1
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DeZern AE, Zahurak M, Jones RJ, Brodsky RA. Uniform conditioning regardless of donor in bone marrow transplantation for severe aplastic anemia. Haematologica 2024; 109:657-660. [PMID: 37675516 PMCID: PMC10828752 DOI: 10.3324/haematol.2023.284022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/31/2023] [Indexed: 09/08/2023] Open
Affiliation(s)
- Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore MD; Department of Medicine, Johns Hopkins University, Division of Hematology, Baltimore, MD.
| | - Marianna Zahurak
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore MD; Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore MD
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore MD; Department of Medicine, Johns Hopkins University, Division of Hematology, Baltimore, MD
| | - Robert A Brodsky
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore MD; Department of Medicine, Johns Hopkins University, Division of Hematology, Baltimore, MD
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2
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Eswaran H, Chaturvedi S, Brodsky RA, Gerber GF, Pan XZ, Moll S. Evaluating complement dysregulation in livedoid vasculopathy using a functional assay. Blood Adv 2023; 7:6604-6607. [PMID: 37722353 PMCID: PMC10641098 DOI: 10.1182/bloodadvances.2022009142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 08/31/2023] [Accepted: 09/10/2023] [Indexed: 09/20/2023] Open
Affiliation(s)
- Harish Eswaran
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Shruti Chaturvedi
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A. Brodsky
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gloria F. Gerber
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiang-Zuo Pan
- Divison of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephan Moll
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Blood Research Center, University of North Carolina School of Medicine, Chapel Hill, NC
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3
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DeZern AE, Brodsky RA. Combining PTCy and ATG for GvHD prophylaxis in non-malignant diseases. Blood Rev 2023; 62:101016. [PMID: 36244884 DOI: 10.1016/j.blre.2022.101016] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/21/2022]
Abstract
Bone marrow transplantation for non-malignant diseases such as aplastic anemia and hemoglobinopathies is a burgeoning clinical area. The goal of these transplants is to correct the hematopoietic defect with as little toxicity as possible. This requires mitigation of transplant-specific toxicities such as graft versus host disease, given this is not needed in non-malignant disorders. This review details current clinical outcomes in the field with a focus on post-transplantation cyclophosphamide and anti-thymoglobulin as intensive graft versus host disease prophylaxis to achieve that goal.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, United States of America.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue | Ross 1025, Baltimore, MD 21205, United States of America.
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4
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Gerber GF, Brodsky RA. ADP: the missing link between thrombosis and hemolysis. Blood Adv 2023; 7:6364-6366. [PMID: 37874560 PMCID: PMC10625892 DOI: 10.1182/bloodadvances.2023011186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Affiliation(s)
- Gloria F Gerber
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
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5
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Gerber GF, Pan XZ, Lederman HM, Brady TM, Brodsky RA. Novel Functional Assay to Characterize Mutations in Alternative Pathway of Complement. J Clin Immunol 2023; 43:1134-1136. [PMID: 37099066 PMCID: PMC10597743 DOI: 10.1007/s10875-023-01496-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/18/2023] [Indexed: 04/27/2023]
Affiliation(s)
- Gloria F Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 1025, Baltimore, MD, 21205, USA.
| | - Xiang-Zuo Pan
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 1025, Baltimore, MD, 21205, USA
| | - Howard M Lederman
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tammy M Brady
- Division of Pediatric Nephrology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Room 1025, Baltimore, MD, 21205, USA
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6
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Chaturvedi S, Yu J, Brown J, Wei A, Selvakumar S, Gerber GF, Moliterno AR, Streiff MB, Kraus P, Logue CM, Yui JC, Naik RP, Latif H, Lanzkron SM, Braunstein EM, Brodsky RA, Gottesman RF, Lin DD. Silent cerebral infarction during immune TTP remission: prevalence, predictors, and impact on cognition. Blood 2023; 142:325-335. [PMID: 37216688 PMCID: PMC10447499 DOI: 10.1182/blood.2023019663] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/05/2023] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) survivors have increased risk of cardiovascular disease, including strokes, and report persistent cognitive difficulties during remission. We conducted this prospective study involving iTTP survivors during clinical remission to determine the prevalence of silent cerebral infarction (SCI), defined as magnetic resonance imaging (MRI) evidence of brain infarction without corresponding overt neurodeficits. We also tested the hypothesis that SCI is associated with cognitive impairment, assessed using the National Institutes of Health ToolBox Cognition Battery. For cognitive assessments, we used fully corrected T scores adjusted for age, sex, race, and education. Based on the diagnostic and statistical manual 5 criteria, we defined mild and major cognitive impairment as T scores with a 1 or 2 standard deviation (SD) and >2 SD below the mean on at least 1 test, respectively. Forty-two patients were enrolled, with 36 completing MRIs. SCI was present in 50% of the patients (18), of which 8 (44.4%) had prior overt stroke including during acute iTTP. Patients with SCI had higher rates of cognitive impairment (66.7% vs 27.7%; P = .026), including major cognitive impairment (50% vs 5.6%; P = .010). In separate logistic regression models, SCI was associated with any (mild or major) cognitive impairment (odds ratio [OR] 10.5 [95% confidence interval (95% CI), 1.45-76.63]; P = .020) and major cognitive impairment (OR 7.98 [95% CI, 1.11-57.27]; P = .039) after adjusting for history of stroke and Beck depression inventory scores. MRI evidence of brain infarction is common in iTTP survivors; the strong association of SCI with impaired cognition suggests that these silent infarcts are neither silent nor innocuous.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jia Yu
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jenna Brown
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aria Wei
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sruthi Selvakumar
- Nova Southeastern University College of Allopathic Medicine, Davie, FL
| | - Gloria F. Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alison R. Moliterno
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael B. Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peggy Kraus
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Claire M. Logue
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer C. Yui
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rakhi P. Naik
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hira Latif
- Division of Hematology and Oncology, MedStar Georgetown University Hospital Center, Washington, DC
| | - Sophie M. Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Evan M. Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F. Gottesman
- Stroke, Cognition and Neuroepidemiology Section, National Institute of Neurological Disease and Stroke Intramural Research Program, Bethesda, MD
| | - Doris D. Lin
- Division of Neuroradiology, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
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7
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DeZern AE, Zahurak M, Symons HJ, Cooke KR, Huff CA, Jain T, Swinnen LJ, Imus PH, Wagner-Johnston ND, Ambinder RF, Levis M, Luznik L, Bolaños-Meade J, Fuchs EJ, Jones RJ, Brodsky RA. Alternative donor BMT with posttransplant cyclophosphamide as initial therapy for acquired severe aplastic anemia. Blood 2023; 141:3031-3038. [PMID: 37084383 DOI: 10.1182/blood.2023020435] [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: 03/10/2023] [Revised: 03/29/2023] [Accepted: 03/29/2023] [Indexed: 04/23/2023] Open
Abstract
Severe aplastic anemia (SAA) is a marrow failure disorder with high morbidity and mortality. It is treated with bone marrow transplantation (BMT) for those with fully matched donors, or immunosuppressive therapy (IST) for those who lack such a donor, which is often the case for underrepresented minorities. We conducted a prospective phase 2 trial of reduced-intensity conditioning HLA-haploidentical BMT and posttransplantation cyclophosphamide (PTCy)-based graft-versus-host (GVHD) prophylaxis as initial therapy for patients with SAA. The median patient age was 25 years (range, 3-63 years), and the median follow-up time was 40.9 months (95% confidence interval [CI], 29.4-55.7). More than 35% of enrollment was from underrepresented racial/ethnic groups. The cumulative incidence of grade 2 or 4 acute GVHD on day 100 was 7% (95% CI, not applicable [NA]-17), and chronic GVHD at 2 years was 4% (95% CI, NA-11). The overall survival of 27 patients was 92% (95% CI, 83-100) at 1, 2, and 3 years. The first 7 patients received lower dose total body irradiation (200 vs 400 cGy), but these patients were more likely to have graft failure (3 of 7) compared with 0 of 20 patients in the higher dose group (P = .01; Fisher exact test). HLA-haploidentical BMT with PTCy using 400 cGy total body irradiation resulted in 100% overall survival with minimal GVHD in 20 consecutive patients. Not only does this approach avoid any adverse ramifications of IST and its low failure-free survival, but the use of haploidentical donors also expands access to BMT across all populations. This trial was registered at www.clinicaltrials.gov as NCT02833805.
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Affiliation(s)
- Amy E DeZern
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Marianna Zahurak
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
- Department of Oncology Biostatistics, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Heather J Symons
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
- Division of Pediatric Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Kenneth R Cooke
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
- Division of Pediatric Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Carol Ann Huff
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Tania Jain
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Lode J Swinnen
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Philip H Imus
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Nina D Wagner-Johnston
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Richard F Ambinder
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Mark Levis
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Leo Luznik
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Javier Bolaños-Meade
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Ephraim J Fuchs
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Richard J Jones
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Robert A Brodsky
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
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8
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Andersen JF, Lei H, Strayer EC, Kanai T, Pham V, Pan XZ, Alvarenga PH, Gerber GF, Asojo OA, Francischetti IMB, Brodsky RA, Valenzuela JG, Ribeiro JMC. A bispecific inhibitor of complement and coagulation blocks activation in complementopathy models via a novel mechanism. Blood 2023; 141:3109-3121. [PMID: 36947859 PMCID: PMC10356578 DOI: 10.1182/blood.2022019359] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/24/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
Inhibitors of complement and coagulation are present in the saliva of a variety of blood-feeding arthropods that transmit parasitic and viral pathogens. Here, we describe the structure and mechanism of action of the sand fly salivary protein lufaxin, which inhibits the formation of the central alternative C3 convertase (C3bBb) and inhibits coagulation factor Xa (fXa). Surface plasmon resonance experiments show that lufaxin stabilizes the binding of serine protease factor B (FB) to C3b but does not detectably bind either C3b or FB alone. The crystal structure of the inhibitor reveals a novel all β-sheet fold containing 2 domains. A structure of the lufaxin-C3bB complex obtained via cryo-electron microscopy (EM) shows that lufaxin binds via its N-terminal domain at an interface containing elements of both C3b and FB. By occupying this spot, the inhibitor locks FB into a closed conformation in which proteolytic activation of FB by FD cannot occur. C3bB-bound lufaxin binds fXa at a separate site in its C-terminal domain. In the cryo-EM structure of a C3bB-lufaxin-fXa complex, the inhibitor binds to both targets simultaneously, and lufaxin inhibits fXa through substrate-like binding of a C-terminal peptide at the active site as well as other interactions in this region. Lufaxin inhibits complement activation in ex vivo models of atypical hemolytic uremic syndrome (aHUS) and paroxysmal nocturnal hemoglobinuria (PNH) as well as thrombin generation in plasma, providing a rationale for the development of a bispecific inhibitor to treat complement-related diseases in which thrombosis is a prominent manifestation.
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Affiliation(s)
- John F. Andersen
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
| | - Haotian Lei
- Research Technologies Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Ethan C. Strayer
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
- Biological and Biomedical Sciences Program, Yale University, New Haven, CT
| | - Tapan Kanai
- Center for Molecular Microscopy, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD
- Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Van Pham
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
| | - Xiang-Zuo Pan
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Patricia Hessab Alvarenga
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
| | - Gloria F. Gerber
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | | | | | - Robert A. Brodsky
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Jesus G. Valenzuela
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
| | - José M. C. Ribeiro
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
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9
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Hill A, de Latour RP, Kulasekararaj AG, Griffin M, Brodsky RA, Maciejewski JP, Marantz JL, Gustovic P, Schrezenmeier H. Concomitant Immunosuppressive Therapy and Eculizumab Use in Patients with Paroxysmal Nocturnal Hemoglobinuria: An International PNH Registry Analysis. Acta Haematol 2023; 146:1-13. [PMID: 36108594 DOI: 10.1159/000526979] [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: 01/28/2022] [Accepted: 09/03/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Complement C5 inhibitor eculizumab is the first approved treatment for paroxysmal nocturnal hemoglobinuria (PNH), a rare hematologic disorder caused by uncontrolled terminal complement activation. Approximately 50% of patients with aplastic anemia (AA) have PNH cells. Limited data are available for patients with AA-PNH taking concomitant immunosuppressive therapy (IST) and eculizumab. METHODS Data from the International PNH Registry (NCT01374360) were used to evaluate the safety and effectiveness of eculizumab and IST in patients taking IST followed by concomitant eculizumab (IST + c-Ecu) or eculizumab followed by concomitant IST (Ecu + c-IST). RESULTS As of January 1, 2018, 181 Registry-enrolled patients were included in the eculizumab effectiveness analyses (n = 138, IST + c-Ecu; n = 43, Ecu + c-IST); 87 additional patients received IST alone. Reductions from baseline with eculizumab were observed in the least squares mean lactate dehydrogenase ratio (IST + c-Ecu, -3.4; Ecu + c-IST, -3.5); thrombotic event incidence rates were similar between groups (IST + c-Ecu, 1.3; Ecu + c-IST, 0.7). Red blood cell transfusion rate ratios decreased from baseline for IST + c-Ecu (0.7) and increased for Ecu + c-IST (1.2); there were none for IST alone. Hematological parameters generally improved for IST + c-Ecu and IST alone, and changed minimally or worsened for Ecu + c-IST. Safety signals were generally consistent with those previously described for the respective therapies. DISCUSSION/CONCLUSION Although some intergroup differences were seen, concomitant eculizumab and IST were safe and effective regardless of treatment sequence.
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Affiliation(s)
- Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - Morag Griffin
- Department of Haematology, St. James University Hospital, Leeds, UK
| | - Robert A Brodsky
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jing L Marantz
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Ulm, Germany
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10
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Brown J, Potugari B, Mazepa MA, Kohli R, Moliterno AR, Brodsky RA, Vaught JA, Burwick R, Chaturvedi S. Maternal and fetal outcomes of pregnancy occurring after a diagnosis of immune-mediated thrombotic thrombocytopenic purpura. Ann Hematol 2022; 101:2159-2167. [PMID: 35932324 PMCID: PMC11060143 DOI: 10.1007/s00277-022-04936-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/23/2022] [Indexed: 11/25/2022]
Abstract
Pregnancy is a well-established trigger for a first episode or relapse of immune thrombotic thrombocytopenic purpura (iTTP). Other outcomes of subsequent pregnancy after a diagnosis of iTTP are less well described. We conducted this retrospective cohort study to evaluate maternal and fetal outcomes of pregnancy in women with prior iTTP from the Johns Hopkins Thrombotic Microangiopathy Cohort. Of 168 women in the cohort, 102 were of reproductive age at diagnosis. Fourteen pregnancies (in 9 women) that occurred after the initial iTTP episode were included in the analysis. iTTP relapse occurred in 9 (64%) pregnancies. Out of the 9 instances of relapse, 5 relapses occurred in 2 women. Seven pregnancies (50%) ended in fetal death or miscarriage in the setting of iTTP relapse and three were electively terminated due to fear of relapse. Four pregnancies (50% of the 8 that progressed beyond 20 weeks) were complicated by preeclampsia or HELLP syndrome, which is over ten-fold higher than that of the general population. No maternal deaths occurred. Only 4 pregnancies resulted in live births, of which, 2 were pre-term. Pregnancy in women with prior iTTP is associated with a substantial risk of iTTP relapse and fetal loss. Preeclampsia and HELLP syndrome is also more common than that in the general population. ADAMTS13 monitoring and preemptive therapy may improve pregnancy outcomes, which needs to be evaluated prospectively.
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Affiliation(s)
- Jenna Brown
- Johns Hopkins University, Baltimore, MD, USA
| | - Bindu Potugari
- Division of Hematology and Oncology, Saint Joseph Mercy Ann Arbor Hospital, Ann Arbor, MI, USA
| | - Marshall A Mazepa
- Division Hematology and Oncology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Ruhail Kohli
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alison R Moliterno
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Ross Research Building Rutland Avenue, Room 1025, Baltimore, MD, 21205, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Ross Research Building Rutland Avenue, Room 1025, Baltimore, MD, 21205, USA
| | - Jason A Vaught
- Department of Obstetrics and Gynecology, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 720 Ross Research Building Rutland Avenue, Room 1025, Baltimore, MD, 21205, USA.
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11
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DeZern AE, Eapen M, Wu J, Talano JA, Solh M, Dávila Saldaña BJ, Karanes C, Horwitz ME, Mallhi K, Arai S, Farhadfar N, Hexner E, Westervelt P, Antin JH, Deeg HJ, Leifer E, Brodsky RA, Logan BR, Horowitz MM, Jones RJ, Pulsipher MA. Haploidentical bone marrow transplantation in patients with relapsed or refractory severe aplastic anaemia in the USA (BMT CTN 1502): a multicentre, single-arm, phase 2 trial. Lancet Haematol 2022; 9:e660-e669. [PMID: 35907408 PMCID: PMC9444987 DOI: 10.1016/s2352-3026(22)00206-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/30/2022] [Accepted: 06/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Relapsed severe aplastic anaemia is a marrow failure disorder with high morbidity and mortality. It is often treated with bone marrow transplantation at relapse post-immunosuppressive therapy, but under-represented minorities often cannot find a suitably matched donor. This study aimed to understand the 1-year overall survival in patients with relapsed or refractory severe aplastic anaemia after haploidentical bone marrow transplantation. METHODS We report the outcomes of BMT CTN 1502, a single-arm, phase 2 clinical trial done at academic bone marrow transplantation centres in the USA. Included patients were children and adults (75 years or younger) with severe aplastic anaemia that was refractory (fulfilment of severe aplastic anaemia disease criteria at least 3 months after initial immunosuppressive therapy) or relapsed (initial improvement of cytopenias after first-line immunosuppressive therapy but then a later return to fulfilment of severe aplastic anaemia disease criteria), adequate performance status (Eastern Cooperative Oncology Group score 0 or 1, Karnofsky or Lansky score ≥60%), and the presence of an eligible related haploidentical donor. The regimen used reduced-intensity conditioning (rabbit anti-thymocyte globulin 4·5 mg/kg in total, cyclophosphamide 14·5 mg/kg daily for 2 days, fludarabine 30 mg/m2 daily for 5 days, total body irradiation 200 cGy in a single fraction), related HLA-haploidentical donors, and post-transplantation cyclophosphamide-based graft-versus-host disease (GVHD) prophylaxis. Additionally, for GVHD prophylaxis, mycophenolate mofetil was given orally at a dose of 15 mg/kg three times a day up to 1 g three times a day (maximum dose 3000 mg per day) from day 5 to day 35, and tacrolimus was given orally or intravenously from day 5 to day 180 as per institutional standards to maintain a serum concentration of 10-15 ng/mL. The primary endpoint was overall survival 1 year after bone marrow transplantation. All patients treated per protocol were analysed. This study is complete and is registered with ClinicalTrials.gov, NCT02918292. FINDINGS Between May 1, 2017, and Aug 30, 2020, 32 patients with relapsed or refractory severe aplastic anaemia were enrolled from 14 centres, and 31 underwent bone marrow transplantation. The median age was 24·9 years (IQR 10·4-51·3), and median follow-up was 24·3 months (IQR 12·1-29·2). Of the 31 patients who received a transplant, 19 (61%) were male and 12 (39%) female. 13 (42%) patients were site-reported as non-White, and 19 (61%) were from under-represented racial and ethnic groups; there were four (13%) patients who were Asian, seven (23%) Black, one (3%) Hawaiian/Pacific Islander, and one (3%) more than one race, with seven (23%) patients reporting Hispanic ethnicity. 24 (77%) of 31 patients were alive with engraftment at 1 year, and one (3%) patient alive with autologous recovery. The 1-year overall survival was 81% (95% CI 62-91). The most common grade 3-5 adverse events (seen in seven or more patients) included seven (23%) patients with abnormal liver tests, 15 (48%) patients with cardiovascular changes (including sinus tachycardia, heart failure, pericarditis), ten (32%) patients with gastrointestinal issues, seven (23%) patients with nutritional disorders, and eight (26%) patients with respiratory disorders. Six (19%) deaths, due to disease and unsuccessful bone marrow transplantation, were reported after transplantation. INTERPRETATION Haploidentical bone marrow transplantation using this approach results in excellent overall survival with minimal GVHD in patients who have not responded to immunosuppressive therapy, and can expand access to bone marrow transplantation across all populations. In clinical practice, this could now be considered a standard approach for salvage treatment of severe aplastic anaemia. Attention to obtaining high cell doses (>2·5 × 108 nucleated marrow cells per kg of recipient ideal bodyweight) from bone marrow harvests is crucial to the success of this approach. FUNDING US National Heart, Lung, and Blood Institute and US National Cancer Institute.
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Affiliation(s)
- Amy E DeZern
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA.
| | - Mary Eapen
- Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Juan Wu
- The EMMES Company, Rockville, MD, USA
| | - Julie-An Talano
- Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | | | | | | | | | - Sally Arai
- Blood and Marrow Transplantation and Cellular Therapy Division, Stanford University, Stanford, CA, USA
| | - Nosha Farhadfar
- UF Health Bone Marrow Transplant, University of Florida, Gainesville, FL, USA
| | - Elizabeth Hexner
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Eric Leifer
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Robert A Brodsky
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Brent R Logan
- Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mary M Horowitz
- Division of Hematologic Malignancies, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard J Jones
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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12
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Lee JW, Brodsky RA, Nishimura JI, Kulasekararaj AG. The role of the alternative pathway in paroxysmal nocturnal hemoglobinuria and emerging treatments. Expert Rev Clin Pharmacol 2022; 15:851-861. [PMID: 35980222 DOI: 10.1080/17512433.2022.2109462] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by uncontrolled activation of the terminal complement pathway, leading to intravascular hemolysis (IVH) and a prothrombotic state. Treatment with terminal complement (C5) inhibitors, the current standard of care, suppresses IVH and reduces the risk of thrombosis and the associated morbidity and mortality. Opportunities exist to further improve care by alternative modes of administration and the reduction of clinically significant anemia and transfusion dependence caused by extravascular hemolysis in some patients. AREAS COVERED This review describes the pathophysiology of PNH, provides an overview of the current standard of care, and discusses potential avenues for enhancing patient care, with a focus on the literature describing new and emerging treatments that target the alternative pathway. Emerging treatments include biosimilars and novel C5 inhibitors as well as agents with novel mechanisms of action that target the proximal complement pathways (C3 inhibitors, factor B inhibitors, and factor D inhibitors). EXPERT OPINION Alternative complement pathway inhibitors may offer further benefit as long as terminal complement is completely inhibited to reduce IVH and disease activity. This may lead to improvements in adherence and health-related quality of life for patients with PNH.
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Affiliation(s)
- Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Austin G Kulasekararaj
- King's College Hospital-NHS Foundation Trust, NIHR/Wellcome King's Clinical Research Facility, UK & King's College London, London, UK
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13
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Kulasekararaj AG, Brodsky RA, Nishimura JI, Patriquin CJ, Schrezenmeier H. The importance of terminal complement inhibition in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221091046. [PMID: 35663504 PMCID: PMC9160915 DOI: 10.1177/20406207221091046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 11/19/2021] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic hematologic disorder associated with inappropriate terminal complement activity on blood cells that can result in intravascular hemolysis (IVH), thromboembolic events (TEs), and organ damage. Untreated individuals with PNH have an increased risk of morbidity and mortality. Patients with PNH experiencing IVH often present with an elevated lactate dehydrogenase (LDH; ⩾ 1.5 × the upper limit of normal) level which is associated with a significantly higher risk of TEs, one of the leading causes of death in PNH. LDH is therefore used as a biomarker for IVH in PNH. The main objective of PNH treatment should therefore be prevention of morbidity and mortality due to terminal complement activation, with the aim of improving patient outcomes. Approval of the first terminal complement inhibitor, eculizumab, greatly changed the treatment landscape of PNH by giving patients an effective therapy and demonstrated the critical role of terminal complement and the possibility of modulating it therapeutically. The current mainstays of treatment for PNH are the terminal complement component 5 (C5) inhibitors, eculizumab and ravulizumab, which have shown efficacy in controlling terminal complement-mediated IVH, reducing TEs and organ damage, and improving health-related quality of life in patients with PNH since their approval by the United States Food and Drug Administration in 2007 and 2018, respectively. Moreover, the use of eculizumab has been shown to reduce mortality due to PNH. More recently, interest has arisen in developing additional complement inhibitors with different modes of administration and therapeutics targeting other components of the complement cascade. This review focuses on the pathophysiology of clinical complications in PNH and explores why sustained inhibition of terminal complement activity through the use of complement inhibitors is essential for the management of patients with this chronic and debilitating disease.
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Affiliation(s)
- Austin G. Kulasekararaj
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
- National Institute of Health Research/Wellcome King’s Clinical Research Facility and King’s College London, London, UK
| | | | - Jun-ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Christopher J. Patriquin
- Division of Medical Oncology & Hematology, University Health Network – Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, and University Hospital Ulm, Ulm, Germany
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14
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Shah H, Kim A, Sukumar S, Mazepa M, Kohli R, Braunstein EM, Brodsky RA, Cataland S, Chaturvedi S. SARS-CoV-2 vaccination and immune thrombotic thrombocytopenic purpura. Blood 2022; 139:2570-2573. [PMID: 35259252 PMCID: PMC8906888 DOI: 10.1182/blood.2022015545] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/20/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hridaya Shah
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ann Kim
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Senthil Sukumar
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Marshall Mazepa
- Division of Hematology and Oncology, University of Minnesota, Minneapolis, MN
| | - Ruhail Kohli
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Spero Cataland
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Gerber GF, DeZern AE, Chaturvedi S, Brodsky RA. A 15-year, single institution experience of anticoagulation management in paroxysmal nocturnal hemoglobinuria patients on terminal complement inhibition with history of thromboembolism. Am J Hematol 2022; 97:E59-E62. [PMID: 34800310 PMCID: PMC10615331 DOI: 10.1002/ajh.26414] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/18/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Gloria F. Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Amy E. DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, MD
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, MD
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17
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Brodsky RA, Lee JW, Nishimura JI, Szer J. Lactate dehydrogenase versus haemoglobin: which one is the better marker in paroxysmal nocturnal haemoglobinuria? Br J Haematol 2021; 196:264-265. [PMID: 34923628 DOI: 10.1111/bjh.17860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Robert A Brodsky
- Division of Hematology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Jeff Szer
- Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Melbourne, Australia
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18
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Brodsky MA, Sukumar S, Selvakumar S, Yanek L, Hussain S, Mazepa MA, Braunstein EM, Moliterno AR, Kickler TS, Brodsky RA, Cataland SR, Chaturvedi S. Major adverse cardiovascular events in survivors of immune-mediated thrombotic thrombocytopenic purpura. Am J Hematol 2021; 96:1587-1594. [PMID: 34460124 DOI: 10.1002/ajh.26341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is a leading cause of death in survivors of immune-mediated thrombotic thrombocytopenic purpura (iTTP), but the epidemiology of major adverse cardiovascular events (MACE) in iTTP survivors is unknown. We evaluated the prevalence and risk factors for MACE, defined as the composite of non-fatal or fatal myocardial infarction (MI), stroke, and cardiac revascularization, during clinical remission in two large iTTP cohorts (Johns Hopkins University and Ohio State University). Of 181 patients followed for ≥ 3 months after recovery from acute iTTP, 28.6% had a MACE event over a median follow up of 7.6 years. Stroke was the most common type of MACE (18.2%), followed by non-fatal MI (6.6%), cardiac revascularization (4.9%) and fatal MI (0.6%). Compared to the general United States population, iTTP survivors were younger at first stroke in remission (males [56.5 years vs. 68.6 years, p = 0.031], females [49.7 years vs. 72.9 years, p < 0.001]) or MI in remission (males [56.5 years vs. 65.6 years, p < 0.001] and females [53.1 years vs. 72.0 years, p < 0.001]). Age (HR 1.03 [95% CI 1.002-1.054]), race (Black/Other vs. White) (HR 2.32 [95% CI 1.12-4.82]), and diabetes mellitus (HR 2.37 [95% CI 1.09-0.03]) were associated with MACE in a Cox regression model also adjusted for sex, hypertension, obesity, hyperlipidemia, chronic kidney disease, atrial fibrillation, autoimmune disease, and relapsing iTTP. Remission ADAMTS13 activity was not significantly associated with MACE. In conclusion, iTTP survivors experience high rates of MACE and may benefit from aggressively screening for and managing cardiovascular risk factors.
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Affiliation(s)
- Max A. Brodsky
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Senthil Sukumar
- Division of Hematology, Department of Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Sruthi Selvakumar
- Nova Southeastern University School of Medicine Fort Lauderdale Florida USA
| | - Lisa Yanek
- Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Sarah Hussain
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Marshall A. Mazepa
- Division of Hematology and Oncology University of Minnesota School of Medicine Minneapolis Minnesota USA
| | - Evan M. Braunstein
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Alison R. Moliterno
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Thomas S. Kickler
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Spero R. Cataland
- Division of Hematology, Department of Medicine The Ohio State University College of Medicine Columbus Ohio USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
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19
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Teye EK, Lu S, Chen F, Yang W, Abraham T, Stairs DB, Wang HG, Yochum GS, Brodsky RA, Pu JJ. PIGN spatiotemporally regulates the spindle assembly checkpoint proteins in leukemia transformation and progression. Sci Rep 2021; 11:19022. [PMID: 34561473 PMCID: PMC8463542 DOI: 10.1038/s41598-021-98218-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/16/2020] [Accepted: 09/06/2021] [Indexed: 12/19/2022] Open
Abstract
Phosphatidylinositol glycan anchor biosynthesis class N (PIGN) has been linked to the suppression of chromosomal instability. The spindle assembly checkpoint complex is responsible for proper chromosome segregation during mitosis to prevent chromosomal instability. In this study, the novel role of PIGN as a regulator of the spindle assembly checkpoint was unveiled in leukemic patient cells and cell lines. Transient downregulation or ablation of PIGN resulted in impaired mitotic checkpoint activation due to the dysregulated expression of spindle assembly checkpoint-related proteins including MAD1, MAD2, BUBR1, and MPS1. Moreover, ectopic overexpression of PIGN restored the expression of MAD2. PIGN regulated the spindle assembly checkpoint by forming a complex with the spindle assembly checkpoint proteins MAD1, MAD2, and the mitotic kinase MPS1. Thus, PIGN could play a vital role in the spindle assembly checkpoint to suppress chromosomal instability associated with leukemic transformation and progression.
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Affiliation(s)
- Emmanuel K Teye
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Shasha Lu
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA.,Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fangyuan Chen
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenrui Yang
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA.,Institute of Hematology, Peking Union Medical College, Tianjin, China
| | - Thomas Abraham
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Douglas B Stairs
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Hong-Gang Wang
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Gregory S Yochum
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Robert A Brodsky
- Division of Hematology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Jeffrey J Pu
- Penn State Cancer Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA. .,University of Arizona Cancer Center, 1515 N Campbell Avenue, #1968C, Tucson, AZ, 85724, USA.
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20
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Abu Al Hamayel N, Waldfogel JM, Hannum SM, Brodsky RA, Bolaños-Meade J, Gamper CJ, Jones RJ, Dy SM. Pain Experiences of Adults With Sickle Cell Disease and Hematopoietic Stem Cell Transplantation: A Qualitative Study. Pain Med 2021; 22:1753-1759. [PMID: 33674866 DOI: 10.1093/pm/pnaa464] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Despite increasing use of hematopoietic stem cell transplantation (HSCT) for adults with sickle cell disease (SCD), little is known about pain management experiences throughout this process. The objective of this study was to explore patients' experiences with pain and pain management during and after HSCT for SCD. METHODS We conducted a qualitative interview study with 10 patients who underwent HSCT for SCD. We transcribed interviews verbatim and inductively identified codes. We used thematic analysis alongside a constant comparative method to develop and refine a codebook that aided in the identification of themes. RESULTS Four key themes emerged. (1) The pain trajectory: patients described a fluctuating course of pain during HSCT, which often extended long afterwards and impacted all aspects of life, particularly affected by pre-HSCT experiences; (2) The role of opioids-a double-edged sword: patients described opioids as reducing pain but insufficiently to balance significant adverse effects and burden; (3) Patient-centered decision making in pain management: patients described insufficient agency in decisions about opioid use and weaning; and (4) Consequences of health-related stigma: patients described experiences with stigma, mainly related to opioid use and weaning, as similar to pre-HSCT. CONCLUSIONS From the perspective of patients who have undergone HSCT for SCD, clinicians should use a patient-centered approach, integrating non-opioid approaches into pain management, particularly psychosocial support. As transplant for SCD becomes increasingly available, incorporating patient perspectives may improve health care delivery and overall patient experiences.
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Affiliation(s)
- Nebras Abu Al Hamayel
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Medical Education, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Julie M Waldfogel
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Susan M Hannum
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Robert A Brodsky
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins and Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Javier Bolaños-Meade
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins and Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher J Gamper
- Division of Pediatric Oncology, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins and Johns Hopkins University School of Medicine
| | - Richard J Jones
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins and Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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21
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Yu J, Gerber GF, Chen H, Yuan X, Chaturvedi S, Braunstein EM, Brodsky RA. Complement dysregulation is associated with severe COVID-19 illness. Haematologica 2021; 107:1095-1105. [PMID: 34289657 PMCID: PMC9052917 DOI: 10.3324/haematol.2021.279155] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may manifest as thrombosis, stroke, renal failure, myocardial infarction, and thrombocytopenia, reminiscent of other complement- mediated diseases. Multiple clinical and preclinical studies have implicated complement in the pathogenesis of COVID-19 illness. We previously found that the SARS-CoV-2 spike protein activates the alternative pathway of complement (APC) in vitro through interfering with the function of complement factor H, a key negative regulator of APC. Here, we demonstrated that serum from 58 COVID-19 patients (32 patients with minimal oxygen requirement, 7 on high flow oxygen, 17 requiring mechanical ventilation and 2 deaths) can induce complementmediated cell death in a functional assay (the modified Ham test) and increase membrane attack complex (C5b-9) deposition on the cell surface. A positive modified Ham assay (>20% cell-killing) was present in 41.2% COVID-19 patients requiring intubation (n=7/17) and only 6.3% in COVID-19 patients requiring minimal oxygen support (n=2/32). C5 and factor D inhibition effectively mitigated the complement amplification induced by COVID-19 patient serum. Increased serum factor Bb level was associated with disease severity in COVID-19 patients, suggesting that APC dysregulation plays an important role. Moreover, SARS-CoV-2 spike proteins directly block complement factor H from binding to heparin, which may lead to complement dysregulation on the cell surface. Taken together, our data suggest that complement dysregulation contributes to the pathogenesis of COVID-19 and may be a marker of disease severity.
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Affiliation(s)
- Jia Yu
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Gloria F Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Hang Chen
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Xuan Yuan
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
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22
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Kulasekararaj AG, Brodsky RA, Hill A. Monitoring of patients with paroxysmal nocturnal hemoglobinuria on a complement inhibitor. Am J Hematol 2021; 96:E232-E235. [PMID: 33780028 DOI: 10.1002/ajh.26176] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Robert A. Brodsky
- Division of Hematology Johns Hopkins School of Medicine Baltimore Maryland
| | - Anita Hill
- Department of Haematology Leeds Teaching Hospitals Leeds UK
- Alexion Pharmaceuticals, Inc. 121 Seaport Blvd Boston Massachusetts
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Brodsky RA. Factor B inhibition for paroxysmal nocturnal haemoglobinuria. Lancet Haematol 2021; 8:e309-e310. [PMID: 33765418 DOI: 10.1016/s2352-3026(21)00061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Robert A Brodsky
- Department of Medicine, Division of Hematology, John Hopkins University, Baltimore, MD, USA.
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Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, clonal, complement-mediated hemolytic anemia with protean manifestations. PNH can present as a hemolytic anemia, a form of bone marrow failure, a thrombophilia, or any combination of the above. Terminal complement inhibition is highly effective for treating intravascular hemolysis from PNH and virtually eliminates the risk of thrombosis, but is not effective for treating bone marrow failure. Here, I present a variety of clinical vignettes that highlight the clinical heterogeneity of PNH and the attributes and limitations of the 2 US Food and Drug Administration-approved C5 inhibitors (eculizumab and ravulizumab) to treat PNH. I review the concept of pharmacokinetic and pharmacodynamic breakthrough hemolysis and briefly discuss new complement inhibitors upstream of C5 that are in clinical development. Last, I discuss the rare indications for bone marrow transplantation in patients with PNH.
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25
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Chaturvedi S, Braunstein EM, Brodsky RA. Antiphospholipid syndrome: Complement activation, complement gene mutations, and therapeutic implications. J Thromb Haemost 2021; 19:607-616. [PMID: 32881236 PMCID: PMC8080439 DOI: 10.1111/jth.15082] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome (APS) is an acquired thromboinflammatory disorder characterized by the presence of antiphospholipid antibodies as well as an increased frequency of venous or arterial thrombosis and/or obstetrical morbidity. The spectrum of disease varies from asymptomatic to a severe form characterized by widespread thrombosis and multiorgan failure, termed catastrophic APS (CAPS). CAPS affects only about ∼1% of APS patients, often presents as a thrombotic microangiopathy and has a fulminant course with >40% mortality, despite the best available therapy. Animal models have implicated complement in the pathophysiology of thrombosis in APS, with more recent data from human studies confirming the interaction between the coagulation and complement pathways. Activation of the complement cascade via antiphospholipid antibodies can cause cellular injury and promote coagulation via multiple mechanisms. Finally, analogous to classic complement-mediated diseases such as atypical hemolytic uremic syndrome, a subset of patients with APS may be at increased risk for development of CAPS because of the presence of germline variants in genes crucial for complement regulation. Together, these data make complement inhibition an attractive and potentially lifesaving therapy to mitigate morbidity and mortality in severe thrombotic APS and CAPS.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tomazos I, Sierra JR, Johnston KM, Cheung A, Brodsky RA, Weitz IC. Cost burden of breakthrough hemolysis in patients with paroxysmal nocturnal hemoglobinuria receiving ravulizumab versus eculizumab. ACTA ACUST UNITED AC 2021; 25:327-334. [PMID: 32856539 DOI: 10.1080/16078454.2020.1807226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objectives: Although complement inhibition is highly effective, patients with paroxysmal nocturnal hemoglobinuria (PNH) may experience intravascular breakthrough hemolysis (BTH). Underlying causes may include elevated free C5, pregnancy, or non-pregnancy complement-activating conditions (e.g. infections). This study compared BTH-related resource utilization and costs in PNH patients treated with eculizumab versus ravulizumab. Methods: A cost model was developed using data from a targeted literature review and a survey of experienced clinicians. Costs associated with BTH episodes were calculated by cause and weighted by the proportion attributed to each cause and the cost of treating each episode. The model captured direct medical costs in 2018 US dollars. Annual BTH-related healthcare resource utilization was also calculated. Results: BTH episodes in the literature were commonly associated with elevated lactate dehydrogenase and aspartate aminotransferase, hemoglobinuria, transfusion needs, and/or recurrence of PNH symptoms. The majority of BTH management costs in eculizumab-treated patients related to changing from the approved dosing regimen following an episode of BTH, rather than acute management. No ongoing dosing changes were expected for ravulizumab-treated patients following episodes of BTH, substantially reducing its ongoing management costs. Resource utilization was greater for eculizumab-treated patients than ravulizumab-treated patients due to higher incidence of BTH, and risk of elevated free C5-related BTH. Total incremental cost was substantially lower for ravulizumab- vs eculizumab-treated patients ($407 vs $9379); results were consistent when pregnant women were not included ($386 vs $3472). Conclusion: Overall resource use and costs for BTH are estimated to be lower for PNH patients receiving ravulizumab compared with eculizumab.
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Affiliation(s)
| | | | | | - Antoinette Cheung
- Broadstreet Health Economics and Outcomes Research, Vancouver, Canada
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ilene C Weitz
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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27
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Kulasekararaj AG, Hill A, Langemeijer S, Wells R, González Fernández FA, Gaya A, Ojeda Gutierrez E, Piatek CI, Mitchell L, Usuki K, Bosi A, Brodsky RA, Ogawa M, Yu J, Ortiz S, Röth A, Lee JW, Peffault de Latour R. One-year outcomes from a phase 3 randomized trial of ravulizumab in adults with paroxysmal nocturnal hemoglobinuria who received prior eculizumab. Eur J Haematol 2021; 106:389-397. [PMID: 33301613 PMCID: PMC8246907 DOI: 10.1111/ejh.13564] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 08/27/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Ravulizumab every 8 weeks showed non‐inferiority to eculizumab every 2 weeks in a 26‐week, phase 3, randomized controlled trial in adults with paroxysmal nocturnal hemoglobinuria (PNH) who were clinically stable on eculizumab (NCT03056040). We report results from the first 26 weeks of the extension period in which patients continued ravulizumab (n = 96) or switched from eculizumab to ravulizumab (n = 95). At week 52, mean (SD) lactate dehydrogenase levels increased 8.8% (29%) with ravulizumab‐ravulizumab and 5.8% (27%) with eculizumab‐ravulizumab from primary evaluation period baseline. During the extension period, four patients (ravulizumab‐ravulizumab, n = 3; eculizumab‐ravulizumab, n = 1) experienced breakthrough hemolysis, but none associated with serum free C5 ≥ 0.5 μg/mL. Mean Functional Assessment of Chronic Illness Therapy (FACIT)‐Fatigue scores remained stable through week 52. During the extension period, proportions of patients avoiding transfusion remained stable (ravulizumab‐ravulizumab, 86.5%; eculizumab‐ravulizumab, 83.2%); 81.2% and 81.1%, respectively, had stabilized hemoglobin. All patients maintained serum free C5 levels < 0.5 μg/mL. Adverse events were generally similar between groups, and rates were lower in the extension period. Adults with PNH on stable eculizumab therapy who received ravulizumab over 52 weeks experienced durable efficacy, with consistent efficacy in patients who received eculizumab during the primary evaluation period and then switched to ravulizumab. Ravulizumab was well tolerated.
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Affiliation(s)
- Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, National Institute of Health Research/Wellcome King's Clinical Research Facility and King's College London, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | - Richard Wells
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - F Ataúlfo González Fernández
- Department of Hematology, Hospital Clinico Universitario San Carlos, The Clınic Institute of Haematological and Oncological Diseases, Madrid, Spain
| | - Anna Gaya
- Department of Hematology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Caroline I Piatek
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | - Alberto Bosi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Robert A Brodsky
- The John Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Ji Yu
- Alexion Pharmaceuticals, Inc., Boston, MA, USA
| | | | - Alexander Röth
- Department of Hematology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Régis Peffault de Latour
- Bone Marrow Transplantation Unit, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital and University Paris Diderot, Paris, France.,Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, the Netherlands
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Brodsky RA, Peffault de Latour R, Rottinghaus ST, Röth A, Risitano AM, Weitz IC, Hillmen P, Maciejewski JP, Szer J, Lee JW, Kulasekararaj AG, Volles L, Damokosh AI, Ortiz S, Shafner L, Liu P, Hill A, Schrezenmeier H. Characterization of breakthrough hemolysis events observed in the phase 3 randomized studies of ravulizumab versus eculizumab in adults with paroxysmal nocturnal hemoglobinuria. Haematologica 2021; 106:230-237. [PMID: 31949012 PMCID: PMC7776354 DOI: 10.3324/haematol.2019.236877] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [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: 09/03/2019] [Accepted: 01/09/2020] [Indexed: 11/28/2022] Open
Abstract
Eculizumab is first-line treatment for paroxysmal nocturnal hemoglobinuria (PNH); however, approximately 11-27% of patients may experience breakthrough hemolysis (BTH) on approved doses of eculizumab. Ravulizumab, a new long-acting C5 inhibitor with a four times longer mean half-life than eculizumab, provides immediate, complete, and sustained C5 inhibition over 8-week dosing intervals. In two phase III studies, ravulizumab was non-inferior to eculizumab (Pinf ≤0.0004) for the BTH endpoint; fewer patients experienced BTH with ravulizumab versus eculizumab in both studies (301 [complement inhibitor−naïve patients], 4.0% vs. 10.7%; 302 [patients stabilized on eculizumab at baseline], 0% vs. 5.1%). In the current analysis, patientlevel data were evaluated to assess causes and clinical parameters associated with incidents of BTH reported during the 26-week treatment periods in the ravulizumab phase III PNH studies. Of the five BTH events occurring in ravulizumab-treated patients across the studies, none were temporally associated with suboptimal C5 inhibition (free C5 ≥0.5 mg/mL); four (80%) were temporally associated with complement-amplifying conditions (CAC). Of the 22 events occurring in eculizumab-treated patients, 11 were temporally associated with suboptimal C5 inhibition, including three events also associated with concomitant infection. Six events were associated with CAC only. Five events were unrelated to free C5 elevation or reported CAC. These results suggest that the immediate, complete, and sustained C5 inhibition achieved through weight-based dosing of ravulizumab reduces the risk of BTH by eliminating BTH associated with suboptimal C5 inhibition in patients with PNH. (Registered at clinicaltrials.gov identifiers: Study 301, NCT02946463; Study 302, NCT03056040.)
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Affiliation(s)
- Robert A Brodsky
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Alexander Röth
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen
| | - Antonio M Risitano
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples
| | - Ilene C Weitz
- Jane Anne Nohl Division of Hematology, Keck-USC School of Medicine, Los Angeles, CA, USA
| | - Peter Hillmen
- Department of Haematology, St James's University Hospital, Leeds
| | | | - Jeff Szer
- Clinical Haematology, Royal Melbourne Hospital, Melbourne
| | - Jong Wook Lee
- The Catholic University of Korea, College of Medicine, Seoul
| | | | | | | | | | | | - Peng Liu
- Alexion Pharmaceuticals, Inc., Boston, MA
| | - Anita Hill
- Department of Haematology, St James's University Hospital, Leeds
| | - Hubert Schrezenmeier
- German Red Cross Blood Transfusion Service, Baden-Wurttemberg-Hessen and University Hospital Ulm
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29
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de Castro C, Grossi F, Weitz IC, Maciejewski J, Sharma V, Roman E, Brodsky RA, Tan L, Di Casoli C, El Mehdi D, Deschatelets P, Francois C. C3 inhibition with pegcetacoplan in subjects with paroxysmal nocturnal hemoglobinuria treated with eculizumab. Am J Hematol 2020; 95:1334-1343. [PMID: 33464651 PMCID: PMC7693064 DOI: 10.1002/ajh.25960] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/21/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired, life-threatening hematologic disease characterized by chronic complement-mediated hemolysis and thrombosis. Despite treatment with eculizumab, a C5 inhibitor, 72% of individuals remain anemic. Pegcetacoplan (APL-2), a PEGylated C3 inhibitor, has the potential to provide more complete hemolysis control in patients with PNH. This open-label, phase Ib study was designed to assess the safety, tolerability, and pharmacokinetics of pegcetacoplan in subjects with PNH who remained anemic during treatment with eculizumab. Pharmacodynamic endpoints were also assessed as an exploratory objective of this study. Data are presented for six subjects in cohort 4 who received treatment for up to 2 years. In total, 427 treatment-emergent adverse events (TEAEs) were reported, 68 of which were possibly related to the study drug. Eight serious TEAEs occurred in two subjects; three of these events were considered possibly related to the study drug. Pegcetacoplan pharmacokinetic concentrations accumulated with repeated dosing, and steady state was reached at approximately 6-8 weeks. Lactate dehydrogenase levels were well controlled by eculizumab at baseline. Pegcetacoplan increased hemoglobin levels and decreased both reticulocyte count and total bilirubin in all six subjects. Improvements were observed in Functional Assessment of Chronic Illness Therapy Fatigue scores. Two subjects discontinued for reasons unrelated to pegcetacoplan. All four subjects who completed the study transitioned to pegcetacoplan monotherapy following eculizumab discontinuation and avoided transfusions. In this small study, pegcetacoplan therapy was generally well-tolerated, and resulted in an improved hematological response by achieving broad hemolysis control, enabling eculizumab discontinuation.
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MESH Headings
- Adult
- Anemia, Hemolytic/drug therapy
- Anemia, Hemolytic/etiology
- Anemia, Hemolytic/prevention & control
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Bilirubin/blood
- Chemical and Drug Induced Liver Injury/etiology
- Complement C3/antagonists & inhibitors
- Complement C5/antagonists & inhibitors
- Drug Substitution
- Female
- Fever/chemically induced
- Hemoglobins/analysis
- Hemoglobinuria, Paroxysmal/blood
- Hemoglobinuria, Paroxysmal/drug therapy
- Hemoglobinuria, Paroxysmal/immunology
- Hemolysis/drug effects
- Humans
- L-Lactate Dehydrogenase/blood
- Male
- Middle Aged
- Pancreatitis/chemically induced
- Prospective Studies
- Reticulocyte Count
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Affiliation(s)
| | | | | | - Jaroslaw Maciejewski
- Translational Hematology and Oncology ResearchTaussig Cancer InstituteClevelandOhioUSA
| | | | | | | | - Lisa Tan
- Lisa Tan Pharma Consulting LtdCambridgeUK
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30
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Yuan X, Yu J, Gerber G, Chaturvedi S, Cole M, Chen H, Metjian A, Sperati CJ, Braunstein EM, Brodsky RA. Ex vivo assays to detect complement activation in complementopathies. Clin Immunol 2020; 221:108616. [PMID: 33148511 DOI: 10.1016/j.clim.2020.108616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 08/18/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022]
Abstract
In complement-driven thrombotic microangiopathies, failure to regulate complement activation leads to end-organ damage. The modified Ham (mHam) test measures complement-mediated killing of a nucleated cell in vitro but lacks a confirmatory assay and reliable positive controls. We demonstrate that C5b-9 accumulation on the surface of TF1 PIGAnull cells correlates with cell killing in the mHam. We also show that Sialidase treatment of cells or addition of Shiga toxin 1 to human serum serve as a more reliable positive control for the mHam than cobra venom factor or lipopolysaccharide. Simultaneously performing the mHam and measuring C5b-9 accumulation either in GVB++ or GVB0 MgEGTA buffer with the addition of complement pathway specific inhibitors (anti-C5 antibody or a factor D inhibitor, ACH-145951) can be used to localize defects in complement regulation. As more targeted complement inhibitors become available, these assays may aid in the selection of personalized treatments for patients with complement-mediated diseases.
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Affiliation(s)
- Xuan Yuan
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jia Yu
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gloria Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael Cole
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hang Chen
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ara Metjian
- Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA
| | - C John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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31
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DeZern AE, Elmariah H, Zahurak M, Rosner GL, Gladstone DE, Ali SA, Huff CA, Swinnen LJ, Imus P, Borrello I, Wagner-Johnston ND, Ambinder RF, Brodsky RA, Cooke K, Luznik L, Fuchs EJ, Bolaños-Meade J, Jones RJ. Shortened-Duration Immunosuppressive Therapy after Nonmyeloablative, Related HLA-Haploidentical or Unrelated Peripheral Blood Grafts and Post-Transplantation Cyclophosphamide. Biol Blood Marrow Transplant 2020; 26:2075-2081. [PMID: 32818556 DOI: 10.1016/j.bbmt.2020.07.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022]
Abstract
With post-transplantation cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis, nonmyeloablative (NMA) HLA-haploidentical (haplo) and HLA-matched blood or marrow transplantation (BMT) have comparable outcomes. Previous reports have shown that discontinuation of immunosuppression (IS) as early as day 60 after infusion of a bone marrow (BM) haplo allograft with PTCy is feasible. There are certain diseases in which peripheral blood (PB) may be favored over BM, but given the higher rates of GVHD with PB, excessive GVHD is of increased concern. We report a completed, prospective single-center trial of stopping IS at days 90 and 60 after NMA PB stem cell transplantation (PBSCT). Between 12/2015-7/2018, 117 consecutive patients with hematologic malignancies associated with higher rates of graft failure after NMA conditioned BMT and PTCy, received NMA PB allografts on trial. The primary objective of this study was to evaluate the safety and feasibility of reduced-duration IS (from day 5 through day 90 in the D90 cohort and through day 60 in the D60 cohort). Of the 117 patients (median age, 64 years; range, 22 to 78 years), the most common diagnoses were myelodysplastic syndrome (33%), acute myelogenous leukemia (with minimal residual disease or arising from an antecedent disorder) (32%), myeloproliferative neoplasms (19%), myeloma (9%), and chronic lymphoblastic leukemia (7%). Shortened IS was feasible in 75 patients (64%) overall. Ineligibility for shortened IS resulted most commonly from GVHD (17 patients), followed by early relapse (11 patients), nonrelapse mortality (NRM) (7 patients), patient/ physician preference (4 patients) or graft failure (3 patients). Of the 57 patients in the D90 cohort, 33 (58%) stopped IS early as planned, and among the 60 patients in the D60 cohort, 42 (70%) stopped IS early as planned. The graft failure rate was 2.6%. After IS cessation, the median time to diagnosis of grade II-IV acute GVHD was 21 days in the D90 cohort and 32 days in the D60 cohort, with almost all cases developing within 40 days. Approximately one-third of these patients resumed IS. All outcome measures were similar in the 2 cohorts and our historical outcomes with 180 days of IS. The cumulative incidence of grade III-IV acute GVHD was low, 2% in the D90 cohort and 7% in the D60 cohort. The incidence of severe chronic GVHD at 2 years was 9% in the D90 cohort and 5% in the D60 cohort. The 2-year overall survival was 67% for both the D90 and D60 cohorts. The 2-year progression-free survival was 47% for the D90 cohort and 52% for the D60 cohort, and the GVHD-free, relapse-free survival was <35% for both cohorts. These data suggest that reduced-duration IS in patients undergoing NMA PBSCT with PTCy is feasible and has an acceptable safety profile. © 2020 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland.
| | - Hany Elmariah
- Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | - Marianna Zahurak
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Gary L Rosner
- Department of Oncology Biostatistics, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Douglas E Gladstone
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Syed Abbas Ali
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Carol Ann Huff
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Lode J Swinnen
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Phil Imus
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ivan Borrello
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Nina D Wagner-Johnston
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Richard F Ambinder
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Robert A Brodsky
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Kenneth Cooke
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Leo Luznik
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Ephraim J Fuchs
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Javier Bolaños-Meade
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland; Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Pediatric Oncology, Sidney Kimmel Cancer Center, Baltimore, Maryland
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Affiliation(s)
- Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael R DeBaun
- Vanderbilt-Meharry Sickle Cell Disease Center of Excellence, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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33
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Chen JY, Galwankar NS, Emch HN, Menon SS, Cortes C, Thurman JM, Merrill SA, Brodsky RA, Ferreira VP. Properdin Is a Key Player in Lysis of Red Blood Cells and Complement Activation on Endothelial Cells in Hemolytic Anemias Caused by Complement Dysregulation. Front Immunol 2020; 11:1460. [PMID: 32793201 PMCID: PMC7387411 DOI: 10.3389/fimmu.2020.01460] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 11/07/2019] [Accepted: 06/04/2020] [Indexed: 12/18/2022] Open
Abstract
The complement system alternative pathway (AP) can be activated excessively in inflammatory diseases, particularly when there is defective complement regulation. For instance, deficiency in complement regulators CD55 and CD59, leads to paroxysmal nocturnal hemoglobinuria (PNH), whereas Factor H mutations predispose to atypical hemolytic uremic syndrome (aHUS), both causing severe thrombohemolysis. Despite eculizumab being the treatment for these diseases, benefits vary considerably among patients. Understanding the molecular mechanisms involved in complement regulation is essential for developing new treatments. Properdin, the positive AP regulator, is essential for complement amplification by stabilizing enzymatic convertases. In this study, the role of properdin in red blood cell (RBC) lysis and endothelial cell opsonization in these AP-mediated diseases was addressed by developing in vitro assays using PNH patient RBCs and human primary endothelial cells, where the effects of inhibiting properdin, using novel monoclonal antibodies (MoAbs) that we generated and characterized, were compared to other complement inhibitors. In in vitro models of PNH, properdin inhibition prevented hemolysis of patient PNH type II and III RBCs more than inhibition of Factor B, C3, and C5 (>17-fold, or >81-fold, or >12-fold lower molar IC90 values, respectively). When tested in an in vitro aHUS hemolysis model, the anti-properdin MoAbs had 11-fold, and 86-fold lower molar IC90 values than inhibition of Factor B, or C3, respectively (P < 0.0001). When comparing target/inhibitor ratios in all hemolysis assays, inhibiting properdin was at least as efficient as the other complement inhibitors in most cases. In addition, using in vitro endothelial cell assays, the data indicate a critical novel role for properdin in promoting complement activation on human endothelial cells exposed to heme (a hemolysis by-product) and rH19-20 (to inhibit Factor H cell-surface protection), as occurs in aHUS. Inhibition of properdin or C3 in this system significantly reduced C3 fragment deposition by 75%. Altogether, the data indicate properdin is key in promoting RBC lysis and complement activation on human endothelial cells, contributing to the understanding of PNH and aHUS pathogenesis. Further studies to determine therapeutic values of inhibiting properdin in complement-mediated diseases, in particular those that are characterized by AP dysregulation, are warranted.
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Affiliation(s)
- Jin Y Chen
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Neeti S Galwankar
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Heather N Emch
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Smrithi S Menon
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Claudio Cortes
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Joshua M Thurman
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Samuel A Merrill
- Section of Hematology/Oncology, Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, United States
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
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Peffault de Latour R, Brodsky RA, Ortiz S, Risitano AM, Jang JH, Hillmen P, Kulagin AD, Kulasekararaj AG, Rottinghaus ST, Aguzzi R, Gao X, Wells RA, Szer J. Pharmacokinetic and pharmacodynamic effects of ravulizumab and eculizumab on complement component 5 in adults with paroxysmal nocturnal haemoglobinuria: results of two phase 3 randomised, multicentre studies. Br J Haematol 2020; 191:476-485. [PMID: 32449174 PMCID: PMC7687070 DOI: 10.1111/bjh.16711] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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: 11/06/2019] [Accepted: 04/10/2020] [Indexed: 02/04/2023]
Abstract
Ravulizumab, a novel long‐acting complement component 5 (C5) inhibitor administered every 8 weeks (q8w), was non‐inferior to eculizumab for all efficacy outcomes in two randomised, open‐label, phase 3 trials in C5 inhibitor‐naïve (Study 301) and eculizumab‐experienced (Study 302) adult patients with paroxysmal nocturnal haemoglobinuria (PNH). This pre‐specified analysis characterised ravulizumab pharmacokinetics (PK), pharmacodynamics (PD; free C5 levels), and PD differences between medications (Study 301, n = 246; Study 302, n = 195). Ravulizumab PK parameters were determined using non‐compartmental analysis. Serum free C5 was quantified with a Gyros‐based fluorescence assay (ravulizumab) and an electrochemiluminescence ligand‐binding assay (eculizumab). Ravulizumab PK parameters were numerically comparable in both studies; the median time to maximum concentrations ranged from 2·3 to 2·8 and 2·3 to 2·6 h in studies 301 and 302, respectively. Ravulizumab steady‐state serum concentrations were achieved immediately after the first dose and sustained throughout treatment. For ravulizumab, the mean (SD) post hoc terminal elimination half‐life was 49·7 (8·9) days. Serum free C5 concentrations <0·5 µg/ml were achieved after the first ravulizumab dose and sustained throughout treatment in both studies. In a minority of patients, free C5 concentrations <0·5 µg/ml were not consistently achieved with eculizumab in either study. Ravulizumab q8w was more consistent in providing immediate, complete, sustained C5 inhibition than eculizumab every‐2‐weeks in patients with PNH.
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Affiliation(s)
- Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and PNH Hematology-Bone Marrow Transplantation, Hôpital Saint-Louis AP-HP, Paris, France.,Université Paris Diderot, Paris, France
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Antonio M Risitano
- Hematology, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Jun H Jang
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Peter Hillmen
- Department of Haematology, St. James's University Hospital, Leeds, UK
| | - Alexander D Kulagin
- Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, NIHR/Wellcome King's Clinical Research Facility, London, UK
| | | | | | - Xiang Gao
- Alexion Pharmaceuticals, Inc., Boston, MA, USA
| | - Richard A Wells
- Division of Medical Oncology and Haematology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeff Szer
- Clinical Haematology at Peter MacCallum Cancer Centre, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
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35
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department – BMT Unit G Papanicolaou Hospital Thessaloniki Greece
| | - Robert A. Brodsky
- Division of Hematology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD USA
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36
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Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired disorder characterized by hemolysis, thrombosis, and bone marrow failure caused by defective expression of glycosylphosphatidylinositol-anchored (GPI-anchored) complement inhibitors. Most commonly, PNH is caused by loss of function of PIGA, which is required for GPI biosynthesis. In this issue of the JCI, Höchsmann et al. report on 4 PNH patients who also had marked autoinflammatory manifestations, including aseptic meningitis. All 4 patients had a germline mutation of the related gene PIGT and a somatically acquired myeloid common deleted region (CDR) on chromosome 20q that deleted the second PIGT allele. The biochemistry and clinical manifestations indicate that these patients have subtle but important differences from those with PNH resulting from PIGA mutations, suggesting PIGT-PNH may be a distinct clinical entity.
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Abstract
The renaissance of complement diagnostics and therapeutics has introduced precision medicine into a widened field of complement-mediated diseases. In particular, complement-mediated diseases (or complementopathies) with ongoing or published clinical trials of complement inhibitors include paroxysmal nocturnal hemoglobinuria, cold agglutinin disease, hemolytic uremic syndrome, nephropathies, HELLP syndrome, transplant-associated thrombotic microangiopathy, antiphospholipid antibody syndrome, myasthenia gravis, and neuromyelitis optica. Recognizing that this field is rapidly expanding, we aim to provide a state-of-the-art review of (a) current understanding of complement biology for the clinician, (b) novel insights into complement with potential applicability to clinical practice, (c) complement in disease across various disciplines (hematology, nephrology, obstetrics, transplantation, rheumatology, and neurology), and (d) the potential future of precision medicine. Better understanding of complement diagnostics and therapeutics will not only facilitate physicians treating patients in clinical practice but also provide the basis for future research toward precision medicine in this field.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Vaught AJ, Braunstein E, Chaturvedi S, Blakemore K, Brodsky RA. A review of the alternative pathway of complement and its relation to HELLP syndrome: is it time to consider HELLP syndrome a disease of the alternative pathway. J Matern Fetal Neonatal Med 2020; 35:1392-1400. [PMID: 32338085 DOI: 10.1080/14767058.2020.1755650] [Citation(s) in RCA: 4] [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] [Indexed: 12/27/2022]
Abstract
Complement is a part of the innate immune system with a critical role in host defense. Although essential for survival, when dysregulated or excessively triggered complement activation can cause tissue damage and drive inflammatory and immune disorders. The alternative pathway of complement (APC) is especially important for survival against infection and can be triggered by a variety of settings: infection, trauma, surgery, or pregnancy. This excessive drive of complement manifest distinctive hemolytic diseases like atypical hemolytic uremic syndrome (aHUS) and paroxysmal nocturnal hemoglobinuria (PNH). These diseases share phenotypic similarities to HELLP syndrome: a hypertensive disorder of pregnancy with hemolysis, elevated liver enzymes, and low platelets. In this manuscript, there will be a brief review of complement activation and a description of important regulator proteins. The review will further discuss pregnancy as a major trigger of the alternative pathway, and how diseases of the APC are treated during pregnancy. Finally, the similarities between HELLP syndrome and diseases of the APC will be examined.
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Affiliation(s)
- Arthur J Vaught
- Division of Maternal Fetal Medicine, The Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Evan Braunstein
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karin Blakemore
- Division of Maternal Fetal Medicine, The Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Gavriilaki E, Touloumenidou T, Sakellari I, Batsis I, Mallouri D, Psomopoulos F, Tsagiopoulou M, Koutra M, Yannaki E, Papalexandri A, Taylor P, Nikolousis E, Stamouli M, Holbro A, Baltadakis I, Liga M, Spyridonidis A, Tsirigotis P, Charchalakis N, Tsakiris DA, Brodsky RA, Passweg J, Stamatopoulos K, Anagnostopoulos A. Pretransplant Genetic Susceptibility: Clinical Relevance in Transplant-Associated Thrombotic Microangiopathy. Thromb Haemost 2020; 120:638-646. [DOI: 10.1055/s-0040-1702225] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractTransplant-associated thrombotic microangiopathy (TA-TMA) is a life-threatening complication of allogeneic hematopoietic cell transplantation (HCT). We hypothesized that pretransplant genetic susceptibility is evident in adult TA-TMA and further investigated the association of TMA-associated variants with clinical outcomes. We studied 40 patients with TA-TMA, donors of 18 patients and 40 control non-TMA HCT recipients, without significant differences in transplant characteristics. Genomic DNA from pretransplant peripheral blood was sequenced for TMA-associated genes. Donors presented significantly lower frequency of rare variants and variants in exonic/splicing/untranslated region (UTR) regions, compared with TA-TMA patients. Controls also showed a significantly lower frequency of rare variants in ADAMTS13, CD46, CFH, and CFI. The majority of TA-TMA patients (31/40) presented with pathogenic or likely pathogenic variants. Patients refractory to conventional treatment (62%) and patients that succumbed to transplant-related mortality (65%) were significantly enriched for variants in exonic/splicing/UTR regions. In conclusion, increased incidence of pathogenic, rare and variants in exonic/splicing/UTR regions of TA-TMA patients suggests genetic susceptibility not evident in controls or donors. Notably, variants in exonic/splicing/UTR regions were associated with poor response and survival. Therefore, pretransplant genomic screening may be useful to intensify monitoring and early intervention in patients at high risk for TA-TMA.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department–BMT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Ioanna Sakellari
- Hematology Department–BMT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioannis Batsis
- Hematology Department–BMT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Despina Mallouri
- Hematology Department–BMT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Fotis Psomopoulos
- Department of Hematology, Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Maria Tsagiopoulou
- Department of Hematology, Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Maria Koutra
- Hematology Department–BMT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Evangelia Yannaki
- Hematology Department–BMT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Pat Taylor
- Department of Haematology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Emmanuel Nikolousis
- Department of Haematology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Maria Stamouli
- Division of Hematology, Second Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Holbro
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Ioannis Baltadakis
- Department of Hematology, Bone Marrow Transplantation Unit, Evangelismos Hospital, Athens, Greece
| | - Maria Liga
- Department of Hematology, BMT Unit, University Hospital of Patras, Patras, Greece
| | | | - Panagiotis Tsirigotis
- Division of Hematology, Second Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Charchalakis
- Department of Hematology, Bone Marrow Transplantation Unit, Evangelismos Hospital, Athens, Greece
| | - Dimitrios A. Tsakiris
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Jacob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Kostas Stamatopoulos
- Department of Hematology, Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
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40
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Shen J, Zhu Y, Lyu C, Feng Z, Lyu S, Zhao Y, Hoyle DL, Ji G, Miao W, Zhang X, Cheng L, Brodsky RA, Cheng T, Wang ZZ. Sequential cellular niches control the generation of enucleated erythrocytes from human pluripotent stem cells. Haematologica 2020; 105:e48-e51. [PMID: 31197070 DOI: 10.3324/haematol.2018.211664] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jun Shen
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yaoyao Zhu
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Cuicui Lyu
- Department of Hematology, the First Central Hospital of Tianjin, Tianjin, China
| | - Zicen Feng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shuzhen Lyu
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yuping Zhao
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Dixie L Hoyle
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guangzhen Ji
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Weimin Miao
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Key Laboratory of Blood Cell Therapy and Technology, Tianjin, China
| | - Xiaobing Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Department of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Linzhao Cheng
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tao Cheng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China .,Center for Stem Cell Medicine, Chinese Academy of Medical Sciences, Tianjin, China.,Department of Stem Cell & Regenerative Medicine, Peking Union Medical College, Tianjin, China
| | - Zack Z Wang
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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41
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Chaturvedi S, Braunstein EM, Yuan X, Yu J, Alexander A, Chen H, Gavriilaki E, Alluri R, Streiff MB, Petri M, Crowther MA, McCrae KR, Brodsky RA. Complement activity and complement regulatory gene mutations are associated with thrombosis in APS and CAPS. Blood 2020; 135:239-251. [PMID: 31812994 PMCID: PMC6978159 DOI: 10.1182/blood.2019003863] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/19/2019] [Indexed: 12/19/2022] Open
Abstract
The antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies, including anti-β2-glycoprotein-I (anti-β2GPI), that are considered central to APS pathogenesis. Based on animal studies showing a role of complement in APS-related clinical events, we used the modified Ham (mHam) assay (complement-dependent cell killing) and cell-surface deposition of C5b-9 to test the hypothesis that complement activation is associated with thrombotic events in APS. A positive mHam (and corresponding C5b-9 deposition) were present in 85.7% of catastrophic APS (CAPS), 35.6% of APS (and 68.5% of samples collected within 1 year of thrombosis), and only 6.8% of systemic lupus erythematosus (SLE) sera. A positive mHam assay was associated with triple positivity (for lupus anticoagulant, anticardiolipin, and anti-β2GPI antibodies) and recurrent thrombosis. Patient-derived anti-β2GPI antibodies also induced C5b-9 deposition, which was blocked completely by an anti-C5 monoclonal antibody, but not by a factor D inhibitor, indicating that complement activation by anti-β2GPI antibodies occurs primarily through the classical complement pathway. Finally, patients with CAPS have high rates of rare germline variants in complement regulatory genes (60%), compared with patients with APS (21.8%) or SLE (28.6%) or normal controls (23.3%), and have mutations at a rate similar to that of patients with atypical hemolytic uremic syndrome (51.5%). Taken together, our data suggest that anti-β2GPI antibodies activate complement and contribute to thrombosis in APS, whereas patients with CAPS have underlying mutations in complement regulatory genes that serve as a "second hit," leading to uncontrolled complement activation and a more severe thrombotic phenotype.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xuan Yuan
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jia Yu
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alice Alexander
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hang Chen
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eleni Gavriilaki
- Department of Hematology, Papanicolaou Hospital, Thessaloniki, Greece
| | - Ravi Alluri
- Division of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Mark A Crowther
- Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Keith R McCrae
- Division of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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43
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Shen J, Lyu C, Zhu Y, Feng Z, Zhang S, Hoyle DL, Ji G, Brodsky RA, Cheng T, Wang ZZ. Defining early hematopoietic-fated primitive streak specification of human pluripotent stem cells by the orchestrated balance of Wnt, activin, and BMP signaling. J Cell Physiol 2019; 234:16136-16147. [PMID: 30740687 PMCID: PMC6689260 DOI: 10.1002/jcp.28272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 11/07/2018] [Revised: 01/16/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
Distinct regions of the primitive streak (PS) have diverse potential to differentiate into several tissues, including the hematopoietic lineage originated from the posterior region of PS. Although various signaling pathways have been identified to promote the development of PS and its mesoderm derivatives, there is a large gap in our understanding of signaling pathways that regulate the hematopoietic fate of PS. Here, we defined the roles of Wnt, activin, and bone morphogenetic protein (BMP) signaling pathways in generating hematopoietic-fated PS from human pluripotent stem cells (hPSCs). We found that the synergistic balance of these signaling pathways was crucial for controlling the PS fate determination towards hematopoietic lineage via mesodermal progenitors. Although the induction of PS depends largely on the Wnt and activin signaling, the PS generated without BMP4 lacks the hematopoietic potential, indicating that the BMP signaling is necessary for the PS to acquire hematopoietic property. Appropriate levels of Wnt signaling is crucial for the development of PS and its specification to the hematopoietic lineage. Although the development of PS is less sensitive to activin or BMP signaling, the fate of PS to mesoderm progenitors and subsequent hematopoietic lineage is determined by appropriate levels of activin or BMP signaling. Collectively, our study demonstrates that Wnt, activin, and BMP signaling pathways play cooperative and distinct roles in regulating the fate determination of PS for hematopoietic development. Our understanding of the regulatory networks of hematopoietic-fated PS would provide important insights into early hematopoietic patterning and possible guidance for generating functional hematopoietic cells from hPSCs in vitro.
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Affiliation(s)
- Jun Shen
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China,Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cuicui Lyu
- Department of Hematology, the First Central Hospital of Tianjin, Tianjin, China
| | - Yaoyao Zhu
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Zicen Feng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Shuo Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China,Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dixie L. Hoyle
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Guangzhen Ji
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Robert A. Brodsky
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tao Cheng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China,Collaborative Innovation Center for Cancer Medicine, Tianjin, China,Tianjin Key Laboratory of Blood Cell Therapy and Technology, Tianjin, China,Correspondence Zack Z. Wang, Division of Hematology, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 1029, Baltimore, MD 21205, USA. ., Tao Cheng, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science, 288 Nanjing Rd, Tianjin 300020, China.
| | - Zack Z. Wang
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Correspondence Zack Z. Wang, Division of Hematology, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 1029, Baltimore, MD 21205, USA. ., Tao Cheng, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science, 288 Nanjing Rd, Tianjin 300020, China.
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44
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Affiliation(s)
- Robert A Brodsky
- From the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
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45
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Merrill SA, Brodsky RA, Lanzkron SM, Naik R. A case-control analysis of hyperhemolysis syndrome in adults and laboratory correlates of complement involvement. Transfusion 2019; 59:3129-3139. [PMID: 31292968 DOI: 10.1111/trf.15445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/10/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hyperhemolysis syndrome (HS) is a poorly understood, severe hemolytic anemia provoked by transfusion. Both host and donor RBCs are destroyed in HS; thus, transfusion paradoxically worsens anemia. Risk factors and mechanism of HS are unknown. STUDY DESIGN AND METHODS A retrospective case-control analysis was performed on adults with HS. Patients with HS were matched 1:1 with matched, transfused controls, and HS risk factors were analyzed with multivariable logistic regression. HS samples were analyzed for complement deposition by flow cytometry, and an in vitro model of bystander hemolysis was developed. RESULTS Forty-one patients with 54 episodes of HS were identified in a 26-year period from 1992 to 2018. Of the HS episodes, only 18.5% were associated with a new alloantibody, and such patients were more tolerant of additional transfusion in the acute episode (p = 0.005). Thirteen percent of episodes were fatal, and HS recurred in 52.6%. Alloimmunization (odds ratio [OR], 17.3), non-B blood type (OR, 9.8), D antigen (OR, 9.1), and infection (OR, 5.5) were associated with HS on multivariable analysis. Hyperbilirubinemia was predictive of fatal HS (OR, 33.6). Increased complement was observed on RBCs during HS episodes, and the in vitro model of bystander hemolysis recapitulated complement decoration of sickled RBCs. CONCLUSIONS HS is associated with significant morbidity, mortality, and recurrence. Risk factors such as known alloimmunization, blood group, and infection predispose to HS. Bystander complement activation may drive HS. These factors may help physicians refine risk-benefit assessments for transfusion and guide further therapeutic development.
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Affiliation(s)
- Samuel A Merrill
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sophie M Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rakhi Naik
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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46
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Abstract
The antiphospholipid syndrome (APS) is characterized by thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). Complement is a system of enzymes and regulatory proteins of the innate immune system that plays a key role in the inflammatory response to pathogenic stimuli. The complement and coagulation pathways are closely linked, and expanding data indicate that complement may be activated in patients with aPL and function as a cofactor in the pathogenesis of aPL-associated clinical events. Complement activation by aPL generates C5a, which induces neutrophil tissue factor-dependent procoagulant activity. Beta-2-glycoprotein I, the primary antigen for pathogenic aPL, has complement regulatory effects in vitro. Moreover, aPL induce fetal loss in wild-type mice but not in mice deficient in specific complement components (C3, C5). Antiphospholipid antibodies also induce thrombosis in wild type mice and this effect is attenuated in C3 or C6 deficient mice, or in the presence of a C5 inhibitor. Increased levels of complement activation products have been demonstrated in sera of patients with aPL, though the association with clinical events remains unclear. Eculizumab, a terminal complement inhibitor, has successfully been used to treat catastrophic APS and prevent APS-related thrombotic microangiopathy in the setting of renal transplant. However, the mechanisms of complement activation in APS, its role in the pathogenesis of aPL related complications in humans, and the potential of complement inhibition as a therapeutic target in APS require further study.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Keith R McCrae
- Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland, OH, United States.,Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH, United States
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47
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Lee JW, Peffault de Latour R, Brodsky RA, Jang JH, Hill A, Röth A, Schrezenmeier H, Wilson A, Marantz JL, Maciejewski JP. Effectiveness of eculizumab in patients with paroxysmal nocturnal hemoglobinuria (PNH) with or without aplastic anemia in the International PNH Registry. Am J Hematol 2019; 94:E37-E41. [PMID: 30370949 DOI: 10.1002/ajh.25334] [Citation(s) in RCA: 10] [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: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Jong Wook Lee
- Department of Hematology; Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Seoul Republic of Korea
| | - Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and PNH; Hôpital Saint-Louis AP-HP; Paris France
- Université Paris Diderot; Paris France
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Jun Ho Jang
- Sungkyunkwan University School of Medicine; Samsung Medical Center; Seoul Republic of Korea
| | - Anita Hill
- Department of Haematology; Leeds Teaching Hospitals; Leeds United Kingdom
| | - Alexander Röth
- Department of Hematology, West German Cancer Center; University Hospital Essen, University of Duisburg-Essen; Essen Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm; Ulm Germany
| | | | | | - Jaroslaw P. Maciejewski
- Department of Translational Hematology and Oncology Research; Taussig Cancer Institute, Cleveland Clinic; Cleveland Ohio
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48
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McCurdy SR, Kanakry CG, Tsai HL, Gojo I, Smith BD, Gladstone DE, Bolaños-Meade J, Borrello I, Matsui WH, Swinnen LJ, Huff CA, Brodsky RA, Ambinder RF, Fuchs EJ, Rosner GL, Jones RJ, Luznik L. Development of Grade II Acute Graft-versus-Host Disease Is Associated with Improved Survival after Myeloablative HLA-Matched Bone Marrow Transplantation using Single-Agent Post-Transplant Cyclophosphamide. Biol Blood Marrow Transplant 2018; 25:1128-1135. [PMID: 30599208 DOI: 10.1016/j.bbmt.2018.12.767] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/26/2018] [Indexed: 01/01/2023]
Abstract
Post-transplant cyclophosphamide (PTCy) can be used as the sole immunosuppression after myeloablative conditioning (MAC) for HLA-matched bone marrow transplantation (BMT). However, the effects of graft-versus-host disease (GVHD) with this platform are undefined. We retrospectively analyzed 298 consecutive adult patients with hematologic malignancies who engrafted after MAC HLA-matched sibling donor (MSD; n = 187) or HLA-matched unrelated donor (MUD; n = 111) T-cell-replete BMT with PTCy 50 mg/kg on days +3 and +4. After MSD and MUD BMT, 35% and 57% of patients, respectively, developed grade II acute GVHD (aGVHD) by 100 days, 11% and 14% grade III to IV aGVHD by 100 days, and 9% and 16% chronic GVHD (cGVHD) by 1 year. In landmark analyses at 100 days after HLA-matched BMT, 4-year overall survival (OS) and progression-free survival (PFS) were 57% (95% confidence interval [CI], .49 to .67) and 40% (95% CI, .31 to .51) in patients without grades II to IV aGVHD, and 68% (95% CI, .59 to .78) and 54% (95% CI, .44 to .65) in patients with grade II aGVHD. In adjusted time-dependent multivariable analyses, grade II aGVHD was associated with improved OS (hazard ratio, .58; 95% CI, .37 to .89; P = .01) and PFS (hazard ratio, .50; 95% CI, .34 to .74; P < .001) after HLA-matched BMT with PTCy. The ability of PTCy to limit grades III to IV aGVHD and cGVHD while maintaining grade II aGVHD may contribute to its effectiveness, and further attempts to reduce aGVHD may be detrimental.
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Affiliation(s)
- Shannon R McCurdy
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher G Kanakry
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hua-Ling Tsai
- Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ivana Gojo
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - B Douglas Smith
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Douglas E Gladstone
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Javier Bolaños-Meade
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ivan Borrello
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - William H Matsui
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Lode J Swinnen
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Carol Ann Huff
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Brodsky
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Richard F Ambinder
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ephraim J Fuchs
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gary L Rosner
- Biostatistics & Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Leo Luznik
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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49
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Abstract
Atypical hemolytic uremic syndrome (aHUS); hemolysis, elevated liver function tests, and low platelets syndrome; and transplant-associated thrombotic microangiopathy are related conditions, in that many patients harbor germline heterozygous mutations in genes that regulate the alternative pathway of complement (APC). Penetrance is variable because development of clinically significant disease appears to require supervention of a process such as inflammation. Complement activation on the endothelial surfaces leads to endothelial damage, platelet consumption, microthrombi, and a mechanical hemolytic anemia with schistocytes. Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal hematopoietic disease caused by expansion of a stem cell that harbors a somatic mutation in PIGA PIGA mutant blood cells are deficient in the complement regulator proteins CD55 and CD59, making them susceptible to intravascular hemolysis due to a failure to regulate the APC on erythrocytes. Eculizumab is a monoclonal antibody that binds to C5 and inhibits terminal complement by interfering with the cleavage of C5 by the C5 convertases. The drug is approved by the US Food and Drug Administration for the treatment of aHUS and PNH; however, a new generation of complement inhibitors that block C5 and other components of the complement cascade is showing promise in preclinical and clinical trials.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- Atypical Hemolytic Uremic Syndrome/blood
- Atypical Hemolytic Uremic Syndrome/drug therapy
- Atypical Hemolytic Uremic Syndrome/genetics
- CD55 Antigens/blood
- CD55 Antigens/genetics
- CD59 Antigens/blood
- CD59 Antigens/genetics
- Complement C5/antagonists & inhibitors
- Complement C5/genetics
- Complement C5/metabolism
- Complement C5 Convertase, Alternative Pathway/antagonists & inhibitors
- Complement C5 Convertase, Alternative Pathway/genetics
- Complement C5 Convertase, Alternative Pathway/metabolism
- Complement Pathway, Alternative/drug effects
- Complement Pathway, Alternative/genetics
- Hemoglobinuria, Paroxysmal/blood
- Hemoglobinuria, Paroxysmal/drug therapy
- Hemoglobinuria, Paroxysmal/genetics
- Hemolysis/drug effects
- Hemolysis/genetics
- Humans
- Membrane Proteins/blood
- Membrane Proteins/genetics
- Mutation
- Penetrance
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Affiliation(s)
- Samuel A Merrill
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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50
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Abstract
Hematopoietic stem cell transplantation (bone marrow transplantation [BMT]) is the only curative treatment of severe aplastic anemia. BMT from an human leukocyte antigen (HLA)-matched sibling donor is the standard of care for young patients; immunosuppressive therapy is used for older patients or those lacking matched sibling donors. Patients with refractory or relapsed disease are increasingly treated with HLA haploidentical BMT. Historically, haploidentical BMT led to high rates of graft rejection and graft-versus-host disease. High-dose post transplant cyclophosphamide, which mitigates the risk of graft-versus-host disease, is a major advance. This article provides an overview of the haploidentical BMT approach in severe aplastic anemia.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, USA.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 1025, Baltimore, MD 21205, USA
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