5/12/2011
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PNH Current Thinking on Disease,
Diagnosis and Treatment
Monica Bessler, MD, PhDBuck Family Professor in Hematology
Director Pediatric & AdultComprehensive Bone Marrow Failure Center
CHOP/UPENN
University of Pennsylvania School of Medicine
Email [email protected]
03/07
500
1000
2000
3000
8/93 1/99 5/00 9/01 2/03 6/04 11/05
AA PNH
Hem
oly
sis
(L
DH
)
Lacta
te d
eh
yd
rog
en
ase
Normal range
Packs o
f
red
blo
od
cells
12
8
4
Red cell transfusions
Eculizumab
Case Study:
31 year old woman with AA/PNH
Blood Clot
Aplastic
Anemia
I.
Hemoglobinuria
II.
Bone Marrow FailureIII.
Blood Clots
Clinical Manifestations of PNH
Blood clot
Thrombus
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Age Distribution of Patients with PNH
J Nishimura et. al. Medicine 2004
Institute of Hematology & Blood
Diseases Hospital
Chinese Academy of Medical
Science
Tianjin
China
Peking Union Medical College
Beijing
China
PNH Occurs in all Parts of the World
Hemoglobinuria
in PNH
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Hemoglobinuria = Hemoglobin in urine
≠ Blood in urine
Hemoglobin in urine
Hemoglobinuria
PNH !
Blood in urine
Hematuria
Not PNH !
centrifugation
microscopic examination
centrifugation
GPI-linked Proteins Deficient on
PNH Blood Cells
Monocytes B Cells T Cells NK CellsGranulocytesRed CellsPlatelets
CD55
CD58
CD59
CD109
(Gova/b- Ag )
PrPc
GP500
CD55 CD58
CD59 CD14
CD16 CD24
(NAB1-Ag)
CD48 CD66b
CD66c CD87
CD109 CD157
LAP NB1
PrPc ADP-RT
p50-80 GPI-80
C D55
CD58
CD59
CD14
{CD16 }
CD48
CDw52
CD87
CD109
CD157
Group-8
PrPc
GPI-80
CD55
CD58
CD59
CD24
CD48
CDw52
{CD73}
{CDw108}
PrPc
CD55
CD58
CD59
{CD16 }
CD48
CDw52
{CD73}
CD87
{CD90}
CDw108
{CD109}
PrPc
ADP-RT
CD55
CD58
CD59
CD16
CD48
CDw52
PrPc
HematopoieticStem Cell
CD59 CD109CD90
CD55, CD59
(Cromer Ag)
CD58, PrPc
AChE
(Cartwrigt-Ag)
CDw108
(John-Milton
-Hagen Ag )
Dombroch
residue
HolleyGregory AG
Bessler 2003
Complement Activation
C3b MAC
C5b-
9
C
5
C5
a
C6 C7 C8 C9
CD5
5
CD5
9
Classica
lLecti
nAlternativ
e
Normal
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Complement
activation
Complement
lysis
CD55
CD59
Red Blood Cell
CD55 and CD59 Protect Red Blood Cells
from Complement Lysis
Complement Mediated Lysis in PNH
PNHlC3b MAC
C5b-
9
C
5
C5
a
C6 C7 C8 C9
CD5
5
CD5
9
Classica
lLecti
nAlternativ
e
Activation -> Deposition on the surface -> Intravascular
Hemolysis
Complement
activation
Complement
lysis
CD55
CD59
Red Blood Cell
Lysis
Lack of CD55 and CD59 in PNH Causes
Complement Lysis of Red Blood Cells
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Complement Attack on PNH Red Blood Cells
Dourmashkin & Rosse WF.Am J Med. 1966 Humphrey & Dourmashkin Adv Immonol1969.
Diagnosis of PNH by the Ham Test
PNH Control
S HS S HSPNH patient
HamTest: 1938
Diagnosis of PNH Today
Deficiency of GPI-Linked Proteins
on PNH-Granulocytes
Bessler 1991
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Flow cytometry
on peripheral white blood cells:
% of Granulocytes deficient for CD59 or FLAER
= Size of the PNH Clone
PNH Testing
PNH Type I Type II Type III
Intermediate No expression
of CD59
I
CD59
PNH Red Blood Cells
PNH
IIIIIIIII III
Co
un
ts
CD59
I
Flow Cytometric Analysis of Red Blood Cells
PNH
PNH I PNH IIPNH I + III PNH I + II + III
PNH PNH
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Bone Marrow Failure
Normal bone marrow Bone Marrow Failure (BMF)
Aplastic Anemia (AA)
The Bone Marrow is the Site of Blood Cell Production
Red
Blood Cells
White
Blood Cells
Platelets
Bone Marrow
Granulocytes
Neutrophils
Lymphocytes
Bone Marrow Biopsy
Iliac Crest
Bone Marrow
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Bone marrow biopsyBone marrow
aspirate
Bone Marrow Examination
Giemsa Wright
Courtesy of J Choi CHOP 400x100x
Bone Marrow in PNH
H&E
Courtesy of J Choi
CHOP
Bone Marrow in PNH
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03/07
500
1000
2000
3000
8/93 1/99 5/00 9/01 2/03 6/04 11/05
AA PNH
Hem
oly
sis
(L
DH
)
Lacta
te d
eh
yd
rog
en
ase
Normal range
Packs o
f
red
blo
od
cells
12
8
4
Red cell transfusions
Eculizumab
Case Study:
31 year old woman with AA/PNH
Blood Clot
Aplastic
Anemia
Hemolytic / Classical PNH AA/ PNH
AA/PNHPNHPNH
Pe
rip
he
ral b
loo
d
ce
ll co
un
t
Normal Normal Normal
Cytopenia
Relationship of PNH with Aplastic Anemia (AA)
Adapted from Rotoli & Luzzatto 1989
AA
AA
MDS within PNH PNH and MDS PNH within MDS
PNH
cloneMDS
% B
loo
d C
ells
MDS
PNH clone
%B
loo
d C
ells
%B
loo
d C
ells MDS
PNH
clone
Relationship of PNH with
Myelodysplastic Syndrome (MDS)
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Red blood cell
Platelet Blood clot
Thrombus
Healthy blood flow Obstructed blood flow
Blood Clots in PNH
Blood Clot in the Liver and Brain
in a Patient with PNH
Courtesy of University of Wisconsin Medical School, Madison, WI.
Sagittal Sinus
Blood clot in the liver vein
Blood Clot in the brain
with a small stroke
The bigger the PNH Clone
The more likely a Blood Clot
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Blood Clots are more Frequent
in Patients With a Large PNH Clone
Nishimura J et al. Medicine. 2004;83:193-207.Hall C et al. Blood. 2003;102:3587-3591.
No Blood Clots Blood Clot
Moyo VM et al. BJH. 2004;126:133-138.
0 5 10 15 200
10
20
30
40
50
60
Incid
en
ce o
fblo
od c
lots
, %
Granulocyte
clone size
>50% (n=67)
Granulocyte clone size
>50% (n=55)0
20
40
60
80
100
CD
59
(-)P
MN
, %
100
80
60
40
20
0P<0.0001
PN
H c
ells
,
%
No Blood Clots Blood Clots
P=0.0001
Follow-up (years)
Blood Clots in Patients with PNH
Blood clots in the
veins
~ 32-40%
Belly ~ 1/3
Head ~ 6%
Legs / Embolus ~ 1/3
Other ~ 1/3
Stroke ~ 14%
Bone Marrow Failure Occurrence of PNH blood cells
Anemia
Infections
Gallstones
Bleeding
Inappropriate complement
activation
Extravascular Hemolysis
Low blood cell counts
Blood Clot
Abdominal pain
Bloating
Back pain
Headache
Erectile dysfunction
Esophagospasm
Fatigue
Hemoglobinuria
Kidney failure
Intravascular Hemolysis
The Mechanisms of Disease in PNH
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Bone Marrow Failure Occurrence of PNH blood cells
Anemia
Infections
Bleeding
Low blood cell counts
The Two Components Causing PNH
Anemia
Bone Marrow Failure Occurrence of PNH blood cells
Infections
Bleeding
Gallstones
Inappropriate complement
activation
Extravascular Hemolysis
Low blood cell counts
The Mechanisms of Disease in PNH
AnemiaBlood Clot
Abdominal pain
Bloating
Back pain
Headache
Erectile dysfunction
Esophagospasm
Fatigue
Hemoglobinuria
Kidney failure
Intravascular Hemolysis
Anemia
Bone Marrow Failure Occurrence of PNH blood cells
Infections
Bleeding
Gallstones
Inappropriate complement
activation
Extravascular Hemolysis
Low blood cell counts
Thrombosis in PNH
AnemiaBlood Clot
Abdominal pain
Bloating
Back pain
Headache
Erectile dysfunction
Esophagospasm
Fatigue
Hemoglobinuria
Kidney failure
Intravascular Hemolysis
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Treatment for PNH
Personalized Treatment PlanCure
Stem Cell Transplant
Spontaneous remission
SupportiveAnticoagulation (blood thinner)
Red cell transfusion
Iron (only in non-transfused patients)
Folate 5mg daily
Erythropoietin (with Soliris)
Pain management
Disease ModifyingImmunosuppression
Complement inhibitors (Eculizumab, Soliris™)
Only Cure(Exception: Spontaneous Remission ~15%)Anemia
Occurrence of PNH blood cells
Gallstones
Inappropriate complement
activation
Extravascular Hemolysis
Blood Clot
Abdominal pain
Bloating
Back pain
Headache
Erectile dysfunction
Esophagospasm
Fatigue
Hemoglobinuria
Kidney failure
Intravascular Hemolysis
Bone Marrow Failure
Infections
Bleeding
Low blood cell counts
Anemia
Treatment of PNH:
• Hematopoietic Stem Cell Transplant
Improves
Blood cell counts
Anemia
Occurrence of PNH blood cells
Gallstones
Inappropriate complement
activation
Extravascular Hemolysis
Blood Clot
Abdominal pain
Bloating
Back pain
Headache
Erectile dysfunction
Esophagospasm
Fatigue
Hemoglobinuria
Kidney failure
Intravascular Hemolysis
Treatment of Bone Marrow Failure in PNH:
• IVIG, Cyclosporine, Growth Factors
Bone Marrow Failure
Infections
Bleeding
Low blood cell counts
Anemia
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Eculizumab (humanized anti-C5 antibody)
Soliris
FDA/ EMEA approval
2007
•100 ml over 30 minutes
•Intravenous
•Initially every week (4x)
•then every other week
Complement
activation
Complement
lysis
CD55
CD59
Red Blood Cell
Soliris Blocks Complement Lysis
of PNH Red Blood Cells
Soliris
03/07
500
1000
2000
3000
8/93 1/99 5/00 9/01 2/03 6/04 11/05
AA PNH
Hem
oly
sis
(L
DH
)
Lacta
te d
eh
yd
rog
en
ase
Normal range
Packs o
f
red
blo
od
cells
12
8
4
Red cell transfusions
Eculizumab
Case Study:
31 year old woman with AA/PNH
Blood Clot
Aplastic
Anemia
5/12/2011
15
Eculizumab Reduces the Frequency of
Transfusions
0
2
4
6
8
10
12
0
2
4
6
8
10
12
Sugar pill Eculizumab
Before After
Median transfusions Mean transfusions
P < 0.000000001
Hillmen et al NEJM 2006:355(12):1233-43.
Before After
Sugar pill Eculizumab
Before After Before After
0
2
4
6
8
10
12
14
16
Before Eculizumab Treatment After Eculizumab Treatment
Th
rom
bo
sis
Even
t R
ate
(TE
per
100 p
t-y
ears
)
P = 0.0001
(n=195) (n=195)
Eculizumab Reduces the Risk of Blood Clots
39 events
3 events
Hillmen P et al. 2007 Blood;110:4123.
Eculizumab Improves but does not
Normalize Hemoglobin Levels
0 5 10 15 20 25Time, weeks
He
mo
glo
bin
g/d
L
Sugar pill
+ red cell
transfusion
Eculizumab
Hillmen et al NEJM 2006:355(12):1233-43.
Normal12
10
8
6
4
2
0
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Intravascular
Hemolysis
Extravascular
Hemolysis
--> Hemoglobinuria
--> High LDH--> No Hemoglobinuria
--> Low LDH
Intravascular Hemolysis
C3b MAC
C5b-
9
C
5
C5
a
C6 C7 C8 C9
CD5
5
CD5
9
Classica
lLecti
nAlternativ
e
PNH
Activation -> Deposition on the surface Intravascular
Hemolysis
Extravascular Hemolysis
C3b MAC
C5b-
9
C
5
C5
a
C6 C7 C8 C9 CD5
5
CD5
9
Classica
lLecti
nAlternativ
e
Activation -> Deposition on the surface Extravascular
Hemolysis
So
liris
Soliri
s
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Blood Clott
Blocks intravascular hemolysis
and associated symptoms
Anemia
Bone Marrow Failure Occurrence of PNH blood cells
Infections
Bleeding
Gallstones
Inappropriate complement
activation
Extravascular Hemolysis
Low blood cell counts
Complement Inhibition in PNH: Eculizumab
AnemiaBlood Clot
Abdominal pain
Bloating
Back pain
Headache
Erectile dysfunction
Esophagospasm
Fatigue
Hemoglobinuria
Kidney failure
Intravascular Hemolysis
Meningococcal Bacterial Infection
• Fever >101
• Chills
• Altered mental status
• Headache
• See your doctor!
• Go to nearest emergency room!
• Start emergency antibiotics!
• Show your “Patient Safety Card” !
• Keep your vaccination up-to-date !
– Meningococcal quadrivalent conjugate vaccine (MCV4
or MenactraT) for adolescents and adults every 5 years
for individuals 2-55 years.
– Meningococcal quadrivalent polysaccharide vaccine
(MPSV4 or Menomune®) for individuals older than 55
years.
– Does not protect against all meningococcal strains!
– In some countries different strains are more abundant. -
> prophylactic antibiotics (Penicillin 250mg 2/day)
Meningococcal Vaccines
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Pregnancy in PNH
Risks of Pregnancy in PNH
Mother:
Anemia
Low platelets and bleeding
Infection (urinary tract)
Recurrence of aplastic anemia
Blood clots during and after pregnancy !
Child:
Early and late fetal death
PNH is not inherited
Management of Pregnancy in PNH
Discuss
Plan
Verify
Prevent
Monitor
Treat early
• Hematologist familiar with PNH
• Obstetrician familiar with
high risk pregnancy
• Neonatologist
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Alternatives to Pregnancy in PNH
• Adoption
• Surrogate pregnancy (legal contract)
– Laws differ from state to state and country to country
– Egg donation (gestational surrogacy)• Risk of bleeding during oocyte harvest
• Risk of thrombosis (hyperstimulation syndrome)
– In vitro fertilization (embryos may be stored)
– Surrogate pregnancy• Gestational contracted motherhood
Sponsored by:
PNH Registry Overview
The PNH Registry is an ongoing global,
observational, non-interventional study collecting
safety, effectiveness, clinical characteristic and
quality of life data on patients with PNH irrespective
of clone size or treatment.
The PNH Registry has been established in order to
describe the real world outcomes of PNH, capturing
a wide range of patients from all over the world.
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PNH Registry Objectives
• Enhance the understanding of PNH demographics
and real world outcomes
• Provide real world data characterizing clinical and
subject-reported outcomes associated with PNH
treatment regimens
• Raise disease awareness in the medical community
and PNH patient population
Highlights from the 2010 American Society of Hematology Meeting:
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Longterm Eculizumab Results
639: Long Term Treatment with Eculizumab In Paroxysmal Nocturnal
Hemoglobinuria (PNH): Sustained Efficacy and Improved Survival. Richard J Kelly, M.B.Ch.B., MRCP(UK), FRCPath, Anita Hill, M.B.Ch.B., MRCP(UK), FRCPath,
Ph.D., Lindsay D Mitchell, M.B.Ch.B., MRCP(UK), FRCPath, Stephen John Richards, Ph.D.,
FRCPath, Louise M Arnold, R.N., B.Sc., Gemma L Valters, R.N., B.Sc., Matthew Cullen, M.Sc.,
Dena R Cohen, M.Sc., Walter M Gregory, Ph.D., and Peter Hillmen, M.B.Ch.B., FRCP, FRCPath,
Ph.D.
4237: Long Term Safety and Efficacy of Sustained Eculizumab Treatment
In Patients with Paroxysmal Nocturnal Hemoglobinuria (PNH). Robert A Brodsky, M.D., Carlos de Castro III, M.D., Hubert Schrezenmeier, M.D., Antonio M.
Risitano, M.D., Ph.D., Joerg Schubert, M.D., Jaroslaw P Maciejewski, M.D., Ph.D., FACP, Ulrich
Duehrsen, M.D., Lucio Luzzatto, M.D., FRCP, FRCPath, Petra Muus, M.D., Ph.D., Jeffrey Szer,
BMedSc, M.B.B.S., FRACP10, Gérard Socié, M.D., Ph.D., and Peter Hillmen, M.B.Ch.B., FRCP,
FRCPath, Ph.D.
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Highlights from the 2010 American Society of Hematology Meeting:
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Extravascular Hemolysis
4240 Low Level Residual Extravascular Haemolysis Is Common
Following Eculizumab Treatment In Paroxysmal Nocturnal
Haemoglobinuria (PNH), but Does Not Affect Transfusion Requirement Austin G Kulasekararaj, Dupe Odunsi, Pramila Krishnamurthy, Hayden Janet, Ibrahim Momoh,
Ghulam J. Mufti, D.M., FRCP, FRCPath, Judith C. W. Marsh, M.D. and Modupe Elebute,
M.B.B.S., M.D., M.R.C.P., FRCPath
New Therapeutics
638 TT30, a Novel Human Complement Inhibitor in Development for Paroxysmal Nocturnal
Hemoglobinuria and Other Hemolytic Disorders, Demonstrates Red Blood Cell Surface
Targeting and Retention in a Model of Complement Alternative Pathway-Mediated
Hemolysis
Masha Fridkis-Hareli, Ph.D., Michael Storek, Ph.D., Antonio M. Risitano, M.D., Ph.D., Ante S.
Lundberg, M.D., Christopher J Horvath, D.V.M., M.S., DACVP, and V. Michael Holers, M.D.
Complement
activation
Complement
lysis
CD55
CD59
Red Blood Cell
TT30 Blocks Complement Activation
on PNH Red Blood Cells
TT
30
Intravascular Hemolysis
C3b MAC
C5b-
9
C
5
C5
a
C6 C7 C8 C9
CD5
5
CD5
9
Classica
lLecti
nAlternativ
e
Activation -> Deposition on the surface Intravascular
Hemolysis
PNH
TT
30
TT
30
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T30 Stops Complement Deposition & Hemolysis
C3b MAC
C5b-
9
C
5
C5
a
C6 C7 C8 C9
CD5
5
CD5
9
Classica
lLecti
nAlternativ
e
Activation ->T
T3
0T
T30
Pediatric & Adult
Comprehensive BMF CenterChildren's Hospital of Philadelphia (CHOP) &
Hospital of the University of Pennsylvania (HUP/UPENN)
University of Pennsylvania School of Medicine
Monica Bessler MD PhD
Email: [email protected]
July 1, 2010
We are always looking for
study participants
For further information
Contact
Monica Bessler MD, PhD
5/12/2011
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We thank all patients and physicians for
participating in our studies
For Information Contact
Thank You !
Monica Bessler MD, PhD
The Children’s Hospital of Philadelphia &
Hospital of the University of Pennsylvania
Acknowledgements
We thank the Aplastic Anemia & MDS
International Foundation
For their support of our research!
Thank You !
Acknowledgements
Florentine Camenish Bursary Research Award 2003 to MB
Kazuhiko Ikeda MD PhD , Aplastic Anemia & MDS International Foundation
Fellowship 2009
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