AUTOIMMUNE HEMOLYTIC ANEMIAS · 2020. 7. 9. · Variability of the erythrocyte response in...
Transcript of AUTOIMMUNE HEMOLYTIC ANEMIAS · 2020. 7. 9. · Variability of the erythrocyte response in...
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440Congresso Nazionale Verona, 20-23 ottobre 2013
AUTOIMMUNE HEMOLYTIC ANEMIAS
A. Zanella Ematologia, Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico, Milano
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ü es#mated incidence 1-‐3 per 105/year, prevalence 17:100,000, mortality rate 11% [Rose 1998].
ü can be either primary or secondary to lymphoprolifera#ve diseases, infec#ons, immunodeficiency, and tumors
ü are classified as “warm”, “cold” (which include CHD and PCH) and “mixed”
according to the thermal range of the autoan#body. “Atypical” cases (DAT nega#ve AIHA, warm IgM AIHA) are reported with increasing frequency
ü may develop gradually, with concomitant physiologic compensa#on, or may have a fulminant presenta#on with rapid onset of profound, life-‐threatening anemia
ü clinical manifesta#ons are determined by the presence/absence of underlying diseases, and by the rate and type of hemolysis which mainly depend on the autoan#body’s characteris#cs
AUTOIMMUNE HEMOLYTIC ANEMIAS (AIHA)
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Factors influencing the autoan#body pathogenicity and the extent of anemia
SEROLOGIC: Ig class, subclass, thermal amplitude, specificity, affinity, C ac#va#ng efficiency, ability to react with macrophages, quan#ty and type of cell-‐bound C/igG, characteris#c of target an#gen Op#mal reac#on T (range) 37°C (0 -‐ 40°C) 4°C (4 -‐ 34°C)
Ig class (C fixa#on) IgG (rare) IgM (common)
Direct An#globulin Test posi#ve IgG (+C3) posi#ve C3 Auto-‐abs specificity an#-‐Rh an#-‐I/i In vivo haemolysis extravascular intra and extra RBC sequestra#on site spleen liver (spleen) Hemolysis rate Extravascular H. Intravascular H.
17.5 mL RBCs/hr 200 mL RBCs/hr OTHER: ac#vity of the re#culoendothelial system
efficacy of the erythroblas#c response
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Reticulocytopenia in autoimmune hemolytic anemia
In a survey of cases of AIHA from the files of Armed Forces Ins#tute of Pathology it was noted that a number of pa#ents exibited, at one #me or another, a definite re#culocytopenia in the presence of severe hemoly#c anemia with a bone marrow that presented a picture of intense erythroid prolifera#on. The phenomenon appears to have a sinister significance.
Crosby & Rappaport, Blood 1956
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Autoimmune hemoly#c anemia with re#culocytopenia.A Medical emergency Conley et al, JAMA 1980
Case Age/Sex Hct Retics Duration RBC units Outcome (%) (days)) (n)
1 52/F 10 0.5 10 19 CR 2 78/F 9 0.5 14 12 CR
3 53/F 10 2.0 90 53 PR
4 35/M 9 0.2 5 5 PR
5 49/F 8 3.0 160 84 PR
Zanella, umpublished data
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Variability of the erythrocyte response in autoimmune hemolytic anemias: analysis of 109 cases. JL Liesveld, JM Rowe,M A Lichtman. Blood 1987;69:820-6
Twenty per cent of 109 adult AIHA cases are associated with reticulocytopenia and marrow erythroid hyperplasia suggesting that reticulocytopenia was due to ineffective erythropoiesis in most cases
Erythropoietin may improve anemia in patients with AIHA associated with reticulocytopenia. Arbach et al. Transf Med Hemother 2012; 39:221-3
Apoptosis may contribute to the mechanism of reticulocytopenia in AIHA
Excessive apoptosis of marrow erythroblasts in a patient with autoimmune haemolytic anaemia with reticulocytopenia. A van de Loosdrecht et al, Br J Haematol 2000;108:313-5
“The administration of EPO should be considered in pts with therapy-refractory AIHA, particularly in the presence of reticulocytopenia”
New insights into childhood autoimmune hemolytic anemia: a Frenh national ob-servational study of 265 children. Aladjidi N et al, Haematologica 2011; 96:655-63
Thirty nine per cent of children with AIHA had reticulocytopenia of variable duration
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Inci
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caldifreddimisti
Age (yrs)
Sokol et al., J Clin Pathol 1992 Warm (IgG) Cold (IgM) Mixed
• cases with Hb
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Author Warm CHD PCH Mixed Total Göesche (1990) * 38 7 22 (33%) 0 67 Sokol (1992) 16 17 13 (27%) 2 48 Vaglio (2007) 64* 26 6 (6%) ** 4 100
*5/64(8%) DAT-‐ nega#ve ** 5/6 (83%) DAT-‐nega#ve
AIHA in infancy and adolescence (age < 16 yrs) 02
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Sokol et al., J Clin Pathol 1992 Warm (IgG) Cold (IgM) Mixed
* “During the last 4 years, we have studied a total of 531 adults and 68 children with clinically and serologically well-‐ defined forms of immune hemoly#c anemias. Among these, Donath-‐Landsteiner (DL) hemolysis was the underlying disease in 22 of the 68 children (32.4%), but was not observed in adults”.
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Clinical presenta#on: Fever (1 m. before onset) 60% Collapse, coma, ARF 3% Jaundice not constant Splenomegaly 31% Hepatomegaly 19% Re#culocytopenia 39% (median 6 d. range 1-‐70)
Immunologic 53% Post-‐infec#ous 10% Primary 37% AIHA + ITP (ES) 37%
New insights into childhood autoimmune hemoly#c anemia: a French na#onal observa#onal study of 265 children. Aladjidi N et al, Haematologica 2011;96:655-‐63
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. Aladjidi N et al, Haematologica 2011;96:655-‐63
10% mortality in the AIHA/ES subset
CR at one month: 58%
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Direct an#globulin test (DAT) An#body screening & iden#fica#on (serum & eluate) Complete erythrocyte phenotyping Addi#onal serological inves#ga#ons
DAT + AIHA Allo-‐IHA DRUG-‐induced Auto Auto+Allo
496 385 69 37 5
AIHA -‐ DIAGNOSTIC ASPECTS
• Posi#ve DAT not specific for AIHA
• Atypical cases (DAT-‐Neg AIHA / Warm IgM AIHA)
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DAT negative AIHA
• Represent 11% of AIHA according to Petz e Garratty (Immune
hemolytic anemias. New York: Churchill Livingstone, 2004)
Causes of false Possible negative results solutions
IgA auto Abs low-affinity IgG Abs
low sensitivity of the tests employed
Use on monospecyfic anti-IgA antisera
test with cold washed RBC test con low-ionic solutions (LISS) polybrene or PEG
More sensitive techniques
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§ RBCs washed with Lo-‐ion § RBCs wash with LISS saline or saline at 4°C § Polybrene § PEG § Microcolumn agglu#na#on technique (CAT) § Solid phase agglu#na#on technique (Yamada, Transfusion 2008) § Immunoenzyma#c assay (Bencomo et al, Immunohematology 2003) § Flow cytometry (Lin et al, Transfusion 2009) § Mytogen-‐s#mulated (MS)-‐DAT (Barcellini et al, Int J Hematol 2010)
DAT -‐ More sen#ve techniques
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Mitogen-stimulated DAT (MS-DAT)
Binding of Auto-Ab to autologous RBC
Mytogenic and/or cytokine stimulation
Auto-Ab in culture
cytokines
ng/ml OD mean OD 1 OD 2 OD 3 ng/ml log OD log2000 636 648 632 629 3,301030 2,8036851000 739 721 746 750 3,000000 2,868644600 800 795 801 805 2,778151 2,903271300 876 845 850 933 2,477121 2,942504150 927 932 948 901 2,176091 2,96708075 1027 1065 1056 961 1,875061 3,011711438 1077 1062 1069 1100 1,574031 3,0322160 1089 1098 1120 1050
y = -0,1284x + 3,248R2 = 0,9753
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3,1
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log anti-IgG ng/ml coated RBC
log O
D
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0 500 1000 1500 2000 2500anti-IgG ng/ml coated RBC
OD
functional test quantitative test
“In the last 10 years we collected 16 cases of DAT(tube, microcolumn a n d s o l i d p h a s e ) -‐nega#ve AIHA in which the diagnosis was made on the basis of a posi#ve MS-‐DAT. These cases represent roughly 10% o f to ta l A IHA observed in the same period”. W. Barcellini et al, Int J Hematol 2010;91:762-‐9
Br J Haematol 2000;111:452-60
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• 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. • Arndt PA, Leger RM, Garratty G.Serologic findings in autoimmune hemolytic anemias associated with immunoglobulin M warm autoantibodies. Transfusion 2009;49: 235-42.
SEVERE 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).
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• Spontaneous RBCs agglu#na#on due to crosslinking of IgM autoabs • Can appear to have only C3 on RBCs by rou#ne DAT • IgG may be present also • Can appear to be DAT– by rou#ne DAT
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The hemolysis remained refractory to treatment with prednisolone and also prednisolone plus azathioprine, but gradually improved aser treatment with prednisolone plus cyclophosphamide. CONCLUSION: Weak or nonagglu#na#ng RBC-‐bound IgM warm an#bodies can be iden#fied by DDAT
T. Bartolmas and A. Swalama Transfusion. 2010 May;50(5):1131-4. Epub 2009 Dec 10
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no Cause of hemolysis
identified?
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Diagnos#c flow-‐chart for suspected AIHA in children
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Negative pharmacologic anamnesis
Test drug dependant and independant antibodies
Positive pharmacologic anamnesis
Anti-IgA antisera washing at 4°C LISS washing PEG ELISA -IRMA cytometry
Other MS-DAT
DDAT
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Standard DAT (polyspecific antisera)
Raccomandazioni per la ges#one del bambino con AIHA AIEOP (oeobre 2013)
+ DAT with monospecyfic antisera (anti-IgG and anti C)
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Test for antibodies in serum (IAT)
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Auto Ab identification
+ eluate
Intravasc Hemol.
DL biphasic hemolysin
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THERAPY OF IDIOPATIC (w)AIHA
azathioprine, CTX, VCR
danazol i.v. immunoglobulins plasmapheresis blood transfusion erythropoie#n
Rituximab Alemtuzumab Other BMT
cyclosporine mycophenolate
steroids
splenectomy
K. Lechner et al: How I treat autoimmune hemoly=c anemias in adult. Blood, 2010;16:1831-‐38 In the era of evidence-‐based medicine it is surprising and regreeable that the treatment of AIHA is s#ll not evidence-‐based. There are no randomized studies and only a few prospec#ve phase 2 trials. Otherwise, only retrospec#ve studies, smal series of (probably selected) pa#ents or single cases have been reported (evidence level 5). There is no formal consensus on the defini#on of CR or PR hematologic remission and refractoriness.
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THERAPY OF IDIOPATHIC (w)AIHA
20-30% no response or need of pred > 0.1-0.2 mg/kg/die to maintain adequate Hb levels
- Rapid response - No predictors of efficacy - Surgical risk - Infective risk
- Delayed response-. side effects
splenectomy cytotoxic-immunesuppressors Cyclophosphamide Azathioprine Cyclosporine Other (Vincristine, 6-MP, 6-TG)
Prednisone (1-1.5 mg/kg/die o 40-60mg/m2 p.o.) for 3-4 weeks, then tapering 5-10 mg/week in 6-12 months
MoAbs: rituximab, alemtuzumab, eculizumab MFM, bortezomib, bendamustin,C1-esterase inhibitor
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2008
ü Low levels of evidence ü Clinically heterogeneous pa#ents ü Response to treatment not univocally defined
ü Effec#ve in primary and secondary AIHA, median OR 60% (40-‐100%), In two recent studies on larger cohorts median OR 77 and 93%, median TTR 3 and 6 w (1-‐16) , DFS 72% at 1 yr, 56% at 2 yr (Bussone et al 2009Penalver et al
2010)
ü Effec#ve in warm AIHA (OR 83-‐87%, CR 54-‐60%), and in CHD (OR 58, CR 4.5%) (Berentsen et al 2006; Schollkopf et a, 2006)
257 AIHA (173 W, 75 C, 9 nd), of whom 56 children
. Br J Haematol 2008;14:149-‐69. Eur J Intern Med 2011;22:220-‐9
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ü Effec#ve in refractory pediatric AIHA, including Evans S. (56 cases, OR 84 -‐100%, CR 67-‐100%)(Quar#er 2001; Zecca et al 2003; Bader-‐Meunier 2007; Rao et al 2008)
ü Response independent from prior treatment, including splenectomy (Berentsen et al 2004; Narat et al 2005; Berentsen et al 2006; Schollkopf et al 2006; Barcellini & Zanella 2011),
ü Retreatment effec#ve, even If repeated ( Rao et al 2008; Narat et al 2005; Trapé et al 2005, Barcellini & Zanella 2013 )
ü Well tolerated also in children (Garvey 2008). Data on long term safety needed (few cases of progressive mul#focal leukoencephalopathy ) (Gea-‐Banacloche 2010)
ü Median dose in adults and children 375 mg/m2/w x 4 w(range 2-‐12)
2008 . Br J Haematol 2008;14:149-‐69.
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Complete and par#al responses (CR and PR) were defined as Hb > 12 g/dL and > 10 g/dL at month +2; Sustained response (SR) was defined as Hb > 10 g/dL at month +6, and +12 in the absence of any treatment.
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apse
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Cold Warm
ü LD rituximab 100 mg fixed dose weekly on days 7, 14, 21, 28 along with standard oral PDN (1 mg/kg/die day +1 to + 30, followed by quick tapering)
ü OR 82.6% at month +2, and subsequently stabilized ~90% at month +6 and +12
ü response was beqer in 14 WAIHA (OR 100% at all #me-‐points) than in 9 CHD (on average 60%)
ü the relapse free survival (RFS) was 100% for WAIHA at +6 and +12 months versus 89% and 59% in CHD
ü The risk of relapse was higher in CHD and in pa#ents with longer interval between diagnosis and enrolment.
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Prednisone (mg/die)
ü Treatment was well tolerated and no adverse events or infec#ons were recorded
ü Re-‐treatment was also effec#ve ü Steroid administra#on was reduced both as cumula#ve
dose (~50%) and dura#on compared with the pa#ent's past history.
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The overall response was 90%, 100%, 100%, and 89% and the relapse-‐free survival 87%, 79%, 68%, and 68% at 6, 12, 24, and 36 months, respec#vely. Response rates were slightly beeer in WAIHA than in CHD, and relapse risk was greater in cold than warm forms (HR 2.1,95% CI 0.6–7.9). Four pa#ents were retreated (one pa#ent twice), all achieving a response, las#ng a median of 18 months (range 9–30). Treatment was well tolerated without adverse events or infec#ons.
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EXPERT OPINIONS Lechner K & Jager U: How I treat autoimmune hemoly=c anemias in adults. Blood 2010; 16:1831-‐8. «It is no doubt that the short-‐term benefit/risk ra#o for rituximab is high and that rituximab is certainly the best op#on for pa#ents who are not eligible for or who refuse splenectomy.» «…In our opinion the sequence of second-‐line treatment in primary warm AIHA should be splenectomy, rituximab, and thereawer any of the immunosuppressive drugs». «Alemtuzumab considered as a «Treatment of last resort (severe anemia nd none of the known drugs have worked)».
Crowther M. et al. Evidence-‐based focused review of the treatment of idiopathic warm immune hemoly=c anemia in adults. Blood 2011;118:4036-‐40. «We suggest for the treatment of relapsed or refractory AIHA that Rituximab (375 mg/m2 weekly for 4 weeks) or splenectomy should be considered over alternate therapies (Grade 2C). Furthermore, although there are no head-‐to-‐head comparison of rituximab and splenectomy, published evidence suppor#ng the use of rituximab is more extensive than splenectomy (ungraded recommenda#on). The choice of second-‐line therapies should depend on pa#ents, values and preferences and local circumstances». «There is some evidence for the use of alemtuzumab, high-‐dose cyclophosphamide, mycophenolate mofe#l, and vincris#ne-‐labeled platelets, but the small number of reported cases and the poten#al side effects prevent us from making a recommenda#on
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Rituximab375 mg/mq/sett x 4 sett
Endoxan10 mg/kg/die x 10 gg
O50 mg/kg/die x 4gg
Splenectomia
Altre terapie:Alemtuzumab, TCSE
Aggiungere immunosoppressoreal fine di ridurre o sospendere PDN
MMF (300-600 mg/mq/2v/die)
AZA (25-200 mg/die)
CYA (2-10 mg/kg/die)
NR
RP
RP
RP
NR
NR
NR
RC
RC
RC
Non risposta a terapiaprima linea
Dipendenza da steroide(>0.1-0.2 mg/kg/die PDN)
Off therapy
Off therapy
Off therapyRP
Continuare (vedi testo)
RC
Off therapy
Raccomandazioni per la ges#one del bambino con AIHA AIEOP (oeobre 2013)
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CONCLUSIONS -‐ TAKE HOME MESSAGES
ü AIHA may be clinically heterogeneous, 1/3 of cases with a severe onset (Hb
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FINE
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Alemtuzumab therapy in idiopathic AIHA
Willis et al J., Bri=sh Journal of Haematology 2001; 114: 891, Alemtuzumab 10 mg/d/iv in: 4 refractory idiopa#c AIHA (adults) (2 warm, 1 cold, 1 mixed): 1CR, 2PR, 1NR) (median follow up 10 m) 3 Evans ( 1 child, 2 adul#).: 2 RC Cheung WW et al, Haematologica 2006, 91 (1) 42-‐3. 1 warm AIHA refractory to rituximab: CR awer a cumula#ve dose of 883 mg CMV reac#va#on. Gomez-‐Almaquer et al Blood 2010;176:4783-‐5 Alemtuzumab 10 mg s.c + 100 mg rituximab in 8 idiopathic warm AIHA: OR 8/8, CR 6/8 Time to response 1-‐31 w Median dura#on of response 46 w (22-‐89) Grade 1 toxicity at first dose. 30% infec#ons.
CR in 13/16 cases
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Alemtuzumab in CLL-‐related AIHA
Osterborg A, Curr Hematol Malig Rep. 2009
CR in 11/12 cases
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Mycophenolate mofe#l therapy in AIHA
Howard, Br J Haematol. 2002;117:712-‐5 4 pts with AIHA and 6 with ITP showed a CR or a good PR Lin JT, Ann Hematol. 2002; 81:723-‐6 1 pts with AIHA secondary to MDS showed CR Alba P, Lupus. 2003;12:633-‐5 2 pts with AIHA secondary to ESL showed a good PR Kotb R, Eur J Hematol 2005; 75: 60-‐4 4 pts with AIHA (1 Evans S.) + 9 ITP showed 100% and 78% response respec#vely “The cumula#ve data suggest a poten#al place for MMF in the treatment arsenal of refractory cytopenias.”
CR/good PR in 11/11 cases
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66 yrs old pa#ent. In 2001 symptoma#c CAD (dispnoea, fa#gue) refractory to steroids. Ini#al response to 5 doses of rituximab. In 2004 e 2006 ritreatment with rituximab: ineffec#ve.
Blood 2009;113:3485-‐6
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ü 52 pa#ents with ITP, AIHA and Evans' syndrome from 50 centres in the EBMT registry
ü Subjected to autologous or allogeneic HSCT up to 2008
ü OS at 5 years was 61±5%
ü Analysis of the 24 children with immune cytopenias (19 allogeneic HSCT and 7 autologous HSCT) confirmed a 60% PFS with allogeneic HSCT vs 35% with autologous HSCT, with a TRM of 20% overall
ü It remains unclear whether symptoma#c ‘cytopenia-‐free survival' is best achieved with autologous or allogeneic HSCT
Snowden JA, EBMT guidelines in severe autoimmune diseases. Bone Marrow Transplant. 2012
BMT IN AIHA
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TAD standardantisiero polispecifico
TAD con antisieri monospecifici
Anti IgG e anti C3d
Ricerca altra causa di emolisi
Sieri monospecifici IgALavaggi a 4°C
Lavaggi con LISSPEG
ELISA-IRMACitofluorimetria
Ricerca anticorpinel siero (IAT)
neg
pos
neg
pos
pos Emolisi Intra vasc
si
pos
Anamnesi per assunzione di farmaci
Ricerca anticorpifarmaco dipendenti efarmaco-indipendenti
Eluato
Altro(MS-DAT)
pos
neg
pos
neg
Anemia emolitica disospetta natura immune
pos
posneg
pos
neg
Identificazoneanticorpi
neg
Stop
Stop
Emolisine bifasiche
DL
Raccomandazioni per la ges#one del bambino con AIHA, AIEOP, oeobre 2013
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Diagnosi di AEA da Ab caldi
PDN per os1-2 mg/kg/die
x 3 sett.
continua PDNx 1 sett.
continua PDNdosaggio pieno
x 2 sett.
Riduzione graduale PDN(almeno 6 mesi)
Continua PDN allaDose minima efficace
Riaumentare PDN a dosaggio precedente
Terapiaseconda linea
Recidiva
RC
RC
RC - RP
NR Riconsiderare diagnosi differenziale
Recidiva
Dipendenza PDN
RP
< 0.1 – 0.2 mg/Kg/die > 0.1 – 0.2 mg/Kg/die
RP
Stoptherapy
Possibili terapie aggiuntive nei casi gravi (v. testo)
M-PDN ad alte dosi e.v.IG e.v.
TrasfusionePlasma exchange
RACCOMANDAZIONI PER LA GESTIONE DEL BAMBINO CON AIHA-‐ AIEOP oqobre 2013