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Ozelo MC, Colella MP, de Paula EV, do Nascimento ACKV, Villaça PR, Bernardo WM. Guideline on immune thrombocytopenia in adults: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Project guidelines: Associação Médica Brasileira - 2018. Hematol Transfus Cell Ther 2018; 40:50-74. [PMID: 30057974 PMCID: PMC6001928 DOI: 10.1016/j.htct.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | | | | | - Paula Ribeiro Villaça
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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Chater C, Terriou L, Duhamel A, Launay D, Chambon JP, Pruvot FR, Rogosnitzky M, Zerbib P. Reemergence of Splenectomy for ITP Second-line Treatment? Ann Surg 2016; 264:772-7. [PMID: 27741009 DOI: 10.1097/SLA.0000000000001912] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Corticosteroids are still the standard first-line treatment for immune thrombocytopenic purpura (ITP). As second-line therapy, splenectomy and Rituximab are both recommended. The aim of our study was to compare the efficacy of Rituximab to splenectomy in persistent or chronic ITP patients. METHODS Between January 1999 and March 2015, we retrospectively selected all consecutive patients who underwent an ITP second-line treatment: Rituximab or splenectomy. The distinction between open (OS) and laparoscopic splenectomy (LS) was analyzed. Primary outcome was composite: hospitalization for bleeding and/or thrombocytopenia and death from hemorrhage or infection. Secondary outcomes were based on response (R) and complete response (CR) rates as defined by the American Society of Hematology. RESULTS Ninety-six patients were included: 30 patients received Rituximab, 37 underwent OS, and 29 underwent LS. The follow-up was 30, 60, and 120 months in Rituximab, LS, and OS groups, respectively. At 30 month, the primary outcome-free survival rate was higher in splenectomy groups (84% for OS, 86% for LS) than Rituximab group (47%) (P = 0.0002). Similarly, at 30 month, R and CR rates were higher for OS (86.5% and 75.7%, respectively) and LS groups (93.1% and 89.7%) than Rituximab (46.7% and 30%) (P = 0.0001). Moreover, R rates remained elevated at 60 month for OS and LS groups (83.7% and 89.6% respectively) and 78.4% at 120 month for OS group. CONCLUSION We observed that splenectomy for ITP second-line treatment was more effective than Rituximab regarding maintenance of R, CR, and overall response rates. OS and LS had similar efficacy.
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Xu T, Li N, Jin F, Wu K, Ye Z. Predictive Factors of Idiopathic Thrombocytopenic Purpura and Long-term Survival in Chinese Adults Undergoing Laparoscopic Splenectomy. Surg Laparosc Endosc Percutan Tech 2017; 26:397-400. [PMID: 27749769 DOI: 10.1097/sle.0000000000000314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The study aimed to investigate the long-term outcomes of laparoscopic splenectomy (LS) in Chinese patients with chronic idiopathic thrombocytopenic purpura (ITP). This was a retrospective analysis of 114 patients with ITP who underwent LS from 2001 to 2013. Patients were classified according to response at last contact: complete response (CR), partial response (PR), and no response (NR). Patients with CR had the highest platelet levels and patients with NR had the lowest. A correlation was observed between postoperative peak platelet count and platelet count on 2-month postoperative (r=0.829, P<0.01). In total, 27 patients showed NR to LS. Ten patients recurred within 3 years. The 140-month response rate to LS was 68%. Multivariate analysis showed that age and postoperative platelet count were independently associated with CR/PR. In conclusion, LS achieved good outcomes in Chinese patients with ITP. Age and postoperative peak platelet were independently associated with response.
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Affiliation(s)
- Tao Xu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Sun D, Shehata N, Ye XY, Gregorovich S, De France B, Arnold DM, Shah PS, Malinowski AK. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy. Blood 2016; 128:1329-35. [PMID: 27402971 DOI: 10.1182/blood-2016-04-710285] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 07/05/2016] [Indexed: 11/20/2022] Open
Abstract
Treatment options for immune thrombocytopenia (ITP) in pregnancy are limited, and evidence to guide management decisions is lacking. This retrospective study of singleton pregnancies from 2 tertiary centers compared the effectiveness of intravenous immunoglobulin (IVIg) and corticosteroids in treatment of ITP. Data from 195 women who had 235 pregnancies were reviewed. Treatment was not required in 137 pregnancies (58%). Of the remaining 98 pregnancies in 91 women, 47 (48%) were treated with IVIg and 51 were treated with corticosteroids as the initial intervention. Mean maternal platelet count at birth did not differ between groups (IVIg 69 × 10(9)/L vs corticosteroids 77 × 10(9)/L; P = .71) nor did the proportion of mothers who achieved a platelet count response (IVIg 38% vs corticosteroids 39%; P = .85). There were no fatal or severe maternal, fetal, or neonatal hemorrhages. Of 203 neonates in whom platelet counts were available, 56 (28%) had a birth platelet count <150 × 10(9)/L and 18 (9%) had platelet counts <50 × 10(9)/L. Nadir platelet counts for most affected neonates occurred at birth, although for some neonates, nadir platelet counts occurred up to 6 days postnatally. Intracranial hemorrhage was noted in 2 neonates (nadir platelet counts were 135 and 18 × 10(9)/L). There were no neonatal deaths. The majority of pregnant women with a history of ITP did not require treatment, and neonatal outcomes were comparable for mothers who received IVIg or corticosteroids for treatment of maternal ITP.
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Grace RF, Bennett CM, Ritchey AK, Jeng M, Thornburg CD, Lambert MP, Neier M, Recht M, Kumar M, Blanchette V, Klaassen RJ, Buchanan GR, Kurth MH, Nugent DJ, Thompson AA, Stine K, Kalish LA, Neufeld EJ. Response to steroids predicts response to rituximab in pediatric chronic immune thrombocytopenia. Pediatr Blood Cancer 2012; 58:221-5. [PMID: 21674758 PMCID: PMC3863944 DOI: 10.1002/pbc.23130] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 02/18/2011] [Indexed: 01/19/2023]
Abstract
BACKGROUND Treatment choice in pediatric immune thrombocytopenia (ITP) is arbitrary, because few studies are powered to identify predictors of therapy response. Increasingly, rituximab is becoming a treatment of choice in those refractory to other therapies. METHODS The objective of this study was to evaluate univariate and multivariable predictors of platelet count response to rituximab. After local IRB approval, 565 patients with chronic ITP enrolled and met criteria for this study in the longitudinal, North American Chronic ITP Registry (NACIR) between January 2004 and October 2010. Treatment response was defined as a post-treatment platelet count ≥ 50,000/µl within 16 weeks of rituximab and 14 days of steroids. Treatment response data were captured both retrospectively at enrollment and then prospectively. RESULTS Eighty (14.2%) patients were treated with rituximab with an overall response rate of 63.8% (51/80). Univariate correlates of response to rituximab included the presence of secondary ITP and a positive response to steroids. In multivariable analysis, response to steroids remained a strong correlate of response to rituximab, OR 6.8 (95% CI 2.0-23.0, P = 0.002). Secondary ITP also remained a strong predictor of response to rituximab, OR 5.6 (95% CI 1.1-28.6, P = 0.04). Although 87.5% of patients who responded to steroids responded to rituximab, 48% with a negative response to steroids did respond to rituximab. CONCLUSION In the NACIR, response to steroids and presence of secondary ITP were strong correlates of response to rituximab, a finding not previously reported in children or adults.
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Affiliation(s)
- Rachael F. Grace
- Division of Hematology/Oncology, Children's Hospital Boston, Boston, Massachusetts,Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts,Correspondence to: Rachael F. Grace, MD, Children's Hospital Boston, 300 Longwood Avenue, Karp 8, Boston, MA 02115.
| | - Carolyn M. Bennett
- Emory University School of Medicine, Children's Healthcare of Atlanta, Aflac Cancer Center and Blood Disorders Service, Atlanta, Georgia
| | - A. Kim Ritchey
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Michael Jeng
- Lucile Packard Children's Hospital, Palo Alto, California
| | | | | | - Michelle Neier
- The Cancer Institute of New Jersey, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Michael Recht
- Oregon Health & Science University, Portland, Oregon
| | | | | | | | | | | | | | | | - Kimo Stine
- Arkansas Children's Hospital, Little Rock, Arkansas
| | - Leslie A. Kalish
- Harvard Medical School, Boston, Massachusetts,linical Research Program, Children's Hospital Boston, Massachusetts
| | - Ellis J. Neufeld
- Division of Hematology/Oncology, Children's Hospital Boston, Boston, Massachusetts,Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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Heng LL, Caguioa P, Chin NS, Chiou TJ, Lee JW, Miyakawa Y, Tambunan KL, Chong BH. Chronic adult primary immune thrombocytopenia (ITP) in the Asia-Pacific region. Int J Hematol 2011; 94:142-149. [PMID: 21766185 DOI: 10.1007/s12185-011-0894-8] [Citation(s) in RCA: 11] [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] [Received: 11/29/2010] [Revised: 06/21/2011] [Accepted: 06/22/2011] [Indexed: 01/15/2023]
Abstract
Patients with primary immune thrombocytopenia (ITP) from the Asia-Pacific region often exhibit characteristics distinct from those of patients from the West. Moreover, as the region itself is heterogeneous, the ITP landscape among individual Asia-Pacific countries can be diverse. The recently released international consensus report on ITP places new emphasis on ITP, but does not address the unique ITP landscape in the Asia-Pacific region, which is home to 60% of the world's population. In an attempt to characterize how the ITP landscape differs between the West and the Asia-Pacific region, an expert panel with representatives from Northeast Asia, Southeast Asia, and Australia was convened. Important differences were identified between the guidance provided in the international consensus report and experience in the Asia-Pacific region, namely diagnostic practices, incidence and approach to ITP secondary to H. pylori infection, systemic lupus erythematosus-related ITP, the use of bone marrow examination, initial treatment strategies, and the role of splenectomy, rituximab, and thrombopoietin receptor agonists.
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Affiliation(s)
- Lee Lai Heng
- Singapore General Hospital, Singapore, Singapore
| | | | - Ng Soo Chin
- Sime Darby Medical Centre, Subang Jaya, Malaysia
| | - Tzeon-Jye Chiou
- Taipei Veterans General Hospital, National Young-Ming University School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Hematology Society of Taiwan, Taipei, Taiwan
| | - Jong Wook Lee
- The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | | | | | - Beng H Chong
- St George Clinical School, University of New South Wales, St George Hospital, Level 2 Pitney Building, Belgrave Street, Kogarah, Sydney, NSW, 2217, Australia.
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Julia A, Kovaleva L, Loria S, Alberca I, Hernandez F, Sandoval V, Sierra J, Vidaller A, Ayguasanosa J, Carretero M. Clinical efficacy and safety of Flebogammadif®, a new high-purity human intravenous immunoglobulin, in adult patients with chronic idiopathic thrombocytopenic purpura. Transfus Med 2009; 19:260-8. [DOI: 10.1111/j.1365-3148.2009.00945.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Neunert CE, Bright BC, Buchanan GR. Severe chronic refractory immune thrombocytopenic purpura during childhood: a survey of physician management. Pediatr Blood Cancer 2008; 51:513-6. [PMID: 18506754 DOI: 10.1002/pbc.21621] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Physician attitudes regarding management of children with severe chronic immune thrombocytopenic purpura (ITP) have not been recently characterized. PROCEDURE We designed a survey of members of the American Society of Pediatric Hematology-Oncology (ASPHO) that described a 5-year-old female with ITP for 1 year who was unresponsive to steroids, IVIG, and anti-D immune globulin and having frequent epistaxis causing interference with her daily activities. A 13-item questionnaire evaluated physician decision-making in this setting. RESULTS Two hundred and ninety-seven surveys (35% response rate) were returned, and 295 were evaluable. Thirty-three percent of respondents stated that they would recommend splenectomy for such a child. Of those who would not recommend splenectomy, 67% reported that they would instead treat with rituximab. If initial drug therapy failed, 47% would proceed with splenectomy. Those who reported treating with rituximab initially were more likely to recommend splenectomy following failure than those who preferred other drug therapy (P < 0.0001). CONCLUSIONS Physician management of patients with chronic ITP is diverse. With the advent of new treatments such as rituximab and thrombopoetic agents it is critically important to compare their cost, adverse effects and efficacy with splenectomy in order to optimally guide treatment practices.
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Affiliation(s)
- Cindy E Neunert
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA.
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Shojaiefard A, Mousavi SA, Faghihi SH, Abdollahzade S. Prediction of response to splenectomy in patients with idiopathic thrombocytopenic purpura. World J Surg 2008; 32:488-93. [PMID: 18196318 DOI: 10.1007/s00268-007-9399-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by destruction of opsonized platelets in the reticuloendothelial system, particularly the spleen, and by resulting low platelet counts. Splenectomy is the standard second-line treatment for patients with ITP who do not respond to corticosteroids. In the present study we determined predictive factors for the response of patients with ITP to splenectomy. MATERIALS AND METHODS For thirty-one patients with ITP referred from the Hematology Department of Shariati Hospital, open surgical splenectomy was performed between February 2002 and December 2004. All potentially important variables of response were collected and analyzed to determine predictive parameters. RESULTS Older patients (>52) responded less positively than younger patients (<52) to splenectomy (p<0.01). Likewise, patients with a sustained remission after splenectomy had a significantly shorter interval of diagnosis of ITP to splenectomy (p<0.05) and shorter duration of corticosteroid therapy before splenectomy (p<0.05). CONCLUSIONS This study confirms that splenectomy is an effective treatment for patients with ITP. Our findings highlight age as the major predictive factor of long-term response to splenectomy in patients with ITP.
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Affiliation(s)
- A Shojaiefard
- Department of Surgery, Shariati Hospital, School of Medicine, Medical Sciences/University of Tehran, Kargar Shomali Avenue, Tehran, Iran.
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Spahr JE, Rodgers GM. Treatment of immune-mediated thrombocytopenia purpura with concurrent intravenous immunoglobulin and platelet transfusion: a retrospective review of 40 patients. Am J Hematol 2008; 83:122-5. [PMID: 17874448 DOI: 10.1002/ajh.21060] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We performed a retrospective review of patients with immune-mediated thrombocytopenia (ITP) treated with prolonged infusions of intravenous immunoglobulin (IVIg) (1 g/kg by continuous infusion over 24 hr) and concurrent platelets (1 pheresis unit every 8 hr), to determine the response rate of this therapy. Patient inclusion criteria included clinically significant thrombocytopenia, with either active bleeding, need for anticoagulation, or a needed surgical procedure. The average pretreatment platelet count was 10,000/microl, which increased to 55,000/microl after 24 hr and 69,000/microl after 48 hr. After 24 hr, 62.7% of patients had a platelet count >50,000/microl. Bleeding was controlled initially in all patients, and those requiring a procedure experienced no bleeding complications. Over half of the patients (52.5%) required additional treatments for recurrent or refractory ITP. Six of the 21 patients requiring retreatment (29%) received IVIg and platelets again in a similar fashion, with similar results. No side effects of the combined treatment were noted. There is limited literature on the optimal dose and schedule for administration of IVIg and platelets. Our approach for administration of IVIg and platelets concurrently was associated with minimal side effects, resolution of bleeding, ability to safely undergo procedures, and rapid restoration of adequate platelet counts.
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Affiliation(s)
- Joseph E Spahr
- Division of Hematology and Oncology, Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah 84112-5550, USA.
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Hoehlig K, Lampropoulou V, Roch T, Neves P, Calderon-Gomez E, Anderton SM, Steinhoff U, Fillatreau S. Immune regulation by B cells and antibodies a view towards the clinic. Adv Immunol 2008; 98:1-38. [PMID: 18772002 DOI: 10.1016/s0065-2776(08)00401-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
B lymphocytes contribute to immunity in multiple ways, including production of antibodies, presentation of antigen to T cells, organogenesis of secondary lymphoid organs, and secretion of cytokines. Recent clinical trials have shown that depleting B cells can be highly beneficial for patients with autoimmune diseases, implicating B cells and antibodies as key drivers of pathology. However, it should be kept in mind that B cell responses and antibodies also have important regulatory roles in limiting autoimmune pathology. Here, we analyze clinical examples illustrating the potential of antibodies as treatment for immune-mediated disorders and discuss the underlying mechanisms. Furthermore, we examine the regulatory functions of activated B cells, their involvement in the termination of some experimental autoimmune diseases, and their use in cell-based therapy for such pathologies. These suppressive functions of B cells and antibodies do not only open new ways for harnessing autoimmune illnesses, but they also should be taken into account when designing new strategies for vaccination against microbes and tumors.
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Affiliation(s)
- Kai Hoehlig
- Laboratory of immune regulation, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, Berlin, Germany
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Kühne T, Blanchette V, Buchanan GR, Ramenghi U, Donato H, Tamminga RYJ, Rischewski J, Berchtold W, Imbach P. Splenectomy in children with idiopathic thrombocytopenic purpura: A prospective study of 134 children from the Intercontinental Childhood ITP Study Group. Pediatr Blood Cancer 2007; 49:829-34. [PMID: 17171689 DOI: 10.1002/pbc.21108] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Splenectomy is an effective procedure for children and adults with severe or refractory idiopathic thrombocytopenic purpura (ITP). Data regarding pediatric patients are limited. PROCEDURE Sixty-eight Intercontinental Childhood ITP Study Group (ICIS) investigators from 57 institutions in 25 countries participated in a splenectomy registry. Data from 153 patients were submitted, of whom 134 had a splenectomy and were analyzed. RESULTS The median age at splenectomy was 11.8 (2.7-20.7) years. The median postsplenectomy follow-up was 2.0 (0.1-4.5) years. Pre-splenectomy vaccination was not administered in 21 children (15.7%). Open and laparoscopic splenectomy procedures were performed in 67 and 65 evaluable children, respectively. Surgical technique was not reported in two children. Overall immediate platelet response to splenectomy was achieved in 113 patients (86.3%). Eighty percent of responders maintained their status of response during the following 4 years. Older age, longer duration of ITP, and male gender correlated with a complete response. Post-splenectomy sepsis was reported in seven patients without lethal outcome, although sepsis might be differently defined at participating institutions. CONCLUSIONS Splenectomy is effective in children with ITP. Management varies greatly in different institutions. These Registry data may serve as a basis for future clinical trials to assess the indication and timing of splenectomy.
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Affiliation(s)
- Thomas Kühne
- University Children's Hospital, Basel, Switzerland.
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Ramenghi U, Amendola G, Farinasso L, Giordano P, Loffredo G, Nobili B, Perrotta S, Russo G, Zecca M. Splenectomy in children with chronic ITP: long-term efficacy and relation between its outcome and responses to previous treatments. Pediatr Blood Cancer 2006; 47:742-5. [PMID: 16933239 DOI: 10.1002/pbc.20978] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This retrospective study was conducted to determine whether the response to splenectomy is related to the response to previous treatments. We examined the records of 90 children splenectomized for chronic ITP. Platelet counts were constantly>50x10(9)/L in 68 patients (75%). An improvement in the quality of life was observed in 79 (85%). The success of splenectomy was strongly correlated with a good response to previous treatment. A negative response to any of the prior treatments had no predictive value. This finding is relevant when elective splenectomy is considered as a treatment option.
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Affiliation(s)
- Ugo Ramenghi
- Department of Pediatrics, University of Torino, Torino, and Department of Pediatrics, Umberto I hospital, Nocera Inferiore, Italy.
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Abstract
OBJECTIVES The aim of this study was to explore the results of Chinese chronic idiopathic thrombocytopenic purpura (ITP) patients who underwent splenectomy (SE). SUBJECTS AND METHODS Data of 149 chronic ITP patients were retrospectively analyzed. Relapse-free survival was estimated by Kaplan-Meier analysis. Differences between responders and non-responders were evaluated using the chi-square. RESULTS The immediate response rate was 82.6% and the sustained response rate was 63.1%. Twenty-nine patients (19.5%) relapsed during follow-up. The 5-year actuarial relapse-free survival was about 75%. The overall morbidity was 26.1% and mortality was 2.7%. Patients with higher postsplenectomy peak platelet count, shorter time from diagnosis to SE and previous response to IVIG therapy were more likely to have sustained response to SE. CONCLUSION SE is potentially a useful therapy to provide long-term control of disease in adults with chronic ITP and is associated with low morbidity and mortality. Postsplenectomy peak platelet count, time from diagnosis to SE and previous response to intravenous immune globulin therapy appear predictive for response to SE.
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Affiliation(s)
- Tingting Wang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
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Kwon HC, Moon CH, Cho YR, Kim MC, Kim KH, Han JY, Lee YH, Oh SY, Kim SH, Kim JS, Kim HJ. Prognostic factors of response to laparoscopic splenectomy in patients with idiopathic thrombocytopenic purpura. J Korean Med Sci 2005; 20:417-20. [PMID: 15953862 PMCID: PMC2782196 DOI: 10.3346/jkms.2005.20.3.417] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Laparoscopic splenectomy (LS) has become the treatment of choice for patients with idiopathic thrombocytopenic purpura (ITP) who do not respond to medical treatment. The aim of this study was to identify factors predictive of outcome after LS for ITP. From May 1997 to December 2002, we performed 30 LS on patients with ITP. A positive response was defined as a postoperative platelet count greater than 50,000/micro L and no requirement for maintenance therapy. Chi-square testing was performed to determine the predictive effects of the following variables: age, sex, preoperative response to steroids or immunoglobulin, duration of disease, antiplatelet antibody, platelet associated antibody, and antinuclear antibody. LS was successfully performed in all patients. For a mean follow-up interval of 24.3 months, response to LS was 73.3%. Splenectomy for steroid nonresponders resulted in an inferior complete response rate (10 of 18, 55.6%) as compared with those that experienced relapse after steroid treatment (11 of 12, 91.7%) (p=0.042). The other significant predictor of outcome by univariate analysis was the time between diagnosis and surgery (p=0.049). The other variables showed no significant correlation with successful splenectomy. We conclude that LS can be performed safely with a satisfactory remission rate in patients with ITP who do not respond to medical treatment, and that the factors most frequently associated with surgical success are a response to steroid and disease duration.
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Affiliation(s)
- Hyuk-Chan Kwon
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Chang Hoon Moon
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Young Rak Cho
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Min Chan Kim
- Department of Surgery, College of Medicine, Dong-A University, Busan, Korea
| | - Kyeong Hee Kim
- Department of Laboratory Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Jin Yeong Han
- Department of Laboratory Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Young Ho Lee
- Department of Pediatrics, College of Medicine, Dong-A University, Busan, Korea
| | - Sung Yong Oh
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Jae-Seok Kim
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Hyo-Jin Kim
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
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Kojouri K, Vesely SK, Terrell DR, George JN. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood 2004; 104:2623-34. [PMID: 15217831 DOI: 10.1182/blood-2004-03-1168] [Citation(s) in RCA: 414] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractSplenectomy has been a standard treatment for adult patients with idiopathic thrombocytopenic purpura (ITP) for more than 50 years. However, the durability of responses, the ability to predict who will respond, and the frequency of surgical complications with splenectomy all remain uncertain. To better interpret current knowledge we systematically identified and reviewed all 135 case series, 1966 to 2004, that described 15 or more consecutive patients who had splenectomy for ITP and that had data for 1 of these 3 outcomes. Complete response was defined as a normal platelet count following splenectomy and for the duration of follow-up with no additional treatment. Forty-seven case series reported complete response in 1731 (66%) of 2623 adult patients with follow-up for 1 to 153 months; complete response rates did not correlate with duration of follow-up (r = -0.103, P = .49). None of 12 preoperative characteristics that have been reported consistently predicted response to splenectomy. Mortality was 1.0% (48 of 4955 patients) with laparotomy and 0.2% (3 of 1301 patients) with laparoscopy. Complication rates were 12.9% (318 of 2465) with laparotomy and 9.6% (88 of 921 patients) with laparoscopic splenectomy. Although the risk of surgery is an important consideration, splenectomy provides a high frequency of durable responses for adult patients with ITP. (Blood. 2004; 104:2623-2634)
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Affiliation(s)
- Kiarash Kojouri
- Hematology-Oncology Section, Department of Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, USA
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Abstract
Primary immune thrombocytopenic purpura (ITP), also referred to as idiopathic thrombocytopenic purpura, is an organ-specific autoimmune disorder in which antibody-coated or immune complex-coated platelets are destroyed prematurely by the reticuloendothelial system, resulting in peripheral blood thrombocytopenia. The disease is heterogeneous with regard to its severity and clinical course and is unpredictable in its response to therapy. Although the basic underlying pathophysiology of ITP has been known for more than 50 years, current treatment guidelines are based on expert opinion rather than on evidence because of a lack of high-quality clinical trials and research. The only patients for whom treatment is clearly required are those with severe bleeding and/or extremely low platelet counts (< 10 x 10(9)/L). Treatment of patients with ITP refractory to corticosteroids and splenectomy requires careful evaluation of disease severity, patient characteristics related to risk of bleeding, and adverse effects associated with treatment. Clinical trials with numerous new agents are under way, which we hope will add more effective and targeted strategies to our therapeutic armamentarium. We describe a logical and structured approach to the clinical management of ITP in adults, based on a literature review and our personal experience.
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MESH Headings
- Adult
- Age Factors
- Alemtuzumab
- Algorithms
- Anti-Inflammatory Agents/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived
- Antibodies, Neoplasm/therapeutic use
- Child
- Danazol/therapeutic use
- Decision Trees
- Disease Progression
- Emergency Treatment/methods
- Estrogen Antagonists/therapeutic use
- Female
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/therapeutic use
- Incidence
- Male
- Patient Selection
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Rho(D) Immune Globulin/therapeutic use
- Rituximab
- Splenectomy
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Affiliation(s)
- Roberto Stasi
- Department of Medical Sciences, "Regina Apostolorum" Hospital, Albano Laziale, Italy.
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Abstract
Infusion of large amounts of intravenous immunoglobulin (IVIG) or polyclonal anti-D can reverse thrombocytopenia in patients with idiopathic thrombocytopenic purpura within hours of the administration of these products. It has been suggested that the effects of IVIG appear to far outlast several half-lives of the product. Several mechanisms have been proposed to explain both the acute and long term effects of IVIG. These will be discussed in this review.
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Affiliation(s)
- Alan H Lazarus
- The Canadian Blood Services, and The Toronto Platelet Immunobiology Group, Ont., Toronto, Canada M5B 1W8.
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Abstract
IVIG is prepared from large pools of plasma from healthy donors and the IgG is present predominantly in monomeric form. It was first reported in 1981 by Dr. Paul Imbach that high doses of IVIG promote fast recovery of ITP in children. Despite extensive clinical use in a variety of autoimmune and inflammatory states, the mechanism of action of IVIG remains as yet incompletely understood. Several theories have been proposed to explain how administration of IVIG to individuals with ITP increases the platelet count. Following is an overview of some of the major theories.
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Affiliation(s)
- Alan H Lazarus
- Canadian Blood Services, and The Toronto Platelet Immunobiology Group, Toronto, Ontario, Canada.
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Cooper N, Woloski BMR, Fodero EM, Novoa M, Leber M, Beer JH, Bussel JB. Does treatment with intermittent infusions of intravenous anti-D allow a proportion of adults with recently diagnosed immune thrombocytopenic purpura to avoid splenectomy? Blood 2002; 99:1922-7. [PMID: 11877261 DOI: 10.1182/blood.v99.6.1922] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This study explored whether repeated infusions of intravenous anti-D could allow adults with recently diagnosed immune thrombocytopenic purpura (ITP) who had failed an initial steroid course to postpone and ultimately avoid splenectomy. Twenty-eight Rh(+), nonsplenectomized adults with ITP diagnosed within 1 to 11 months and platelet counts 30 x 10(9)/L (30 000/microL) or below were enrolled. Anti-D was infused whenever the platelet count decreased to 30 x 10(9)/L (30 000/microL) or below. "Response" was defined as a platelet increase of more than 20 x 10(9)/L (20 000/microL) to more than 30 x 10(9)/L (30 000/microL) within 7 days of treatment. Patients were a median 3.5 months from ITP diagnosis at enrollment and had received a median of 2 previous therapies, including prednisone in 26 of 28 cases. They were followed for a median 26 months. A total of 93% responded to their initial infusion of anti-D, and 68% repeatedly responded with counts maintained above 30 x 10(9)/L (30 000/microL) using anti-D alone. Currently, 12 (43%) of 28 patients have been off all treatment for more than 6 months without undergoing splenectomy, 6 maintaining counts above 100 x 10(9)/L (100 000/microL). Seven continue on treatment, 8 underwent splenectomy, and 1 was lost to follow-up at 10 months. One patient discontinued anti-D because of toxicity. Patients with platelet counts at least 14 x 10(9)/L (14 000/microL) at enrollment were more likely to discontinue treatment (P <.05). Anti-D was an effective maintenance treatment for two thirds of Rh(+), nonsplenectomized adults with ITP who had failed an initial steroid course. Intermittent infusions of intravenous anti-D allowed more than 40% of these adults to avoid splenectomy and to achieve stable platelet counts off all therapy, even after many months of treatment. Platelet count at study entry was the primary predictor of outcome.
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Affiliation(s)
- Nichola Cooper
- Department of Pediatrics, Division of Hematology/Oncology, New York Presbyterian Hospital-Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021, USA.
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