1
|
Zafar A, Lim MY, Abou-Ismail MY. Eculizumab in the management of drug-induced thrombotic microangiopathy: A scoping review of the literature. Thromb Res 2023; 224:73-79. [PMID: 36871347 DOI: 10.1016/j.thromres.2023.02.012] [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: 11/15/2022] [Revised: 01/16/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
Drug-induced TMA (DI-TMA) is a thrombotic microangiopathy (TMA) caused by certain drugs, usually managed by drug discontinuation and supportive measures. Data on the use of complement-inhibition with eculizumab in DI-TMA is scarce, and its benefit in cases of severe or refractory DI-TMA is unclear. We conducted a comprehensive search in PubMed, Embase and MEDLINE databases (2007-2021). We included articles that reported on DI-TMA patients treated with eculizumab and its clinical outcomes. All other causes of TMA were excluded. We evaluated the outcomes of hematologic recovery, renal recovery, and a composite of both (complete TMA recovery). 35 studies fulfilled our search criteria, which included 69 individual cases of DI-TMA treated with eculizumab. Most cases were secondary to chemotherapeutic agents, and the most implicated drugs were gemcitabine (42/69), carfilzomib (11/69), and bevacizumab (5/69). The median number of eculizumab doses given was 6 (range 1-16). 55/69 (80 %) patients achieved renal recovery, after 28-35 days (5-6 doses). 13/22 (59 %) patients were able to discontinue hemodialysis. 50/68 (74 %) patients achieved complete hematologic recovery after 7-14 days (1-2 doses). 41/68 (60 %) patients met criteria for complete TMA recovery. Eculizumab was safely tolerated in all cases, and appeared to be effective in achieving both hematologic and renal recovery in DI-TMA refractory to drug discontinuation and supportive measures, or with severe manifestations associated with significant morbidity or mortality. Our findings suggest that eculizumab may be considered as a potential treatment for severe or refractory DI-TMA that does not improve after initial management, although larger studies are needed.
Collapse
Affiliation(s)
- Aneeqa Zafar
- Division of Hematology, Bone Marrow Transplant and Cellular Therapy, Department of Internal Medicine, University of California, San Francisco, United States of America
| | - Ming Yeong Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health Sciences Center, United States of America
| | - Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health Sciences Center, United States of America.
| |
Collapse
|
2
|
Rodriguez-Ramirez S, Yau K, Kitchlu A, John R, Rose AA, Hogg D, Kim SJ. Pegylated Liposomal Doxorubicin and Kidney-Limited Thrombotic Microangiopathy in a Kidney Transplant Recipient: A Case Report. Kidney Med 2022; 4:100461. [PMID: 35509676 PMCID: PMC9058600 DOI: 10.1016/j.xkme.2022.100461] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
A 64-year-old man with Kaposi sarcoma in clinical remission after treatment with pegylated liposomal doxorubicin and a history of deceased-donor kidney transplantation 4 years prior presented with a slowly progressive increase in his serum creatinine level, well-controlled hypertension, stable subnephrotic-range proteinuria, and bland urinary sediment. An allograft kidney biopsy demonstrated thrombotic microangiopathy, without clinical or laboratory features of systemic involvement. Based on the timing of drug initiation preceding thrombotic microangiopathy, complete recovery after drug withdrawal, and the absence of other etiologies, it was concluded that pegylated liposomal doxorubicin was the likely cause of kidney-limited thrombotic microangiopathy. When pegylated liposomal doxorubicin was resumed, the patient developed hypertension and kidney allograft dysfunction. A new kidney biopsy was not performed because of the overall risk benefit. The case highlights the importance of recognizing novel etiologies of thrombotic microangiopathy in kidney transplant patients with malignancy. Although Kaposi sarcoma has not been linked to thrombotic microangiopathy, pegylated liposomal doxorubicin has been increasingly associated with drug-induced thrombotic microangiopathy. To our knowledge, this is the first case report that etiologically links pegylated liposomal doxorubicin to kidney-limited thrombotic microangiopathy in a kidney transplant patient.
Collapse
Affiliation(s)
- Sonia Rodriguez-Ramirez
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Yau
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Rohan John
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - April A.N. Rose
- Department of Oncology, McGill University, Montreal, Quebec, Canada
- Segal Cancer Centre and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - David Hogg
- Department of Medical Oncology and Hematology, University of Toronto, Toronto, Ontario, Canada
| | - S. Joseph Kim
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University of Toronto, Toronto, Ontario, Canada
- University Health Network, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Saad R, Hannun A, Temraz S, Finianos A, Zeenny RM. Oxaliplatin-induced thrombotic microangiopathy: a case report. J Med Case Rep 2022; 16:110. [PMID: 35303936 PMCID: PMC8933951 DOI: 10.1186/s13256-022-03309-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/02/2022] [Indexed: 01/26/2023] Open
Abstract
Background Oxaliplatin-based chemotherapy represents a standard of care in the treatment of metastatic colorectal cancer. We report a rare case of fulminant oxaliplatin-induced thrombotic microangiopathy, clinically suggestive of hemolytic–uremic syndrome, occurring in a female patient with a prolonged history of exposure to oxaliplatin for the treatment of metastatic colon cancer. Case presentation A 73-year-old Caucasian female with a treatment history including several lines of chemotherapy for the management of metastatic colon cancer was reinitiated on chemotherapy with oxaliplatin, fluorouracil, and leucovorin with bevacizumab for disease progression. She presented to the emergency department with malaise, headache, vomiting, and decreased urine output appearing a few hours after chemotherapy administration. Clinical symptoms and laboratory findings were suggestive of thrombotic microangiopathy, with a triad of microangiopathic hemolytic anemia, pronounced thrombocytopenia, and acute renal failure. The predominance of the severe renal failure was evocative of hemolytic–uremic syndrome. The rapid development of the thrombotic microangiopathy was linked to exposure to oxaliplatin. The patient was promptly managed with daily plasma exchange and high-dose corticosteroids, platelet, and red blood cell transfusions in conjunction with intermittent hemodialysis, and she recovered progressively. Conclusion Our case confirms the risk of hemolytic–uremic syndrome as a rare and life-threatening complication of oxaliplatin-based chemotherapy. A dose-dependent, drug-induced toxicity mechanism is suggested. Physicians need to maintain a high level of clinical suspicion to diagnose and treat this acute life-threatening disorder.
Collapse
Affiliation(s)
- Rhea Saad
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Audra Hannun
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Sally Temraz
- American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Rony M Zeenny
- American University of Beirut Medical Center, Beirut, Lebanon. .,INSPECT-LB (Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie-Liban), Beirut, Lebanon.
| |
Collapse
|
4
|
Abstract
INTRODUCTION Drug-induced thrombotic microangiopathy (DITMA) is an acquired condition resulting from exposure to a drug that induces the formation of platelet-rich thrombi in small arterioles or capillaries secondary to drug-dependent antibodies or direct tissue toxicity. Carfilzomib is a selective proteasome inhibitor approved to treat selected patients with Multiple Myeloma (MM). It is one of the drugs with the strongest evidence for a causal association with non-antibody-mediated DITMA. CASE REPORT A 75-year-old man presented to the emergency department for the outbreak of vomit, asthenia, oliguria and dark stool emission. He was recently diagnosed with multiple myeloma, treated with lenalidomide, dexamethasone and carfilzomib. Laboratory exams were significant for microangiopathic haemolytic anaemia, thrombocytopenia and new-onset renal failure. ADAMTS-13 levels were in range, and no infectious signs were found both in blood nor in stool test. MANAGEMENT & OUTCOME A carfilzomib induced thrombotic microangiopathy was soon suspected. Thus, since daily haemodialysis and supportive care did not seem to get a fast enough recovery, the patient was treated with eculizumab with a good general outcome. DISCUSSION Drug-induced thrombotic microangiopathy is a rare and often life-threatening acquired condition whose diagnosis can be challenging and whose therapy is not always limited to supportive treatment and drug avoidance. Carfilzomib, along with other proteasome inhibitors, is one of the described potential drugs which can trigger such a manifestation.
Collapse
Affiliation(s)
- Valentina Scheggi
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| | - Irene Merilli
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| | - Edoardo Cesaroni
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| | - Bruno Alterini
- Division of Cardiovascular and Perioperative Medicine, Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy
| |
Collapse
|
5
|
Shields MD, Skelton WP, Laber DA, Verbosky M, Ashraf N. A Novel Case of Leflunomide-Induced Thrombotic Thrombocytopenic Purpura. J Hematol 2021; 10:139-142. [PMID: 34267852 PMCID: PMC8256916 DOI: 10.14740/jh837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/03/2021] [Accepted: 04/23/2021] [Indexed: 02/01/2023] Open
Abstract
Leflunomide has not been previously associated with thrombotic thrombocytopenic purpura (TTP), a rare life-threatening clinical syndrome characterized by thrombotic microangiopathy (TMA) due to inability to cleave ADAMTS13. Here, we present the first case of leflunomide-induced TTP. Our patient developed encephalopathy, thrombocytopenia, anemia and hyperbilirubinemia 2 months after starting leflunomide. Schistocytes were noted on peripheral smear and ADAMTS13 activity was low (< 5%), consistent with acquired TTP. He received therapeutic plasma exchange, corticosteroids, rituximab and caplacizumab with normalization of hemolysis labs and ADAMTS13 activity. However, pancytopenia persisted, raising the suspicion for leflunomide toxicity. Oral cholestyramine treatment was empirically started before teriflunomide (a leflunomide metabolite) level was found to be elevated. Blood counts normalized after cholestyramine and have remained normal at last follow-up over a year later. This is the first reported case of TTP precipitated by leflunomide. Our case highlights the importance of recognizing drugs as an etiology of TMA and adds leflunomide to this list.
Collapse
Affiliation(s)
- Misty Dawn Shields
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Morsani School of Medicine, University of South Florida, Tampa, FL, USA
| | - William Paul Skelton
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Morsani School of Medicine, University of South Florida, Tampa, FL, USA
| | - Damian A Laber
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Morsani School of Medicine, University of South Florida, Tampa, FL, USA
| | - Michael Verbosky
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Noman Ashraf
- Morsani School of Medicine, University of South Florida, Tampa, FL, USA.,Department of Hematology Oncology, James A. Haley Veterans Hospital, Tampa, FL, USA
| |
Collapse
|
6
|
Liou AA, Skiver BM, Yates E, Persad P, Meyer D, Farland AM, Rocco MV. Acute Thrombotic Microangiopathy and Cortical Necrosis Following Administration of Alemtuzumab: A Case Report. Am J Kidney Dis 2018; 73:615-619. [PMID: 30528935 DOI: 10.1053/j.ajkd.2018.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/20/2018] [Accepted: 09/12/2018] [Indexed: 12/11/2022]
Abstract
Alemtuzumab, a humanized monoclonal antibody that targets CD52 antigens on lymphocytes and monocytes, has shown efficacy in preventing relapse in relapsing-remitting multiple sclerosis. Despite known severe (yet rare) renal side effects such as anti-glomerular basement membrane disease and membranous glomerulopathy, to our knowledge, alemtuzumab has never been documented to cause drug-induced thrombotic microangiopathy. We describe a 39-year-old woman with relapsing-remitting multiple sclerosis who developed acute kidney injury requiring renal replacement therapy after 1 dose of alemtuzumab, as well as microangiopathic hemolytic anemia and thrombocytopenia. Pathologic examination of a kidney biopsy specimen demonstrated extensive cortical necrosis and arteriolar fibrin thrombi with nonspecific immunofluorescence staining of immunoglobulin M and C3 and absence of immune deposits on electron microscopy. These findings were consistent with the diagnosis of acute thrombotic microangiopathy. She received dexamethasone and underwent plasmapheresis, which was unsuccessful at removing alemtuzumab. The patient received renal replacement therapy for approximately 7 weeks, followed by slow recovery of kidney function that returned close to her baseline.
Collapse
Affiliation(s)
- Ashley A Liou
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brent M Skiver
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eric Yates
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Paul Persad
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - David Meyer
- Triad Neurological Associates, Winston-Salem, NC
| | - Andrew M Farland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael V Rocco
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| |
Collapse
|
7
|
Aseem F, Zamora BG, Kauffman L, Miller PJ, John VJ. Bilateral exudative retinal detachments due to thrombotic microangiopathy associated with intravenous abuse of Opana ER. Am J Ophthalmol Case Rep 2018; 11:72-74. [PMID: 29998206 PMCID: PMC6038103 DOI: 10.1016/j.ajoc.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 07/30/2017] [Accepted: 06/01/2018] [Indexed: 11/28/2022] Open
Abstract
Purpose To report the only known case, to our knowledge, of bilateral exudative retinal detachments in the setting of thrombotic microangiopathy associated with intravenous abuse of extended-release oxymorphone (Opana ER). Observations A 35-year-old male presented with headaches and acute, painless vision loss in the context of daily IV abuse of crushed oral Opana ER. The patient was found to have microangiopathic hemolytic anemia (MAHA), acute kidney injury in conjunction with hypertensive crisis and bilateral exudative retinal detachments. Conclusions and importance Bilateral exudative retinal detachments are rare ophthalmic complications that have been reported with thrombotic thrombocytopenic purpura (TTP). Non-TTP thrombotic microangiopathy, initially described as a “TTP-like illness” consisting of MAHA and thrombocytopenia, has been associated with the IV abuse of Opana ER. We report a case of bilateral exudative retinal detachments due to thrombotic microangiopathy in the setting of IV abuse of Opana ER.
Collapse
Affiliation(s)
- Fazila Aseem
- Department of Ophthalmology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Brian G Zamora
- Department of Ophthalmology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Levi Kauffman
- Department of Ophthalmology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Peter J Miller
- Department of Internal Medicine, Sections on Hematology and Oncology, and Pulmonary, Critical Care, Allergy and Immunologic Medicine, Department of Anesthesia, Section on Critical Care, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Vishak J John
- Department of Ophthalmology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA
| |
Collapse
|
8
|
Turner JL, Reardon J, Bekaii-Saab T, Cataland SR, Arango MJ. Gemcitabine-Associated Thrombotic Microangiopathy: Response to Complement Inhibition and Reinitiation of Gemcitabine. Clin Colorectal Cancer 2016; 16:S1533-0028(16)30178-5. [PMID: 27743743 DOI: 10.1016/j.clcc.2016.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/08/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Jeffrey L Turner
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Joshua Reardon
- Department of Pharmacy, The James Comprehensive Cancer Center at The Ohio State University, Columbus, OH
| | - Tanios Bekaii-Saab
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Spero R Cataland
- Division of Hematology, Department of Medicine, The James Comprehensive Cancer Center at The Ohio State University, Columbus, OH
| | - Matthew J Arango
- Department of Pharmacy, The James Comprehensive Cancer Center at The Ohio State University, Columbus, OH.
| |
Collapse
|