Mario Bazzan

Thrombosis-free survival and life expectancy in 187 consecutive patients with essential thrombocythemia.

Abstract A total of 187 consecutive patients with essential thrombocythemia (ET) were diagnosed and followed by our Hematology Department in the period October 1980–November 1994. The overall follow-up was 773 patient-years. Thrombosis-free survival and overall survival were calculated for the whole cohort; the same parameters were then calculated after arbitrary division of the cohort into two groups, according to the median age at diagnosis (55 years). Fifty percent of the patients had at least one thrombotic episode within 9 years after diagnosis. The thrombosis-free survival curves calculated for patients younger or older than 55 years at diagnosis were comparable. About 85% of the patients were alive 10 years after diagnosis. The survival curves for patients younger and older than 55 years at diagnosis were not significantly different in the observation period, and the observed mortality (seven patients) among patients younger than 55 years at diagnosis was significantly higher than expected (1.68 cases). The relative risk of death was four times greater (SMR=4.17, 95% C.I. 1.6–8.6, p<0.01) than for healthy, age-matched people living in the same area. Age at diagnosis, smoking, sex, hypercholesterolemia, peak number of platelets, hypertension, and diabetes were not significant prognostic cardiovascular risk factors in our cohort. In conclusion, our data show that ET has to be considered a serious disease that significantly decreases both quality of life (expected life without thrombosis) and life expectancy for younger patients.

Combined differentiating therapy for myelodysplastic syndromes : A phase II study

An in vitro synergism between different inducers of AML cell differentiation has been previously observed. Therefore, we treated 53 myelodysplastic (MDS) patients with a low dose combination of cis-retinoic acid (cRA, 20-40 mg/day) and 1,25 alpha (OH)2 cholecalciferol [(OH)2D3, 1-1.5 micrograms/day] +/- intermittent 6-thioguanine (30 mg/m2/day). The latter was reserved for patients with bone marrow (BM) blast excess (> or = 5%). The treatment was well tolerated, without major toxicity. Among 25 patients with BM blasts less than 5%, we observed one complete, eight partial and four minor responses (response rate 52%) with a median response duration of 8 months (2 +/- 24). Median survival, which did not correlate with response, is projected at 76 months. Thirty-one patients with BM blast excess (> or = 5%), including three of the previous group who progressed to refractory anemia with excess of blasts (RAEB), were treated with the three-drug protocol. One complete, 12 partial and six minor responses were obtained (response rate 61%) with a median response duration of 6 months (2-29+). A significant difference in survival (P < 0.005) was observed between the 19 responders (median 25 months) and the 12 non-responders (median 9 months). A reduction in the transfusion need was observed in 41% of the transfusion-dependent patients with blast excess and in 53% of those without blast excess. Therefore, combined differentiating therapy seems more effective than previously reported single agent treatments and should be considered for a larger randomized study to assess its actual impact on survival of MDS patients.

Treatment-induced downregulation of antiphospholipid antibodies: effect of rituximab alone on clinical and laboratory features of antiphospholipid syndrome

Sir, In 2000, a 20-year-old woman came to our attention with aphasia, transitory dysarthria, (CT scan compatible with stroke) and thrombocytopenia (platelet count 29 10/l). Laboratory tests revealed anticardiolipin antibodies (aCL) 328/ 15U/l (ELISA kit Phadia, Uppsala, Sweden, EliA Cardiolipin IgG/IgM, normal value <40 U/l), antibeta-2 glycoprotein I antibodies 104/9U/l (ELISA kit Phadia, Uppsala, Sweden, EliA ß2 Glycoprotein I IgG/IgM, normal value <40U/l), and positivity for lupus anticoagulant (LAC). LAC measurement included: dilute Russell’s viper venom time (dRVVT) (Hemosil, LA-screen/confirm, Instrumentation Laboratory, Lexington, USA), partial thromboplastin time-LA (PTT-LA) (Diagnostica Stago, Asnières, France), silica clotting time (SCT) (HemosIL, DiaPharma Group, Inc. Ohio, USA) and kaolin clotting time (KCT) (homemade, according to Exner). If PTT-LA was prolonged, the hexagonal phospholipid neutralization test was performed as confirmatory (STACLOT-LA, Diagnostica Stago, Asnières, France). A diagnosis of primary antiphospholipid syndrome (APS) was made when antiphospholipid antibody (aPL) positivity was confirmed 3 months later. Therapy with prednisone (50mg/day) and intravenous immunoglobulins (IVIG, 400mg/kg/ day for 5 days) was started, resulting in an increase in platelet count. Oral anticoagulation therapy (OAT) was started when the platelet count reached 60 10/l. Platelet levels increased up to 110 10/l within 4 weeks and remained stable between 130 and 140 10/l for 4 months, when they dropped again to 70 10/l. The patient was then treated with adjusted doses of prednisone (37.5mg/day) and IVIG (400mg/kg/day for five more days). Prednisone treatment was slowly tapered to a daily dose of 7.5mg and finally discontinued in May 2007, when platelet counts were between 120 and 150 10/l. In 2009, the patient presented with a worsening of thrombocytopenia (platelet count 40 10/l) and was treated with the same regime of IVIG, with partial response (platelet count up to 90 10/l). She relapsed within 3 weeks. Splenectomy was not performed due to the high risk of thromboembolic and/or haemorrhagic complications. After ruling out possible contraindications, treatment with rituximab (RTX) was started at the conventional weekly dose of 375mg/m (days 1, 8, 15 and 22). Two more monthly doses after the last infusion (day 22) were administered, based on the protocol we employ for mixed cryoglobulinaemia with good results on long-lasting disease remission. Prednisone treatment (daily dose of 10mg at day 1) was tapered and finally discontinued 4 weeks after first RTX infusion. No other immunosuppressive drugs were associated. Treatment was well tolerated and no side effects were observed. RTX administration led to an increase in the platelet count (Figure 1). In addition, aCL, antibeta2-GPI antibodies and LAC ratio were downregulated (Figure 1). In this case, RTX-induced downregulation of aPL was observed. It was associated with a significant improvement in thrombocytopenia, thus allowing OAT to be administered. Successful amelioration of thrombocytopenia in APS after treatment with immunosuppressive therapy has previously been reported. However, a non-negligible percentage of patients become resistant/non-responsive to immunosuppression, and sometimes splenectomy cannot be performed because of the high risk of bleeding and/or thrombotic events. Some authors have reported that RTX is effective in treating APS and reducing aPL, but drug-induced aPL downregulation remains a challenge. Notably, in a observational study in patients with systemic lupus erythematosus, RTX resulted in a significant reduction in levels of IgG aCL. To our knowledge, this is the first report showing downregulation of aPL after RTX alone in a patient with primary APS who was not treated with immunosuppressive drugs prior to anti-CD20 antibody therapy. Some authors reported a close correlation between aCL titre reduction and an improvement in platelet count in patients with primary APS who were treated with RTX Correspondence to: Dario Roccatello, Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare (CMID), Struttura Complessa a Direzione Universitaria di Immunologia Clinica, Ospedale Torino Nord Emergenza San G. Bosco ed Università di Torino, Piazza del Donatore di Sangue 3, 10154 Torino, Italy Email: dario.roccatello@unito.it Received 29 September 2010; accepted 17 January 2010

Patients with antiphosholipid syndrome and thrombotic recurrences: A real world observation (the Piedmont cohort study)

Background Patients with antiphospholipid syndrome (APS) often have thrombotic recurrences, sometimes despite appropriate ongoing anticoagulant treatment. Identifying APS vascular patients at high risk for thrombotic recurrences is still an unsolved issue. Objectives To report the real-life experience of thrombotic recurrences in APS patients included in the Piedmont observational cohort study, and evaluate clinical and laboratory risk factors for thrombotic recurrences. Patients A multi-centre observational study was performed by enrolling 177 patients with vascular APS (primary APS in 99 subjects (56%)); the median follow-up was five years (range 1–26 years). Results The observed thrombotic recurrence rate was about 7.5/100 patient years in the first five years after the first thrombotic event. While the first recurrence often occurred (45%) in patients who were not on oral anticoagulant therapy (OAT), the second recurrence mainly occurred despite ongoing OAT (80%). However, due to the real-life observational nature of this study, treatment was based on the treating physician’s judgement, and no structured therapeutic protocol was applied. Moreover, compliance with OAT was not available. No differences in antiphospholipid antibodies (aPL) profile were observed between patients with or without thrombotic recurrences, but a high risk aPL profile (Miyakis type 1 and 2a) was present in 96% of our patients, 26% of whom had triple positivity. Diabetes (p < 0.01, OR 10), inherited thrombophilia (p < 0.0078, OR 4) and OAT withdrawal were independent risk factors for recurrences. Conclusions With the limit of a real-life observational cohort study, the thrombotic recurrence rate in APS was as high as 7.5/100 patient years in the first five years after the first thrombotic event. OAT discontinuation, diabetes and inherited thrombophilia, when associated with a high-risk aPL profile, are risk factors for thrombotic recurrences.

Systemic lupus erythematosus and thrombosis

Systemic Lupus Erythematosus (SLE) is an acquired, multiorgan, autoimmune disease. Clinical presentation is extremely variable and heterogeneous. It has been shown that SLE itself is an independent risk factor for developing both arterial and venous thrombotic events since SLE patients have an Odds Ratio (OR) for thrombosis that varies depending on the clinical and laboratory characteristics of each study cohort. The risk of developing a thrombotic event is higher in this setting than in the general population and may further increase when associated with other risk factors, or in the presence of inherited or acquired pro-thrombotic abnormalities, or trigger events. In particular, a striking increase in the number of thrombotic events was observed when SLE was associated with antiphospholipid antibodies (aPL). The presence of aPLs has been described in about 50% of SLE patients, while about 20% of antiphospholipid syndrome (APS) patients have SLE. While APS patients (with or without an autoimmune disease) have been widely studied in the last years, fewer studies are available for SLE patients and thrombosis in the absence of APS. Although the available literature undoubtedly shows that SLE patients have a greater prevalence of thrombotic events as compared to healthy subjects, it is difficult to obtain a definite result from these studies because in some cases the study cohort was too small, in others it is due to the varied characteristics of the study population, or because of the different (and very copious) laboratory assays and methods that were used. When an SLE patient develops a thrombotic event, it is of great clinical relevance since it is potentially life-threatening. Moreover, it worsens the quality of life and is a clinical challenge for the clinician.

Absence of (−)[3H]desmethoxyverapamil binding sites on human platelets and lack of evidence for voltage-dependent calcium channels

The two major pathways for Ca2+ entry into cells are potential-sensitive channels and receptor-operated channels. The main object of this investigation was to identify which mechanism regulates Ca2+ entry into human platelets. Platelet stimulation with thrombin, adenosine diphosphate, platelet activating factor and arachidonic acid resulted in a concentration-dependent 2.5-3-fold increase in cytoplasmic free calcium concentration over the basal levels (140 +/- 32 nM or 104 +/- 21 respectively) as measured with the fluorescent dyes Quin-2 and Fura-2. Adrenaline and collagen had no effect in promoting intracellular Ca2+ increase as measured with Quin-2 and little effect when measured with Fura-2. Incubation of Quin-2-loaded platelets with the calcium antagonists verapamil and diltiazem, which are known to inhibit Ca2+ entry from voltage-gated channels in many types of cells, over the concentration range 10(-8) - 10(-4) M did not alter significantly either the resting or the cytoplasmic free Ca2+ after stimulation of platelets by several agonists. Moreover, the calcium antagonists exhibited little or no effect on aggregation and 5-hydroxytryptamine secretion induced by platelet activating factor, adenosine diphosphate, collagen or arachidonic acid in whole blood, platelet-rich plasma or washed platelets when employed at concentration ranges as above. Similar results were obtained in washed thrombin-stimulated platelets. High doses of verapamil (but not diltiazem) inhibited platelet aggregation and secretion in response to adrenaline. Direct radioligand binding studies with (-)[3H]desmethoxyverapamil showed that platelet membranes have no receptors for this drug, suggesting that Ca2+ entry occurs in human platelets via a pathway different from potential-sensitive Ca2+ channels.(ABSTRACT TRUNCATED AT 250 WORDS)

Novel diagnostic and therapeutic frontiers in thrombotic anti-phospholipid syndrome

The anti-phospholipid syndrome (APS) is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity, associated with a persistent positivity for anti-phospholipid antibodies (aPL). The current classification criteria for APS include three laboratory tests: lupus anti-coagulant (LA), anti-cardiolipin (aCL), and anti-β2 glycoprotein-I (β2GPI). To date, the therapeutic approach for thrombotic APS mainly centers on long-term anti-coagulation with a vitamin K antagonist (VKA). APS management may represent a challenge for the treating physicians. Patients with different aPL profiles need a tailored risk-stratified approach. Moreover, in patients with recurrent thrombotic events despite therapy with VKA, or in those with microvascular involvement, new therapeutic options are highly needed. In this review, we aim to elucidate recent findings about new aPL specifities, available risk scoring models, and novel therapeutic approaches in APS management.

Clonal populations of hematopoietic cells with paroxysmal nocturnal hemoglobinuria phenotype in patients with splanchnic vein thrombosis

INTRODUCTION Splanchnic vein thrombosis (SVT) is a serious complication in patients with paroxysmal nocturnal hemoglobinuria (PNH). Mutant PNH clones can be associated with an increased risk of SVT even in the absence of overt disease, but their prevalence in non-selected SVT patients remains unknown. MATERIALS AND METHODS Patients with objective diagnosis of SVT and without known PNH were tested for the presence of PNH clone using high-sensitivity flow cytometric analysis. RESULTS A total of 202 SVT patients were eligible, 58.4% were males, mean age was 54.6years (range 17-94), site of thrombosis was portal in 103 patients, mesenteric in 67, splenic in 37, and supra-hepatic in 10. SVT was associated with JAK2 V6167F in 28 of 126 (22.2%) screened patients, liver cirrhosis in 15.3% patients, recent surgery in 10.9%, and myeloproliferative neoplasm in 10.6%, whereas in 34.6% of patients neither permanent nor transient risk factors were detected. None of the patients had a clearly demonstrable PNH clone, but in two patients (0.99%, 95% CI 0.17-3.91) we observed very small PNH clones (size 0.014% and 0.16%) confirmed in two independent samples. One patient had portal vein thrombosis and no associated risk factors, the second had superior mesenteric vein thrombosis and inflammatory bowel disease. CONCLUSIONS Very small PNH clones can be detected in patients with SVT and no clinical manifestations of disease. Future studies are needed to explore the potential role of this finding in the pathogenesis of SVT.

Duration of anticoagulant treatment and recurrence of venous thromboembolism in patients with and without thrombophilic abnormalities

Duration of anticoagulant treatment and recurrence of venous thromboembolism in patients with and without thrombophilic abnormalities -

Outpatient percutaneous native renal biopsy: Safety profile in a large monocentric cohort

Objectives We aim to evaluate the safety of performing percutaneous native kidney biopsy (PKB) as an outpatient procedure (implying an observation period of 6 hours) compared with the traditional inpatient policy. Design, setting, participants and measurements Group I, in whom PKB was performed in the outpatient department (2012–2016) and followed by 6 hours’ observation period and then by regular outpatient visits and group II, in whom PKB was performed and followed by at least 1 day hospital admission. Group II included retrospectively retrieved patients who underwent PKB in our Institution between January 2000 and November 2012 as an inpatient procedure. All biopsies were performed by a single nephrologist following a structured protocol. Results 462 biopsies were reviewed, 210 (45.5%) of patients were women and the mean age was 54.7±17.9 years. One hundred and twenty-nine (27.9%) of these biopsies were performed in outpatients. A total of 36 (7.8%) of patients developed a complication, and of those, 9 (1.9%) suffered for a major complication (arteriovenous fistula (six cases, 1.2%), ischaemic stroke (2; 0.4%), thromboembolic pulmonary embolism (1; 0.2%)) and 27 (5.8%) for minor(macroscopic haematuria (12 cases, 2.6%), haematomas on sonography not requiring intervention (15 cases, 3.2%)). When comparing the complication rate between groups I and II, no statical difference was observed. When analysing together both groups, after multivariate analysis, serum creatinine >3 mg/dL (OR 2.03, 95% CI 1.18 to 6.81) and known severe hypertension (OR 2.01, 95% CI 1.2 to 4.7) were found to be independent risk factors for minor and major complications, respectively. Conversely, we found no association of risk with the number of biopsy passes, gender, age, diagnosis, presence of haematuria before the kidney biopsy nor the degree of proteinuria. Conclusions Outpatient biopsy could be a valuable, safe and perhaps cost-effective method of obtaining diagnostic renal tissue in the majority of patients.