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Zheng XL. Novel mechanisms of action of emerging therapies of hereditary thrombotic thrombocytopenic purpura. Expert Rev Hematol 2024:1-11. [PMID: 38752747 DOI: 10.1080/17474086.2024.2356763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Hereditary thrombotic thrombocytopenic purpura (hTTP) is caused by deficiency of plasma ADAMTS13 activity, resulting from ADAMTS13 mutations. ADAMTS13 cleaves ultra large von Willebrand factor (VWF), thus reducing its multimer sizes. Hereditary deficiency of plasma ADAMTS13 activity leads to the formation of excessive platelet-VWF aggregates in small arterioles and capillaries, resulting in hTTP. AREAS COVERED PubMed search from 1956 to 2024 using thrombotic thrombocytopenic purpura and therapy identified 3,675 articles. Only the articles relevant to the topic were selected for discussion, which focuses on pathophysiology, clinical presentations, and mechanisms of action of emerging therapeutics for hTTP. Current therapies include infusion of plasma, or coagulation factor VIII, or recombinant ADAMTS13. Emerging therapies include anti-VWF A1 aptamers or nanobody and gene therapies with adeno-associated viral vector or self-inactivated lentiviral vector or a sleeping beauty transposon system for a long-term expression of a functional ADAMTS13 enzyme. EXPERT OPINION Frequent plasma infusion remains to be the standard of care in most parts of the world, while recombinant ADAMTS13 has become the treatment of choice for hTTP in some of the Western countries. The success of gene therapies in preclinical models may hold a promise for future development of these novel approaches for a cure of hTTP.
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Affiliation(s)
- X Long Zheng
- Department of Pathology and Laboratory Medicine and Institute of Reproductive Medicine and Developmental Sciences, the University of Kansas Medical Center, Kansas, KS, USA
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Kremer Hovinga JA, Braschler TR, Buchkremer F, Farese S, Hengartner H, Lovey PY, Largiadèr CR, Mansouri Taleghani B, Tarasco E. Insights from the Hereditary Thrombotic Thrombocytopenic Purpura Registry: Discussion of Key Findings Based on Individual Cases from Switzerland. Hamostaseologie 2020; 40:S5-S14. [PMID: 33187004 DOI: 10.1055/a-1282-2264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The Hereditary TTP Registry is an international cohort study for patients with a confirmed or suspected diagnosis of hereditary thrombotic thrombocytopenic purpura (hTTP) and their family members. Hereditary TTP is an ultra-rare blood disorder (prevalence of ∼1-2 cases per million), the result of autosomal-recessively inherited congenital ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) deficiency (ADAMTS13 activity <10% of the normal), and associated with yet many unanswered questions. Until December 2017, the Hereditary TTP Registry had enrolled 123 confirmed hTTP patients. Their median age at disease onset was 4.5 years (range: 0-70) and at clinical diagnosis 16.7 years (range: 0-69), a difference that highlights the existing awareness gap in recognizing hTTP. The systematic collection of clinical data of individual patients revealed their substantial baseline comorbidities, as a consequence of recurring TTP episodes in the past. Most notable was the high proportion of patients having suffered from premature arterial thrombotic events, mainly transient ischemic attacks, ischemic strokes, and to a lesser extent myocardial infarctions. At 40 to 50 years of age and above, more than 50% of patients had suffered from at least one such event, and many had experienced arterial thrombotic events despite regular plasma infusions every 2 to 3 weeks that supplements the missing plasma ADAMTS13. The article by van Dorland et al. (Haematologica 2019;104(10):2107-2115) and the ongoing Hereditary TTP Registry cohort study were recognized with the Günter Landbeck Excellence Award at the 50th Hemophilia Symposium in Hamburg in November 2019, the reason to present the Hereditary TTP Registry in more detail here.
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Affiliation(s)
- Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | - Florian Buchkremer
- Division of Nephrology, Dialysis and Transplantation, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Stefan Farese
- Department of Nephrology, Burgerspital, Solothurn, Switzerland
| | - Heinz Hengartner
- Pediatric Hematology-Oncology Unit, Children's Hospital of Sankt Gallen, Sankt Gallen, Switzerland
| | - Pierre-Yves Lovey
- Service d'hématologie, Hôpital du Valais-Institut Central, Sion, Switzerland
| | - Carlo R Largiadèr
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Behrouz Mansouri Taleghani
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Erika Tarasco
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
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Sakai K, Fujimura Y, Nagata Y, Higasa S, Moriyama M, Isonishi A, Konno M, Kajiwara M, Ogawa Y, Kaburagi S, Hara T, Kokame K, Miyata T, Hatakeyama K, Matsumoto M. Success and limitations of plasma treatment in pregnant women with congenital thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2929-2941. [PMID: 33433066 DOI: 10.1111/jth.15064] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Congenital thrombotic thrombocytopenic purpura (cTTP), otherwise known as Upshaw-Schulman syndrome, is an extremely rare hereditary disease. Pregnancy is identified as a trigger for TTP episodes in patients with cTTP. OBJECTIVES To investigate the ideal management of pregnant patients with cTTP. PATIENTS/METHODS We identified 21 patients with a reproductive history (38 pregnancies) in a Japanese cTTP registry. Fetal outcomes were compared between two groups: group 1 (n = 12), pregnancy after diagnosis of confirmed cTTP by ADAMTS13 gene analysis; and group 2 (n = 26), pregnancy before diagnosis of confirmed cTTP. RESULTS In group 1, ADAMTS13 activity was closely monitored until delivery in most cases. Among 10 pregnancies in group 1, prophylactic fresh frozen plasma (FFP) infusions during pregnancy were performed to replenish ADAMTS13. In group 2, prophylactic FFP infusions were not administrated in 23 pregnancies and FFP test infusions were performed in only three pregnancies. The live birth rate of group 1 was significantly higher than that of group 2 (91.7% vs 50.0%, respectively, P = .027). The fetal survival rates of women without FFP infusions were dramatically decreased after 20 weeks of gestation. The FFP infusion dosage in group 1 was generally higher than 5 mL/kg/wk by 20 weeks of gestation. CONCLUSIONS Our results indicate that FFP infusions of more than 5 mL/kg/wk should be initiated as soon as patients become pregnant. However, even with these infusions, patients with repeated TTP episodes before pregnancy might have difficulty giving birth successfully. Recombinant ADAMTS13 products might be new treatment options for pregnant patients with cTTP.
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Affiliation(s)
- Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - Yasuyuki Nagata
- Division of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Masato Moriyama
- Department of Medical Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Ayami Isonishi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Mutsuko Konno
- Department of Pediatrics, Sapporo-Kosei General Hospital, Sapporo, Japan
| | - Michiko Kajiwara
- Center for Blood Transfusion and Cell Therapy, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shigehiko Kaburagi
- Department of Internal Medicine, Sano Memorial Clinic, Fujinomiya, Japan
| | - Tomoko Hara
- Division of Hematology, Tokushima Red Cross Hospital, Komatsushima, Japan
| | - 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
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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Schelpe AS, Orlando C, Ercig B, Geeroms C, Pareyn I, Vandeputte N, Velásquez Pereira LC, Roose E, Fostier K, Nicolaes GAF, Deckmyn H, De Meyer SF, Vanhoorelbeke K, Jochmans K. Child-onset thrombotic thrombocytopenic purpura caused by p.R498C and p.G259PfsX133 mutations in ADAMTS13. Eur J Haematol 2018; 101:191-199. [PMID: 29763513 DOI: 10.1111/ejh.13094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Patients suffering from congenital thrombotic thrombocytopenic purpura (cTTP) have a deficiency in ADAMTS13 due to mutations in their ADAMTS13 gene. OBJECTIVE The aim of this study was to determine ADAMTS13 parameters (activity, antigen, and mutations), to investigate if the propositus suffered from child-onset cTTP, and to study the in vitro effect of the ADAMTS13 mutations. METHODS ADAMTS13 activity and antigen were determined using the FRETS VWF73 assay and ELISA and ADAMTS13 mutations via sequencing of the exons. Mutant proteins were expressed in Chinese hamster ovary cells, and their expression was studied using fluorescence microscopy and ELISA. Molecular modeling was used to evaluate the effect of the mutations on ADAMTS13 structure and stability. RESULTS The propositus was diagnosed with cTTP at the age of 20. ADAMTS13 activity was below 10%, and 2 compound heterozygous mutations, the p.R498C point and the p.G259PfsX133 frameshift mutation, were identified. Expression of ADAMTS13 mutants revealed that the p.R498C and the p.G259PfsX133 mutation cause secretion and translation defects in vitro, respectively. Molecular modeling showed that the R498 intra-domain interactions are lacking in the p.R498C mutant, resulting in protein instability. CONCLUSION The ADAMTS13 mutations result in a severe ADAMTS13 deficiency explaining the patient's phenotype.
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Affiliation(s)
- An-Sofie Schelpe
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Christelle Orlando
- Department of Haematology, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Bogac Ercig
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- PharmaTarget B.V., Maastricht, The Netherlands
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Chloë Geeroms
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Inge Pareyn
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Nele Vandeputte
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | | | - Elien Roose
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Karel Fostier
- Department of Haematology, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Gerry A F Nicolaes
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- PharmaTarget B.V., Maastricht, The Netherlands
| | - Hans Deckmyn
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Kristin Jochmans
- Department of Haematology, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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Ng CJ, McCrae KR, Ashworth K, Sosa LJ, Betapudi V, Manco‐Johnson MJ, Liu A, Dong J, Chung D, White‐Adams TC, López JA, Di Paola J. Effects of anti-β2GPI antibodies on VWF release from human umbilical vein endothelial cells and ADAMTS13 activity. Res Pract Thromb Haemost 2018; 2:380-389. [PMID: 30046742 PMCID: PMC5974922 DOI: 10.1002/rth2.12090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 01/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is characterized by recurrent thromboembolic events in the setting of pathologic autoantibodies, some of which are directed to β2-Glycoprotein 1 (β2GPI). The mechanisms of thrombosis in APS appear to be multifactorial and likely include a component of endothelial activation. Among other things, activated endothelium secretes von Willebrand factor, a hemostatic protein that in excess can increase the risk of thrombosis. OBJECTIVE We hypothesized that anti-β2GPI antibodies could regulate the release and modulation of VWF from endothelial cells. PATIENTS/METHODS Isolated anti-β2GPI antibodies from patients with APS were assayed for their ability to induced VWF release from HUVECs and modulate the effects of ADAMTS13 in a shear-dependent assay. RESULTS We observed that anti-β2GPI antibodies from some patients with APS induced VWF release from human endothelial cells but did not induce formation of cell-anchored VWF-platelet strings. Finally, we also determined that one of the Anti-β2GPI antibodies tested can inhibit the function of ADAMTS13, the main modulator of extracellular VWF. CONCLUSIONS These results suggest that VWF and ADAMTS13 may play a role in the prothrombotic phenotype of APS.
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Affiliation(s)
- Christopher J. Ng
- Department of PediatricsUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - Keith R. McCrae
- Department of Cellular and Molecular MedicineLerner Research InstituteClevelandOHUSA
- Taussig Cancer InstituteCleveland ClinicClevelandOHUSA
| | - Katrina Ashworth
- Department of PediatricsUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - Lucas J. Sosa
- Department of PediatricsUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | | | | | - Alice Liu
- Department of PediatricsUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - Jing‐Fei Dong
- Bloodworks Research Institute‐Puget SoundSeattleWAUSA
| | - Dominic Chung
- Bloodworks Research Institute‐Puget SoundSeattleWAUSA
| | - Tara C. White‐Adams
- Department of PediatricsUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
| | - José A. López
- Bloodworks Research Institute‐Puget SoundSeattleWAUSA
| | - Jorge Di Paola
- Department of PediatricsUniversity of Colorado and Children's Hospital ColoradoAuroraCOUSA
- Human Medical Genetics and GenomicsUniversity of Colorado DenverAuroraCOUSA
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Taleghani M, von Krogh AS, Fujimura Y, George JN, Hrachovinova I, Knöbl PN, Quist-Paulsen P, Schneppenheim R, Lämmle B, Hovinga JA. Hereditary thrombotic thrombocytopenic purpura and the hereditary TTP registry. Hamostaseologie 2018; 33:138-43. [DOI: 10.5482/hamo-13-04-0026] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 05/06/2013] [Indexed: 11/05/2022] Open
Abstract
SummaryHereditary thrombotic thrombocytopenic purpura (TTP), also known as Upshaw-Schulman syndrome, is a rare recessively inherited disease. Underlying is a severe constitutional deficiency of the von Willebrand factor-cleaving protease, ADAMTS13, due to compound heterozygous or homozygous mutations in the ADAMTS13 gene. The clinical picture is variable and more and more patients with an adult-onset are diagnosed.In the majority of countries the only available treatment is plasma, which when administered regularly can efficiently prevent acute disease bouts. The decision to initiate regular prophylaxis is often not easy, as evidence based guidelines and long term outcome data are lacking. Through the hereditary TTP registry (www.ttpregistry.net, ClinicalTrials.gov identifier: NCT01257269), which was initiated in 2006 and is open to all patients diagnosed with Upshaw-Schulman syndrome and their family members, we aim to gain further information and insights into this rare disease, which eventually will help to improve clinical management of affected patients.
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Delmas Y, Helou S, Chabanier P, Ryman A, Pelluard F, Carles D, Boisseau P, Veyradier A, Horovitz J, Coppo P, Combe C. Incidence of obstetrical thrombotic thrombocytopenic purpura in a retrospective study within thrombocytopenic pregnant women. A difficult diagnosis and a treatable disease. BMC Pregnancy Childbirth 2015; 15:137. [PMID: 26081109 PMCID: PMC4469004 DOI: 10.1186/s12884-015-0557-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 05/15/2015] [Indexed: 02/06/2023] Open
Abstract
Background Thrombotic thrombocytopenic Purpura (TTP) defined as ADAMTS-13 (A Disintegrin And Metalloprotease with ThromboSpondin type 1 domain 13) activity <10 % is a rare aetiology of thrombocytopenia during pregnancy, although the precise incidence is unknown. During pregnancy, the diagnosis of TTP is crucial as it has high feto-maternal morbidity-mortality and requires urgent plasma exchange. The purpose of this study was to assess the incidence of TTP retrospectively and to describe case presentations and follow-up. Methods A monocentric retrospective study (2008–2009) was conducted among pregnant women followed in a tertiary care obstetrical unit who experienced at least one episode of severe thrombocytopenia (platelets ≤75 G/L) during 2008 and 2009. In cases of uncertain aetiology of thrombocytopenia, ADAMTS-13 activity was assessed by the full length technique. Results Among 8,908 deliveries over the 2 year period, 79 women had a platelet count nadir ≤75 G/L. Eighteen had a known aetiology of thrombocytopenia and 11 were lost to follow-up. Among 50 remaining patients, ADAMTS-13 activity was undetectable (<5 %) in 4, consistent with the diagnosis of TTP. Platelet count spontaneously normalized in 3 patients after delivery. None presented focal cerebral involvement. Three of the four, who were primipara patients, had a sustained severe deficiency in the absence of anti-ADAMTS-13 antibodies, and ADAMTS-13 gene sequencing indicated a constitutive deficiency. The fourth, a multipara patient, had an acquired, auto-immune TTP. Placental pathology in the three primipara patients showed severe and non-specific ischemic lesions. Two patients lost their babies shortly after birth. In subsequent pregnancies in these two patients, prophylactic plasma infusion initiated early with increasing volume throughout pregnancy prevented TTP relapse, improved placental pathology, and led to normal delivery. Conclusions The prevalence of TTP among thrombocytopenic pregnant women is high, up to 5 % in a tertiary unit. Platelet count normalization after delivery does not eliminate TTP. Clinicians should be aware of TTP during pregnancy, and, even if assessed retrospectively, ADAMTS-13 assessment is of particular importance for identifying patients with congenital TTP. In these patients, preventive plasma infusion and/or exchange can dramatically improve foetal prognosis, resulting in successful childbirth.
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Affiliation(s)
- Yahsou Delmas
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Sébastien Helou
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Pierre Chabanier
- Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Pôle Gynécologie-Obstétrique-et Médecine Foetale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Anne Ryman
- Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Service d'Hémostase Spécialisée, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - Fanny Pelluard
- Service d'Anatomie Pathologique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Dominique Carles
- Service d'Anatomie Pathologique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Pierre Boisseau
- Service de Génétique Médicale, Centre Hospitalier Universitaire de Nantes Hôtel Dieu, Nantes, France.
| | - Agnès Veyradier
- Service d'hématologie, Centre Hospitalier Universitaire de Lariboisière, Assistance Publique Hôpitaux de Paris, Université Paris 7 Denis Diderot, Paris, France. .,Centre de Référence des Microangiopathies Thrombotiques, Paris, France.
| | - Jacques Horovitz
- Pôle Gynécologie-Obstétrique-et Médecine Foetale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Paris, France. .,Service d'Hématologie Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, Paris, France. .,Université Pierre et Marie Curie (UPMC), Univ Paris 6, Paris, France.
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Centre de Compétence des Microangiopathies Thrombotiques, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. .,Université Bordeaux Segalen, Bordeaux, France.
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von Auer C, von Krogh AS, Kremer Hovinga JA, Lämmle B. Current insights into thrombotic microangiopathies: Thrombotic thrombocytopenic purpura and pregnancy. Thromb Res 2015; 135 Suppl 1:S30-3. [DOI: 10.1016/s0049-3848(15)50437-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ogawa Y, Matsumoto M, Sadakata H, Isonishi A, Kato S, Nojima Y, Fujimura Y. A Unique Case Involving a Female Patient with Upshaw-Schulman Syndrome: Low Titers of Antibodies against ADAMTS13 prior to Pregnancy Disappeared after Successful Delivery. Transfus Med Hemother 2014; 42:59-63. [PMID: 25960717 DOI: 10.1159/000370225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/19/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Upshaw-Schulman syndrome (USS) is usually suspected based on severe deficiency of ADAMTS13 activity without ADAMTS13 antibody, but the definitive diagnosis is made by ADAMTS13 gene analysis. We present a unique case of USS with low titers of ADAMTS13 antibodies before pregnancy. Interestingly, titers of ADAMTS13 antibodies decreased to almost undetectable levels after delivery. CASE REPORT In patient LL4, the diagnosis of USS was confirmed at age 27 by ADAMTS13 gene analysis. She became pregnant at age 30. During the pregnancy, she received regular fresh frozen plasma (FFP) infusion. Plasma von Willebrand factor levels increase as pregnancy progresses. To prevent platelet thrombi, much more ADAMTS13 supplementation is necessary during late gestation in patients with USS. Therefore, we shortened the interval between and increased the volume of FFP infusions as pregnancy progressed. At 39 weeks, she delivered a healthy baby girl. Before pregnancy, she had low titers of both neutralizing and binding anti-ADAMTS13 antibodies. Despite frequent FFP infusions, titers of the antibodies did not increase, but rather decreased to almost undetectable levels during pregnancy. CONCLUSION Both the neutralizing and binding antibodies against ADAMTS13 decreased to almost undetectable levels after delivery in this patient, which can be caused by an immunological reset.
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Affiliation(s)
- Yoshiyuki Ogawa
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Maebashi City, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Japan
| | - Hisanobu Sadakata
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi City, Japan
| | - Ayami Isonishi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Japan
| | - Seiji Kato
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Japan
| | - Yoshihisa Nojima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Maebashi City, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara City, Japan
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Falter T, Kremer Hovinga JA, Lackner K, Füllemann HG, Lämmle B, Scharrer I. Late onset and pregnancy-induced congenital thrombotic thrombocytopenic purpura. Hamostaseologie 2014; 34:244-8. [PMID: 24994604 DOI: 10.5482/hamo-14-03-0023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/26/2014] [Indexed: 11/05/2022] Open
Abstract
UNLABELLED We report on our patient (case 2) who experienced a first acute episode of thrombotic thrombocytopenic purpura (TTP) at the age of 19 years during her first pregnancy in 1976 which ended in a spontaneous abortion in the 30th gestational week. Treatment with red blood cell concentrates was implemented and splenectomy was performed. After having suffered from several TTP episodes in 1977, possibly mitigated by acetylsalicylic acid therapy, an interruption and sterilization were performed in 1980 in her second pregnancy thereby avoiding another disease flare-up. Her elder sister (case 1) had been diagnosed with TTP in 1974, also during her first pregnancy. She died in 1977 during her second pregnancy from a second acute TTP episode. DIAGNOSIS In 2013 a severe ADAMTS13 deficiency of <10% without detectable ADAMTS13 inhibitor was repeatedly found. Investigation of the ADAMTS13 gene showed that the severe ADAMTS13 deficiency was caused by compound heterozygous ADAMTS13 mutations: a premature stop codon in exon 2 (p.Q44X), and a missense mutation in exon 24 (p.R1060W) associated with low but measurable ADAMTS13 activity. CONCLUSION Genetic analysis of the ADAMTS13 gene is important in TTP patients of all ages if an ADAMTS13 inhibitor has been excluded.
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Affiliation(s)
- T Falter
- Tanja Falter, Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, 55131 Mainz, Germany, Tel. +49/(0)61 31/17 32 63, E-mail:
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