aHUS patients treated with plasma-based therapy. Although both aHUS and acquired thrombotic thrombocytopenic purpura (TTP) remain clinical diagnoses, an increased understanding of both conditions has improved our ability to differentiate aHUS from acquired TTP. These same data have also demonstrated the importance of a more rapid identification and diagnosis of aHUS as the recovery of end-organ injury present appears to be related to the time to initiate therapy with eculizumab. The diagnosis of acquired TTP can be confirmed by the finding of severely deficient ADAMTS13 activity (<10%) with evidence of an ADAMTS13 antibody inhibitor whereas merely deficient ADAMTS13 activity in the absence of an ADAMTS13 autoantibody is more consistent with congenital TTP. In the absence of an objective diagnostic test, clinicians must rely collectively on platelet count, serum creatinine, and ADAMTS13 activity in the context of the response to plasma exchange therapy to identify patients whose diagnosis is most consistent with aHUS, and thus be more likely to benefit from therapy with eculizumab.
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Cataland SR, Wu HM. Diagnosis and management of complement mediated thrombotic microangiopathies. Blood Rev 2014; 28:67-74. [DOI: 10.1016/j.blre.2014.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/21/2014] [Accepted: 01/24/2014] [Indexed: 02/08/2023]
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Peyvandi F, Mannucci PM, Valsecchi C, Pontiggia S, Farina C, Retzios AD. ADAMTS13 content in plasma-derived factor VIII/von Willebrand factor concentrates. Am J Hematol 2013; 88:895-8. [PMID: 23813910 DOI: 10.1002/ajh.23527] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/18/2013] [Accepted: 06/20/2013] [Indexed: 11/06/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a microangiopathy syndrome caused by a congenital or acquired deficiency of ADAMTS13, a plasma metalloprotease that cleaves von Willebrand factor (VWF) and thus prevents the formation of platelet-rich thrombi in the microcirculation. TTP can be fatal if not appropriately and timely treated with the infusion of fresh frozen plasma (FFP) or exchange plasmapheresis, that reverse the process of microangiopathy by removing anti-ADAMTS13 autoantibodies and replacing functional ADAMTS13. The treatment of TTP with FFP is not free from risks and must be administered in hospitals or clinics, owing to the substantial amount of plasma volume infused or exchanged and the frequent need of catheter application. Moreover, most FFPs are not subjected to treatments to remove or inactivate blood-borne infectious agents. A number of recent reports indicate that certain plasma-derived VWF-factor VIII (FVIII) concentrates are clinically effective in the treatment of congenital TTP. In this study, we measured ADAMTS13 levels in various plasma-derived VWF-FVIII concentrates, showing that Koate(®) -DVI (Grifols), contained relatively high amounts of ADAMTS13 and that Alphanate(®) (Grifols) was the closest other product in terms of protease content. Koate(®) -DVI contains, on average (five lots tested), 0.091 ± 0.007 Units of ADAMTS13 activity per IU of FVIII. On the basis of this analysis and other reports of VWF-FVIII concentrate utilization in congenital TTP, potential dosing, and future clinical developments are discussed.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; University of Milan, Luigi Villa Foundation; Milan Italy
| | - Pier M. Mannucci
- Scientific Direction; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Milan Italy
| | - Carla Valsecchi
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; University of Milan, Luigi Villa Foundation; Milan Italy
| | - Silvia Pontiggia
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; University of Milan, Luigi Villa Foundation; Milan Italy
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Shah N, Rutherford C, Matevosyan K, Shen YM, Sarode R. Role of ADAMTS13 in the management of thrombotic microangiopathies including thrombotic thrombocytopenic purpura (TTP). Br J Haematol 2013; 163:514-9. [DOI: 10.1111/bjh.12569] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/14/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Neil Shah
- Department of Pathology; Division of Transfusion Medicine and Hemostasis; Dallas TX USA
| | - Cynthia Rutherford
- Department of Internal Medicine; Division of Hematology/Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Karen Matevosyan
- Department of Pathology; Division of Transfusion Medicine and Hemostasis; Dallas TX USA
| | - Yu-Min Shen
- Department of Internal Medicine; Division of Hematology/Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Ravi Sarode
- Department of Pathology; Division of Transfusion Medicine and Hemostasis; Dallas TX USA
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Cataland SR, Wu HM. Atypical hemolytic uremic syndrome and thrombotic thrombocytopenic purpura: clinically differentiating the thrombotic microangiopathies. Eur J Intern Med 2013; 24:486-91. [PMID: 23739653 DOI: 10.1016/j.ejim.2013.05.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The increased understanding of the pathophysiology of both atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP) in recent years has led to significant therapeutic advances for both conditions. These advances have placed an increased emphasis on a more rapid differentiation of both disorders which remain clinical diagnoses. In particular, recent data demonstrating the effectiveness of complement inhibition in patients with aHUS have increased the need for a more rapid and accurate differentiation of aHUS and TTP. Previously utilized criteria have used the presence or absence of neurologic or renal injury and the pretreatment ADAMTS13 activity to differentiate aHUS from TTP. The use of presenting clinical symptoms and findings alone to differentiate these conditions is problematic given their overlapping clinical presentations. Similarly, the use of the pretreatment ADAMTS13 activity alone to differentiate aHUS from TTP is also problematic, and could lead to the inappropriate witholding of plasma exchange (PEX) therapy. However, when used collectively, the pretreatment clinical findings (symptoms and laboratory data) and ADAMTS13 activity in the context of the patient's response to PEX therapy can allow for a more effective differentiation of these two disorders in a timely fashion that will allow for the prompt initiation of the most appropriate therapy.
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Affiliation(s)
- Spero R Cataland
- Department of Medicine, Ohio State University, Columbus, OH, USA.
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38
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Feng S, Liang X, Cruz MA, Vu H, Zhou Z, Pemmaraju N, Dong JF, Kroll MH, Afshar-Kharghan V. The interaction between factor H and Von Willebrand factor. PLoS One 2013; 8:e73715. [PMID: 23991205 PMCID: PMC3753316 DOI: 10.1371/journal.pone.0073715] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 07/30/2013] [Indexed: 01/22/2023] Open
Abstract
Complement factor H (fH) is a plasma protein that regulates activation of the alternative pathway, and mutations in fH are associated with a rare form of thrombotic microangiopathy (TMA), known as atypical hemolytic uremic syndrome (aHUS). A more common TMA is thrombotic thrombocytopenic purpura, which is caused by the lack of normal ADAMTS-13-mediated cleavage of von Willebrand factor (VWF). We investigated whether fH interacts with VWF and affects cleavage of VWF. We found that factor H binds to VWF in plasma, to plasma-purified VWF, and to recombinant A1 and A2 domains of VWF as detected by co-immunoprecipitation (co-IP) and surface plasmon resonance assays. Factor H enhanced ADAMTS-13-mediated cleavage of recombinant VWF-A2 as determined by quantifying the cleavage products using Western-blotting, enhanced cleavage of a commercially available fragment of VWF-A2 (FRETS-VWF73) as determined by fluorometric assay, and enhanced cleavage of ultralarge (UL) VWF under flow conditions as determined by cleavage of VWF-platelet strings attached to histamine stimulated endothelial cells. Using recombinant full-length and truncated fH molecules, we found that the presence of the C-terminal half of fH molecule is important for binding to VWF-A2 and for enhancing cleavage of the A2 domain by ADAMTS-13. We conclude that factor H binds to VWF and may modulate cleavage of VWF by ADAMTS-13.
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Affiliation(s)
- Shuju Feng
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Xiaowen Liang
- Institute of Biosciences and Technology, Texas A&M University Health Science Center, Houston, Texas, United States of America
| | - Miguel A. Cruz
- Cardiovascular Research Section, Baylor College of Medicine, Houston, Texas, United States of America
| | - Hangoc Vu
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Zhou Zhou
- Puget Sound Blood Center, Seattle, Washington, United States of America
| | - Naresh Pemmaraju
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Jing-Fei Dong
- Puget Sound Blood Center, Seattle, Washington, United States of America
| | - Michael H. Kroll
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Vahid Afshar-Kharghan
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
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39
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Abstract
Complement dysregulation leads to atypical hemolytic uremic syndrome (aHUS), while ADAMTS13 deficiency causes thrombotic thrombocytopenic purpura. We investigated whether genetic variations in the ADAMTS13 gene partially explain the reduced activity known to occur in some patients with aHUS. We measured complement activity and ADAMTS13 function, and completed mutation screening of multiple complement genes and ADAMTS13 in a large cohort of aHUS patients. In over 50% of patients we identified complement gene mutations. Surprisingly, 80% of patients also carried at least 1 nonsynonymous change in ADAMTS13, and in 38% of patients, multiple ADAMTS13 variations were found. Six of the 9 amino acid substitutions in ADAMTS13 were common single nucleotide polymorphisms; however, 3 variants-A747V, V832M, and R1096H- were rare, with minor allele frequencies of 0.0094%, 0.5%, and 0.32%, respectively. Reduced complement and ADAMTS13 activity (<60% of normal activity) were found in over 60% and 50% of patients, respectively. We concluded that partial ADAMTS13 deficiency is a common finding in aHUS patients and that genetic screening and functional tests of ADAMTS13 should be considered in these patients.
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40
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Manenti L, Gnappi E, Vaglio A, Allegri L, Noris M, Bresin E, Pilato FP, Valoti E, Pasquali S, Buzio C. Atypical haemolytic uraemic syndrome with underlying glomerulopathies. A case series and a review of the literature. Nephrol Dial Transplant 2013; 28:2246-59. [DOI: 10.1093/ndt/gft220] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Fyfe-Brown A, Clarke G, Nerenberg K, Chandra S, Jain V. Management of pregnancy-associated thrombotic thrombocytopenia purpura. AJP Rep 2013; 3:45-50. [PMID: 23943710 PMCID: PMC3699152 DOI: 10.1055/s-0032-1331380] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 08/14/2012] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenia purpura (TTP) is an infrequent but serious disease. Pregnancy is a known risk factor for presentation or relapse of TTP. Difficulties in differentiating TTP from preeclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome, and current treatment recommendations are discussed in this case report. A woman with previously treated and stable TTP had a relapse at 36 weeks' gestation. Careful surveillance led to an early diagnosis. Severe disease in the peripartum period was treated successfully with cryosupernatant plasma-based plasmapheresis and platelet transfusion, with good maternal and neonatal outcomes. Cryosupernatant plasma is a viable alternative to fresh frozen plasma for plasmapheresis for TTP and may offer some therapeutic and logistical advantages. Platelet transfusion can be undertaken safely if needed to prevent or treat significant hemorrhage.
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Affiliation(s)
- Ashley Fyfe-Brown
- Division of Maternal-Fetal Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada
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42
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Shah N, Sarode R. Thrombotic thrombocytopenic purpura-what is new? J Clin Apher 2013; 28:30-5. [DOI: 10.1002/jca.21264] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 01/15/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Neil Shah
- Division of Transfusion Medicine and Hemostasis; Department of Pathology; UT Southwestern Medical Center; Dallas; Texas
| | - Ravi Sarode
- Division of Transfusion Medicine and Hemostasis; Department of Pathology; UT Southwestern Medical Center; Dallas; Texas
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Jamale TE, Hase NK, Kulkarni M, Iqbal AM, Rurali E, Kulkarni MG, Shetty P, Pradeep KJ. Hereditary ADAMTS 13 deficiency presenting as recurrent acute kidney injury. Indian J Nephrol 2012; 22:298-300. [PMID: 23162276 PMCID: PMC3495354 DOI: 10.4103/0971-4065.101257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report here a case of 26-year-old male who presented with history of recurrent acute renal failure associated with microangiopathic hemolytic anemia and thrombocytopenia. ADAMTS 13 deficiency due to mutation in the gene encoding for ADAMTS 13 was identified as the cause. After eight episodes of acute kidney injury (AKI), patient started developing hypertension, proteinuria, and renal insufficiency. Treatment with regular monthly plasma infusions prevented further episodes of AKI and stabilized the renal function. Hypertension and proteinuria are controlled with angiotensin II receptor blockers.
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Affiliation(s)
- T E Jamale
- Department of Nephrology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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Abstract
Haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopaenic purpura (TTP) are diseases characterized by microvascular thrombosis, with consequent thrombocytopaenia, haemolytic anaemia and dysfunction of affected organs. Advances in our understanding of the molecular pathology led to the recognition of three different diseases: typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS); atypical HUS (aHUS), associated with genetic or acquired disorders of regulatory components of the complement system; and TTP that results from a deficiency of ADAMTS13, a plasma metalloprotease that cleaves von Willebrand factor. In this Review, we discuss data indicating that complement hyperactivation is a common pathogenetic effector that leads to endothelial damage and microvascular thrombosis in all three diseases. In STEC-HUS, the toxin triggers endothelial complement deposition through the upregulation of P-selectin and possibly interferes with the activity of complement regulatory molecules. In aHUS, mutations in the genes coding for complement components predispose to hyperactivation of the alternative pathway of complement. In TTP, severe ADAMTS13 deficiency leads to generation of massive platelet thrombi, which might contribute to complement activation. More importantly, evidence is emerging that pharmacological targeting of complement with the anti-C5 monoclonal antibody eculizumab can effectively treat not only aHUS for which it is indicated, but also STEC-HUS and TTP in some circumstances.
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45
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Evaluation of efficacy and safety of the anti-VWF Nanobody ALX-0681 in a preclinical baboon model of acquired thrombotic thrombocytopenic purpura. Blood 2012; 120:3603-10. [PMID: 22948047 DOI: 10.1182/blood-2012-04-420943] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
ALX-0681 is a therapeutic Nanobody targeting the A1-domain of VWF. It inhibits the interaction between ultra-large VWF and platelet GpIb-IX-V, which plays a crucial role in the pathogenesis of thrombotic thrombocytopenic purpura (TTP). In the present study, we report the efficacy and safety profile of ALX-0681 in a baboon model of acquired TTP. In this model, acute episodes of TTP are induced by administration of an ADAMTS13-inhibiting mAb. ALX-0681 completely prevented the rapid onset of severe thrombocytopenia and schistocytic hemolytic anemia. After induction of TTP, platelet counts also rapidly recovered on administration of ALX-0681. This effect was corroborated by the full neutralization of VWF activity. The schistocytic hemolytic anemia was also halted and partially reversed by ALX-0681 treatment. Brain CT scans and post mortem analysis did not reveal any sign of bleeding, suggesting that complete neutralization of VWF by ALX-0681 under conditions of thrombocytopenia was not linked with an excessive bleeding risk. The results obtained in this study demonstrate that ALX-0681 can successfully treat and prevent the most important hallmarks of acquired TTP without evidence of a severe bleeding risk. Therefore, ALX-0681 offers an attractive new therapeutic option for acquired TTP in the clinical setting.
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46
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Kessler CS, Khan BA, Lai-Miller K. Thrombotic Thrombocytopenic Purpura: A Hematological Emergency. J Emerg Med 2012; 43:538-44. [DOI: 10.1016/j.jemermed.2012.01.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 09/23/2011] [Accepted: 01/16/2012] [Indexed: 12/11/2022]
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47
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Obeidat M, Obeidat M, Ballermann BJ. Glomerular endothelium: A porous sieve and formidable barrier. Exp Cell Res 2012; 318:964-72. [DOI: 10.1016/j.yexcr.2012.02.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 02/24/2012] [Indexed: 12/20/2022]
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48
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Cataland SR, Yang S, Wu HM. The use of ADAMTS13 activity, platelet count, and serum creatinine to differentiate acquired thrombotic thrombocytopenic purpura from other thrombotic microangiopathies. Br J Haematol 2012; 157:501-3. [PMID: 22296585 DOI: 10.1111/j.1365-2141.2012.09032.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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49
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Gresele P, Momi S. Inhibitors of the interaction between von Willebrand factor and platelet GPIb/IX/V. Handb Exp Pharmacol 2012:287-309. [PMID: 22918736 DOI: 10.1007/978-3-642-29423-5_12] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The formation of platelet-rich thrombi, a critical step in the pathogenesis of atherothrombotic events, is a multistep process involving several components, among which von Willebrand Factor (VWF) plays a central role. Ruptured atherosclerotic plaques expose subendothelial matrix proteins which bind VWF that represents a bridge between the injured blood vessel and activated platelets, playing a crucial role in platelet adhesion and aggregation, especially in conditions of high-shear rate. Due to these peculiarities, the binding of VWF to GPIbα is an attractive drug target. Here we summarize the present knowledge on the different classes of drugs targeting the VWF-GPIb interaction and we give an account of their level of clinical development. In particular, the following compounds are discussed: AJW200, an IgG4 humanized monoclonal antibody against VWF-A1; 82D6A3, a monoclonal antibody against VWF-A3; ALX-0081 and ALX-0681, bivalent humanized nanobodies targeting the VWF-A1 domain; ARC1779 and its advanced formulation ARC15105, second-generation aptamers that bind the VWF-A1 domain; h6B4-Fab, a murine monoclonal antibody, and GPG-290, a recombinant chimeric protein, both directed against GPIbα.
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Affiliation(s)
- Paolo Gresele
- Division of Internal and Cardiovascular Medicine, Department of Internal Medicine, University of Perugia, Via E. dal Pozzo, 06126, Perugia, Italy.
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50
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Therapeutic Apheresis. Transfus Med 2011. [DOI: 10.1002/9781444398748.ch19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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