Le point sur l’Hémoglobinurie Paroxystique Nocturne U 728.

Le point sur l’Hémoglobinurie

Paroxystique Nocturne

U 728

British Journal of Hematology 2000;108:470-9

Lack of expression of the GPI-anchored proteins on hematopoietic cells

Disease of the hematopoietic stem cell

Coexistence of a mutated (GPI-) and “normal” (GPI +) hematopoiesis

Acquired somatic mutation of the PIG-A gene

Linked to other hematological disorders; SAA & MDS

Hémoglobinurie Paroxystique Nocturne

Acquired hemolytic anemia

+/- aplastic anemia

thrombosis

(1/3 of patients with AA will have a + Ham’s test)

1/3 of patient with AA have GPI- cells at diagnosis

PIG-A mutations, in AA with GPI- cells = those with de novo PNH

Definition

AA PNH

MDS

AA

MDS

PNH

1/3 previously considered idiopathic AA = AA/PNH (GPI-; PIG-A mutated)

Physiopathologie

Phosphoethanolamine

P

I

O OC=O

C-C-C

P

C=O

NH 2

Protein

I

Mannose

Glucosamine

Phosphoinositol

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

CD55

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

Holley Gregory AG

Bessler 2003

Physiopathologie

PIGSPIGTPIGUPIGK

PIGL

DPM1DPM2DPM3MPDU1

PIGN PIGBPIGMPIGX

PIGW

PIGV

PIGFPIGOGPI7

PIGAPIGCPIGHGPI1GPIP

DMP2

GPIY

GAA1

Phosphoethanolamine

P

I

O OC=O

C-C-C

P

C=O

NH2

Protein

I

Mannose

Glucosamine

Phosphoinositol

UDP

COOH COOH

NH2

NH2

DG

GDP

Dol-P

Dol-P

Ac

Ac

UDPacetate

acyl-CoA

Dol-PDol-P

DG

Endoplasmic reticulum

Dol-PDol-P

Dol-PDG

GDP

Defective in PNHPIG-A; X p22-1

Physiopathologie

Somatic mutations in PIG-A gene

COCOO

CHCH2

O POO

O

OCH2

INOS

GLUMAN

OO

O

(a 1-2)(a 1-6)

( 1-4)

CO

N

CH2

CH2

NH

O P OO

O

MANO

PHOSPHATIDYL-INOSITOL

GLYCAN COREPHOSPHO-ETHANOLAMINE

PROTEIN

MAN

1189 1452982849716

6633 555522 44

1

11

Impaired synthesis

of GPI-anchor

Lack of surface GPI-

Anchored Proteins

Cytoplasm

COOH

NH2

COOH

NH2

Extracellularspace

Physiopathologie

Physiopathologie

?

Physiopathologie

APC C3 convertaseC3bBbP

APC C5 convertase[C3b]2BbP

MACC5b-9

CD55DAF-

CD59-

Chute du pH nocturne; pas de régulation = HémolyseMAIS …

Physiopathologie de la thrombose

Activation plaquettaireActivation endothéliale

Hypo-fibrinolyseGénération de thrombine

Hémoglobine libre Déficit en NO

Dystonie

Vasoconstriction

Complément

Microvésicules

Phospholipides

THROMBOSE

Hemoglobinuria

Thrombosis

Fatigue

Renal Failure

Significant Impact on Quality of

Life

Significant Impact on Survival

Smooth Muscle Dystonias including

Dysphagia, Abdominal Pain,

and Male ED

Pulmonary Hypertension

Normal red blood cells are protected from

complement attack by a shield of terminal

complement inhibitors

Without this protective complement inhibitor shield, PNH red blood

cells are destroyed

Intact RBCHemoglobin in

the Blood from Destroyed PNH RBCs

ComplementActivation

Anemia

Physiopathologie

R3

R3

R4 R5

A

B (iii)

(iii)

(iv)

(ii)

(ii)

(i)

(i)

Normal

GPI – Blood Cells in Pat ients with Aplastic Anemia (AA) Schubert

(1994)

Schrezenmeier

(1995)

Griscelli

(1995)

Yamaguchi

(2000)

Tooze

(1995)

Dunn

(1999)

Azenishi

(1999)

Mukhina

(2001)

Maciejewski

(2001)

Meletis (2001)

29 52 37 21 70 115 73 23 115 21 No of pat ients % of pat ients with GPI- cells 41 52 35 29 23 22 28 16 32 33

GPI – Blood Cells in Pat ients with Myelodysplast ic Syndrome (MDS)

Dunn

(1999)

Yamaguchi

(2000)

Meletis

(2001)

Maciejewski

(2001)

Mukhina

(2001)

Wang

(2002)

No of pat ients 39 18 133 120 9 119 % of pat ients with

GPI- cells 23 28 17 18 0 18

Diagnostic

CD59CD55

CTRL isoCtrl neg

TémoinCtrl pos

Patient

Analyse sur FC 500

Hématies HPN

Hématies HPN

Hématies normales

Hématies normales

PN NeutroClone « PNH »

PN Eosino

Analyse des leucocytes

PN Neutro

Analyse sur FC 500

CD24

CD16

FLAER aerolysin (Aeromonas Hydrophila)

toxin (Clostridium septicum)

Peghini et al. Cytometry 2005

Shin et al. BBRC 2004

Toxines bactériennes

AA (aplasie médullaire) et HPN

Nakao et al.2005

Patients (n=460)

• Gender F (%): 54.3

• Median age at diagnosis: 34.2 years

0

20

40

60

80

100

120

140

160

180

1950 1960 1970 1980 1990 2000

CMF-CMF+

15 new patients / year

210

33

20

18

21

15

15

Diagnostic

Characteristics n (%)

Previous AA* 106 / 23.0%

Thrombosis 33 / 7.2%

Anemia (<12 g/dl)

Pancytopenia

414 / 91.4%

175 / 39.1%

Initial treatment:

Androgens

Danazole

Steroids alone

Immunosuppressive therapy §

Transplantation

73 / 16.2%

40 / 8.9%

40 / 8.9%

92 / 20.2%

26 / 5.7%

§Antithymoglobuline Cyclosporine*Aplastic anemia

Survie globale

Years after diagnosis

Sur

viva

l1

0.8

0.2

0.4

0.6

010 20 30 400

Median follow-up: 6.0 +/- 0.5 years

Median survival time : 22.0 +/- 2.5 years

> 96 deaths / 455 patients with follow up

Complications

Aplastic anemia

Thrombosis

10-year CI* (%): 19.8 (15.2-24.3) 10-year CI* (%): 30.7 (25.4-35.9)

Cumulative incidence (CI); death and SCT as competing events

*Cumulative Incidence (Confidence Interval)

Complications

ThrombosisThrombosis Risk Factors RR p

10-year CI* (%): 30.7 (25.4-35.9)

Cumulative incidence (CI); death and SCT as competing events

*Cumulative Incidence (Confidence Interval)

Age >55

Thrombosis (DG)

Warfarin (prophylaxis)

Transfusions

IST

1.8

3.7

5.2

1.7

0.5

.01

<.001

<.001

.01

.02

10-year CI* (%): 5.2 (2.9-7.6) 10-year CI* (%): 2.4 (0.7-4.0)

MyelodysplasiaAcute leukemia

Cumulative incidence (CI); death and SCT as competing events

*Cumulative Incidence (Confidence Interval)

Complications

Facteurs Pronostiques (Survie)

Overall population

Period ≤ 1995

Age > 40 yearsHb < 10 g/dlNeutropenia

No treatment (first year)

Aplastic anemia (evolution)Thrombosis (evolution)MDS/AML (evolution)

RR

2.7

2.22.81.8

2.3

4.618.210.0

p

0.01

0.0010.0080.02

<.001

<.001<.001<.001

Formes Cliniques

Classical

(n=113)

Hb.<12g/dl and/or thrombosis

Neutrophils>1.5 and Pt>120

AA – PNH syndrome

(n=224)*Hb10g/dl, Platelets 80G/L, Neutrophils 1 G/L

2 or 3 lineages*

Unclassified

(n=93)

Parker C, Blood 2005

0.6

Sur

viva

l1

0.8

0.2

0.4

Years10 20 30 40

0

0

Unclassified PNH

AA-PNH

Classical PNH

Survie globale

Complications : Thromboses

0.6

0.5

10 20 30 400

0

0.4

0.3

0.2

0.1 Unclassified PNH

AA-PNH

Classical PNH

Years

Cum

ulat

ive

Inci

denc

e

10-year CI:27.8%

10-year CI:27.3%

10-year CI:37.9%

Complications : Pancytopénie

Years

Cum

ulat

ive

Inci

denc

e0.5

0

0.4

0.3

0.2

0.1

Unclassified PNH

AA-PNH

Classical PNH

10-year CI:20.5%

10-year CI:19.1%

10-year CI:20.4%

10 20 30 400

Facteurs Pronostiques (Survie)

Period ≤ 1985

Age:> 40 years> 55 years

No thrombocytopeniaNo Andro/Dan (first year)No ISTTransfusions

Aplastic anemia (evolution)Thrombosis (evolution)MDS/AML (evolution)

ClassicalPNH

3.6 (.01)

5.4 (<10-3)21.4 (<10-3)

6.0 (.01)8.5 (.03)

7.3 (<10-3)7.8 (<10-3)

AA / PNH

2.8 (.04)2.9 (.005)

9.9 (<10-3)43.4 (<10-3)59.4 (<10-3)

UnclassifiedPNH

5.7 (.05)

5.7 (.02)6.4 (.007)

17.6 (<10-3)38.5 (.003)

HPN :Traitement

Key issue ; 1. Will RIC reduced TRM ?2. Unrelated SCT; When and how ?

0.0

0.3

0.5

0.8

1.0

0.0 730.0 1460.0 2190.0 2920.0 3650.0

time after treatment (days)

Surv

ival

n = 121 patients

0.56 (0.46-0.66)

Survival at 10 years

0.0

0.3

0.5

0.8

1.0

0.0 730.0 1460.0 2190.0 2920.0 3650.0

time after treatment (days)

Surv

ival

1980-1993, n=33

1993-1997, n=34

1998-2002, n=18

HPN :Traitement

Time (months)

4000

3000

2000

1000

0

%

1,00

,90

,80

,70

,60

,50

N = 38

49% hemolysis 66% pancytopenia

Treatment:29 Transfused

28 First line Tt including:Steroids (LD); 18%

CSA ; 21%CSA+ATG; 26%Danazole;8%

16 (58%) 2nd lineTt failure or relapse

Key issue ;1. No efficacious Tt in Hemolytic form2. AA/PNH respond to IST

CH1CH1

CH

3C

H2

Hinge Hinge

CLCL

Human Framework RegionsHuman Framework Regions

Human IgG2 Heavy ChainHuman IgG2 Heavy ChainConstant Region 1 and HingeConstant Region 1 and Hinge

SolirisTM (eculizumab) Anti - C5 Antibody

TRIUMPH SHEPHERD

ParameterPlaceboN = 44

EculizumabN = 43

Eculizumab N = 97

Mean Age (SD) 38.4 (13.4) 42.1 (15.5) 41.1 (14.4)

Gender - Female (%) 29 (65.9) 23 (53.5) 49 (50.5)

History of AA or MDS (%) 12 (27.3) 8 (18.7) 29 (29.9)

Concomitant Anticoagulants(%) 20 (45.5) 24 (55.8) 59 (61)

Concomitant Steroids/IST (%) 16 (36.4) 14 (32.6) 46 (47.4)

Median PRBC in previous 12 months 17.0 18.0 8.0

Mean Hgb setpoint 7.7 (0.75) 7.8 (0.79) N/A

Pre-treatment LDH levels 2,234.5 2,032.0 2,051.0

Free Hemoglobin at baseline 46.2 40.5 34.9

TRIUMPH and SHEPHERD Demographics

Change in Lactate DehydrogenaseDuring Eculizumab Treatment Over 52 Weeks