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Vorster L, Kirk SE, Muscal E, Despotovic JM, Cohen CT, Sartain SE. COVID-19 vaccine (mRNA BNT162b2) and COVID-19 infection-induced thrombotic thrombocytopenic purpura in adolescents. Pediatr Blood Cancer 2022; 69:e29681. [PMID: 35373880 PMCID: PMC9088367 DOI: 10.1002/pbc.29681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/08/2022] [Accepted: 03/04/2022] [Indexed: 12/13/2022]
Abstract
The mRNA COVID-19 vaccine and COVID-19 infection caused by the SARS-CoV-2 virus may be immunologic triggers for the development of thrombotic thrombocytopenic purpura (TTP). There is not yet literature that discusses TTP induced by COVID-19 vaccination or infection in pediatric or adolescent patients. We describe three adolescents presenting with TTP (both de novo and relapsed disease) following administration of the Pfizer COVID-19 vaccine or after COVID-19 infection. Our observations demonstrate that the Pfizer-BioNTech mRNA vaccine and COVID-19 infection can act as triggers for the development/relapse of both congenital and acquired TTP.
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Affiliation(s)
- Luna Vorster
- Department of Pediatrics, Baylor College of MedicineTexas Children's HospitalHoustonTexasUSA
| | - Susan E. Kirk
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Eyal Muscal
- Department of Pediatrics, Section of Rheumatology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
- Department of Pediatrics, Section of Neurology/Developmental Neuroscience, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Jenny M. Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Clay T. Cohen
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
| | - Sarah E. Sartain
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of MedicineTexas Children's HospitalHoustonTXUSA
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Unusual Presentation of Thrombotic Thrombocytopenic Purpura in a Newly Diagnosed Pediatric Patient With Systemic Lupus Erythematosus in the Setting of MIS-C. J Pediatr Hematol Oncol 2022; 44:e812-e815. [PMID: 35319513 DOI: 10.1097/mph.0000000000002370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/26/2021] [Indexed: 11/25/2022]
Abstract
The understanding of coronavirus disease 2019 (COVID-19) immune dysregulation is evolving. Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with alternations in both innate and adaptive immunity, probably caused by a complex interplay of genetics and environmental exposure with various triggers. A rare hematological complication of SLE as well as recently reported in an adult with COVID-19 is thrombotic thrombocytopenic purpura. We report a pediatric case with features suggestive of the multisystem inflammatory syndrome in children with coronary artery ectasia, thrombotic thrombocytopenic purpura, and new-onset SLE.
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Chen J, Jin JX, Xu XF, Zhang XX, Ye XN, Huang J. Successful treatment of plasma exchange-refractory thrombotic thrombocytopenic purpura with rituximab: A case report. World J Clin Cases 2020; 8:2617-2622. [PMID: 32607340 PMCID: PMC7322435 DOI: 10.12998/wjcc.v8.i12.2617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/05/2020] [Accepted: 05/21/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP), a subtype of thrombotic microangiopathy, has a very high fatality rate if there is no timely diagnosis or treatment. Here, we report a case of TTP refractory to high displacement plasma exchange, which was later successfully treated with rituximab.
CASE SUMMARY Here we report a case of refractory TTP in a 63-year-old woman with a low platelet count and decreased ADAMTS13 activity. Her platelet count was 9 × 109/L, hemoglobin level was 81 g/L, and ADAMTS13 was < 5%. She was diagnosed with thrombotic thrombocytopenic purpura. After 8 d of daily plasma exchange (PEX), her platelet levels were still low. However, after 6 d of treatment with rituximab, her platelet count increased and ADAMTS13 activity returned to normal.
CONCLUSION PEX can cure most patients, but the relapse rate can be up to 50%-60%. This case suggested that rituximab can improve the curative efficiency of PEX and prevent disease relapse in TTP.
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Affiliation(s)
- Jian Chen
- Department of Ultrasonography, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, Zhejiang Province, China
| | - Jing-Xia Jin
- Department of Hematology, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, Zhejiang Province, China
| | - Xiao-Fei Xu
- Department of Hematology, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, Zhejiang Province, China
| | - Xuan-Xuan Zhang
- Department of Ultrasonography, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, Zhejiang Province, China
| | - Xing-Nong Ye
- Department of Hematology, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, Zhejiang Province, China
| | - Jian Huang
- Department of Hematology, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu 322000, Zhejiang Province, China
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4
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Patient Experience with Congenital (Hereditary) Thrombotic Thrombocytopenic Purpura: A Conceptual Framework of Symptoms and Impacts. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:503-512. [PMID: 31359341 PMCID: PMC6697707 DOI: 10.1007/s40271-019-00365-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background and Objective Thrombotic thrombocytopenic purpura is a rare, life-threatening disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia, with variable clinical manifestations (e.g., central nervous system, renal, gastrointestinal, and cardiac effects). This study’s objective was to gain an in-depth understanding of patients’ experiences with the congenital form of thrombotic thrombocytopenic purpura, including the most salient symptoms and impacts associated with congenital thrombotic thrombocytopenic purpura and its treatment. Methods An initial conceptual model of thrombotic thrombocytopenic purpura symptoms and impacts was derived from a targeted literature review, refined by interviews with expert hematologists, and further refined by concept elicitation telephone interviews with adults with congenital thrombotic thrombocytopenic purpura in the USA. Patients reported the duration, frequency, and severity experienced for each concept, and rated level of disturbance on a minimum to maximum scale of 0–10. Results Interviews were conducted with 11 patients (mean age, 38.2 years; range 21–52 years) in three waves (n = 4, n = 4, n = 3). The most salient symptoms (reported most frequently and rated by patients as most disturbing) were fatigue, headache, bruising, joint pain, muscular pain, forgetfulness, and difficulty communicating. The most salient impacts included diminished ability to work/study, financial distress, feeling depressed, feeling anxious, and mood swings. Patients’ comments reflected the pervasive nature of congenital thrombotic thrombocytopenic purpura symptoms and impacts, and unmet treatment needs. Conclusions The final conceptual model, which includes salient symptoms and impacts of congenital thrombotic thrombocytopenic purpura and reflects the disease burden, was derived by integrating inputs from the literature review, expert opinion, and patient interviews, and will be used to develop a congenital thrombotic thrombocytopenic purpura–specific, patient-reported outcome instrument. Electronic supplementary material The online version of this article (10.1007/s40271-019-00365-y) contains supplementary material, which is available to authorized users.
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Chen X, Cheng X, Zhang S, Wu D. ADAMTS13: An Emerging Target in Stroke Therapy. Front Neurol 2019; 10:772. [PMID: 31379722 PMCID: PMC6650536 DOI: 10.3389/fneur.2019.00772] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/02/2019] [Indexed: 12/11/2022] Open
Abstract
Thrombosis is the predominant underlying mechanism of acute ischemic stroke (AIS). Though thrombolysis with tPA has been proven to be effective in treating AIS within the time window, the majority of AIS patients fail to receive tPA due to various reasons. Current medical therapies for AIS have limited efficacy and pose a risk of intracerebral hemorrhage. ADAMTS13 (a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13) is a metalloprotease that effectively breaks down the von Willebrand Factor (VWF), a key factor in thrombus formation. Previous studies have proven that dysfunction of ADAMTS13 is associated with many diseases. Recently, ADAMTS13 has been reported to be closely related to stroke. In this review, we briefly described the structure of ADAMTS13 and its role in thrombosis, inflammation, as well as angiogenesis. We then focused on the relationship between ADAMTS13 and AIS, ranging from ischemic stroke occurrence, to AIS treatment and prognosis. Based on research findings from in vitro, animal, and clinical studies, we propose that ADAMTS13 is a potential biomarker to guide appropriate treatment for ischemic stroke and a promising therapeutic agent for tPA resistant thrombi.
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Affiliation(s)
- Xin Chen
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shufan Zhang
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Danhong Wu
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
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6
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Cassis P, Cerullo D, Zanchi C, Corna D, Lionetti V, Giordano F, Novelli R, Conti S, Casieri V, Matteucci M, Locatelli M, Taraboletti G, Villa S, Gastoldi S, Remuzzi G, Benigni A, Zoja C. ADAMTS13 Deficiency Shortens the Life Span of Mice With Experimental Diabetes. Diabetes 2018; 67:2069-2083. [PMID: 29976618 DOI: 10.2337/db17-1508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/18/2018] [Indexed: 11/13/2022]
Abstract
In patients with diabetes, impaired activity of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13), the plasma metalloprotease that cleaves highly thrombogenic von Willebrand factor multimers, is a major risk factor of cardiovascular events. Here, using Adamts13-/- mice made diabetic by streptozotocin, we investigated the impact of the lack of ADAMTS13 on the development of diabetes-associated end-organ complications. Adamts13-/- mice experienced a shorter life span than their diabetic wild-type littermates. It was surprising that animal death was not related to the occurrence of detectable thrombotic events. The lack of ADAMTS13 drastically increased the propensity for ventricular arrhythmias during dobutamine-induced stress in diabetic mice. Cardiomyocytes of diabetic Adamts13-/- mice exhibited an aberrant distribution of the ventricular gap junction connexin 43 and increased phosphorylation of Ca2+/calmodulin-dependent kinase II (CaMKII), and with the consequent CaMKII-induced disturbance in Ca2+ handling, which underlie propensity for arrhythmia. In vitro, thrombospondin 1 (TSP1) promoted, in a paracrine manner, CaMKII phosphorylation in murine HL-1 cardiomyocytes, and ADAMTS13 acted to inhibit TSP1-induced CaMKII activation. In conclusion, the deficiency of ADAMTS13 may underlie the onset of lethal arrhythmias in diabetes through increased CaMKII phosphorylation in cardiomyocytes. Our findings disclose a novel function for ADAMTS13 beyond its antithrombotic activity.
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Affiliation(s)
- Paola Cassis
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Domenico Cerullo
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Cristina Zanchi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Daniela Corna
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Vincenzo Lionetti
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- UOS Anesthesia and Intensive Care, Fondazione Toscana "G. Monasterio," Pisa, Italy
| | - Fabrizio Giordano
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Rubina Novelli
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Sara Conti
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | | | - Marco Matteucci
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Monica Locatelli
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Giulia Taraboletti
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Sebastian Villa
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Sara Gastoldi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Giuseppe Remuzzi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST), Papa Giovanni XXIII, Bergamo, Italy
- "L. Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Ariela Benigni
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Carlamaria Zoja
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
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A STARD-compliant prediction model for diagnosing thrombotic microangiopathies. J Nephrol 2018; 31:405-410. [PMID: 29353400 DOI: 10.1007/s40620-018-0468-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
Aim of the study was the definition of a predictive model for the initial diagnosis of thrombotic microangiopathies (TMA). We retrospectively collected data on all adult patients admitted to the Gemelli Hospital from 2010 to 2014. ICD-9 codes from primary diagnoses were used for TMA diagnosis. Demographic and laboratory characteristics on admission of patients with TMA were then compared with a random sample of 500 patients with other diagnoses. The prediction model was externally validated in a cohort from another hospital. Overall, 23 of 187,183 patients admitted during the study period received a primary diagnosis of TMA. LDH (OR 1.26, 95% CI 1.05, 1.63) and platelets (OR 0.96, 95% CI 0.94, 0.98) were the only independent predictors of TMA. The AUROC of the final model including only LDH and platelets was 0.96 (95% CI 0.91, 1.00). The Hosmer-Lemeshow (HL) test (p = 0.54) suggested good calibration. Our model also confirmed good discriminatory power (AUROC 0.72 95% CI 0.60, 0.84) and calibration (HL test p = 0.52) in the validation sample. We present a simple prediction model for use in diagnosing TMA in hospitalized patients. The model performs well and can help clinicians to identify patients at high risk of TMA.
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Dhaliwal G, Mojtahed A, Fogerty AE, Kadauke S, Mack JP. Case 36-2017. A 30-Year-Old Man with Fatigue, Rash, Anemia, and Thrombocytopenia. N Engl J Med 2017; 377:2074-2083. [PMID: 29166229 DOI: 10.1056/nejmcpc1710565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Gurpreet Dhaliwal
- From the Medical Service, San Francisco Veterans Affairs Medical Center, and the Department of Medicine, University of California San Francisco School of Medicine - both in San Francisco (G.D.); and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Massachusetts General Hospital, and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Harvard Medical School - both in Boston
| | - Amirkasra Mojtahed
- From the Medical Service, San Francisco Veterans Affairs Medical Center, and the Department of Medicine, University of California San Francisco School of Medicine - both in San Francisco (G.D.); and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Massachusetts General Hospital, and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Harvard Medical School - both in Boston
| | - Annemarie E Fogerty
- From the Medical Service, San Francisco Veterans Affairs Medical Center, and the Department of Medicine, University of California San Francisco School of Medicine - both in San Francisco (G.D.); and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Massachusetts General Hospital, and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Harvard Medical School - both in Boston
| | - Stephan Kadauke
- From the Medical Service, San Francisco Veterans Affairs Medical Center, and the Department of Medicine, University of California San Francisco School of Medicine - both in San Francisco (G.D.); and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Massachusetts General Hospital, and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Harvard Medical School - both in Boston
| | - Johnathan P Mack
- From the Medical Service, San Francisco Veterans Affairs Medical Center, and the Department of Medicine, University of California San Francisco School of Medicine - both in San Francisco (G.D.); and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Massachusetts General Hospital, and the Departments of Radiology (A.M.), Medicine (A.E.F.), and Pathology (S.K., J.P.M.), Harvard Medical School - both in Boston
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Abstract
Thrombotic thrombocytopenic purpura (TTP; also known as Moschcowitz disease) is characterized by the concomitant occurrence of often severe thrombocytopenia, microangiopathic haemolytic anaemia and a variable degree of ischaemic organ damage, particularly affecting the brain, heart and kidneys. Acute TTP was almost universally fatal until the introduction of plasma therapy, which improved survival from <10% to 80-90%. However, patients who survive an acute episode are at high risk of relapse and of long-term morbidity. A timely diagnosis is vital but challenging, as TTP shares symptoms and clinical presentation with numerous conditions, including, for example, haemolytic uraemic syndrome and other thrombotic microangiopathies. The underlying pathophysiology is a severe deficiency of the activity of a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), the protease that cleaves von Willebrand factor (vWF) multimeric strings. Ultra-large vWF strings remain uncleaved after endothelial cell secretion and anchorage, bind to platelets and form microthrombi, leading to the clinical manifestations of TTP. Congenital TTP (Upshaw-Schulman syndrome) is the result of homozygous or compound heterozygous mutations in ADAMTS13, whereas acquired TTP is an autoimmune disorder caused by circulating anti-ADAMTS13 autoantibodies, which inhibit the enzyme or increase its clearance. Consequently, immunosuppressive drugs, such as corticosteroids and often rituximab, supplement plasma exchange therapy in patients with acquired TTP.
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von Krogh AS, Quist-Paulsen P, Waage A, Langseth ØO, Thorstensen K, Brudevold R, Tjønnfjord GE, Largiadèr CR, Lämmle B, Kremer Hovinga JA. High prevalence of hereditary thrombotic thrombocytopenic purpura in central Norway: from clinical observation to evidence. J Thromb Haemost 2016; 14:73-82. [PMID: 26566785 DOI: 10.1111/jth.13186] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
UNLABELLED Essentials The population prevalence of hereditary thrombotic thrombocytopenic purpura (TTP) is unknown. We studied the prevalence of hereditary TTP and population frequencies of two ADAMTS-13 mutations. A high frequency of hereditary TTP related to ADAMTS-13 mutation c.4143_4144dupA was found. Vicinity of ABO blood group and ADAMTS-13 loci may facilitate screening of ADAMTS-13 mutations. SUMMARY Background Hereditary thrombotic thrombocytopenic purpura (TTP) caused by ADAMTS-13 mutations is a rare, but serious condition. The prevalence is unknown, but it seems to be high in Norway. Objectives To identify all patients with hereditary TTP in central Norway and to investigate the prevalence of hereditary TTP and the population frequencies of two common ADAMTS-13 mutations. Patients/Methods Patients were identified in a cross-sectional study within the Central Norway Health Region by means of three different search strategies. Frequencies of ADAMTS-13 mutations, c.4143_4144dupA and c.3178 C>T (p.R1060W), were investigated in a population-based cohort (500 alleles) and in healthy blood donors (2104 alleles) by taking advantage of the close neighborhood of the ADAMTS-13 and ABO blood group gene loci. The observed prevalence of hereditary TTP was compared with the rates of ADAMTS-13 mutation carriers in different geographical regions. Results We identified 11 families with hereditary TTP in central Norway during the 10-year study period. The prevalence of hereditary TTP in central Norway was 16.7 × 10(-6) persons. The most prevalent mutation was c.4143_4144dupA, accounting for two-thirds of disease causing alleles among patients and having an allelic frequency of 0.33% in the central, 0.10% in the western, and 0.04% in the southeastern Norwegian population. The allelic frequency of c.3178 C>T (p.R1060W) in the population was even higher (0.3-1%), but this mutation was infrequent among patients, with no homozygous cases. Conclusions We found a high prevalence of hereditary TTP in central Norway and an apparently different penetrance of ADAMTS-13 mutations.
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Affiliation(s)
- A S von Krogh
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Haematology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - P Quist-Paulsen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Haematology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - A Waage
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Haematology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Ø O Langseth
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - K Thorstensen
- Department of Clinical Chemistry, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - R Brudevold
- Department of Haematology, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - C R Largiadèr
- Department of Clinical Chemistry, Bern University Hospital and University of Bern, Inselspital, Bern, Switzerland
| | - B Lämmle
- Department of Haematology and Central Haematology Laboratory, Bern University Hospital and University of Bern, Inselspital, Bern, Switzerland
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Mainz, Germany
| | - J A Kremer Hovinga
- Department of Haematology and Central Haematology Laboratory, Bern University Hospital and University of Bern, Inselspital, Bern, Switzerland
- Department of Clinical Research, University of Bern, Bern, Switzerland
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11
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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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12
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Franchini M. Atypical hemolytic uremic syndrome: from diagnosis to treatment. ACTA ACUST UNITED AC 2015; 53:1679-88. [DOI: 10.1515/cclm-2015-0024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/25/2015] [Indexed: 11/15/2022]
Abstract
AbstractThrombotic microangiopathy (TMA) is a relatively rare condition but a medical urgency requiring immediate intervention to avoid irreversible organ damage or death. Symptoms on presentation include microangiopathic haemolytic anaemia, thrombocytopenia and organ damage. The most frequent direct causes of TMA are thrombotic thrombocytopenic purpura (TTP) and haemolytic uremic syndrome (HUS). The most common form of HUS is related to Shiga toxin producing
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13
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Rurali E, Noris M, Chianca A, Donadelli R, Banterla F, Galbusera M, Gherardi G, Gastoldi S, Parvanova A, Iliev I, Bossi A, Haefliger C, Trevisan R, Remuzzi G, Ruggenenti P. ADAMTS13 predicts renal and cardiovascular events in type 2 diabetic patients and response to therapy. Diabetes 2013; 62:3599-609. [PMID: 23733198 PMCID: PMC3781447 DOI: 10.2337/db13-0530] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In patients with diabetes, impaired ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) proteolysis of highly thrombogenic von Willebrand factor (VWF) multimers may accelerate renal and cardiovascular complications. Restoring physiological VWF handling might contribute to ACE inhibitors' (ACEi) reno- and cardioprotective effects. To assess how Pro618Ala ADAMTS13 variants and related proteolytic activity interact with ACEi therapy in predicting renal and cardiovascular complications, we genotyped 1,163 normoalbuminuric type 2 diabetic patients from BErgamo NEphrologic DIabetes Complications Trial (BENEDICT). Interaction between Pro618Ala and ACEi was significant in predicting both renal and combined renal and cardiovascular events. The risk for renal or combined events versus reference Ala carriers on ACEi progressively increased from Pro/Pro homozygotes on ACEi (hazard ratio 2.80 [95% CI 0.849-9.216] and 1.58 [0.737-3.379], respectively) to Pro/Pro homozygotes on non-ACEi (4.77 [1.484-15.357] and 1.99 [0.944-4.187]) to Ala carriers on non-ACEi (8.50 [2.416-29.962] and 4.00 [1.739-9.207]). In a substudy, serum ADAMTS13 activity was significantly lower in Ala carriers than in Pro/Pro homozygotes and in case subjects with renal, cardiovascular, or combined events than in diabetic control subjects without events. ADAMTS13 activity significantly and negatively correlated with all outcomes. In patients with diabetes, ADAMTS13 618Ala variant associated with less proteolytic activity, higher risk of chronic complications, and better response to ACEi therapy. Screening for Pro618Ala polymorphism may help identify patients with diabetes at highest risk who may benefit the most from early reno- and cardioprotective therapy.
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Affiliation(s)
- Erica Rurali
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Marina Noris
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
- Corresponding author: Marina Noris,
| | | | - Roberta Donadelli
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Federica Banterla
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Miriam Galbusera
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Giulia Gherardi
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Sara Gastoldi
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Aneliya Parvanova
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Ilian Iliev
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Antonio Bossi
- Unit of Diabetology, Treviglio Hospital, Bergamo, Italy
| | | | - Roberto Trevisan
- Unit of Diabetology, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Remuzzi
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
- Unit of Nephrology, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Piero Ruggenenti
- IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
- Unit of Nephrology, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
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14
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Radhi M, Carpenter SL. Thrombotic microangiopathies. ISRN HEMATOLOGY 2012; 2012:310596. [PMID: 22888446 PMCID: PMC3410315 DOI: 10.5402/2012/310596] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/10/2012] [Indexed: 01/13/2023]
Abstract
Thrombotic microangiopathy results from thrombotic occlusion of the microvasculature leading to fragmentation of red blood cells, profound thrombocytopenia, and a microangiopathic hemolytic anemia with elevation of lactate dehydrogenase and negative direct Coomb's test. This constellation of clinical and laboratory findings is not due to one disease entity; rather, it represents a variety of underlying diagnoses. Among the major disease entities are TTP/HUS, which can be congenital or acquired, bacterial infections, medications, vascular or endothelial pathology like Kasabach-Merritt phenomenon, and stem cell transplantation. In this paper, we offer a review of some of the major causes of thrombotic microangiopathy.
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Affiliation(s)
- Mohamed Radhi
- Pediatric Hematology/Oncology/Stem Cell Transplant, Children's Mercy Hospital, Kansas City, MO 64108, USA
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15
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Réti M, Farkas P, Csuka D, Rázsó K, Schlammadinger Á, Udvardy ML, Madách K, Domján G, Bereczki C, Reusz GS, Szabó AJ, Prohászka Z. Complement activation in thrombotic thrombocytopenic purpura. J Thromb Haemost 2012; 10:791-8. [PMID: 22372946 DOI: 10.1111/j.1538-7836.2012.04674.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Ultra-large von Willebrand factor and deficiency of its cleaving protease are important factors in the events leading to thrombotic microangiopathy; however, the mechanisms involved are only partly understood. Whereas pathological activation of the alternative complement pathway is linked to atypical hemolytic uremic syndrome, the role of complement activation in thrombotic thrombocytopenic purpura (TTP) is unknown. The aim of this study was to investigate whether signs of complement activation are characteristic of TTP. PATIENTS AND METHODS Twenty-three patients with TTP (18 women, median age 38 years) and 17 healthy controls (13 women, median age 38 years) were included. Complement parameters (C3, Factors H, I, B and total alternative pathway activity) together with complement activation fragments (C3a) or complexes (C1rs-INH, C3bBbP, sC5b9) were measured by ELISA or RID. ADAMTS13 activity and anti-ADAMTS13 inhibitory antibodies were measured by the VWF-FRET73 assay. RESULTS Increased levels of C3a, and SC5b9 were observed in TTP during acute episodes, as compared with healthy controls. Decreased complement C3 levels indicative of complement consumption occurred in 15% of acute TTP patients. Significant decrease of complement activation products C3a and SC5b9 was observed during plasma exchange (PEX). The sustained presence of anti-ADAMTS13 inhibitory antibodies in complete remission was associated with increased complement activation. CONCLUSION These data document in an observational study the presence of complement activation in TTP. Further investigation is needed to determine its potential pathogenetic significance.
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Affiliation(s)
- M Réti
- Department of Hematology and Stem Cell Transplantation, St István and St László Hospital of Budapest, Budapest, Hungary
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16
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Current management and therapeutical perspectives in thrombotic thrombocytopenic purpura. Presse Med 2012; 41:e163-76. [DOI: 10.1016/j.lpm.2011.10.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 10/26/2011] [Accepted: 10/28/2011] [Indexed: 12/26/2022] Open
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Abstract
The multidomain metalloprotease ADAMTS13 limits thrombus formation via the cleavage of large multimeric forms of von Willebrand factor. Deficiency of functional ADAMTS13 is associated with a number of disease pathologies including thrombotic thrombocytopenic purpura, cardiovascular disease and inflammation. To date, deficiency is known to result from mutations in the ADAMTS13 gene or from inhibitory and non-neutralizing antibodies. The exact contributory effect of genetic variation in ADAMTS13 on observable pathology is unclear, and specifically, polymorphisms of ADAMTS13 have not been the focus of much systematic study. Here we have amassed an up-to-date collection of ADAMTS13 polymorphisms described in the literature and from the National Center for Biotechnology Information’s SNP database. This article considers the effect that these polymorphisms may have on the expression and function of ADAMTS13 and speculates on their relevance in future therapies based on pharmacogenomics.
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Affiliation(s)
- Sandra Chang Tseng
- Laboratory of Hemostasis, Division of Hematology, Center for Biologics Evaluation & Research, US FDA, Bethesda, MD 20892, USA
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Barker CA, Yahalom J. Histone Deacetylase Inhibition As a Mechanism for the Therapeutic Effect of Statins (3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Inhibitors) in Follicular Lymphoma. J Clin Oncol 2010; 28:e426; author reply e427-8. [DOI: 10.1200/jco.2010.28.9488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Noris M, Remuzzi G. Genetics and Genetic Testing in Hemolytic Uremic Syndrome/Thrombotic Thrombocytopenic Purpura. Semin Nephrol 2010; 30:395-408. [DOI: 10.1016/j.semnephrol.2010.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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20
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Verbeke L, Delforge M, Dierickx D. Current insight into thrombotic thrombocytopenic purpura. Blood Coagul Fibrinolysis 2010; 21:3-10. [DOI: 10.1097/mbc.0b013e32833335eb] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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