Anemie emolitiche autoimmuni · •Severity of anemia, high median LDH levels, and previous...
Transcript of Anemie emolitiche autoimmuni · •Severity of anemia, high median LDH levels, and previous...
Anemie emolitiche
autoimmuni
Wilma Barcellini
Classificazione e diagnosi
Meccanismi patogenetici
Terapia
Anemie emolitiche
autoimmuni
Wilma Barcellini
Classificazione e diagnosi
Meccanismi patogenetici
Terapia
Autoantibody characteristics
DAT positivity
In vivo
hemolysis (RBC
sequestration)
Clinical associationClass
Optimal T of
reaction
(range)
Specificity
1. Warm AIHA
IgG
(possible
complement
fixation)
37°C
(0-40)
Rh
systemIgG or IgG+C
Extravascular
(spleen)
primary or secondary to
autoimmune,
lymphoproliferative, or
neoplastic diseases
2. Cold AIHA
2a. Cold agglutinin
disease (CAD)
IgM
(common
complement
fixation)
4°C
(4-34)
I/i
systemC
Intravascular
and
extravascular
(liver/spleen)
primary or secondary to
infections (acute
transitory) or to
lymphoproliferative
diseases (chronic)
2b. Paroxysmal Cold
Hemoglobinuria
(PCH)
IgG
(common
complement
fixation)
Reacts at
4°C and
hemolyses
at 37°C
P
antigen
Positive
Donath-
Landsteiner
test
Intravascular
and
extravascular
(liver/spleen)
primary or secondary to
syphilis (chronic) or to
other infections (acute
transitory)
3. Mixed AIHA warm IgG and
cold IgM
4°C and
37°C
IgG+high titer
cold IgM
Extravascular/
Intravascular
(spleen /liver)
primary or secondary to
lymphoproliferative or
autoimmune diseases
W. Barcellini, Current treatment strategies in autoimmune hemolytic disorders. Expert Rev Hematol. 2015
60-70%
20-25%
5-10%
1-5%
• estimated incidence 1-3 per 105/year, prevalence of 17:100,000
• heterogeneous condition (from fully compensated to life-threatening )
• major determinants of clinical severity: autoantibody class, thermal amplitude, efficiency in activating complement,
activity of the reticuloendothelial system (in spleen, liver and lymphoid organs), and the efficacy of the bone marrow
compensatory response
Autoimmune hemolytic anemia (AIHA)
• associated infections(Mycoplasma EBV, CMV,HIV, HCV, HBV, etc)
• Autoantibodies for systemic autoimmune
diseases (ANA, anti-DNA, ENA, LAC, ACA, anti-b2).
• careful anamnesis to identify
• drug-associated immune hemolysis (rare but
frequently undiagnosed),
• recent transfusions (DHR) or
• solid organ transplant (passenger
lymphocyte syndrome)
• Bone marrow biopsy and flow cytometry
and TC scan to exclude an underlying
lymphoproliferative disorder
• in all CAD cases prior to therapy
• In warm and mixed cases relapsed after
steroid therapy
• In case of DAT negativity, other causes of
hemolysis should be considered
(membrane and enzyme defects, PNH, HUS, TTP,
mechanical hemolysis, toxic noxae, Gaucher disease)
Diagnostic workup in AIHA include investigation to identify:
Represent 11% of AIHA (Petz e Garratty (Immune hemolytic anemias. New York
Churchill Livingstone, 2004)
Causes of false negative results Possible solutions
IgA auto Abs Use of monospecyfic anti-IgA antisera
low-affinity IgG Abs test with cold washed RBC
test with low-ionic solutions (LISS)
polybrene or PEG
low sensitivity of the tests Use of more sensitive techniques
Microcolumn agglutination technique (CAT)
Solid phase agglutination technique
Immunoenzymatic assay
Flow cytometry
Mitogen-stimulated (MS)-DAT
Positive DAT not specific for AIHA0.007–0.1% of healthy population and 0.3–8% of hospitalized patients
without AIHA have a +DAT
False positive DAT (hypergammaglobulinemia, high dose immunoglobulin therapy) Valent P, Lechner K,Wien Klin Wochenschr. 2008
Positive DAT for alloantibodies (in recently trasfused patients)
DAT negative AIHA
Yamada, Transfusion 2008, Bencomo et al, Immunohematology 2003, Lin et al, Transfusion 2009,
Barcellini et al, BJH 2000, Int J Hematol 2010
• McCann EL et al. IgM autoagglutinins in warm AIHA: a poor prognostic feature. Acta Hematol 1992;82:120-5.
• Garratty G et al. Severe AIHA associated with IgM warm autoantibodies directed against determinants on or
associated with glycophorin A. Vox Sang 1997;72:124-30.
• Friedman AM et al. Fatal AIHA in a child due to warm-reactive immunoglobulin M antibody. J Pediatr
Hematol Oncol 1998;20:502-5.
• Nowak-Wegrzyn A et al. Fatal warm AIHA resulting from IgM autoagglutinins. J Pediatr Hematol Oncol
2001;23:250-2.
• Shirey RS et al. Fatal immune hemolytic anemia and hepatic failure associated with a warm-reacting IgM
autoantibody. Vox Sang 1987; 52:210-22.
• McCann EL et al. IgM autoagglutinins in warm AIHA: a poor prognostic feature. Acta Hematol 1992;82:120-5.
• Garratty G et al. Severe AIHA associated with IgM warm autoantibodies directed against determinants on or
associated with glycophorin A. Vox Sang 1997;72:124-30.
• Friedman AM et al. Fatal AIHA in a child due to warm-reactive immunoglobulin M antibody. J Pediatr
Hematol Oncol 1998;20:502-5.
• Nowak-Wegrzyn A et al. Fatal warm AIHA resulting from IgM autoagglutinins. J Pediatr Hematol Oncol
2001;23:250-2.
• Shirey RS et al. Fatal immune hemolytic anemia and hepatic failure associated with a warm-reacting IgM
autoantibody. Vox Sang 1987; 52:210-22.
Severe and lethal AIHA caused by “warm” IgM autoantibodiesSevere and lethal AIHA caused by “warm” IgM autoantibodies
�“...AIHAs associated with IgM warm auto Abs are often severe with more fatalities than other
types of AIHA….” (Garratty et al, Vox Sang. 1997,72:124-30).
�Can appear to be DAT negative by routine DAT or to have only C3 on RBCs by routine DAT
�Spontaneous RBCs agglutination due to crosslinking of IgM autoabs
�Difficult and delayed diagnosis
Additional factors that influence the clinical characteristics of AIHA
The major determinants of the clinical severity of AIHA are rate and type of hemolysis which depend
on
• the autoantibody class, thermal amplitude, and efficiency in activating complement
• the activity of the reticuloendothelial system (in spleen, liver and lymphoid organs)
• the efficacy of the bone marrow compensatory response
• AIHA with reticulocytopenia. A Medical emergency(Conley CL et al, JAMA, 1980;244:1688)
• Reticulocytopenia is present in 20% adults and 39% children(Liesveld et al, 1987; Aladjidi et al, 2011: Barcellini et al, 2014)
• Reticulocytopenia is present in severe cases
• Erythropoietin useful to overcome the temporary bone
marrow failure in compensating hemolysis
• Erythropoietin may reduce transfusion need and avoid
hemolysis related to overtransfusion
• Due to autoimmune reaction against BM erythroid
precursors?
• the reticulocyte index was lower in cases with Hb<6 g/dL
(65 vs 98, p<0.001), along with more frequent inadequate
reticulocytosis (87 vs 70%, p=0.01)
Clinical follow-up of 378 patients with AIHAfrom 9 italian centers: prognostic impact of Hb levels,
autoAb class, and reticulocytopenia at onset on the relapse risk and outcome
Absolute reticulocyte counts as a
function of Hb at onset
05
10
15
hb
1 2 3 5
Hb as a function of autoAb class and
thermal characteristics
CAD wIgG wIgG+C /Mix Atypical
(n=109) (n=159) (n=90) (n=20)
Anemia severity at onset is associated with
an increased risk of relapse
HR 1.98 for Hb<6 g/dL,
HR 1.74 for Hb 6.1-8 g/dL
HR 1.61 for Hb 8.1-10 g/dL
HR 1.21 for forms other than warm IgG AIHA
HR 1.84 for Evans association
The association of 3 conditions led to a ~4-fold
increased risk of multiple relapses
/refractoriness to therapy (multivariate Cox regression analysis)
Anemie emolitiche
autoimmuni
Wilma Barcellini
Classificazione e diagnosi
Meccanismi patogenetici
Terapia
Barcellini W. New Insights in the Pathogenesis of Autoimmune Hemolytic Anemia. Transfus Med Hemother. 2015;42:287-93
Role of the spleen in the pathogenesis of AIHA
• Major organ for antibody synthesis
• Major site of immune destruction of IgG-coated erythrocytes
• Splenectomy usually ineffective in CAD since most RBC
destruction occurs in liver
• Effective in about 70% of warm AIHA
• Ineffective in about 30% of cases, presumably because there is
still an elevated synthesis of autoantibodies in other lymphoid
organs, and the liver replaces the spleen’s function of RBC
destruction
• The rate of splenectomy is about 10-15% of all AIHA cases, but
is nowadays decreasing given the availability of equally
effective second line medical treatments, primarily rituximab
• No reliable predictors of its effectiveness, such as the extent of
splenic sequestration assessed by radiolabeled erythrocytes,
disease duration and the response to steroids
• The emergence of long-lived autoreactive plasma cells in the
spleen of primary warm AIHA patients relapsed after
rituximab. Spleens (obtained after splenectomy) showed the
presence of non-proliferative memory B-cells and plasma cells,
possibly sustained by increased BAFF (new therapeutic
options?)
Mahévas M et al, J Autoimmun. 2015 Aug;62:22-30
hemolysis
thrombosis
thrombocytopenia
renal failure
hemolysis
thrombosis
thrombocytopenia
renal failure
Close integration between the complement cascade (grey) and the coagulation cascade (green)Close integration between the complement cascade (grey) and the coagulation cascade (green)
Hill A et al. Blood 2013;121:25
•Thrombotic risk in Autoimmune hemolytic anemia
•There is increasing awareness of the thrombotic risk in hemolytic conditions, mainly coming from the experience
on paroxysmal nocturnal hemoglobinuria (PNH)
• In the retrospective multicenter GIMEMA study a thrombotic event was recorded in 34/308 (11%) of patients and
included 11 cases of pulmonary embolisms, 13 deep venous thrombosis, 5 splanchnic thrombosis, 1 disseminated
intravascular coagulation, 3 strokes, 2 transient ischemic attacks and 3 cardiac ischemic events (with 5 patients
experiencing more than one event). (Barcellini, Blood 2014)
•In a case-control single-center study a venous thromboembolism (VTE) was reported in 8/40 patients (20%), all
pulmonary embolus associated with a deep venous thrombosis in 4 (Lecouffe-Desprets , Autoimmun Rev. 2015 ).
•By using a USA cohort of commercial insurance enrolees (Truven Health MarketScan® Databases) the risk of VTE in
AIHA was 10-fold increased (19 per 1,000 person-years, versus 1.9 in the control group) with an adjusted hazard
ratio of 6.30 (95% confidence interval: 4.44-8.94) (Yusuf H, Thromb Res. 2015 ).
•Severity of anemia, high median LDH levels, and previous splenectomy have been associated with the occurrence
of thrombotic events, whereas the role of anti-cardiolipin antibodies or LAC is still controversial
• Recommendations:
• The risk of thrombotic events (both venous and arterial) should be taken into account, mostly during acute
hemolytic flares and in splenectomized patients
• Assessment of a general thrombotic risk factor is advisable in AIHAs (age >70 years, active cancer, previous VTE,
reduced mobility, already known thrombophilic condition, recent trauma and/or surgery, heart and/or
respiratory failure, acute infection, etc)
• VTE prophylaxis should be considered in patients with marked hemolysis and associated risk factors
• Recommendations:
• The risk of thrombotic events (both venous and arterial) should be taken into account, mostly during acute
hemolytic flares and in splenectomized patients
• Assessment of a general thrombotic risk factor is advisable in AIHAs (age >70 years, active cancer, previous VTE,
reduced mobility, already known thrombophilic condition, recent trauma and/or surgery, heart and/or
respiratory failure, acute infection, etc)
• VTE prophylaxis should be considered in patients with marked hemolysis and associated risk factors
Anemie emolitiche
autoimmuni
Wilma Barcellini
Classificazione e diagnosi
Meccanismi patogenetici
Terapia
Treatment algorithm for warm AIHA in adults
Zanella A & Barcellini W,
Haematologica, 2014
• Response to steroids in 75-80% of
patients
• estimated cure rate 20-30% only
• 50% require maintenance doses
• 20-30% need additional 2nd line
therapies
• Side effects vary with length of
administration
(hypertension, diabetes, weight gain,
anxiety, osteoporosis, gastro-
intestinal ulcers, immune-
suppression, psychosis, cataract)
•Transfusions, never deny, but avoid if
unnecessary
•Decide on patient’s clinical status and
comorbidities rather than on the Hb
level
•Generally, Hb<6 g/dL, acuteness of
onset, and hemodynamic instability
deserve support
•RBCs should be administered slowly,
possibly not exceeding 1 ml/kg/h
(avoid overtransfusion!)
•Attention to alloantibodies, known to
occur in 12%-40% of AIHA patients,
that may be responsible for severe
hemolytic reactions
22ndnd line treatmentline treatment
Rituximab SplenectomyNR
Zanella & Barcellini, Haematologica, 2014, Barcellini, Expert Rev Hematol, 2015
Warm AIHA
• Increasingly preferred among 2nd line options
• unfitted for surgery, refuse splenectomy
• Predictors of response • younger age
• early administration as second-line therapy
• Response 70-80% (half of cases CR)
• Median duration of response of 1-2 years
• DFS ~70% at one and ~55% at two years
• Low-dose equally effective
• Median time to response is 4-6 weeks
(responses after 3-4 months possible)
• Response in primary and secondary AIHA,
independent from prior treatment, re-
treatment and combination possible
• Good safety profile (infectious events in roughly
7%, rare cases of PML, HBV reactivation)
• Age < 65-70 y, women that wish to become
pregnant, good performance status
• response ∼∼∼∼70%, presumed curative rate ∼∼∼∼20%
• current rate 10-14%, but progressively decreasing
• The drawbacks • overwhelming sepsis (3-5% of cases, mortality rate 50%,
even after the recommended vaccination against
pneumococci, meningococci, and hemophilus, and re-
vaccination every 5 years)
• thrombotic events
• lack of reliable predictors of outcome
• surgical complications
• patient education (early administration of oral antibiotics,
prompt referral to hospital for suspected sepsis)
• discouraged age >65-70 years or comorbidity (cardiopulmonary disorders, previous history or serious risk of
thrombosis, hepatitis C, underlying immunodeficiency,
lymphoproliferative, and systemic autoimmune conditions
• laparoscopic splenectomy preferred but should
be performed by experienced operatorsRituximab subcutaneous formulation (SC-R) is safe,
effective and cost-Saving in Patients with AIHA, Francesco Iuliano, ASH 2016
Treatment of cold agglutinin disese (CAD)
Treatment Algorithm
Primary CAD Secondary CAS
W & W
Cold agglutinin mediated AIHA
Symptomatic (anemia, transfusion, circulatory symptoms)
Asymptomatic
Supportive
Care/Therapy
Rituximab(375 mg/m2 weekly x 4)
(Rituximab + Benda-
mustine for fit patients)
Clinical Trial (if available)
Emergency Situation Eculizumab
Plasmapheresis
Rituximab
+ Bendamustine
No Response/
Relapse
Clinical Trial /
Experimental TreatmentEculizumab, Ibrutinib,
Venetoclax ...
Rituximab
+ Fludarabine or
Bortezomib
Relapse
Treat underlying
disease(if possible)
Supportive
Care/Therapy
• Ab anti-platelets
• Ab anti-
megakaryocyte
• T Cytotoxic
• ↓↓↓↓ Tregs
• APC activity
• ↑↑↑↑IL-2, TNF-αααα
• TGF-1ββββ, ↓ Tregs
Increased spleen
destruction
↓↓↓↓ megakaryocyte maturation
↑↑↑↑ megakaryocyte apoptosis
TPO deficiency
IL-2IFN-γγγγ
ITP has a compound and heterogeneous pathophysiology with 3 main drivers
• Ab anti-platelets
• Ab anti-
megakaryocyte
• T Cytotoxic
• ↓↓↓↓ Tregs
• APC activity
• ↑↑↑↑IL-2, TNF-αααα
• TGF-1ββββ, ↓ Tregs
Increased spleen
destruction
↓↓↓↓ megakaryocyte maturation
↑↑↑↑ megakaryocyte apoptosis
TPO deficiency
IL-2IFN-γγγγ
TPO-RA
Splenectomy
Immunesuppressors
(targeting T and B
lymphocytes)
ITP has a compound and heterogeneous pathophysiology with 3 main drivers
Increased spleen
destruction
ITP and AIHA second cousins not brothers…AIHA has a compound and heterogeneous pathophysiology with various main
drivers
The complement system
Bone marrow erythroid hyperplasia
Displasia ?
Apoptosis ?
Fibrosis ?
EPO ? ?
• five paradigmatic cases of
refractory/relapsing autoimmune
cytopenias, namely autoimmune hemolytic
anemia (AIHA), immune thrombocytopenia
(ITP), and chronic idiopathic neutropenia
(CIN), that evolved to IDUS/bone marrow
failure syndromes over time
• Idiopathic cytopenia of uncertain
significance (ICUS) and idiopathic dysplasia
of uncertain significance (IDUS) are two
recently recognized provisional conditions
characterized by isolated/unexplained
cytopenia and/or dysplasia in <10% bone
marrow cells
• The relationship between myelodysplasia
and autoimmunity is supported by their
epidemiologic association, the existence of
common immune-mediated
physiopathologic mechanisms, and the
response to similar immunosuppressive
therapies
STUDY GROUP MF0 N=30 MF>1 N=17
Hb, g/dL, 7.4 (3.5-13.1) 8 (2-11)
LDH x UNL 1.27 (0.4-7) 1 (0-3)
Ret x103/mmc 113 (13-275) 157 (58-284)*
Bone marrow characteristics
Cellularity, %
Normo, N (%)
Hypo, N (%)
Hyper, N (%)
52.5 (25-90)
12 (40)
2 (7)
16 (53)
65(20-99)**
2 (12)
1 (6)
14 (82)*
Diserythro N (%) 16 (53) 14 (82)*
Lymphoid infiltrate
T-cell, N (%)
B-cell, N (%)
Mixed, N (%)
8 (26)
4 (13)
10 (30)
2 (12)
3 (18)
10 (59)
(A) loose network of reticulin fibers
with many intersections (MF-1),
(B) The hyperplastic erythropoietic
series shows some grade of
dyserytropoiesis
(C) centro-lacunar lymphoid aggregate predominantly
composed of CD20-positive small B lymphocytes,
(D) with scattered small CD3-positive T lymphoid cells.
(E) focal and interstitial lymphoid infiltrate composed
mainly of CD3+ small T-lymphoytes
Cytokine serum levels in patients with (black)
and without (white) bone marrow fibrosis
• Reticulinic fibrosis (MF1) is present in 36% of AIHA cases and
correlates with the presence of a hypercellular dyserythropoietic
bone marrow , increased levels of TGF-ββββ , , , , and a higher rate of
relapse and treatment requirement
• These chronic refractory cases may show clinical/pathologic
features similar to low-risk myelodysplastic syndromes and
recently described idiopathic cytopenia/dysplasia of unknown
significance (ICUS/IDUS)
• MF0 AIHA patients seems to present with a more florid
hemolytic disease, increased immune activation and cytokine
release, more frequent thrombotic events, and a better response
to immunesuppression
T
Complement
IL2R
CD20
C1
MACC3C5
FcγγγγR
Syk
MMF
Rituximab
CD52
CD52BCR
BCRi
EPO EltrombopagLuspatercet
EculizumabC3i
C1i
Bortezomib
FostamatinibSYNT001
IL2
CD38
Bone marrow
Daratumumab
B
Alemtuzumab
Spleen
Activated lymphocytes, phagocytes
Liver
IgG
IgM
Proteosome
Phagocytes
AIHA Clinical Studies 2017 – clinical trials.gov (N=18)
Study Title Conditions Interventions Locations Recruitment
Efficacy and safety of BIVV009 open in
transfusion- dependent (Cardinal) and vs
placebo in non-transfusion dep (Cadenza)
CAD BV009 (C1 inhibitor) US- Europe
Bioverativ
recruiting
Safety, tolerability, efficacy of APL-2 in
patients with wAIHA or CAD
WAIHA
CAD
APL-2 (C3 peptide inhibitor) Lakes Research, Miami Lakes, FL, US
Apellis
recruiting
A safety and efficacy study of R935788 in the
treatment of warm AIHA
WAIHA Fostamatinib 150mg bid UCSD, Insitute of Hope and innovation,
Downey, Arizona Oncology Assoc.-US
recruiting
SYNT001 in subjects with chronic, stable
WAIHA
WAIHA SYNT001
(biologic with FcRn affinity)
US (incl. Mass. General) recruiting
Interleukin-2 in WAIHA resistant to
conventional treatment
WAIHA IL-2 Bordeaux, Hopital Haut Leveque, Pessac,
FR
recruiting
Take home messages
•AIHA may be challenging (severe and refractory), particularly IgG+C wAIHA, mixed, and
atypical forms (warm IgM and DAT-negative)
•Prompt therapy with rituximab (and possibly PEX) is recommended in severe cases
•Rituximab is becoming the preferred second line therapy for steroid-refractory wAIHA
and is recommended as first line in CAD
•Splenectomy, when feasible, is still a valid option for wAIHA but its exact timing is
difficult to establish
•Early diagnosis/prevention of thrombotic events (occurring in 10-20% of AIHA),
particularly after splenectomy and in cases with severe onset and intravascular
hemolysis is mandatory
•Careful follow-up to monitor infections, particularly after splenectomy, acute renal
failure, and Evans’ syndrome are recommended. All this complications and multi-
treatment are predictors of fatal outcome
•New therapeutic drugs directed at “pathogenic” mechanism (complement or Fc
blocking) are in progress
•Possible evolution of autoimmune cytopenias to idiopathic cytopenia of uncertain
significance (ICUS) and idiopathic dysplasia of uncertain significance (IDUS) should be
taken into account to avoid improper therapy