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Maisons V, Duval A, Mesnard L, Frimat M, Fakhouri F, Grangé S, Servais A, Cartery C, Fauchier L, Coppo P, Titeca-Beauport D, Fage N, Delmas Y, Quérard AH, Seret G, Bobot M, Le Quintrec M, Ville S, von Tokarski F, Chauvet S, Wynckel A, Martins M, Schurder J, Barbet C, Sautenet B, Gatault P, Caillard S, Vuiblet V, Halimi JM. Assessment of epidemiology and outcomes of adult patients with kidney-limited thrombotic microangiopathies. Kidney Int 2024; 105:1100-1112. [PMID: 38431217 DOI: 10.1016/j.kint.2024.02.014] [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: 11/12/2023] [Revised: 01/31/2024] [Accepted: 02/12/2024] [Indexed: 03/05/2024]
Abstract
Thrombotic microangiopathies (TMA) are usually associated with hematological features (RH-TMA). The epidemiology of TMA limited to kidneys (RL-TMA) is unclear Therefore, patients with TMA and native kidney biopsies were identified during 2009-2022 in 20 French hospitals and results evaluated. RL-TMA was present in 341/757 (45%) patients and associated with lower creatinine levels (median 184 vs 346 μmol/L) than RH-TMA. RL-TMA resulted from virtually all identified causes, more frequently from anti-VEGF treatment and hematological malignancies but less frequently from shigatoxin-associated hemolytic uremic syndrome (HUS), systemic sclerosis, gemcitabine and bacterial infection, and even less frequently when three or more causes/triggers were combined (RL-TMA: 5%; RH-TMA: 12%). RL-TMA was associated with significantly lower major cardiovascular events (10% vs 20%), kidney replacement therapy (23% vs 43%) and death (12% vs 20%) than RH-TMA during follow-up (median 28 months). Atypical HUS (aHUS) was found in 326 patients (RL-TMA: 43%, RH-TMA: 44%). Among the 69 patients with proven complement-mediated aHUS, eculizumab (anti-C5 therapy) was used in 43 (62%) (RL-TMA: 35%; RH-TMA: 71%). Among the 257 other patients with aHUS, including 51% with RL-TMA, eculizumab was used in 29 but with unclear effects of this treatment. Thus, RL-TMA represents a very high proportion of patients with TMA and results from virtually all known causes of TMA and includes 25% of patients with complement-mediated aHUS. Adverse outcomes of RL-TMA are lower compared to RH-TMA but remain significant. Anti-C5 therapy was rarely used in RL-TMA, even in proven complement-mediated aHUS, and its effects remain to be assessed.
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Affiliation(s)
- Valentin Maisons
- Service de Néphrologie, CHU de Tours, Tours, France; U1246, INSERM, SPHERE, Université de Tours, Université de Nantes, Tours, Nantes, France
| | - Anna Duval
- Service de Néphrologie, CHU de Strasbourg, Strasbourg, France
| | | | - Marie Frimat
- Service de Néphrologie, CHU de Lille, Lille, France
| | - Fadi Fakhouri
- Service de Néphrologie, CHU Vaudois, Lausanne, Switzerland
| | | | - Aude Servais
- Service de Néphrologie, APHP Hopital Necker, Paris, France
| | - Claire Cartery
- Service de Néphrologie, CH de Valenciennes, Valenciennes, France
| | | | - Paul Coppo
- Service d'Hématologie, Centre de référence pour les microangiopathies thrombotiques (CNR-MAT), APHP Hopital Saint-Antoine, Paris, France
| | | | - Nicolas Fage
- Service de Néphrologie, Département de médecine intensive reanimation-médecine hyperbare, CHU d'Angers, Angers, France
| | - Yahsou Delmas
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | | | - Guillaume Seret
- Service de Néphrologie, Pole Santé Sud Echo Le Mans, Le Mans, France
| | - Mickaël Bobot
- Service de Néphrologie, CHU de Marseille; Aix, Marseille Université, INSERM 1263, INRAE 1260, C2VN, CERIMED, Marseille, France
| | | | - Simon Ville
- Service de Néphrologie, CHU de Nantes, Nantes, France
| | | | - Sophie Chauvet
- Service de Néphrologie, APHP Hopital Européen Georges Pompidou, Paris, France
| | | | - Manon Martins
- Service de Néphrologie, CHU de Rennes, Rennes, France
| | - Juliet Schurder
- Service de Néphrologie, CH de Saint-Malo, Saint-Malo, France
| | | | | | - Philippe Gatault
- Service de Néphrologie, CHU de Tours, U1327, INSERM, ISCHEMIA, Université de Tours, Tours, France
| | - Sophie Caillard
- U1246, INSERM, SPHERE, Université de Tours, Université de Nantes, Tours, Nantes, France
| | - Vincent Vuiblet
- Service de Pathologie, Institut d'Intelligence Artificielle en Santé, CHU de Reims et Université de Reims Champagne Ardenne, Reims, France
| | - Jean-Michel Halimi
- Service de Néphrologie, CHU de Tours, U1327, INSERM, ISCHEMIA, Université de Tours, Tours, France.
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Muñoz NG, Ortega S, Solanich X, Cid J, Díaz M, Moreno AB, Ancochea Á, Santos M, Hernández I, Sanchez JM, Luaña A, García J, Escoda L, Medina L, Ferrer GJ, López J, Céspedes R, Díaz JA, Pons V, Valcárcel D, Grifols JR. Diagnosis and clinical management of thrombotic thrombocytopenic purpura (TTP): a consensus statement from the TTP Catalan group. Blood Transfus 2024; 22:176-184. [PMID: 37677097 PMCID: PMC10920070 DOI: 10.2450/bloodtransfus.522] [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] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a low prevalence disease characterized by severe deficiency of the enzyme ADAMTS13, leading to the development of thrombotic microangiopathy (TMA) and often resulting in severe organ disfunction. TTP is an extremely serious condition and, therefore, timely and appropriate treatment is critical to prevent life-threatening complications.Over the past 25 years, significant advances in the understanding of the pathophysiology of immune TTP have led to the development of readily available techniques for measuring ADAMTS13 levels, as well as new drugs that are particularly effective in the acute phase and in preventing relapses. These developments have improved the course of the disease.Given the complexity of the disease and its various clinical and laboratory manifestations, early diagnosis and treatment can be challenging.To address this challenge, a group of experienced professionals from the Catalan TTP group have developed this consensus statement to standardize terminology, diagnosis, treatment and follow up for immune TTP, based on currently available scientific evidence in the field. This guidance document aims to provide healthcare professionals with a comprehensive tool to make more accurate and timely diagnosis of TTP and improve patient outcomes.
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Affiliation(s)
- Nadia García Muñoz
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary of Bellvitge, L’Hospitalet de Llobregat, Catalonia, Spain
| | - Sandra Ortega
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary of Bellvitge, L’Hospitalet de Llobregat, Catalonia, Spain
| | - Xavier Solanich
- Internal Medicine, Hospital Universitary of Bellvitge, L’Hospitalet de Llobregat, Catalonia, Spain
| | - Joan Cid
- Hemotherapy and Hemostasis, ICMHO, Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Maribel Díaz
- Hemostasis and Erythropathology Pathology Department CDB, Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Ana B. Moreno
- Hemostasis and Erythropathology Pathology Department CDB, Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Águeda Ancochea
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary Germans Trias I Pujol, Badalona, Catalonia, Spain
| | - Mireia Santos
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary Germans Trias I Pujol, Badalona, Catalonia, Spain
| | - Inés Hernández
- Hemathology, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Juan M. Sanchez
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary Arnau de Vilanova, Lleida, Catalonia, Spain
| | - Armando Luaña
- Hemathology, Hospital Universitary Arnau de Vilanova, Lleida, Catalonia, Spain
| | - Jose García
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary de Tarragona Joan XIII, University Rovira i Virgili, Catalonia, Spain
| | - Lourdes Escoda
- Hemathology, Catalan Institute of Oncology Tarragona Hospital Universitary de Tarragona Joan XIII, University Rovira i Virgili, Tarragona, Catalonia, Spain
| | - Laura Medina
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Gonzalo J. Ferrer
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Jordi López
- Hemathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Roberto Céspedes
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Doctor Josep Trueta, Girona, Catalonia, Spain
| | - Johana A. Díaz
- Hemathology, Catalan Institute of Oncology, Hospital Doctor Josep Trueta, Girona, Catalonia, Spain
| | - Verónica Pons
- Hemotherapy, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Hospital Universitary de la Vall d’Hebron, Barcelona, Catalonia, Spain
| | - David Valcárcel
- Hemathology, VHIO, Hospital Universitary de la Vall d’Hebron, Barcelona, Catalonia, Spain
| | - Joan R. Grifols
- Medical Direction, Banc de Sang i Teixits, Càtedra UAB de Medicina Transfusional i Teràpia Cel·lular i Tissular, Barcelona, Catalonia, Spain
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Frimat M, Gnemmi V, Stichelbout M, Provôt F, Fakhouri F. Pregnancy as a susceptible state for thrombotic microangiopathies. Front Med (Lausanne) 2024; 11:1343060. [PMID: 38476448 PMCID: PMC10927739 DOI: 10.3389/fmed.2024.1343060] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
Pregnancy and the postpartum period represent phases of heightened vulnerability to thrombotic microangiopathies (TMAs), as evidenced by distinct patterns of pregnancy-specific TMAs (e.g., preeclampsia, HELLP syndrome), as well as a higher incidence of nonspecific TMAs, such as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, during pregnancy. Significant strides have been taken in understanding the underlying mechanisms of these disorders in the past 40 years. This progress has involved the identification of pivotal factors contributing to TMAs, such as the complement system, ADAMTS13, and the soluble VEGF receptor Flt1. Regardless of the specific causal factor (which is not generally unique in relation to the usual multifactorial origin of TMAs), the endothelial cell stands as a central player in the pathophysiology of TMAs. Pregnancy has a major impact on the physiology of the endothelium. Besides to the development of placenta and its vascular consequences, pregnancy modifies the characteristics of the women's microvascular endothelium and tends to render it more prone to thrombosis. This review aims to delineate the distinct features of pregnancy-related TMAs and explore the contributing mechanisms that lead to this increased susceptibility, particularly influenced by the "gravid endothelium." Furthermore, we will discuss the potential contribution of histopathological studies in facilitating the etiological diagnosis of pregnancy-related TMAs.
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Affiliation(s)
- Marie Frimat
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
- Inserm, Institut Pasteur de Lille, Univ. Lille, Lille, France
| | | | | | - François Provôt
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, CHUV and University of Lausanne, Lausanne, Switzerland
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Launois A, Valade S, Mariotte E, Galicier L, Azoulay E, Roose E, Vanhoorelbeke K, Veyradier A, Joly BS. Hemophagocytic lymphohistiocytosis is associated with deficiency and closed conformation of ADAMTS-13. Res Pract Thromb Haemost 2024; 8:102292. [PMID: 38371335 PMCID: PMC10869956 DOI: 10.1016/j.rpth.2023.102292] [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] [Received: 10/17/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 02/20/2024] Open
Abstract
Background A disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13 (ADAMTS-13) is the specific von Willebrand factor-cleaving protease and circulates in a closed and latent conformation due to a spacer/CUB1 domain interaction. ADAMTS-13 is allosterically activated after binding of its substrate or antibodies, inducing an open conformation. Recently, we suggested a potential role of plasmin (fibrinolysin) in hemostasis disorders reported in most patients with hemophagocytic lymphohistiocytosis (HLH), a rare and life-threatening condition related to a severe systemic inflammatory state. Most patients with HLH had a partial ADAMTS-13 deficiency, and plasmin could induce a truncation of the C-terminal part of ADAMTS-13 and thus an open conformation. Objectives To understand the effect of plasmin on ADAMTS-13, our study aimed to investigate ADAMTS-13 conformation in patients with HLH. Methods Forty-five critically ill patients with HLH were prospectively enrolled between April 2015 and December 2018. ADAMTS-13 activity was measured by fluorescent resonance energy transfer-VWF73 assay, ADAMTS-13 antigen, and conformation with our homemade 3H9-enzyme-linked immunosorbent assay and 1C4-enzyme-linked immunosorbent assay. Results ADAMTS-13 activity ranged from <10 to 65 IU/dL, and 41 of the 45 patients had a quantitative deficiency in ADAMTS-13 (activity <50 IU/dL). Twenty patients had a severe ADAMTS-13 deficiency (activity <20 IU/dL). ADAMTS-13 conformation was folded in all patients under normal conditions. Surprisingly, the switch of ADAMTS-13 conformation expected with the monoclonal antibody 17G2 (anti-CUB1) was disturbed in 6 patients (activity <20 IU/dL). Conclusion Our study reported that ADAMTS-13 conformation is closed in HLH and provides an indirect proof that plasmin is not able to massively degrade ADAMTS-13. Further studies on glycosylation and citrullination profiles of ADAMTS-13 are needed to understand their role in HLH.
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Affiliation(s)
- Amélie Launois
- Service d’Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
- Equipe d'Accueil 3518, Institut de Recherche Saint-Louis, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - Sandrine Valade
- Service de Réanimation médicale, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
| | - Eric Mariotte
- Service de Réanimation médicale, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
| | - Lionel Galicier
- Service d’Immunologie clinique, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
| | - Elie Azoulay
- Service de Réanimation médicale, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
| | - Elien Roose
- Laboratory for Thrombosis Research, Interdisciplinarity Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Interdisciplinarity Research Facility Life Sciences, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Agnès Veyradier
- Service d’Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
- Equipe d'Accueil 3518, Institut de Recherche Saint-Louis, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - Bérangère S. Joly
- Service d’Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris Nord, Université Paris Cité, Paris, France
- Equipe d'Accueil 3518, Institut de Recherche Saint-Louis, Hôpital Saint-Louis, Université Paris Cité, Paris, France
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Kunwor B, Sharma B, Chhetri ST, Joshi P, Pradhan D. Atypical hemolytic uremic syndrome in a child: A rare case report. Clin Case Rep 2024; 12:e8356. [PMID: 38161638 PMCID: PMC10753129 DOI: 10.1002/ccr3.8356] [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] [Received: 07/24/2023] [Revised: 11/07/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Atypical hemolytic uremic syndrome, a rare thrombotic microangiopathy, necessitates early diagnosis and comprehensive care due to its potential severity, emphasizing the importance of a multidisciplinary approach to improve outcomes.
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Affiliation(s)
- Bishal Kunwor
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | - Bishal Sharma
- Nepalese Army Institute of Health SciencesKathmanduNepal
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Nagaoka K, Kaneko K, Miyagawa E, Abe S, Kohno C, Tsurane K, Mito A, Ozawa N, Sago H, Arata N, Murashima A. Clinical features of women with thrombotic microangiopathy in pregnancy: A case series from a single Japanese tertiary perinatal care center. J Obstet Gynaecol Res 2023; 49:2804-2810. [PMID: 37671494 DOI: 10.1111/jog.15790] [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: 04/04/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023]
Abstract
AIM Although perinatal thrombotic microangiopathy has become increasingly understood, the racial characteristics of patients with this condition remain unclear. Herein, we report the characteristics of patients with perinatal thrombotic microangiopathy at a single institution in Japan. METHODS We conducted a retrospective study over a 5-year period from January 1, 2017, to December 31, 2021, using the electronic medical records of pregnant women who delivered at the perinatal center of our hospital. We extracted the data of those who developed perinatal thrombotic microangiopathy and evaluated their characteristics at the time of disease onset, final diagnosis, and maternal and fetal outcomes. RESULTS Of the 10 224 deliveries that occurred during the 5-year period, only seven patients (0.06%) had perinatal thrombotic microangiopathy. The median pre-pregnant body mass index was 18.65 kg/m2 (minimum 17.3 kg/m2 , maximum 20.7 kg/m2 ). More than half of the patients were conceived by in-vitro fertilization, and 42% these had twin deliveries. Four patients had a history of rheumatic disease. The other three patients without underlying diseases developed thrombotic microangiopathy with HELLP syndrome, and one patient transitioned to atypical hemolytic uremic syndrome. CONCLUSIONS Based on low body mass index and in-vitro fertilization, which are characteristic of Japanese women, medical complications and twin pregnancies may be a risk for thrombotic microangiopathy. Additionally, depending on the cause of thrombotic microangiopathy, its timing and onset differed.
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Affiliation(s)
- Kanako Nagaoka
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kayoko Kaneko
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eiko Miyagawa
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Sawako Abe
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Chie Kohno
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kotoyi Tsurane
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Asako Mito
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuaki Ozawa
- Department of Obstetrics, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Department of Obstetrics, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Naoko Arata
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Department of Maternal Medicine, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Postmus T, Graça NAG, Ferreira de Santana J, Ercig B, Langerhorst P, Luken B, Joly BS, Vanhoorelbeke K, Veyradier A, Coppo P, Voorberg J. Impact of N-glycan mediated shielding of ADAMTS-13 on the binding of pathogenic antibodies in immune thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:3402-3413. [PMID: 37633643 DOI: 10.1016/j.jtha.2023.08.017] [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: 12/31/2022] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic disorder, with 1.5 to 6.0 cases per million per year. The majority of patients with TTP develop inhibitory autoantibodies that predominantly target the spacer domain of ADAMTS-13. ADAMTS-13 is responsible for cleaving von Willebrand factor (VWF) multimers, thereby regulating platelet adhesion at sites of high-vascular shear stress. Inhibition and/or clearance of ADAMTS-13 by pathogenic autoantibodies results in accumulation of VWF multimers that promotes the formation of platelet-rich microthrombi. Previously, we have shown that insertion of a single N-glycan (NGLY) in the spacer domain prevents the binding of antispacer domain antibodies. OBJECTIVES To explore whether NGLY mediated shielding of the ADAMTS-13 spacer domain effectively prevents binding of pathogenic antispacer autoantibodies in patients with immune-mediated TTP (iTTP). METHODS We screened 5 NGLY-ADAMTS-13 variants (NGLY3, NGLY7, NGLY8, NGLY3+7, and NGLY3+8) for binding of autoantibodies and for their activity in the presence and absence of 50 samples derived from patients with iTTP. RESULTS NGLY variants showed greatly reduced antibody binding, down to 27% of wild-type (wt) ADAMTS-13 binding. Moreover, NGLY variants of ADAMTS-13 remained more active in FRETS-VWF73 assay in the presence of the plasma samples from these 50 patients with acute phase iTTP when compared with wtADAMTS-13. On average, wtADAMTS-13 activity was reduced to 37% of regular levels in the presence of plasma, while NGLY3 and NGLY3+7 remained 69% and 81% active, respectively. CONCLUSION These results reinforce our previous findings that NGLYs shield ADAMTS-13 from antibody binding and hence restore ADAMTS-13 activity in the presence of autoantibodies.
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Affiliation(s)
- Tim Postmus
- Department of Molecular Hematology, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Nuno A G Graça
- Department of Molecular Hematology, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Juliana Ferreira de Santana
- Department of Molecular Hematology, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Bogac Ercig
- Division of Biochemistry and Oncode Institute, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Pieter Langerhorst
- Department of Molecular Hematology, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, The Netherlands
| | | | - Bérangère S Joly
- Centre National de Référence des Microangiopathies Thrombotiques, hôpital Saint-Antoine, AP-HP. Sorbonne Université, Paris, France; Service d'hématologie biologique, hôpital Lariboisière et EA3518 Institut de Recherche Saint-Louis, AP-HP. Nord, Université Paris Cité, Paris, France
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Agnès Veyradier
- Centre National de Référence des Microangiopathies Thrombotiques, hôpital Saint-Antoine, AP-HP. Sorbonne Université, Paris, France; Service d'hématologie biologique, hôpital Lariboisière et EA3518 Institut de Recherche Saint-Louis, AP-HP. Nord, Université Paris Cité, Paris, France
| | - Paul Coppo
- Centre National de Référence des Microangiopathies Thrombotiques, hôpital Saint-Antoine, AP-HP. Sorbonne Université, Paris, France; Service d'hématologie biologique, hôpital Lariboisière et EA3518 Institut de Recherche Saint-Louis, AP-HP. Nord, Université Paris Cité, Paris, France
| | - Jan Voorberg
- Department of Molecular Hematology, Sanquin-Academic Medical Center Landsteiner Laboratory, Amsterdam, The Netherlands; Department of Experimental Vascular Medicine, Amsterdam UMC, Amsterdam, The Netherlands.
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Qureshi ZA, Altaf F, Khanzada M, Thet A, Espinosa L. Ceftriaxone-Induced Thrombotic Thrombocytopenic Purpura Treated Successfully With Plasmapheresis and Eculizumab: A Rare Case Report. Cureus 2023; 15:e48898. [PMID: 38024015 PMCID: PMC10653270 DOI: 10.7759/cureus.48898] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a subtype of thrombotic microangiopathy (TMA) resulting in thrombocytopenia, anemia, fever, renal and neurological deficits. Although many drugs have been associated with drug-induced TTP, ceftriaxone has never been reported. Our case reports a patient who was started on ceftriaxone and developed TTP. Peripheral smear showed schistocytes and thrombocytopenia. Surprisingly, antibody formation against the metalloproteinase (ADAMTS13) levels were low-normal. The patient was treated with plasmapheresis and eczulimab, leading to platelet recovery and symptom resolution. TTP is a rare disorder and can be acquired or idiopathic. TTP can be diagnosed with normal ADAMTS13 as well. Further research is required to assess the mechanism by which ceftriaxone causes TTP. Physicians should consider the possibility of TTP in patients with similar presentations following ceftriaxone therapy and use it for timely diagnosis and treatment. Early diagnosis and treatment of ceftriaxone-induced TTP can prevent devastating consequences.
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Affiliation(s)
- Zaheer A Qureshi
- Internal Medicine, The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, USA
- Internal Medicine, BronxCare Health System, Bronx, USA
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | - Faryal Altaf
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Aung Thet
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Luis Espinosa
- Internal Medicine, BronxCare Health System, Bronx, USA
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9
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Nusrat S, Beg K, Khan O, Sinha A, George J. Hereditary Thrombotic Thrombocytopenic Purpura. Genes (Basel) 2023; 14:1956. [PMID: 37895305 PMCID: PMC10606562 DOI: 10.3390/genes14101956] [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: 09/07/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/29/2023] Open
Abstract
Hereditary thrombotic thrombocytopenic purpura (hTTP), also known as Upshaw-Schulman syndrome, is a rare genetic disorder caused by mutations in the ADAMTS13 gene that leads to decreased or absent production of the plasma von Willebrand factor (VWF)-cleaving metalloprotease ADAMTS13. The result is circulating ultra-large multimers of VWF that can cause microthrombi, intravascular occlusion and organ damage, especially at times of turbulent circulation. Patients with hTTP may have many overt or clinically silent manifestations, and a high index of suspicion is required for diagnosis. For the treatment of hTTP, the goal is simply replacement of ADAMTS13. The primary treatment is prophylaxis with plasma infusions or plasma-derived factor VIII products, providing sufficient ADAMTS13 to prevent acute episodes. When acute episodes occur, prophylaxis is intensified. Recombinant ADAMTS13, which is near to approval, will immediately be the most effective and also the most convenient treatment. In this review, we discuss the possible clinical manifestations of this rare disease and the relevant differential diagnoses in different age groups. An extensive discussion on prophylaxis and treatment strategies is also presented. Unique real patient cases have been added to highlight critical aspects of hTTP manifestations, diagnosis and treatment.
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Affiliation(s)
- Sanober Nusrat
- Hematology-Oncology Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Kisha Beg
- Jimmy Everest Section of Pediatric Hematology-Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Osman Khan
- Jimmy Everest Section of Pediatric Hematology-Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Arpan Sinha
- Jimmy Everest Section of Pediatric Hematology-Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - James George
- Hematology-Oncology Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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10
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Rodas MA, Astorquizaga L, Lisanti C, Rojas S, de Mena A. Thrombotic thrombocytopenic purpura in pediatrics. A case report. ARCH ARGENT PEDIATR 2023; 121:e202202758. [PMID: 36724140 DOI: 10.5546/aap.2022-02758.eng] [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] [Indexed: 01/28/2023]
Abstract
Thrombotic thrombocytopenic purpura is a rare disease in pediatrics, but it has a high mortality if not managed in an adequate and timely manner. It is characterized by microangiopathic hemolytic anemia associated with neurological, cardiac, abdominal, and less frequently, renal signs and symptoms; it may be accompanied by fever. In children, diagnosis is based on clinical and laboratory findings. ADAMTS13 activity < 10% supports the diagnosis but does not confirm it and, given its severity, the result should not delay treatment initiation. Here we describe the case of a previously healthy 15-year-old female patient with neurological signs associated with hemolytic anemia and thrombocytopenia. During hospitalization, she was diagnosed with acquired thrombotic thrombocytopenic purpura.
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Affiliation(s)
- María A Rodas
- Clinical Pediatrics, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Lucía Astorquizaga
- Clinical Pediatrics, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Camila Lisanti
- Clinical Pediatrics, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Sonia Rojas
- Clinical Pediatrics, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Arturo de Mena
- Clinical Pediatrics, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
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11
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Bertoni I, Soares MF, Roberts ISD, Connor T. Radiation nephropathy is associated with a glomerular thrombotic microangiopathy and progression to end-stage kidney disease. Clin Kidney J 2023; 16:1534-1537. [PMID: 37664570 PMCID: PMC10468744 DOI: 10.1093/ckj/sfad133] [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: 10/11/2022] [Indexed: 09/05/2023] Open
Abstract
Radiation nephropathy is a rare complication following total body irradiation (TBI) and peptide receptor radionuclide therapy (PRRT). Yttrium 90-DOTATOC (Y90) is a somatostatin analogue labelled with Y90 used for somatostatin-positive neuroendocrine tumours. Y90 is renally excreted and has a cumulative effect in the renal parenchyma Despite fractionation and co-administration of renoprotective intravenous amino acids, targeted radionuclide therapy can still be nephrotoxic. Rising adoption of PRRT has led to the re-emergence of radiation nephropathy. We report on three recent cases of insidious onset of progressive kidney dysfunction and biopsy-proven thrombotic microangiopathy following PRRT and TBI.
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Affiliation(s)
| | - Maria F Soares
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ian S D Roberts
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Béranger N, Tsatsaris V, Coppo P, Veyradier A, Joly BS. High sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor) Ratio in Pregnancy-Onset Thrombotic Thrombocytopenic Purpura. Hypertension 2023; 80:e140-e142. [PMID: 37170814 DOI: 10.1161/hypertensionaha.123.20987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- Nicolas Béranger
- Service d'Hématologie biologique, Hôpital Lariboisière, AP-HP.Nord (N.B., A.V., B.S.J.), Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis (N.B., A.V., B.S.J.), Université Paris Cité, Paris, France
| | - Vassilis Tsatsaris
- Maternité Port Royal, Hôpital Cochin, AP-HP.Centre (V.T.), Université Paris Cité, Paris, France
- Inserm UMR-S 1139, Physiopathologie et pharmacotoxicologie placentaire humaine (V.T.), Université Paris Cité, Paris, France
| | - Paul Coppo
- Service d'Hématologie, Centre de référence des microangiopathies thrombotiques (CNR-MAT), Hôpital Saint-Antoine, AP-HP.Sorbonne Université, Paris, France (P.C.)
| | - Agnès Veyradier
- Service d'Hématologie biologique, Hôpital Lariboisière, AP-HP.Nord (N.B., A.V., B.S.J.), Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis (N.B., A.V., B.S.J.), Université Paris Cité, Paris, France
| | - Bérangère S Joly
- Service d'Hématologie biologique, Hôpital Lariboisière, AP-HP.Nord (N.B., A.V., B.S.J.), Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis (N.B., A.V., B.S.J.), Université Paris Cité, Paris, France
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Padilha WSC, Cesar BN, Pacheco ST, De Sousa AA, Ledesma FL, Malheiros DMAC, Teixeira MCA. Bevacizumab-Associated Thrombotic Microangiopathy Treated with Eculizumab: A Case Report. Am J Case Rep 2023; 24:e940906. [PMID: 37644709 PMCID: PMC10474846 DOI: 10.12659/ajcr.940906] [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: 04/24/2023] [Revised: 07/18/2023] [Accepted: 07/15/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Bevacizumab is an approved targeted therapy for metastatic cancer treatment. It can have adverse effects on multiple organs. Despite its low incidence, thrombotic microangiopathy (TMA) is the most severe complication. TMA has been associated with complement dysregulation, and treatment with eculizumab can be effective, despite the paucity of literature on eculizumab therapy for bevacizumab-associated TMA. To date, 10 cases have been reported, with less than half of them including a kidney biopsy. We present a new case of bevacizumab-associated TMA successfully treated with eculizumab, along with kidney biopsy records and an overview of mechanisms underlying TMA development in bevacizumab-treated patients. CASE REPORT A female patient diagnosed with metastatic breast cancer who was treated with bevacizumab in conjunction with chemotherapy was admitted to the hospital for acute kidney injury requiring hemodialysis, microangiopathic hemolytic anemia, and thrombocytopenia. TMA was diagnosed and was later confirmed by a kidney biopsy. Primary causes for TMA, such as ADAMTS13 deficiency and shiga toxin associated hemolytic-uremic syndrome, were ruled out, and the patient's condition was ultimately found to be triggered by exposure to bevacizumab. After discontinuing bevacizumab and receiving 4 weekly doses of eculizumab, kidney function and hematological parameters improved. CONCLUSIONS Bevacizumab-associated TMA can be reversed or attenuated in some patients with the use of eculizumab (inhibiting complement system overactivation), possibly reducing time to recovery, with fewer long-term sequelae. This additional case encourages future clinical trials to evaluate the safety and efficacy of eculizumab in cases of TMA associated with bevacizumab.
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Affiliation(s)
| | - Bruno Nogueira Cesar
- Department of Nephrology, Hospital DFStar Rede D’Or São Luiz, Brasília, DF, Brazil
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Fuentes AD, Rubio GT, Acuña CA, Rubio FD, Milic FB, Troncoso PC. Near-fatal cocaine intoxication in an infant with thrombotic microangiopathy associated with multiple organ failure. Rev Paul Pediatr 2023; 42:e2022159. [PMID: 37646745 PMCID: PMC10503420 DOI: 10.1590/1984-0462/2024/42/2022159] [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] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 04/21/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To report a pediatric case of drug-induced thrombotic microangiopathy caused by cocaine. CASE DESCRIPTION We report a nine-month-old patient who developed thrombotic microangiopathies after extreme cocaine intoxication, multiple organ dysfunction syndrome with hemodynamic dysfunction, anuric renal failure, liver failure, encephalopathy, and myocardial injury, corresponding phenotypically to thrombocytopenia-associated multiple organ failure. The patient received continuous venous hemofiltration and therapeutic plasma exchange, recovering satisfactorily. She was discharged after 30 days of hospitalization under the guidance of the childcare service, and was healthy after one year of follow-up. Toxicological samples confirmed high levels of cocaine and derivatives in blood, urine and hair. COMMENTS To our knowledge, this is the first reported pediatric case. There are particularities of cocaine intoxication pathophysiology that can trigger thrombotic microangiopathies because of vasoconstriction, direct endothelial injury, platelet activation, and increasing von Willebrand factor and fibrinogen levels. All of which results in a prothrombotic state, inflammatory dysregulation, and microvascular thrombi. The increasing use of cocaine, especially among young adults, puts children at high risk of toxicity, either by passive unintentional exposure, or abuse due to the increased availability in homes.
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Affiliation(s)
| | | | - Camila Ampuero Acuña
- Hospital Clínico Dra. Eloísa Díaz I., Pediatric Critical Care Unit, Santiago, Chile
| | - Franco Díaz Rubio
- Hospital Clínico Dra. Eloísa Díaz I., Pediatric Critical Care Unit, Santiago, Chile
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Noutsos T, Isbister GK. Snakebite-associated thrombotic microangiopathy: a spotlight on pharmaceutical interventions. Expert Rev Clin Pharmacol 2023. [PMID: 37259708 DOI: 10.1080/17512433.2023.2220963] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Snakebite is a neglected public health issue causing death and disability, disproportionately affecting tropical and subtropical resource poor countries globally. Snakebite-associated thrombotic microangiopathy (TMA) occurs in a subset of snakebites and is associated with acute kidney injury (sometimes requiring renal replacement therapy), and a risk of chronic kidney disease. AREAS COVERED This expert review synthesizes current evidence on therapeutic interventions in snakebite-associated TMA, via PubMed search for cohort studies and randomized controlled trials (RCT) in snakebite-associated TMA from 1970 to October 2022. EXPERT OPINION There are no interventional RCTs in snakebite-associated TMA. Recent cohort studies from Sri Lanka, India and Australia report clinical and laboratory endpoint outcomes for intervention with antivenom and therapeutic plasma-exchange (TPE). TPE is a resource intense and costly treatment using large volumes of blood donor plasma. There is no consistent evidence supporting TPE in snakebite-associated TMA with respect to patient survival, dialysis free survival, or hospital length of stay. Antivenom is the standard of care for patients with snake envenoming, but there is no specific evidence of benefit in snakebite-associated TMA. Emerging new therapies in snakebite more broadly are untested in snakebite-associated TMA. RCTs are needed to improve the evidence for treatment of snakebite-associated TMA.
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Affiliation(s)
- Tina Noutsos
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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Mohamed KH, Shiza ST, Samreen I, Agboola AA, Mohamed AS, Kalluru PKR, Haseeb M, Munawar RZ, Nasir H. Non-ST-Segment Elevation Myocardial Infarction As Initial Thrombotic Event of Thrombotic Thrombocytopenic Purpura: A Rare Challenging Case. Cureus 2023; 15:e36363. [PMID: 37082484 PMCID: PMC10112854 DOI: 10.7759/cureus.36363] [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] [Accepted: 03/18/2023] [Indexed: 04/22/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare autoimmune and devastating blood disorder that results in micro-clots throughout the body, leading to tissue damage and organ dysfunction resulting in widespread microangiopathic hemolytic anemia, thrombocytopenia, fever, and neurological symptoms. TTP patients commonly manifest renal and neurological symptoms; however, cardiovascular involvement is not widely reported in the literature. We report a case of non-ST-segment elevation myocardial infarction (NSTEMI) as an initial manifestation of TTP. Although rare, TTP complications must be considered among other possible causes of unexpected thrombocytopenia during acute phase treatment of acute coronary syndrome because of high morbidity and mortality.
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Affiliation(s)
- Khalid H Mohamed
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, GBR
| | - Saher T Shiza
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | - Iqra Samreen
- Internal Medicine, Deccan College of Medical Sciences, Hyderabad, IND
| | | | | | | | - Muhammad Haseeb
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
- Internal Medicine, Mount Sinai Hospital, Brooklyn, USA
| | | | - Hira Nasir
- Internal Medicine, Mayo Hospital, Lahore, PAK
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Völker LA, Kaufeld J, Balduin G, Merkel L, Kühne L, Eichenauer DA, Osterholt T, Hägele H, Kann M, Grundmann F, Kolbrink B, Schulte K, Gäckler A, Kribben A, Boss K, Potthoff SA, Rump LC, Schmidt T, Mühlfeld AS, Schulmann K, Hermann M, Gaedeke J, Sauerland K, Bramstedt J, Hinkel UP, Miesbach W, Bauer F, Westhoff TH, Bruck H, Buxhofer-Ausch V, Müller TJ, Wendt R, Harth A, Schreiber A, Seelow E, Tölle M, Gohlisch C, Bieringer M, Geuther G, Jabs WJ, Fischereder M, von Bergwelt-Baildon A, Schönermarck U, Knoebl P, Menne J, Brinkkoetter PT. Impact of first-line use of caplacizumab on treatment outcomes in immune thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:559-572. [PMID: 36696206 DOI: 10.1016/j.jtha.2022.11.010] [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: 07/01/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The von Willebrand factor-directed nanobody caplacizumab has greatly changed the treatment of immune thrombotic thrombocytopenic purpura (iTTP) in recent years. Data from randomized controlled trials established efficacy and safety. OBJECTIVES This study aims to address open questions regarding patient selection, tailoring of therapy duration, obstacles in prescribing caplacizumab in iTTP, effect on adjunct treatment, and outcomes in the real-world setting. METHODS We report retrospective, observational cohorts of 113 iTTP episodes treated with caplacizumab and 119 historical control episodes treated without caplacizumab. We aggregated data from the caplacizumab phase II/III trials and real-world data from France, the United Kingdom, Germany, and Austria (846 episodes, 396 treated with caplacizumab, and 450 historical controls). RESULTS Caplacizumab was efficacious in iTTP, independent of the timing of therapy initiation, but curtailed the time of active iTTP only when used in the first-line therapy within 72 hours after diagnosis and until at least partial ADAMTS13-activity remission. Aggregated data from multiple study populations showed that caplacizumab use resulted in significant absolute risk reduction of 2.87% for iTTP-related mortality (number needed to treat 35) and a relative risk reduction of 59%. CONCLUSION Caplacizumab should be used in first line and until ADAMTS13-remission, lowers iTTP-related mortality and refractoriness, and decreases the number of daily plasma exchange and hospital stay. This trial is registered at www. CLINICALTRIALS gov as #NCT04985318.
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Affiliation(s)
- Linus A Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany
| | - Jessica Kaufeld
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | - Gesa Balduin
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lena Merkel
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lucas Kühne
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany
| | - Thomas Osterholt
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Holger Hägele
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Kann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany
| | - Franziska Grundmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anja Gäckler
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Kristina Boss
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sebastian A Potthoff
- University Hospital Düsseldorf, Department of Nephrology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany, Germany
| | - Lars C Rump
- University Hospital Düsseldorf, Department of Nephrology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany, Germany
| | - Tilman Schmidt
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Anja S Mühlfeld
- Uniklinik RWTH Aachen, Department of Medicine, Division of Nephrology, Aachen, Germany
| | - Karsten Schulmann
- Klinik für Hämatologie, Onkologie Palliativmedizin und Stammzelltransplantation, Klinikum Hochsauerland GmbH, Walburga Krankenhaus Meschede, Meschede, Germany; MVZ Hochsauerland GmbH, Praxis für Hämatologie und Onkologie, Arnsberg, Germany
| | - Matthias Hermann
- Medizinische Klinik V, Hämatologie/Onkologie, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg
| | - Jens Gaedeke
- Department of Nephrology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kristin Sauerland
- Klinik für Innere Medizin, Hämatologie/Onkologie, Stammzelltransplantation und Palliativmedizin, Johannesstift, Bielefeld, Germany
| | - Jörn Bramstedt
- Medizinische Klinik II Sektion Nephrologie, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Ulrich P Hinkel
- Klinik für Nephrologie, Zentralklinik Bad Berka GmbH, Bad Berka, Germany
| | - Wolfgang Miesbach
- Department of Hemostaseology-Hemophilia Center, University Hospital Frankfurt, Frankfurt, Germany
| | - Frederic Bauer
- Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Germany
| | - Timm H Westhoff
- Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Germany
| | - Heike Bruck
- Medical Clinic III, Helios Hospital Krefeld, Krefeld, Germany
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I with Hematology, Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinen, Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Tobias J Müller
- Department of Neurology, University Hospital Ruppin-Brandenburg, Brandenburg Medical School, Neuruppin, Germany
| | - Ralph Wendt
- Department of Infectious Diseases/Tropical Medicine, Nephrology/KfH Renal Unit and Rheumatology, St. Georg Hospital Leipzig, Germany
| | - Ana Harth
- Department of Nephrology, Transplantation, and Medical Intensive Care, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Adrian Schreiber
- Department of Nephrology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Experimental and Clinical Research Center, Charité, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Evelyn Seelow
- Department of Nephrology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Experimental and Clinical Research Center, Charité, Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Markus Tölle
- Charité-Universitätsmedizin Berlin, Cooperate Member of Freie Universität and Humboldt Universität, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Christopher Gohlisch
- Charité-Universitätsmedizin Berlin, Cooperate Member of Freie Universität and Humboldt Universität, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Markus Bieringer
- Department of Cardiology and Nephrology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Gesa Geuther
- Nordbadpraxis München-Praxis für Innere Medizin, Schwerpunktpraxis für Hämatologie, Onkologie, HIV und Palliativmedizin, München, Germany
| | - Wolfram J Jabs
- Department of Nephrology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Michael Fischereder
- Nephrology Division, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | | | - Ulf Schönermarck
- Nephrology Division, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Paul Knoebl
- Division of Hematology and Hemostasis, Department of Medicine 1, Medical University of Vienna, Vienna, Austria
| | - Jan Menne
- KRH Klinikum Mitte-Location Siloah, Hannover, Germany
| | - Paul T Brinkkoetter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany.
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Ostrominski JW, Bhatt DL, Scirica BM. Pulling Out All the Stops: A Case of Progressive Dyspnea. Circulation 2023; 147:688-693. [PMID: 36802880 DOI: 10.1161/circulationaha.122.062753] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Bosisio FG, Mingardi D, Moretti E, Muzi G, Russomanno F, Tassani N, Stassaldi D, Agabiti Rosei C, De Ciuceis C, Salvetti M, Muiesan ML. Case report: Area of focus in a case of malignant hypertension. Front Cardiovasc Med 2023; 9:1108666. [PMID: 36712261 PMCID: PMC9880852 DOI: 10.3389/fcvm.2022.1108666] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
Malignant hypertension (MH) is characterized by severe hypertension (usually grade 3) associated with fundoscopic changes (flame hemorrhages and/or papilledema), microangiopathy and disseminated intravascular coagulation. In addition encephalopathy, acute heart failure and acute deterioration in renal function may be present. The term "malignant" reflects the very poor prognosis for this condition if untreated. When severe hypertension is associated with hypertension-mediated organ damage (HMOD) a life-threatening situation that requires immediate but careful intervention occurs (hypertensive emergency). In the last few years an increase in the number of patients with malignant hypertension has been observed, especially among those patients with black ethnicity. Limited access to treatment and the poor adherence to anti-hypertensive therapy may contribute to the development of hypertensive emergencies. It is considered appropriate to study patients in order to rule out thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. In fact, the microvascular damage caused by malignant hypertension can favor intravascular hemolysis like Thrombotic Microangiopathies (TMs). TMs may present in three different clinical conditions: typical hemolytic uremic syndrome (HUS), atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP). TMs can arise in the context of other pathological processes, including malignant hypertension.
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Affiliation(s)
- Francesca Gaia Bosisio
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Emergency Medicine ASST Spedali Civili Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Desirè Mingardi
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Emergency Medicine ASST Spedali Civili Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elisabetta Moretti
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Emergency Medicine ASST Spedali Civili Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giorgia Muzi
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Emergency Medicine ASST Spedali Civili Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesco Russomanno
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Nicola Tassani
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Emergency Medicine ASST Spedali Civili Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Claudia Agabiti Rosei
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Carolina De Ciuceis
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Salvetti
- Emergency Medicine ASST Spedali Civili Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Lorenza Muiesan
- UOC 2 Medicina, ASST Spedali Civili di Brescia, Brescia, Italy,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy,*Correspondence: Maria Lorenza Muiesan,
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20
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Gumulec J, Demel I, Lančová K, Drbohlavová E, Piegzová A, Kořístek Z, Navrátil M, Černý V. Selected severe „haematological“ syndromes in adult intensive care patients. Vnitr Lek 2022; 68:498-507. [PMID: 36575067 DOI: 10.36290/vnl.2022.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Haemophagocytic syndrome, diffuse alveolar haemorrhage, catastrophic antiphospholipid syndrome and various types of thrombotic microangiopathies are rare conditions with significant morbidity and mortality. A common feature is late diagnosis, which can affect the success of treatment. The aim of this review article is to summarize the basic diagnostic and therapeutic steps of the present subpopulation of critically ill patients.
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21
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Sarno L, Conca P, Capuano A, Tarantino G, Russo D, Guida M. A Life-Threating Postpartum Atypical Hemolytic-Uremic Syndrome with Multiorgan Involvement. J Clin Med 2022; 11. [PMID: 36498532 DOI: 10.3390/jcm11236957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Atypical Hemolytic Uremic Syndrome is a very rare condition that can be triggered in predisposed patients. It can remain undiagnosed and can result in a life-threatening event or permanent renal failure. We report a case of a 36-year-old pregnant woman who developed atypical hemolytic uremic syndrome postpartum. She underwent an emergency caesarean section due to abruptio placenta, and she developed biochemical alterations suggestive of a thrombotic microangiopathy. Due to worsening of renal function after plasma exchange therapy, we decided to start therapy with eculizumab. Therapy was carried out with a weekly dose of 900 mg IV for five weeks. An improvement of clinical and biochemical parameters was rapidly observed, and her renal function completely recovered. The therapy was continued for six months, with a dose of 1200 mg of eculizumab every two weeks. One year after discontinuation of the therapy, her blood pressure and renal function were still normal. Our case confirms that it is important to promptly identify a pregnancy-related thrombotic microangiopathy and that early therapy can be life-saving for the patient and can preserve renal function, avoiding dialysis.
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22
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Adeyemi A, Razakariasa F, Chiorean A, de Passos Sousa R. Epidemiology, treatment patterns, clinical outcomes, and disease burden among patients with immune-mediated thrombotic thrombocytopenic purpura in the United States. Res Pract Thromb Haemost 2022; 6:e12802. [PMID: 36176310 PMCID: PMC9481884 DOI: 10.1002/rth2.12802] [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] [Received: 03/03/2022] [Revised: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 11/11/2022] Open
Abstract
Background Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy. Due to its rarity, epidemiology and real-world outcomes data are scarce. Objectives The aim was to assess epidemiology, treatment patterns, clinical outcomes, and disease burden in patients with iTTP in the United States. Methods This longitudinal, retrospective observational study of the Optum-Humedica database included patients with an iTTP diagnosis (≥1 documented ADAMTS13 activity less than 10% or one or more iTTP episodes) from January 2007 to December 2019. Results Of 666 patients with an iTTP diagnosis between October 2015 and December 2019, 302 (45%) had one or more iTTP episodes. The pooled annual incidence of documented iTTP during this period was 3.43/million, and the annual incidence of one or more iTTP episodes was 1.81/million. Patients with one or more iTTP episodes received a median of six therapeutic plasma exchange (TPE) sessions per episode; 86% received corticosteroids, and 59% received rituximab. Exacerbations occurred in 17% (52/302) and relapse in 11% (34/302); 34% (103/302) had one or more thromboembolic events. Mortality rates during the study period were 25% (167/666) among all patients with iTTP diagnosis, and 14% (41/302) among patients with one or more iTTP episodes. In the assessment of disease burden (January 2007 to September 2019), patients in the iTTP cohort (n = 514) presented with a mean of 14 comorbidities, compared with 3 in a matched non-iTTP cohort (n = 2570). In a cluster analysis, duration of iTTP episode and mortality rate were greater in older versus younger patients. Conclusions Despite treatment with TPE and immunosuppressants, patients with iTTP have high risk of morbidity and mortality, demonstrating the need for more effective therapies.
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Affiliation(s)
- Ayoade Adeyemi
- Sanofi Cambridge Massachusetts USA.,Present address: Alexion Boston Massachusetts USA
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23
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Lewandowska M, Englert-Golon M, Krasiński Z, Jagodziński PP, Sajdak S. A Rare Case of HELLP Syndrome with Hematomas of Spleen and Liver, Eclampsia, Severe Hypertension and Prolonged Coagulopathy-A Case Report. Int J Environ Res Public Health 2022; 19:ijerph19137681. [PMID: 35805359 PMCID: PMC9265485 DOI: 10.3390/ijerph19137681] [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] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 02/05/2023]
Abstract
The HELLP syndrome (hemolysis, liver damage and thrombocytopenia) is a rare (0.5−0.9%) but serious complication of pregnancy or puerperium associated with a higher risk of maternal and fetal mortality and morbidity. Liver and spleen hematomas rarely entangle (<2%) HELLP cases, but rupture of the hematomas presents an immediate threat to life. We present the history of a 35-year old pregnant woman (at the 31st week) admitted to our hospital due to the risk of premature delivery. On the first day, the patient did not report any complains, and the only abnormality was thrombocytopenia 106 G/L. However, within several hours, tests showed platelet levels of 40.0 G/L, LDH 2862.0 U/L and AST 2051.6 U/L, and the woman was diagnosed with severe HELLP syndrome, complicated by hematomas of the liver and spleen, seizures (eclampsia), severe arterial hypertension and coagulation disorders. The purpose of this article is to highlight the need for early investigation of the causes of thrombocytopenia and the differentiation of HELLP from other thrombotic microangiopathies (TMAs).
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Affiliation(s)
- Małgorzata Lewandowska
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznan, Poland;
- Division of Gynecological Surgery, University Hospital, 33 Polna Str., 60-535 Poznan, Poland
- Correspondence:
| | - Monika Englert-Golon
- Department of Gynaecology Obstetrics and Gynaecological Oncology, Division of Gynecological Surgery, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (M.E.-G.); (S.S.)
| | - Zbigniew Krasiński
- Department of Vascular, Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Paweł Piotr Jagodziński
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, 60-781 Poznan, Poland;
| | - Stefan Sajdak
- Department of Gynaecology Obstetrics and Gynaecological Oncology, Division of Gynecological Surgery, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (M.E.-G.); (S.S.)
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Blasco M, Guillén-Olmos E, Diaz-Ricart M, Palomo M. Complement Mediated Endothelial Damage in Thrombotic Microangiopathies. Front Med (Lausanne) 2022; 9:811504. [PMID: 35547236 PMCID: PMC9082680 DOI: 10.3389/fmed.2022.811504] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 11/08/2021] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
Thrombotic microangiopathies (TMA) constitute a group of different disorders that have a common underlying mechanism: the endothelial damage. These disorders may exhibit different mechanisms of endothelial injury depending on the pathological trigger. However, over the last decades, the potential role of the complement system (CS) has gained prominence in their pathogenesis. This is partly due to the great efficacy of complement-inhibitors in atypical hemolytic syndrome (aHUS), a TMA form where the primary defect is an alternative complement pathway dysregulation over endothelial cells (genetic and/or adquired). Complement involvement has also been demonstrated in other forms of TMA, such as thrombotic thrombocytopenic purpura (TTP) and in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (STEC-HUS), as well as in secondary TMAs, in which complement activation occurs in the context of other diseases. However, at present, there is scarce evidence about the efficacy of complement-targeted therapies in these entities. The relationship between complement dysregulation and endothelial damage as the main causes of TMA will be reviewed here. Moreover, the different clinical trials evaluating the use of complement-inhibitors for the treatment of patients suffering from different TMA-associated disorders are summarized, as a clear example of the entry into a new era of personalized medicine in its management.
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Affiliation(s)
- Miquel Blasco
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Elena Guillén-Olmos
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Marta Palomo
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain.,Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
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25
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Khaja M, Qureshi ZA, Kandhi S, Altaf F, Yapor L. Mitomycin-Induced Thrombotic Thrombocytopenic Purpura Treated Successfully With Plasmapheresis and Steroid: A Case Report. Cureus 2022; 14:e23525. [PMID: 35494991 PMCID: PMC9038578 DOI: 10.7759/cureus.23525] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 11/12/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) caused by severely reduced ADAMTS13 or the von Willebrand factor-cleaving protease (VWFCP) enzyme resulting in low platelet and red blood cell counts along with severe renal, cardiac, and neurological dysfunction. Plasmapheresis is the treatment of choice. Mitomycin, a widely used chemotherapeutic agent for gastrointestinal (GI) cancers anal and breast cancers, has been reported to occasionally cause severe TTP and hemolytic uremic syndrome (HUS) cases. Here, we present a case of a 57-year-old African American transgender patient who presented with worsening kidney function, thrombocytopenia, and anemia following mitomycin therapy for her anal squamous cell carcinoma. Peripheral smear showed numerous schistocytes, and the patient was diagnosed with TTP because of low ADAMTS13 levels. The patient was started on plasmapheresis and steroid with ultimate improvement in condition. TTP is a rare condition that can be idiopathic or acquired. Further research is required to assess the complexity of the underlying mechanism. Early diagnosis and aggressive management often lead to a favorable outcome.
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Affiliation(s)
- Misbahuddin Khaja
- Internal Medicine/Pulmonary Critical Care, Icahn School of Medicine at Mount Sinai/BronxCare Health System, New York City, USA
| | - Zaheer A Qureshi
- Internal Medicine, Icahn School of Medicine at Mount Sinai/BronxCare Health System, New York City, USA
| | - Sameer Kandhi
- Internal Medicine, BronxCare Health System, New York City, USA
| | - Faryal Altaf
- Internal Medicine, Icahn School of Medicine at Mount Sinai/BronxCare Health System, New York City, USA
| | - Laura Yapor
- Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai/BronxCare Health System, New York City, USA
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26
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Kühne L, Kaufeld J, Völker LA, Wendt R, Schönermarck U, Hägele H, Osterholt T, Eichenauer DA, Bieringer M, von Bergwelt-Baildon A, Fischereder M, Buxhofer-Ausch V, Menne J, Brinkkoetter PT, Knöbl P. Alternate-day dosing of caplacizumab for immune-mediated thrombotic thrombocytopenic purpura. J Thromb Haemost 2022; 20:951-960. [PMID: 35000278 DOI: 10.1111/jth.15637] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The anti-von Willebrand factor (VWF) nanobody caplacizumab directly prevents the fatal microthrombi formation in immune-mediated thrombotic thrombocytopenic purpura (iTTP), thereby adding a new therapeutic principle to the treatment of this disorder. However, real-world treatment modalities beyond clinical trials remain heterogeneous. METHODS Here, we describe the risks and benefits of an alternate-day dosing regimen for caplacizumab by thoroughly analyzing the timing and outcome of this approach in a retrospective cohort of 25 iTTP patients treated with caplacizumab at seven different medical centers in Austria and Germany between 2018 and 2021. RESULTS Alternate-day dosing of caplacizumab appeared feasible and led to persisting normal platelet counts in most patients. Five patients experienced iTTP exacerbations or relapses that led to the resumption of daily caplacizumab application. VWF activity was repeatedly measured in 16 of 25 patients and documented sufficient suppression by caplacizumab after 24 and 48 h in line with published pharmacodynamics. CONCLUSION Extension of caplacizumab application intervals from daily to alternate-day dosing may be safely considered in selected patients after 3 to 4 weeks of daily treatment. Earlier modifications may be discussed in low-risk patients but require close monitoring for clinical and laboratory features of thrombotic microangiopathy.
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Affiliation(s)
- Lucas Kühne
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Jessica Kaufeld
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | - Linus A Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Ralph Wendt
- Department of Nephrology and Kuratorium for Dialysis and Transplantation Renal Unit, Hospital St. Georg, Leipzig, Germany
| | - Ulf Schönermarck
- Klinikum der Universität München - Medizinische Klinik und Poliklinik IV, Nephrologisches Zentrum, Munich, Germany
| | - Holger Hägele
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Thomas Osterholt
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Dennis A Eichenauer
- Department I of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany
| | - Markus Bieringer
- Department of Cardiology and Nephrology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Anke von Bergwelt-Baildon
- Klinikum der Universität München - Medizinische Klinik und Poliklinik IV, Nephrologisches Zentrum, Munich, Germany
| | - Michael Fischereder
- Klinikum der Universität München - Medizinische Klinik und Poliklinik IV, Nephrologisches Zentrum, Munich, Germany
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I with Hematology, Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinnen, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Jan Menne
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | - Paul T Brinkkoetter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Paul Knöbl
- Division of Hematology and Department of Medicine 1, Medical University of Vienna, Vienna, Austria
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Prével R, Delmas Y, Guillotin V, Gruson D, Rivière E. Complement Blockade Is a Promising Therapeutic Approach in a Subset of Critically Ill Adult Patients with Complement-Mediated Hemolytic Uremic Syndromes. J Clin Med 2022; 11:jcm11030790. [PMID: 35160242 PMCID: PMC8837052 DOI: 10.3390/jcm11030790] [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] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) gathers consumptive thrombocytopenia, mechanical haemolytic anemia, and organ damage. Hemolytic uremic syndromes (HUS) are historically classified as primary or secondary to another disease once thrombotic thrombocytopenic purpura (TTP), Shiga-toxin HUS, and cobalamin C-related HUS have been ruled out. Complement genetics studies reinforced the link between complement dysregulation and primary HUS, contributing to reclassifying some pregnancy- and/or post-partum-associated HUS and to revealing complement involvement in severe and/or refractory hypertensive emergencies. By contrast, no firm evidence allows a plausible association to be drawn between complement dysregulation and Shiga-toxin HUS or other secondary HUS. Nevertheless, rare complement gene variants are prevalent in healthy individuals, thus providing an indication that an investigation into complement dysregulation should be carefully balanced and that the results should be cautiously interpreted with the help of a trained geneticist. Several authors have suggested reclassifying HUS in two entities, regardless of they are complement-mediated or not, since the use of eculizumab, an anti-C5 antibody, dramatically lowers the proportion of patients who die or suffer from end-stage renal disease within the year following diagnosis. Safety and the ideal timing of eculizumab discontinuation is currently under investigation, and the long-term consequences of HUS should be closely monitored over time once patients exit emergency departments.
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Affiliation(s)
- Renaud Prével
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-(0)5-56-79-55-17; Fax: +33-(0)5-56-79-54-18
| | - Yahsou Delmas
- CHU Bordeaux, Nephrology Transplantation Dialysis Apheresis Unit, F-33076 Bordeaux, France;
| | - Vivien Guillotin
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
| | - Etienne Rivière
- CHU Bordeaux, Internal Medicine Department, F-33000 Bordeaux, France;
- University Bordeaux, Biology of Cardiovascular Diseases, InsermU1034, F-33604 Pessac, France
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28
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Burguet L, Taton B, Prezelin-Reydit M, Rubin S, Picard W, Gruson D, Ryman A, Contin-Bordes C, Coppo P, Combe C, Delmas Y. Urine Protein/Creatinine Ratio in Thrombotic Microangiopathies: A Simple Test to Facilitate Thrombotic Thrombocytopenic Purpura and Hemolytic and Uremic Syndrome Diagnosis. J Clin Med 2022; 11:648. [PMID: 35160098 DOI: 10.3390/jcm11030648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Early diagnosis of thrombotic thrombocytopenic purpura (TTP) versus hemolytic and uremic syndrome (HUS) is critical for the prompt initiation of specific therapies. Objective: To evaluate the diagnostic performance of the proteinuria/creatininuria ratio (PU/CU) for TTP versus HUS. Patients/Methods: In a retrospective study, in association with the “French Score” (FS) (platelets < 30 G/L and serum creatinine level < 200 µmol/L), we assessed PU/CU for the diagnosis of TTP in patients above the age of 15 with thrombotic microangiopathy (TMA). Patients with a history of kidney disease or with on-going cancer, allograft or pregnancy were excluded from the analysis. Results: Between February 2011 and April 2019, we identified 124 TMA. Fifty-six TMA patients for whom PU/CU were available, including 35 TTP and 21 HUS cases, were considered. Using receiver–operating characteristic curves (ROC), those with a threshold of 1.5 g/g for the PU/CU had a 77% sensitivity (95% CI (63, 94)) and a 90% specificity (95% CI (71, 100)) for TTP diagnosis compared with those having an 80% sensitivity (95% CI (66, 92)) and a 90% specificity (95% CI (76, 100) with a FS of 2. In comparison, a composite score, defined as a FS of 2 or a PU/CU ≤ 1.5 g/g, improved sensitivity to 99.6% (95% CI (93, 100)) for TTP diagnosis and enabled us to reclassify seven false-negative TTP patients. Conclusions: The addition of urinary PU/CU upon admission of patients with TMA is a fast and readily available test that can aid in the differential diagnosis of TTP versus HUS alongside traditional scoring.
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Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK. Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel) 2022; 14:57. [PMID: 35051033 DOI: 10.3390/toxins14010057] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.
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Dainese C, Valeri F, Pizzo E, Valpreda A, Sivera P, Montaruli B, Porreca A, Massaia M, Bruno B, Borchiellini A. ADAMTS13 Autoantibodies and Burden of Care in Immune Thrombotic Thrombocytopenic purpura: New Evidence and Future Implications. Clin Appl Thromb Hemost 2022; 28:10760296221125785. [PMID: 36124377 PMCID: PMC9490478 DOI: 10.1177/10760296221125785] [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: 11/16/2022] Open
Abstract
The introduction Caplacizumab in the management of Immune thrombotic thrombocytopenic purpura (iTTP) has raised different questions, considering its cost-efficacy and the optimal immunosuppressive treatment (IST) to associate. A retrospective multicenter collection of 42 first iTTP cases was conducted to identify variables associated with a higher burden of care and necessity of an implemented IST with early Rituximab (RTX) rescue. A significant correlation resulted between ADAMTS13 inhibitors (ADAMTS13inh) at diagnosis with total plasma exchange (PEXtot) and PEX needed to achieve clinical response (PEXtoCR, r = 0.46; r = 0.48), along with age (r = - 0.31; r = -0.35), platelet count (r = -0.30; r = -0.30), LDH (r = 0.44; r = 0.41) and total bilirubin (r = 0.54; r = 0.35). ADAMTS13inh also correlated with number of days of hospitalization (DoH, r = 0.44). A significant difference was observed in terms of median ADAMTS13inh titer at diagnosis in patient treated with RTX rescue and those responding to only steroid treatment. Thus, ADAMTS13inh titer resulted a marker of iTTP burden of care, associated with higher number of PEXtot, PEXtoCR, DoH and higher probability of needing RTX rescue to achieve clinical response and could be a useful tool for management of new iTTP cases and an interesting variable to optimize iTTP cases stratification in future Caplacizumab cost-efficacy analysis.
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Affiliation(s)
- Cristina Dainese
- Regional Reference Center for Thrombotic and Haemorrhagic disorders of the adult, Department of Hematology and Oncology, 18691Azienda Ospedaliera Città della Salute e della Scienza di Torino - Molinette, 10126, Turin, Italy
| | - Federica Valeri
- Regional Reference Center for Thrombotic and Haemorrhagic disorders of the adult, Department of Hematology and Oncology, 18691Azienda Ospedaliera Città della Salute e della Scienza di Torino - Molinette, 10126, Turin, Italy
| | - Eleonora Pizzo
- School of Medicine, Study University of Turin, 10126 Turin, Italy
| | | | - Piera Sivera
- Hematology Unit, Ordine Mauriziano Hospital, Turin, 10128, Italy
| | - Barbara Montaruli
- Laboratory Analysis, Ordine Mauriziano Hospital, 10128, Turin, Italy
| | - Annamaria Porreca
- Department of Medical, Oral and Biotechnologies Sciences, University of Chieti-Pescara, 66100, Chieti, Italy
| | - Massimo Massaia
- Division of Hematology, "Santa Croce e Carle di Cuneo" Hospital, 12100, Cuneo, Italy
| | - Benedetto Bruno
- Hematology Unit, Department of Hematology and Oncology, Azienda Ospedaliera Città della Salute e della Scienza di Torino - Molinette, 10126, Turin, Italy
| | - Alessandra Borchiellini
- Regional Reference Center for Thrombotic and Haemorrhagic disorders of the adult, Department of Hematology and Oncology, 18691Azienda Ospedaliera Città della Salute e della Scienza di Torino - Molinette, 10126, Turin, Italy
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Zamora DI, Gonzalez LM. Hypertensive Emergency as the Initial Presentation of Acquired Thrombotic Thrombocytopenic Purpura: A Case Report. Cureus 2021; 13:e20176. [PMID: 34877232 PMCID: PMC8645183 DOI: 10.7759/cureus.20176] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/29/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a type of thrombotic microangiopathy (TMA) related to a deficiency of ADAMTS13 protein, which could lead to fatal outcomes. TTP presents a vast array of symptoms, making its diagnosis a challenge to physicians. In this report, we discuss the case of an 80-year-old male who presented with abdominal pain and hypertension with underlying severe thrombocytopenia and hemolysis. Although his presentation could also be secondary to malignant hypertension, he was promptly diagnosed with TTP based on these findings. TTP is a hematologic emergency, and it should be kept in the differential diagnosis when a patient presents with thrombocytopenia and hemolysis with or without accompanying symptoms.
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Affiliation(s)
- Diana I Zamora
- General Medicine, Universidad de Ciencias Medicas, San Jose, CRI
| | - Laura M Gonzalez
- General Medicine, Universidad de Ciencias Medicas, San Jose, CRI
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32
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Thoreau B, von Tokarski F, Bauvois A, Bayer G, Barbet C, Cloarec S, Mérieau E, Lachot S, Garot D, Bernard L, Gyan E, Perrotin F, Pouplard C, Maillot F, Gatault P, Sautenet B, Rusch E, Frémeaux-Bacchi V, Vigneau C, Fakhouri F, Halimi JM. Infection in Patients with Suspected Thrombotic Microangiopathy Based on Clinical Presentation. Clin J Am Soc Nephrol 2021; 16:1355-1364. [PMID: 34497111 PMCID: PMC8729578 DOI: 10.2215/cjn.17511120] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In contrast to shigatoxin-associated Escherichia coli (STEC) causing hemolytic uremic syndrome, STEC-unrelated infections associated with thrombotic microangiopathy are less characterized. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our retrospective study in a four-hospital institution of 530 consecutive patients with adjudicated thrombotic microangiopathies during the 2009-2016 period studied STEC-unrelated infections' epidemiology and major outcomes (death, acute dialysis, and major cardiovascular events). RESULTS STEC-unrelated infection was present in 145 of 530 (27%) patients, thrombotic microangiopathies without infection were present in 350 of 530 (66%) patients, and STEC causing hemolytic and uremic syndrome was present in 35 of 530 (7%) patients. They (versus thrombotic microangiopathy without infection) were associated with age >60 years (36% versus 18%), men (53% versus 27%), altered consciousness (32% versus 11%), mean BP <65 mm Hg (21% versus 4%), lower hemoglobin and platelet count, and AKI (72% versus 49%). They were associated with more than one pathogen in 36 of 145 (25%) patients (either isolated [14%] or combined [86%] to other causes of thrombotic microangiopathy); however, no significant clinical or biologic differences were noted between the two groups. They were more frequently due to bacteria (enterobacteria [41%], Staphylococcus aureus [11%], and Streptococcus pneumonia [3%]) than viruses (Epstein-Barr [20%], cytomegalovirus [18%], influenza [3%], hepatitis C [1%], HIV [1%], and rotavirus [1%]). STEC-unrelated infections were independent risk factors for in-hospital death (odds ratio, 2.22; 95% confidence interval, 1.18 to 4.29), major cardiovascular event (odds ratio, 3.43; 95% confidence interval, 1.82 to 6.69), and acute dialysis (odds ratio, 3.48; 95% confidence interval, 1.78 to 7.03). Bacteria (versus other pathogens), and among bacteria, enterobacteria, presence of more than one bacteria, and E. coli without shigatoxin were risk factors for acute dialysis. CONCLUSIONS Infections are frequent thrombotic microangiopathy triggers or causes, and they are mostly unrelated to STEC. Infections convey a higher risk of death and major complications. The most frequent pathogens were enterobacteria, S. aureus, Epstein-Barr virus, and cytomegalovirus. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_09_07_CJN17511120.mp3.
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Affiliation(s)
- Benjamin Thoreau
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Florent von Tokarski
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Adeline Bauvois
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Guillaume Bayer
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Christelle Barbet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Sylvie Cloarec
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Elodie Mérieau
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Sébastien Lachot
- Service d'Hématologie Biologique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Denis Garot
- Service de Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Louis Bernard
- Service de Maladies Infectieuses, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Emmanuel Gyan
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHU Tours, Equipe de recherche Labellisée, Centre National pour le Recherche Scientifique 7001, Université de Tours, Tours, France
| | - Franck Perrotin
- Service de Gynécologie Obstétrique B. Maternité Olympe de Gouges, Hôpital Bretonneau, CHU Tours, Tours, France.,Institut National de la Santé et de la Recherche Médicale U1253 Imaging and Brain (iBrain), Université de Tours, Tours, France
| | - Claire Pouplard
- Service d'Hématologie-Hémostase, Hôpital Trousseau, CHU Tours, Tours, France.,EA7501, François-Rabelais University, Tours, France
| | - François Maillot
- Service de Médecine interne, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Philippe Gatault
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France.,EA4245, François-Rabelais University, Tours, France
| | - Bénédicte Sautenet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France.,Institut National de la Santé et de la Recherche Médicale U1246 the methodS in Patient-centered outcomes and HEalth ResEarch, Université de Tours, Université de Nantes, Tours, France
| | - Emmanuel Rusch
- Laboratoire de Santé Publique, Hôpital Bretonneau, CHU Tours, Tours, France
| | | | - Cécile Vigneau
- CHU Pontchaillou, Service de Néphrologie, Rennes, France.,Université Rennes 1, Institut National de la Santé et de la Recherche Médicale Institut de Recherche en Santé, environnement et Travail, Unité Mixte de Recherche 1085, Rennes, France
| | - Fadi Fakhouri
- Service of Nephrology, Department of Medicine, Centre Hospitalier Universitaire Vaudois and Université de Lausanne, Lausanne, Switzerland
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France .,EA4245, François-Rabelais University, Tours, France
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Dekimpe C, Roose E, Kangro K, Bonnez Q, Vandenbulcke A, Tellier E, Kaplanski G, Feys HB, Tersteeg C, Männik A, De Meyer SF, Vanhoorelbeke K. Determination of anti-ADAMTS-13 autoantibody titers in ELISA: Influence of ADAMTS-13 presentation and autoantibody detection. J Thromb Haemost 2021; 19:2248-2255. [PMID: 33728786 DOI: 10.1111/jth.15297] [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: 01/06/2021] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is caused by inhibitory and/or clearing anti-ADAMTS-13 (A Disintegrin and Metalloprotease with ThromboSpondin type 1 repeats, member 13) autoantibodies. To determine the presence and total level of anti-ADAMTS-13 autoantibodies, commercial and in-house developed ELISAs are performed. However, different ELISA methods vary in relation to the presentation of recombinant (r)ADAMTS-13 and the detection method of the anti-ADAMTS-13 autoantibodies. Currently, the influence of those different approaches on anti-ADAMTS-13 autoantibody titers is not known. OBJECTIVES To assess the influence of different ADAMTS-13 presentation- and autoantibody detection methods on anti-ADAMTS-13 autoantibody titers in ELISA. MATERIALS/METHODS Anti-ADAMTS-13 autoantibody titers from 18 iTTP patients were determined using four different set-ups of anti-ADAMTS-13 autoantibody ELISAs. The ELISAs varied in the used presentation of rADAMTS-13 (directly coated full-length rADAMTS-13, directly coated rMDTCS and rT2C2, or antibody-captured full-length rADAMTS-13) and the detection antibodies (polyclonal anti-human IgG or monoclonal anti-human IgG1-4 antibodies). RESULTS Strong correlations between the different anti-ADAMTS-13 autoantibody ELISA approaches were observed, when using polyclonal anti-human IgG detection antibodies recognizing all IgG subclasses similarly, independent of the method of rADAMTS-13 presentation. Anti-ADAMTS-13 autoantibody titers correlated less when using a mixture of monoclonal anti-human IgG1-4 , because not all IgG subclasses were recognized with similar affinities. CONCLUSION Anti-ADAMTS-13 autoantibody levels using different methods of rADAMTS-13 presentation strongly correlate. However, the levels of anti-ADAMTS-13 autoantibodies are highly dependent on the detection antibody used, which should detect all IgG subclasses (IgG1-4 ) equally well.
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Affiliation(s)
- Charlotte Dekimpe
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Elien Roose
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Kadri Kangro
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
- Icosagen Cell Factory OÜ, Kambja vald, Tartumaa, Estonia
| | - Quintijn Bonnez
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Aline Vandenbulcke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Edwige Tellier
- C2VN, INSERM, INRAE, Aix Marseille Universite, Marseille, France
| | - Gilles Kaplanski
- C2VN, INSERM, INRAE, Aix Marseille Universite, Marseille, France
- Hôpital de la Conception, Service de médecine interne, APHM, C2VN, INSERM, INRAE, Aix Marseille Universite, Marseille, France
| | - Hendrik B Feys
- Transfusion Research Center, Belgian Red Cross-Flanders, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Andres Männik
- Icosagen Cell Factory OÜ, Kambja vald, Tartumaa, Estonia
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, IRF Life Sciences, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
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Bullor C, Martínez Deocare D, Rodríguez B, Zuzel PY, Aliano J, Marqués Burgos P, Nuñez I, Díaz Pumará E. [Pseudo-thrombotic microangiopathy due to vitamin B12 deficiency in an infant]. ARCH ARGENT PEDIATR 2021; 119:e326-e329. [PMID: 34309311 DOI: 10.5546/aap.2021.e326] [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: 06/02/2020] [Accepted: 01/21/2021] [Indexed: 11/12/2022]
Abstract
Pseudo-thrombotic microangiopathy, or Moschcowitz syndrome, is a rare manifestation of vitamin B12 deficiency. It is characterized by microangiopathic hemolytic anemia, reticulocytes, and hematimetric indices that can be normal or that might present a mild megaloblastosis, and which are associated with neurological manifestations. Vitamin B12 can be found in animal-based protein foods. Breastfeeding is an adequate source of this vitamin for children, when maternal serum levels are normal. The case of a 16-month-old infant is presented. She was admitted for hemolytic anemia with transfusion requirement, thrombocytopenia, failure to thrive and developmental delay. During her hospitalization, she was diagnosed with pseudothrombotic microangiopathy caused by vitamin B12 deficiency.
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Affiliation(s)
- Carolina Bullor
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniela Martínez Deocare
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | - Brenda Rodríguez
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | - Paula Y Zuzel
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | - Johanna Aliano
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | - Paula Marqués Burgos
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ignacio Nuñez
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Estanislao Díaz Pumará
- Unidad 6 de Clínica Pediátrica, Hospital de Niños Ricardo Gutiérrez, Ciudad Autónoma de Buenos Aires, Argentina
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Noutsos T, Currie BJ, Isoardi KZ, Brown SGA, Isbister GK. Snakebite-associated thrombotic microangiopathy: an Australian prospective cohort study [ASP30]. Clin Toxicol (Phila) 2021; 60:205-213. [PMID: 34328386 DOI: 10.1080/15563650.2021.1948559] [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: 10/20/2022]
Abstract
BACKGROUND Snakebite-associated thrombotic microangiopathy (TMA) occurs in a subset of patients with venom-induced consumption coagulopathy (VICC) following snakebite. Acute kidney injury (AKI) is the commonest end-organ manifestation of TMA. The epidemiology, diagnostic features, outcomes, and effectiveness of interventions including therapeutic plasma-exchange (TPE), in snakebite-associated TMA are poorly understood. METHODS We reviewed all patients with suspected or confirmed snakebite recruited to the Australian Snakebite Project (2004-2018 inclusive), a prospective cohort study, from 202 participating Australian hospitals across the country. TMA was defined as anemia with schistocytosis. RESULTS 2069 patients with suspected snakebite were enrolled, with 1158 (56.0%) systemically envenomed, of which 842 (72.7%) developed VICC, from which 104 (12.4%) developed TMA. Of those systemically envenomed, TMA occurred in 26% (13/50) taipan, 17% (60/351) brown, and 8% (16/197) tiger snakebites. Thrombocytopenia was present in 90% (94/104) of TMA cases, and a further eight (8%) had a > 25% decrease in platelets from the presentation. Patients with TMA were significantly older than non-TMA patients with VICC (53 [35-61] versus 41 [24-55] years, median [IQR], p < 0.0001). AKI developed in 94% (98/104) of TMA patients, with 34% (33/98) requiring dialysis (D-AKI). There were four deaths. In D-AKI TMA cases, eventual dialysis-free survival (DFS) was 97% (32/33). TPE was used in five D-AKI cases, with no significant difference in DFS or time to independence from dialysis. >90-day follow-up for 25 D-AKI cases (130 person-years) showed no end-stage kidney disease but 52% (13/25) had ≥ stage 3 chronic kidney disease (CKD). CONCLUSION Our findings support a definition of snakebite-associated TMA as anemia with schistocytosis and either thrombocytopenia or >25% drop in platelet count. AKI occurring with snakebite-associated TMA varied in severity, with most achieving DFS, but with a risk of long-term CKD in half. We found no evidence of benefit for TPE in D-AKI.
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Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Simon G A Brown
- Centre for Clinical Research in Emergency Medicine, University of Western Australia, Perth, Australia.,Aeromedical and Medical Retrieval Division, Ambulance Tasmania, Hobart, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
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Burwick RM, Moyle K, Java A, Gupta M. Differentiating Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome and Atypical Hemolytic Uremic Syndrome in the Postpartum Period. Hypertension 2021; 78:760-768. [PMID: 34275337 DOI: 10.1161/hypertensionaha.121.17311] [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: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Richard M Burwick
- From the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA (R.M.B.)
| | - Kimberly Moyle
- Department of Obstetrics and Gynecology, University of Utah Health (K.M.)
| | - Anuja Java
- Division of Nephrology, Department of Medicine, Washington University School of Medicine in St. Louis (A.J.)
| | - Megha Gupta
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT (M.G.)
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Moulton MN, Kay CL, Romain JT, Morrow BD, Bobele GM. Clostridioides difficile-Associated Atypical Hemolytic-Uremic Syndrome Successfully Treated With Eculizumab: A Case Report and Literature Review. Crit Care Explor 2021; 3:e0475. [PMID: 34278311 DOI: 10.1097/CCE.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Clostridioides difficile infection is a rare precipitant for patients to develop atypical hemolytic-uremic syndrome, of which the pathogenesis remains unclear. Previous reports suggest activation of cytokine storm from binding of cyotoxins A and B to colonic wall membranes. CASE SUMMARY We present a case of a previously healthy 21-year-old woman who developed fulminant C. difficile colitis and atypical hemolytic-uremic syndrome requiring abdominal surgery and renal replacement therapy. She was ultimately treated with eculizumab without the use of plasmapheresis and remains in remission with full renal recovery. CONCLUSIONS Our patient's significant response to terminal complement inhibitor, without the use of plasmapheresis, suggests that the underlying pathology is significantly driven by the alternative complement pathway. We propose that C. difficile-associated atypical hemolytic-uremic syndrome be defined as primary atypical hemolytic-uremic syndrome and strongly consider eculizumab as first-line therapy.
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Abstract
A 65-year-old female patient with breast cancer and soft tissue sarcoma who
experienced a gemcitabine-induced thrombotic microangiopathies manifestation
visited the emergency department. The renal biopsy revealed endothelial cell
swelling, focal reduplication of glomerular basement membrane, and narrowed
capillary lumens with fibrin deposition and fragmented erythrocytes which are
compatible with thrombotic microangiopathies. The patient was presented with
organ injury, acute renal failure with the need for hemodialysis technique. The
patient recovered after the appropriate treatment. Continuous observation of
renal function during gemcitabine treatment regularly and withdrawal of
treatment if acute kidney injury occurs is essential as acute kidney injury
along with thrombotic microangiopathies may prove to be life-threatening.
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Affiliation(s)
- Mohammed Ali Madkhali
- Division of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
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Satoh K, Okuyama M, Irie Y, Kameyama K, Kitamura T, Nakae H. Continuous plasma exchange with dialysis for thrombotic microangiopathy in intensive care unit: Retrospective observational study. Ther Apher Dial 2021; 25:377-383. [PMID: 33885227 DOI: 10.1111/1744-9987.13654] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022]
Abstract
Continuous plasma exchange with dialysis is a novel method of blood purification and is a modification of the plasma exchange. Technically, this process suggests a reduction in adverse events, cost-effectiveness, and compatibility with hemodynamic instability. The therapeutic effect of plasma exchange on thrombotic microangiopathies has been established. We present three clinical cases in the intensive care unit that illustrate continuous plasma exchange with dialysis as a flexible blood purification therapy for critically ill patients; a radical treatment, thrombotic microangiopathies; supportive therapy, multiple organ failure; and fluid balance regulator. The retrospective analysis of 13 continuous plasma exchange with dialysis sessions showed that the platelet count increased significantly (p = 0.0096) after its administration. The total protein, albumin, fibrinogen, or calcium did not decrease significantly after continuous plasma exchange with dialysis, suggesting therapeutic efficacy and fewer adverse events. A prospective study on thrombotic microangiopathies for continuous plasma exchange with dialysis is currently underway.
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Affiliation(s)
- Kasumi Satoh
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Manabu Okuyama
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yasuhito Irie
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Koumei Kameyama
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Toshiharu Kitamura
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Hajime Nakae
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, Japan
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40
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Blasco M, Guillén E, Quintana LF, Garcia-Herrera A, Piñeiro G, Poch E, Carreras E, Campistol JM, Diaz-Ricart M, Palomo M. Thrombotic microangiopathies assessment: mind the complement. Clin Kidney J 2021; 14:1055-1066. [PMID: 33841853 PMCID: PMC8023218 DOI: 10.1093/ckj/sfaa195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 06/21/2020] [Accepted: 08/31/2020] [Indexed: 12/11/2022] Open
Abstract
When faced with microangiopathic haemolytic anaemia, thrombocytopenia and organ dysfunction, clinicians should suspect thrombotic microangiopathy (TMA). The endothelial damage that leads to this histological lesion can be triggered by several conditions or diseases, hindering an early diagnosis and aetiological treatment. However, due to systemic involvement in TMA and its low incidence, an accurate early diagnosis is often troublesome. In the last few decades, major improvements have been made in the pathophysiological knowledge of TMAs such as thrombotic thrombocytopenic purpura [TTP, caused by ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin Type 1 motif, member 13) deficiency] and atypical haemolytic uraemic syndrome (aHUS, associated with dysregulation of the alternative complement pathway), together with enhancements in patient management due to new diagnostic tools and treatments. However, diagnosis of aHUS requires the exclusion of all the other entities that can cause TMA, delaying the introduction of terminal complement blockers, which have shown high efficacy in haemolysis control and especially in avoiding organ damage if used early. Importantly, there is increasing evidence that other forms of TMA could present overactivation of the complement system, worsening their clinical progression. This review addresses the diagnostic and therapeutic approach when there is clinical suspicion of TMA, emphasizing complement evaluation as a potential tool for the inclusive diagnosis of aHUS, as well as for the improvement of current knowledge of its pathophysiological involvement in other TMAs. The development of both new complement activation biomarkers and inhibitory treatments will probably improve the management of TMA patients in the near future, reducing response times and improving patient outcomes.
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Affiliation(s)
- Miquel Blasco
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
- Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Elena Guillén
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
- Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | | | - Gastón Piñeiro
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
- Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Esteban Poch
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
- Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clinic/University of Barcelona Campus, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Josep M Campistol
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
- Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Barcelona Endothelium Team, Barcelona, Spain
- Department of Pathology, Hematopathology Unit, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic/University of Barcelona Campus, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
- Department of Pathology, Hematopathology Unit, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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41
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Noutsos T, Currie BJ, Brown SG, Isbister GK. Schistocyte quantitation, thrombotic microangiopathy and acute kidney injury in Australian snakebite coagulopathy [ASP28]. Int J Lab Hematol 2021; 43:959-965. [PMID: 33615713 PMCID: PMC8519151 DOI: 10.1111/ijlh.13497] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/26/2021] [Accepted: 02/06/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The major systemic manifestation of hemotoxicity in human snakebite envenoming is venom-induced consumption coagulopathy (VICC). A subset of patients with VICC develop thrombotic microangiopathy (TMA), in which acute kidney injury (AKI) occurs. We aimed to investigate the association between schistocytosis in snakebite patients with VICC and AKI, compared to non-envenomed patients. METHODS Serial blood films collected from a prospective cohort of snakebite patients (Australian Snakebite Project) were examined. Cases were classified a priori as non-envenomed snakebites (normal controls), envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI based on defined clinical and laboratory criteria. The percentage of schistocytes between groups was compared and correlated by Kendall's tau b test. RESULTS Seven hundred and eighty blood films from 234 snakebite cases were analyzed. There was a statistically significant correlation (τ = .69, SE .03, P < .001) for schistocytosis between the ordered groups of non-envenomed snakebites, envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI groups. Patients with VICC and AKI had a platelet nadir median of 42 × 109 /L (interquartile range [IQR] :25-130 × 109 /L), hemoglobin nadir of median 107 g/L (IQR 66-122 g/L), and maximum LDH median of 1128 U/L (IQR 474-3255 U/L). A 1.0% threshold for schistocytosis yielded 90% sensitivity (95% CI: 67%-98%) and 71% specificity (95% CI: 62%-79%) for predicting AKI in patients with VICC. CONCLUSION Schistocyte quantitation has good diagnostic utility in snakebite patients with VICC. A definition of snakebite TMA as MAHA with ≥1.0% schistocytes and thrombocytopenia, would appear to be appropriate.
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Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Simon G Brown
- Centre for Clinical Research in Emergency Medicine, University of Western Australia, Perth, WA, Australia.,Aeromedical and Medical Retrieval Division, Ambulance Tasmania, Hobart, TAS, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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42
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Åkesson A, Martin M, Blom AM, Rossing M, Gabrielaite M, Zetterberg E, Klintman J. Clinical characterization and identification of rare genetic variants in atypical hemolytic uremic syndrome: A Swedish retrospective observational study. Ther Apher Dial 2021; 25:988-1000. [PMID: 33609329 DOI: 10.1111/1744-9987.13634] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/27/2021] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Abstract
Complement-mediated atypical hemolytic uremic syndrome (aHUS) is an ultra-rare renal disease primarily caused by genetic alterations in complement proteins. The genetic work-up required for confirmation of diagnosis is complicated and not always logistically accessible. The aim of the present study was to apply a diagnostic scheme compliant with the American College of Medical Genetics and Genomics guidelines to investigate the prevalence of complement-mediated aHUS among subjects formerly included in a retrospective cohort of clinically suspected aHUS. Clinical outcomes and genetic correlations to complement analyses were assessed. Subjects were investigated with medical record reviewing, inquiries, and laboratory analyses composed of whole genome sequencing; enzyme-linked immunosorbent assays for factor I, factor H, and factor H-specific antibodies; nephelometry for complement components three of four; flow cytometry for CD46 surface expression and immunoblotting for the presence of factor H-related protein 1. In total, 45% (n = 60/134) of the subjects were deceased at the time of study. Twenty of the eligible subjects consented to study participation. Based on genetic sequencing and clinical characteristics, six were categorized as definite/highly suspected complement-mediated aHUS, 10 as non-complement-mediated aHUS and four as having an HUS-like phenotype. In the complement-mediated aHUS group, two subjects had not received an aHUS diagnosis during the routine clinical management. Disease-contributing/likely disease-contributing genetic variants were identified in five subjects, including a novel missense variant in the complement factor H gene (c.3450A>G, p.I1150M). This study illustrates the risk for misdiagnosis in the management of patients with complement-mediated aHUS and the importance of a comprehensive assessment of both phenotype and genotype to reach a diagnosis.
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Affiliation(s)
- Alexander Åkesson
- The Clinical Coagulation Research Unit, Department of Translational Medicine, Lund University, Skane University Hospital, Malmo, Sweden
| | - Myriam Martin
- The Medical Protein Chemistry Research Group, Department of Translational Medicine, Lund University, Malmo, Sweden
| | - Anna M Blom
- The Medical Protein Chemistry Research Group, Department of Translational Medicine, Lund University, Malmo, Sweden
| | - Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Migle Gabrielaite
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Zetterberg
- The Clinical Coagulation Research Unit, Department of Translational Medicine, Lund University, Skane University Hospital, Malmo, Sweden
| | - Jenny Klintman
- The Clinical Coagulation Research Unit, Department of Translational Medicine, Lund University, Skane University Hospital, Malmo, Sweden
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43
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Cosmai L, Porta C, Foramitti M, Perrone V, Mollica L, Gallieni M, Capasso G. Preventive strategies for acute kidney injury in cancer patients. Clin Kidney J 2020; 14:70-83. [PMID: 33564407 PMCID: PMC7857811 DOI: 10.1093/ckj/sfaa127] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 02/10/2020] [Indexed: 12/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication of cancer that occurs in up to 50% of neoplastic patients during the natural history of their disease; furthermore, it has a huge impact on key outcomes such as overall prognosis, length of hospitalization and costs. AKI in cancer patients has different causes, either patient-, tumour- or treatment-related. Patient-related risk factors for AKI are the same as in the general population, whereas tumour-related risk factors are represented by compression, obstruction, direct kidney infiltration from the tumour as well by precipitation, aggregation, crystallization or misfolding of paraprotein (as in the case of multiple myeloma). Finally, treatment-related risk factors are the most common observed in clinical practice and may present also with the feature of tumour lysis syndrome or thrombotic microangiopathies. In the absence of validated biomarkers, a multidisciplinary clinical approach that incorporates adequate assessment, use of appropriate preventive measures and early intervention is essential to reduce the incidence of this life-threatening condition in cancer patients.
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Affiliation(s)
- Laura Cosmai
- Onco-Nephrology Outpatient Clinic, Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Camillo Porta
- Department of Biomedical Sciences and Human Oncology, University of Bari 'A. Moro', Bari, Italy.,Division of Medical Oncology, AOU Consorziale Policlinico di Bari, Bari
| | | | - Valentina Perrone
- Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Ludovica Mollica
- Division of Medical Oncology, AOU Consorziale Policlinico di Bari, Bari.,Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Maurizio Gallieni
- Department of Clinical and Biomedical Sciences 'Luigi Sacco', University of Milano, Milan, Italy.,Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy.,Biogem Research Institute, Ariano Irpino, Italy
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44
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So S, Fischer E, Gangadharan Komala M, Bose B. Postpartum atypical hemolytic uremic syndrome: Evaluating thrombotic microangiopathy in the pregnant woman. Obstet Med 2020; 14:105-108. [PMID: 34394720 DOI: 10.1177/1753495x20926043] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury in women during pregnancy and the puerperium is often ascribed to hypertensive complications of pregnancy, especially pre-eclampsia. However, rarer causes, including atypical hemolytic uremic syndrome (aHUS) can be triggered by pregnancy. We present a case of a woman with post-partum acute kidney injury due to aHUS, which was successfully treated with the C5a inhibitor eculizumab. We also present a summary of the evaluation and management of thrombotic microangiopathy in pregnancy.
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Affiliation(s)
- S So
- Department of Renal Medicine, Nepean Hospital, Kingswood, Australia
| | - E Fischer
- Department of Renal Medicine, Nepean Hospital, Kingswood, Australia
| | - M Gangadharan Komala
- Department of Renal Medicine, Nepean Hospital, Kingswood, Australia.,Nepean Clinical School, University of Sydney, Kingswood, Australia
| | - B Bose
- Department of Renal Medicine, Nepean Hospital, Kingswood, Australia.,Nepean Clinical School, University of Sydney, Kingswood, Australia
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45
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Kozlowski P, Kameran Behnam K, Uggla B, Åström M. Carfilzomib-induced hemolysis is noticeably common but rarely shows features of thrombotic microangiopathy: A retrospective study. Eur J Haematol 2020; 104:588-593. [PMID: 32115785 PMCID: PMC7318150 DOI: 10.1111/ejh.13401] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/29/2022]
Abstract
Objective Hemolysis is a sporadically reported but potentially serious side effect of the proteasome inhibitor carfilzomib. We aimed to investigate the frequency of hemolysis in an unselected cohort. Methods We performed a retrospective, single‐center study of the incidence of hemolysis in patients treated with carfilzomib, based mainly on consecutive haptoglobin levels. The patients were diagnosed with myeloma (n = 20), AL amyloidosis (n = 3), and light‐chain deposition disease (n = 1). Carfilzomib treatment was applied after a median of 3 (range: 1‐7) therapy lines. Results Haptoglobin levels were normal/increased before, generally suppressed during, and normalized after treatment with carfilzomib. Very low haptoglobin (<0.1 g/L) implying the presence of hemolysis was observed in 16 of 24 (67%) patients during carfilzomib therapy. Hemolysis was mild in 11 of 16 (69%) affected patients, whereas 5 of 16 (31%) required transfusion. Severe hemolysis was explained by thrombotic microangiopathy (TMA) in one patient who died of the complication. Mechanisms were unclear in the remaining 15 patients. Conclusions Hemolysis was surprisingly common but mostly mild during carfilzomib treatment. However, the possibility of TMA should be kept in mind in this setting. Hypothetically, non‐TMA hemolysis could be attributed to the accumulation of globin chains due to the suppression of eukaryotic translation initiation inhibition by carfilzomib.
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Affiliation(s)
- Piotr Kozlowski
- Division of Hematology, Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Klodia Kameran Behnam
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bertil Uggla
- Division of Hematology, Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Åström
- Division of Hematology, Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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46
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Bongetti E, Kavanagh D, Martin K, Bendall A, Hill P, Steinberg A, Rajaram Y, Ierino F. Cocaine-associated atypical haemolytic uraemic syndrome in a genetically susceptible individual. Nephrology (Carlton) 2020; 25:518-521. [PMID: 31900968 DOI: 10.1111/nep.13690] [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: 09/21/2019] [Revised: 11/21/2019] [Accepted: 12/02/2019] [Indexed: 11/27/2022]
Abstract
Atypical haemolytic uraemic syndrome (aHUS) is a severe, life-threatening condition that requires early recognition and urgent treatment. In aHUS rare genetic variants in CFH, CFI, CD46, C3 and CFB predispose to complement over activation. This case describes a case of aHUS in which there was a strong temporal association between disease onset and the use of smoked cocaine. The patient was found to have a rare genetic variant in the CFI gene which may have been unmasked by first-time exposure to cocaine. The patient stabilized and improved with early administration of eculizumab, supporting the notion of an underlying immunological pathogenesis and the importance of early intervention.
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Affiliation(s)
- Elisa Bongetti
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - David Kavanagh
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kylie Martin
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Anna Bendall
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Prue Hill
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Adam Steinberg
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Yogeshwar Rajaram
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Francesco Ierino
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
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47
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Timmermans SAMEG, Wérion A, Damoiseaux JGMC, Morelle J, Reutelingsperger CP, van Paassen P. Diagnostic and Risk Factors for Complement Defects in Hypertensive Emergency and Thrombotic Microangiopathy. Hypertension 2019; 75:422-430. [PMID: 31865800 DOI: 10.1161/hypertensionaha.119.13714] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hypertensive emergency can cause thrombotic microangiopathy (TMA) in the kidneys with high rates of end-stage renal disease (ESRD) and vice versa. The conundrum of hypertension as the cause of TMA or consequence of TMA on the background of defects in complement regulation remains difficult. Patients with hypertensive emergency and TMA on kidney biopsy were tested for ex vivo C5b9 formation on the endothelium and rare variants in complement genes to identify complement-mediated TMA. We identified factors associated with defects in complement regulation and poor renal outcomes. Massive ex vivo C5b9 formation was found on resting endothelial cells in 18 (69%) out of 26 cases at the presentation, including the 9 patients who carried at least one rare genetic variant. Thirteen (72%, N=18) and 3 (38%, N=8) patients with massive and normal ex vivo complement activation, respectively, progressed to ESRD (P=0.03). In contrast to BP control, inhibition of C5 activation prevented ESRD to occur in 5 (83%, N=6) patients with massive ex vivo complement activation. TMA-related graft failure occurred in 7 (47%, N=15) donor kidneys and was linked to genetic variants. The assessment of both ex vivo C5b9 formation and screening for rare variants in complement genes may categorize patients with hypertensive emergency and TMA into different groups with potential therapeutic and prognostic implications. We propose an algorithm to recognize patients at the highest risk for defects in complement regulation.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- From the Department of Nephrology and Clinical Immunology (S.A.M.E.G.T., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
- Department of Biochemistry (S.A.M.E.G.T., C.P.R., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
| | - Alexis Wérion
- Division of Nephrology, Cliniques universitaires Saint-Luc (A.W., J.M.)
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center (J.G.M.C.D.), Cardiovascular Research Institute Maastricht, the Netherlands
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc (A.W., J.M.)
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium (J.M.)
| | - Chris P Reutelingsperger
- Department of Biochemistry (S.A.M.E.G.T., C.P.R., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
| | - Pieter van Paassen
- From the Department of Nephrology and Clinical Immunology (S.A.M.E.G.T., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
- Department of Biochemistry (S.A.M.E.G.T., C.P.R., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
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Renaghan AD, Jaimes EA, Malyszko J, Perazella MA, Sprangers B, Rosner MH. Acute Kidney Injury and CKD Associated with Hematopoietic Stem Cell Transplantation. Clin J Am Soc Nephrol 2019; 15:289-297. [PMID: 31836598 PMCID: PMC7015091 DOI: 10.2215/cjn.08580719] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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: 12/14/2022]
Abstract
Hematopoietic stem cell transplantation is a life-saving therapy for many patients with cancer, as well as patients with some nonmalignant hematologic disorders, such as aplastic anemia, sickle cell disease, and certain congenital immune deficiencies. Kidney injury directly associated with stem cell transplantation includes a wide range of structural and functional abnormalities, which may be vascular (hypertension, thrombotic microangiopathy), glomerular (albuminuria, nephrotic glomerulopathies), and/or tubulointerstitial. AKI occurs commonly after stem cell transplant, affecting 10%-73% of patients. The cause is often multifactorial and can include sepsis, nephrotoxic medications, marrow infusion syndrome, hepatic sinusoidal obstruction syndrome, thrombotic microangiopathy, infections, and graft versus host disease. The risk of post-transplant kidney injury varies depending on patient characteristics, type of transplant (allogeneic versus autologous), and choice of chemotherapeutic conditioning regimen (myeloablative versus nonmyeloablative). Importantly, AKI is associated with substantial morbidity, including the need for KRT in approximately 5% of patients and the development of CKD in up to 60% of transplant recipients. AKI has been associated universally with higher all-cause and nonrelapse mortality regardless of transplant type, and studies have consistently shown extremely high (>80%) mortality rates in those patients requiring acute dialysis. Accordingly, prevention, early recognition, and prompt treatment of kidney injury are essential to improving kidney and patient outcomes after hematopoietic stem cell transplantation, and for realizing the full potential of this therapy.
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Affiliation(s)
| | - Edgar A Jaimes
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Mark A Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.,Veterans Affairs Medical Center, West Haven, Connecticut
| | - Ben Sprangers
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Belgium; and.,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; and
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Laboratory of Immunology, Hôpital Européen Georges-Pompidou, Paris, France
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50
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Palomo M, Blasco M, Molina P, Lozano M, Praga M, Torramade-Moix S, Martinez-Sanchez J, Cid J, Escolar G, Carreras E, Paules C, Crispi F, Quintana LF, Poch E, Rodas L, Goma E, Morelle J, Espinosa M, Morales E, Avila A, Cabello V, Ariceta G, Chocron S, Manrique J, Barros X, Martin N, Huerta A, Fraga-Rodriguez GM, Cao M, Martin M, Romera AM, Moreso F, Manonelles A, Gratacos E, Pereira A, Campistol JM, Diaz-Ricart M. Complement Activation and Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2019; 14:1719-1732. [PMID: 31694864 PMCID: PMC6895490 DOI: 10.2215/cjn.05830519] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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: 05/13/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Atypical hemolytic uremic syndrome is a form of thrombotic microangiopathy caused by dysregulation of the alternative complement pathway. There is evidence showing complement activation in other thrombotic microangiopathies. The aim of this study was to evaluate complement activation in different thrombotic microangiopathies and to monitor treatment response. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Complement activation was assessed by exposing endothelial cells to sera or activated-patient plasma-citrated plasma mixed with a control sera pool (1:1)-to analyze C5b-9 deposits by immunofluorescence. Patients with atypical hemolytic uremic syndrome (n=34) at different stages of the disease, HELLP syndrome (a pregnancy complication characterized by hemolysis, elevated liver enzymes, and low platelet count) or severe preeclampsia (n=10), and malignant hypertension (n=5) were included. RESULTS Acute phase atypical hemolytic uremic syndrome-activated plasma induced an increased C5b-9 deposition on endothelial cells. Standard and lower doses of eculizumab inhibited C5b-9 deposition in all patients with atypical hemolytic uremic syndrome, except in two who showed partial remission and clinical relapse. Significant fibrin formation was observed together with C5b-9 deposition. Results obtained using activated-plasma samples were more marked and reproducible than those obtained with sera. C5b-9 deposition was also increased with samples from patients with HELLP (all cases) and preeclampsia (90%) at disease onset. This increase was sustained in those with HELLP after 40 days, and levels normalized in patients with both HELLP and preeclampsia after 6-9 months. Complement activation in those with malignant hypertension was at control levels. CONCLUSIONS The proposed methodology identifies complement overactivation in patients with atypical hemolytic uremic syndrome at acute phase and in other diseases such as HELLP syndrome and preeclampsia. Moreover, it is sensitive enough to individually assess the efficiency of the C5 inhibition treatment.
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Affiliation(s)
- Marta Palomo
- Josep Carreras Leukaemia Research Institute; .,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Patricia Molina
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Institut Clinic de Malalties Hematologiques i Oncologiques (ICMHO), IDIBAPS, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Sergi Torramade-Moix
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Julia Martinez-Sanchez
- Josep Carreras Leukaemia Research Institute.,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Institut Clinic de Malalties Hematologiques i Oncologiques (ICMHO), IDIBAPS, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Gines Escolar
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute.,Barcelona Endothelium Team, Barcelona, Spain
| | - Cristina Paules
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Fatima Crispi
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Luis F Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Esteban Poch
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Lida Rodas
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Emma Goma
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía e Instituto Maimonides de Investigaciones Biológicas de Córdoba (IMIBIC), Córdoba, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain
| | - Ana Avila
- Department of Nephrology and Renal Transplantation, Hospital Universitario Dr Peset, Valencia, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Virgen del Rocio, Sevilla, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Materno-Infantil, Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Sara Chocron
- Department of Pediatric Nephrology, Hospital Materno-Infantil, Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Joaquin Manrique
- Department of Nephrology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitari Josep Trueta, Girona, Spain
| | - Nadia Martin
- Department of Nephrology, Hospital Universitari Josep Trueta, Girona, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - Gloria M Fraga-Rodriguez
- Department of Pediatric Nephrology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mercedes Cao
- Department of Nephrology, Complejo Hospitalario Universitario A Coruña, Coruña, Spain
| | - Marisa Martin
- Department of Nephrology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Ana Maria Romera
- Department of Nephrology, Hospital General Universitario, Ciudad Real, Spain
| | - Francesc Moreso
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain
| | - Anna Manonelles
- Kidney Transplant Unit, Department of Nephrology, Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain; and
| | - Eduard Gratacos
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | | | - Josep M Campistol
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
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