Literatur
Bohm M., Vigh T. und Scharrer I. (2002) Evaluation and clinical application of a new method for measuring activity of von Willebrand factor-cleaving metalloprotease (ADAMTS13). Ann Hematol.; 81:430-435
Thrombotic thrombocytopenic purpura (TTP) is associated with acquired or congenital deficiency of a plasma von Willebrand factor-cleaving protease (VWFcp). Based on partial amino acid sequence and genome-wide linkage analysis of pedigrees with congenital TTP, VWFcp was recently identified as a new member of the ADAMTS family and designated ADAMTS13. We developed a new, rapid, and simple method for measuring VWFcp activity based on the positive correlation between VWF multimeric size and Ristocetin cofactor activity (VWF:RCo). After dilution of plasma with low ionic Tris buffer and activation of the protease with barium chloride, a VWF concentrate is digested in the presence of urea. Subsequently, the residual VWF:RCo of the samples is assessed and used to calculate the VWFcp activity of the samples. The accuracy of the new technique is verified by estimating VWFcp activity for 282 plasma samples with the RCo-based assay and the original immunoblotting assay. The method is reproducible as shown by low intra- and interassay coefficients of variation (2.8% and 7.5% for normal samples, respectively, and 8.7% and 12.9% for abnormal samples, respectively). Furthermore, the clinical application of the new method is illustrated by measuring VWFcp of 14 patients with 22 episodes of acute TTP as well as other thrombotic, thrombocytopenic, or hemolytic disorders. Severe VWFcp deficiency was restricted to patients with acute, classic TTP. The majority of patients with low titer inhibitor respond to plasma exchange treatment with increase of VWFcp activity, whereas VWFcp deficiency persists in some patients with high titer inhibitor despite clinical remission.
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Fontana S., Hovinga J.A., Studt J.D., Alberio L., Lammle B. und Taleghani B.M. (2004) Plasma therapy in thrombotic thrombocytopenic purpura: review of the literature and the Bern experience in a subgroup of patients with severe acquired ADAMTS-13 deficiency. Semin.Hematol.; 41:48-59
Based on clinical studies daily plasma exchange (PE) has become the first-choice therapy for thrombotic thrombocytopenic purpura (TTP) since 1991. Recent findings may explain its effectiveness, which particularly may include supply of ADAMTS-13 and removal of anti-ADAMTS-13 autoantibodies and unusually large von Willebrand factor (VWF) multimers. The most preferable PE regimens as well as replacement fluids are discussed and treatment-related adverse reactions are summarized. Proposals for a potential reduction of their frequency and for improvement of treatment efficiency are given. These suggestions are partially based on the experience of our institution in adult patients with severe ADAMTS-13 deficiency (<5% activity), and include (1) continuous calcium-gluconate infusion during PE in order to reduce citrate-related adverse reactions; (2) the evaluation of solvent/detergent-treated (S/D) plasma as replacement fluid in order to reduce adverse events due to fresh frozen plasma (FFP); (3) the evaluation of immunoadsorption in order to increase procedural efficiency in autoantibody removal; and (4) the substitution of ADAMTS-13 by means of recombinant drug instead of plasma.
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George J.N., Kremer Hovinga J.A., Terrell D.R., Vesely S.K. und Lammle B. (2008) The Oklahoma Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome Registry: the Swiss connection. Eur.J.Haematol.; 80:277-286
OBJECTIVES: Thrombotic thrombocytopenic purpura (TTP) was initially described as an uncommon and usually fatal disorder. With effective treatment it is more frequently diagnosed, the clinical presentations are more diverse, and long-term sequelae are becoming recognized. METHODS: Patient data are from The Oklahoma TTP-hemolytic uremic syndrome (HUS) Registry, an inception cohort of 348 consecutive patients with their first episode of clinically diagnosed TTP or HUS, 1989-2006. The Registry enrolls all patients in a defined region who are diagnosed with TTP or HUS and for whom plasma exchange treatment is requested. ADAMTS13 activity has been analyzed on 235 (93%) of 254 patients since 1995 at the University of Berne, Switzerland. Patients are described by clinical categories, related to their associated conditions and clinically apparent etiologies, and by the presence of severe ADAMTS13 deficiency. RESULTS AND CONCLUSIONS: The clinical spectrum of syndromes described as TTP is variable with multiple etiologies. Advances in clinical and laboratory investigation have provided better understanding of the pathogenesis of these syndromes, their clinical evaluation and management, and their long-term outcomes. In addition to new information about TTP, these studies provide a model for translational research to define the complete community spectrum of uncommon disorders.
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Heidel F., Lipka D.B., von A.C., Huber C., Scharrer I. und Hess G. (2007) Addition of rituximab to standard therapy improves response rate and progression-free survival in relapsed or refractory thrombotic thrombocytopenic purpura and autoimmune haemolytic anaemia. Thromb.Haemost.; 97:228-233
Treatment of relapsed or refractory autoimmune mediated haemolytic syndromes, such as autoimmune haemolytic anaemia (AIHA) and thrombotic thrombocytopenic purpura (TTP), represents a therapeutic challenge. Here we report on our experience with the monoclonal anti-CD20 antibody rituximab (R) compared to standard treatment in these diseases. Patients with non-familial TTP or AIHA and no underlying malignancy were included in our analysis. Safety and efficacy of R-treatment were compared to results obtained in standard treatment approaches. Altogether, 27 patients were analyzed, comprising 15 patients with TTP and 12 patients with AIHA. The patients' average age at the time of diagnosis was 54 years. Eleven patients received antibody treatment (8 TTP, 3 AIHA). No acute or late WHO grade III/IV toxicity associated with rituximab was noted. With standard therapy, the overall response rate (ORR) was 66.7% for AIHA and 65.8% for TTP, respectively. For the R-containing regimens the ORR was 100%. In patients with TTP, median progression free survival (PFS) with R-treatment was 3.8 years, as compared to 0.1 years in the standard-treatment group. In patients with AIHA median PFS was not reached for R-containing treatment; all patients are in sustained remissions with a median follow up of 12.5 months. In the absence of prospective trials, our data underline the safety and efficacy of rituximab in relapsed and refractory autoimmune anaemias with favourable response rates and promising long-term progression-free survival. Therefore, prospective clinical trials evaluating rituximab as salvage- and first-line-therapy are clearly warranted.
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Lammle B., Kremer Hovinga J.A. und Alberio L. (2005) Thrombotic thrombocytopenic purpura. J.Thromb.Haemost.; 3:1663-1675
This overview summarizes the history of thrombotic thrombocytopenic purpura (TTP) from its initial recognition in 1924 as a most often fatal disease to the discovery in 1997 of ADAMTS-13 deficiency as a major risk factor for acute disease manifestation. The cloning of the metalloprotease, ADAMTS-13, an essential regulator of the extremely adhesive unusually large von Willebrand factor (VWF) multimers secreted by endothelial cells, as well as ADAMTS-13 structure and function are reviewed. The complex, initially devised assays for ADAMTS-13 activity and the possible limitations of static in vitro assays are described. A new, simple assay using a recombinant 73-amino acid VWF peptide as substrate will hopefully be useful. Hereditary TTP caused by homozygous or double heterozygous ADAMTS-13 mutations and the nature of the mutations so far identified are discussed. Recognition of this condition by clinicians is of utmost importance, because it can be easily treated and--if untreated--frequently results in death. Acquired TTP is often but not always associated with severe, autoantibody-mediated ADAMTS-13 deficiency. The pathogenesis of cases without severe deficiency of the VWF-cleaving protease remains unknown, affected patients cannot be distinguished clinically from those with severely decreased ADAMTS-13 activity. Survivors of acute TTP, especially those with autoantibody-induced ADAMTS-13 deficiency, are at a high risk for relapse, as are patients with hereditary TTP. Patients with thrombotic microangiopathies (TMA) associated with hematopoietic stem cell transplantation, neo-plasia and several drugs, usually have normal or only moderately reduced ADAMTS-13 activity, with the exception of ticlopidine-induced TMA. Diarrhea-positive-hemolytic uremic syndrome (D+ HUS), mainly occurring in children is due to enterohemorrhagic Escherichia coli infection, and cases with atypical, D- HUS may be associated with factor H abnormalities. Treatment of acquired idiopathic TTP involves plasma exchange with fresh frozen plasma (FFP), and probably immunosuppression with corticosteroids is indicated. We believe that, at present, patients without severe acquired ADAMTS-13 deficiency should be treated with plasma exchange as well, until better strategies become available. Constitutional TTP can be treated by simple FFP infusion that rapidly reverses acute disease and--given prophylactically every 2-3 weeks--prevents relapses. There remains a large research agenda to improve diagnosis of TMA, gain further insight into the pathophysiology of the various TMA and to improve and possibly tailor the management of affected patients.
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McCarthy L.J., Dlott J.S., Orazi A., Waxman D., Miraglia C.C. und Danielson C.F. (2004) Thrombotic thrombocytopenic purpura: yesterday, today, tomorrow. Therap.Apher.Dial.; 8:80-86
Although much has been learned about the pathophysiologic process of thrombotic thrombocytopenic purpura (TTP), both diagnostically and therapeutically, since its initial description by Moschcowitz in 1924, its etiology and treatments remain, in many instances, problematic. Thrombotic thrombocytopenic purpura remains a rare entity whose etiology is usually unknown, but several drugs and infections have now been implicated in its development (i.e. Cyclosporine A, Mitomycin-C, Ticlopidine, Simvastatin, Lipitor, Plavix, FK 506, Rapamune (sirolimus), HIV). Although its treatment by plasma exchange has gained worldwide acceptance since the late 1970s, the optimal exchange media is not known, nor the volume and duration of exchange therapy, nor appropriate salvage therapy(ies). Without the benefit of randomized controlled trials, its treatment, to a large extent, remains not evidence-based but 'eminence-based', making the same mistakes with increasing confidence over an impressive number of years.
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Moake J.L. (2002) Thrombotic microangiopathies. N.Engl.J.Med.; 347:589-600
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Scully M., Longair I., Flynn M., Berryman J. und Machin S.J. (2007) Cryosupernatant and solvent detergent fresh-frozen plasma (Octaplas) usage at a single centre in acute thrombotic thrombocytopenic purpura. Vox Sang.; 93:154-158
BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is an acute, life-threatening disorder and plasma exchange (PEX) remains the mainstay of treatment. METHODS: We reviewed 50 acute TTP episodes to establish the efficacy and safety of cryosupernatant (CPP) and Octaplas. RESULTS: Twelve episodes used CPP only and 15 episodes started with CPP and changed to Octaplas. Once Octaplas had been used, it was continued on further admissions. Cryosupernatant was used exclusively in 24% and Octaplas exclusively in 42% of all episodes. The number of citrate reactions and allergic (plasma) reactions were halved in those receiving only Octaplas compared with cryosupernatant. There were 22 line infections and in approximately 70% of cases the infection was associated with a reduction in platelet count. In all 50 episodes, the only documented thrombosis was a superficial non-central vein. In episodes receiving only cryosupernatant or Octaplas, there was no significant difference in the median number of PEX to remission, 7.0 (interquartile range, IQR 5-8.8) and 8.0 (IQR 6.5-22), respectively. Baseline viral screen in all episodes was negative after discharge following an acute episode. CONCLUSION: There was no difference in number of PEX to remission with cryosupernatant and solvent/detergent fresh-frozen plasma (Octaplas). However, allergic/urticarial and citrate reactions were more common with cryosupernatant. There was no documented viral transmission with either product.
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