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Hansen DL, Maquet J, Lafaurie M, Möller S, Berentsen S, Frederiksen H, Moulis G, Gaist D. Primary autoimmune haemolytic anaemia is associated with increased risk of ischaemic stroke: A binational cohort study from Denmark and France. Br J Haematol 2024; 204:1072-1081. [PMID: 38098244 DOI: 10.1111/bjh.19242] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/09/2023] [Accepted: 11/22/2023] [Indexed: 03/14/2024]
Abstract
Primary autoimmune haemolytic anaemia (AIHA) causes the destruction of red blood cells and a subsequent pro-thrombotic state, potentially increasing the risk of ischaemic stroke. We investigated the risk of ischaemic stroke in patients with AIHA in a binational study. We used prospectively collected data from nationwide registers in Denmark and France to identify cohorts of patients with primary AIHA and age- and sex-matched general population comparators. We followed the patient and comparison cohorts for up to 5 years, with the first hospitalization of a stroke during follow-up as the main outcome. We estimated cumulative incidence, cause-specific hazard ratios (csHR) and adjusted for comorbidity and exposure to selected medications. The combined AIHA cohorts from both countries comprised 5994 patients and the 81 525 comparators. There were 130 ischaemic strokes in the AIHA cohort and 1821 among the comparators. Country-specific estimates were comparable, and the overall adjusted csHR was 1.36 [95% CI: 1.13-1.65], p = 0.001; the higher rate was limited to the first year after AIHA diagnosis (csHR 2.29 [95% CI: 1.77-2.97], p < 10-9 ) and decreased thereafter (csHR 0.89 [95% CI: 0.66-1.20], p = 0.45) (p-interaction < 10-5 ). The findings indicate that patients diagnosed with primary AIHA are at higher risk of ischaemic stroke in the first year after diagnosis.
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Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Julien Maquet
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Odense University Hospital, Odense, Denmark
| | - Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Haugesund, Norway
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Toulouse University Hospital, Toulouse, France
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
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Maquet J, Lafaurie M, Michel M, Lapeyre-Mestre M, Moulis G. Drug-induced immune hemolytic anemia: detection of new signals and risk assessment in a nationwide cohort study. Blood Adv 2024; 8:817-826. [PMID: 37782770 PMCID: PMC10874903 DOI: 10.1182/bloodadvances.2023009801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023] Open
Abstract
ABSTRACT More than 130 drugs have been suspected to induce immune hemolytic anemia. Comparative studies measuring the risk of drug-induced immune hemolytic anemia (DIIHA) are lacking. We aimed (1) to detect new signals of DIIHA, excluding vaccines, and (2) to assess the association between all suspected drugs and the occurrence of immune hemolytic anemia in a nationwide comparative study. The new signals were identified using a disproportionality study (case/noncase design) in the World Pharmacovigilance Database, Vigibase, among the cases of adverse drug reactions reported up to February 2020 (>20 million). We then conducted a comparative study in the French National health database that links sociodemographic, out-of-hospital, and hospital data for the entire population (67 million individuals). Associations between exposure to drugs (those already reported as DIIHA, plus new signals identified in Vigibase) and incident cases of immune hemolytic anemia (D59.0 and D59.1 diagnosis codes of the International Classification of Diseases, version 10) from 2012 to 2018 were assessed with case-control and case-crossover designs. In Vigibase, 3371 cases of DIIHA were recorded. Fifty-nine new signals were identified resulting in a final list of 112 drugs marketed in France and measurable in the nationwide cohort (n = 4746 patients with incident immune hemolytic anemia included in the case-control analysis matched with 22 447 controls from the general population). We identified an association between immune hemolytic anemia occurrence and some antibiotics, antifungal drugs, ibuprofen, acetaminophen, furosemide, azathioprine, and iomeprol.
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Affiliation(s)
- Julien Maquet
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Team PEPSS Pharmacologie en Population, Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- Clinical Investigation Center 1436, Team PEPSS Pharmacologie en Population, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Marc Michel
- Department of Internal Medicine, National Reference Center for Adult Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hopitaux de Paris, University Paris-Est Créteil, Créteil, France
| | - Maryse Lapeyre-Mestre
- Clinical Investigation Center 1436, Team PEPSS Pharmacologie en Population, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Team PEPSS Pharmacologie en Population, Toulouse University Hospital, Toulouse, France
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Mageau A, Helary A, Ruckly S, Strukov A, Papo T, Timsit JF, Sacre K. High incidence of immune-mediated inflammatory diseases in sepsis survivors: A nationwide exposed-nonexposed epidemiological study. J Intern Med 2024; 295:242-252. [PMID: 37983848 DOI: 10.1111/joim.13745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Sepsis is characterized by an excessive release of inflammatory cytokines. Cytokine dysregulation is pivotal to the pathophysiology of immune-mediated inflammatory diseases (IMIDs). We aimed to analyze the incidence of IMIDs in patients who survived sepsis. METHODS We performed a matched-cohort study using the National Medico-Administrative Hospital database in order to analyze the association between sepsis and incident IMIDs in 2020 in France. Sepsis was defined by the combination of at least one infection diagnosis code and one organ failure code. Patients with a first sepsis diagnosed in 2020 were randomly matched with patients admitted during the same period for acute myocardial infarction (AMI) with an exact matching procedure using age, gender, and comorbidities as matching variables. The main outcome was an IMID diagnosis in a 9-month follow-up period starting the first day of hospitalization for sepsis or AMI. RESULTS In France, the incidence rate of IMIDs after a sepsis in 2020-analyzed in 62,257 patients-was of 7956 (95% confidence interval [95% CI] 7392-8520) per 100,000 patient-years. As compared to the AMI population, we observed an increased risk for IMIDs of 2.80 (hazard ratio [HR]; 95% CI [2.22-3.54]) starting from day 16 after admission in the sepsis population. The risk of IMIDs onset in sepsis survivors depended on the type of IMIDs and was higher for immune thrombocytopenia (5.51 [1.97-15.4]), autoimmune hemolytic anemia (HR 4.83 [1.45-16.1]), and antineutrophil cytoplasmic antibody-associated vasculitis (4.66 [2.05-10.6]). Association between sepsis and IMIDs onset appeared well balanced across pathogen categories. CONCLUSION Our study shows a high incidence of IMIDs among sepsis survivors.
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Affiliation(s)
- Arthur Mageau
- IAME, UMR 1137 INSERM, Team Descid Université Paris Cité and Université Sorbonne Paris Nord, Paris, France
- Département de Médecine Interne, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
- CRI, UMR 1149 INSERM, ERL 8252 CNRS, LabEx Inflamex, Université Paris Cité, Paris, France
| | - Aloïs Helary
- IAME, UMR 1137 INSERM, Team Descid Université Paris Cité and Université Sorbonne Paris Nord, Paris, France
- Département de Médecine Interne, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Stephane Ruckly
- IAME, UMR 1137 INSERM, Team Descid Université Paris Cité and Université Sorbonne Paris Nord, Paris, France
- OUTCOME REA network, Drancy, France
| | - Andrey Strukov
- Département d'Information Médicale, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Thomas Papo
- Département de Médecine Interne, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
- CRI, UMR 1149 INSERM, ERL 8252 CNRS, LabEx Inflamex, Université Paris Cité, Paris, France
| | - Jean-François Timsit
- IAME, UMR 1137 INSERM, Team Descid Université Paris Cité and Université Sorbonne Paris Nord, Paris, France
- Département de Réanimation Médicale et Infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, Paris, France
| | - Karim Sacre
- Département de Médecine Interne, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
- CRI, UMR 1149 INSERM, ERL 8252 CNRS, LabEx Inflamex, Université Paris Cité, Paris, France
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Mulder FVM, Evers D, de Haas M, Cruijsen MJ, Bernelot Moens SJ, Barcellini W, Fattizzo B, Vos JMI. Severe autoimmune hemolytic anemia; epidemiology, clinical management, outcomes and knowledge gaps. Front Immunol 2023; 14:1228142. [PMID: 37795092 PMCID: PMC10545865 DOI: 10.3389/fimmu.2023.1228142] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired hemolytic disorder, mediated by auto-antibodies, and has a variable clinical course ranging from fully compensated low grade hemolysis to severe life-threatening cases. The rarity, heterogeneity and incomplete understanding of severe AIHA complicate the recognition and management of severe cases. In this review, we describe how severe AIHA can be defined and what is currently known of the severity and outcome of AIHA. There are no validated predictors for severe clinical course, but certain risk factors for poor outcomes (hospitalisation, transfusion need and mortality) can aid in recognizing severe cases. Some serological subtypes of AIHA (warm AIHA with complement positive DAT, mixed, atypical) are associated with lower hemoglobin levels, higher transfusion need and mortality. Currently, there is no evidence-based therapeutic approach for severe AIHA. We provide a general approach for the management of severe AIHA patients, incorporating monitoring, supportive measures and therapeutic options based on expert opinion. In cases where steroids fail, there is a lack of rapidly effective therapeutic options. In this era, numerous novel therapies are emerging for AIHA, including novel complement inhibitors, such as sutimlimab. Their potential in severe AIHA is discussed. Future research efforts are needed to gain a clearer picture of severe AIHA and develop prediction models for severe disease course. It is crucial to incorporate not only clinical characteristics but also biomarkers that are associated with pathophysiological differences and severity, to enhance the accuracy of prediction models and facilitate the selection of the optimal therapeutic approach. Future clinical trials should prioritize the inclusion of severe AIHA patients, particularly in the quest for rapidly acting novel agents.
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Affiliation(s)
- Femke V. M. Mulder
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Dorothea Evers
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Masja de Haas
- Sanquin Research and Landsteiner Laboratory, Translational Immunohematology, Amsterdam UMC, Amsterdam, Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | | | - Sophie J. Bernelot Moens
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wilma Barcellini
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Department of Hematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Josephine M. I. Vos
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, Netherlands
- Department of Hematology and Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Sekhar Das S, Chaudhuri K, Mukherjee S. Clinical and immunohematological characterization of autoimmune hemolytic anemia in children. Transfus Apher Sci 2023:103703. [PMID: 36934038 DOI: 10.1016/j.transci.2023.103703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 12/07/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
Autoimmune Hemolytic Anemia (AIHA) in childhood is uncommon and estimated to be three per million annually under 18 years of age. Detailed immunohematological and clinical characterizations are essential for correct diagnosis of the disease and its management. In this study we described AIHA in children with regards to patient demography, underlying etiology, disease classification, antibody characterization, clinical features, degree of in vivo hemolysis and transfusion management. The prospective observational study was conducted over a period of 6 years and included 29 children with newly diagnosed AIHA. Patient details were obtained from the hospital information system and patient treatment file. The median age of the children was 12 years with a female preponderance. Secondary AIHA was observed in 62.1% patients. The mean hemoglobin and reticulocyte were 7.1 gm/dL and 8.8 percentages respectively. The median polyspecific direct antiglobulin test (DAT) grading was 3+. Red cell bound multiple autoantibodies were found in 27.6% children. Free serum autoantibodies were present in 62.1% patients. Twenty six of the 42 units transfused were "best match" or "least incompatible". Follow-up of 21 children showed clinical and laboratory improvement with DAT still positive at the end of 9 months. AIHA in childhood requires advanced and efficient clinical, immunohematological and transfusion support. Detailed characterization of AIHA is important, as they determine degree of in vivo hemolysis, disease severity, serological incompatibility and necessity of blood transfusion. Although blood transfusion in AIHA is a challenge but it should not be withheld in critically ill patients.
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Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India.
| | | | - Sourav Mukherjee
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India
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Abstract
Warm autoimmune hemolytic anemia (wAIHA) is characterized by evidence of red blood cell (RBC) hemolysis and a direct antiglobulin test positive for IgG and sometimes complement. While varying with the extent of the compensatory increase in RBC production, symptoms of anemia predominate, as does jaundice, the latter often exacerbated by concurrent Gilbert's syndrome. Initial treatment with corticosteroids is highly effective, with over 85% of patients responding but with less than one-third maintaining that response upon weaning. Subsequent rituximab administration in those failing corticosteroids provides complete remission in over 75% of patients and may be long-lasting. Over 50% of patients failing rituximab respond to erythropoiesis-stimulating agents or immunosuppressive agents. Splenectomy is best deferred if possible but does offer long-term remission in over two-thirds of patients. A number of new treatments for wAIHA (fostamatinib, rilzabrutinib, and FcRn inhibitors) show promise. A treatment algorithm for wAIHA is proposed to avoid the excessive use of corticosteroids.
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Affiliation(s)
- David J. Kuter
- Correspondence David J. Kuter, Hematology Division, Massachusetts General Hospital, Ste 118, Rm 110, Zero Emerson Pl, Boston, MA 02114; e-mail:
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Pouchelon C, Lafont C, Lafarge A, Comont T, Riviere E, Boutboul D, Fieschi C, Dossier A, Audia S, Vaidie J, Ruivard M, Gobert D, Bonnard G, Graveleau J, Mahevas M, Godeau B, Michel M. Characteristics and outcome of adults with severe autoimmune hemolytic anemia admitted to the intensive care unit: Results from a large French observational study. Am J Hematol 2022; 97:E371-E373. [PMID: 35871779 DOI: 10.1002/ajh.26665] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Clara Pouchelon
- Department of Internal Medicine, National Reference Center for Adult' Immune Cytopenias, Henri Mondor University Hospital, Université Paris-Est Créteil, Assistance Publique Hôpitaux de Paris, Créteil, France
| | - Charlotte Lafont
- Service de Santé Publique, Univ Paris Est Creteil, INSERM, IMRB, Creteil, France.,Service de Santé Publique, AP-HP, hôpital Henri-Mondor, Créteil, France
| | - Antoine Lafarge
- Intensive Care Unit, Saint Louis Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Thibault Comont
- Department of Internal Medicine and Clinical Immunology, Institut Universitaire du Cancer Toulouse - Oncopôle, Toulouse, France
| | - Etienne Riviere
- Department of Internal Medicine and Infectious diseases, Haut-Lévêque University Hospital, Bordeaux, France
| | - David Boutboul
- Departement of Clinical Immunology, Saint Louis Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Claire Fieschi
- Departement of Clinical Immunology, Saint Louis Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Antoine Dossier
- Department of Internal Medicine and Clinical Immunology, Bichat University Hospital, Université de Paris, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Sylvain Audia
- Department of Internal Medicine and Clinical Immunology, Reference Center for Adult' Immune Cytopenias, Le Bocage Université Hospital, Dijon, France
| | - Julien Vaidie
- Department of Hematology, Dupuytren University Hospital, Limoges, France
| | - Marc Ruivard
- Department of Internal Medicine and Clinical Immunology, D'Estaing University Hospital, Clermont-Ferrand, France
| | - Delphine Gobert
- Department of Internal Medicine and Clinical Immunology, Saint Antoine University Hospital, Paris-Sorbonne Université, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Guillaume Bonnard
- Department of Internal Medicine and Clinical Immunology, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Julie Graveleau
- Department of Internal Medicine and Clinical Immunology, Hôtel Dieu University Hospital, Nantes, France
| | - Matthieu Mahevas
- Department of Internal Medicine, National Reference Center for Adult' Immune Cytopenias, Henri Mondor University Hospital, Université Paris-Est Créteil, Assistance Publique Hôpitaux de Paris, Créteil, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Reference Center for Adult' Immune Cytopenias, Henri Mondor University Hospital, Université Paris-Est Créteil, Assistance Publique Hôpitaux de Paris, Créteil, France
| | - Marc Michel
- Department of Internal Medicine, National Reference Center for Adult' Immune Cytopenias, Henri Mondor University Hospital, Université Paris-Est Créteil, Assistance Publique Hôpitaux de Paris, Créteil, France
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Hansen DL, Möller S, Frederiksen H. Survival in autoimmune hemolytic anemia remains poor, results from a nationwide cohort with 37 years of follow-up. Eur J Haematol 2022; 109:10-20. [PMID: 35276014 PMCID: PMC9314695 DOI: 10.1111/ejh.13764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023]
Abstract
Introduction Autoimmune hemolytic anemia (AIHA) is considered a chronic disease, with an overall good prognosis. However, recent reports indicate pre‐mature mortality. Causes of death have not been evaluated previously. Methods In a nationwide setting, we identified all patients with warm type AIHA or cold agglutinin disease (CAD), and age–sex‐matched comparators from Denmark, 1980–2016. We estimated overall survival and cause‐specific mortality from anemia, infection, cardiovascular causes, hematological or solid cancer, bleeding, or other causes, using cumulative incidence proportions. Results We identified 1460 patients with primary AIHA, 1078 with secondary AIHA, 112 with CAD, and 130 801 comparators. One‐year survival and median survival were, 82.7% and 9.8 years for primary AIHA, 69.1% and 3.3 years for secondary AIHA, and 85.5% and 8.8 years for CAD. Prognosis was comparable to the general population only in patients with primary AIHA below 30 years. In all other age and subgroups, the difference was considerable. Cumulated cause‐specific mortality at 1 year was increased among patients versus comparators. Discussion All groups of autoimmune hemolytic anemia are associated with increased overall and cause‐specific mortality compared to the general population. This probably reflects unmet needs in both treatment and follow‐up programs.
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Affiliation(s)
- Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN, Odense University Hospital, Odense, Denmark
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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