AIHA

Diagnosis dan Penatalaksanaan Anemia Hemolitik AutoimunR. Satriyo Budhi Susilo

Pembimbing : dr. H. Suradi Maryono, SpPD-KHOM, FINASIM

Tinjauan Pustaka

1

DEFINISI AIHA :kelainan dimana autoantibodi

menempel pada antigen di membran sel darah merah

pemendekan masa hidup sel darah merah ± komplemen dan penghancuran di SRE

2

Williams hematology. 8th 2010Diagnostic criteria in autoimmune diseases. 2008

Postgraduate haematology. 6th 2011

INSIDENSI AIHA :1 : 100.000 WARM AIHA1

1 : 1.000.000 COLD AIHA1

1.700 : 1.000.000 CKD2

3

1Autoimmun Rev. 20102JAMA. 2007

4

Warm-Autoantibody Type Primary or idiopathic warm AHA

Secondary warm AHA

Cold-Autoantibody TypeMediated by cold agglutinins

Idiopathic (primary) chronic cold agglutinin disease

Secondary cold agglutinin hemolytic anemia

Mediated by cold hemolysins

Idiopathic (primary) paroxysmal cold hemoglobinuria

Secondary

Mixed Cold and Warm AutoantibodiesPrimary or idiopathic mixed AHA

Secondary mixed AHA

Drug-Immune Hemolytic Anemia

KLASIFIKASI AIHA

Williams hematology. 8th 2010

5

Tanda Frek. (%) Gejala Frek. (%)Splenomegali 82 Lemas 88Hepatomegali 45 Pusing 50Limfadenopati 34 Demam 37Ikterik 21 Perdarahan 10Edema 6 Sesak nafas 9Gagal jantung 5 Batuk 6Pucat 4 Berat badan turun 5

Gangguan GIT 5Anoreksia 4Urin warna gelap 3Angina 2

Tanda dan gejala pada AIHA

Williams hematology. 8th ed. 2010

6

Penemuan laboratorium berdasarkan evidence based

Autoimmun Rev. 2010 Mar;9(5):A350-4.

Perkiraan Kasus Kondisi

Hiperbilirubinemia 80 %Indirek, prehepatik bilirubin meningkat

Peningkatan LDH 100 % Iso-form 5Retikulositosis 100 %Coombs test 90% (agglutinasi) 95% (Flow cytometri)

7

8

DIAGNOSIS AIHA :

9

KLINIS ANEMIA HEMOLITIK

POIN DIAGNOSIS AIHA

DIRECT ANTIGLOBULIN TEST

COLD atau WARM AIHA

AIHA PRIMER atau SEKUNDER10

ALUR DIAGNOSIS AIHAExpert Rev. Hematol. 4(6), 607–618 (2011)

ANEMIA HEMOLITIK

anemia normo/makrositik, retikulositosis, haptoglobin ↓, bilirubin indirek ↑, LDH ↑

DAT

POSITIF NEGATIF

AIHA

IgG±C3d C3d

WAIHA CAIHA

Cari underlying disease

11

12

AIHA type Epidemiology/type of hemolysis

Autoantibody isotype

Optimal temperature DAT pattern

Warm AIHA ~70–80% of all AIHAs

Adults > childrenEV hemolysis,

IgG >> IgA, IgM 37°C IgG ± C3d

Cold agglutinin syndrome

~20–30% of all AIHAAge >50 years EV hemolysis

IgM >>> IgA or IgG titer >1/500 4°C C3d

Cold transient

AIHAChildren and adults

IV hemolysis Polyclonal IgM

titer ≥1/64 4°C C3d

Paroxysmal cold

hemoglobinuria

Children (rare ++), exceptional in adults Acute IV hemolysis

IgG (DL hemolysin) >30°C C3d

Mixed-type AIHA

Adult Mainly EV hemolysis

IgG, IgM ± AF ~1/500

Wide range (4–37°C) IgG ± C3d

Main characteristics of various types of autoimmune hemolytic anemia.

Expert Rev. Hematol. 4(6), 607–618 (2011)

Direct antiglobulin test differential diagnostic

Direct antiglobulintest pattern Differential diagnosis

IgG aloneWarm antibody autoimmune hemolytic anemiaDrug-immune hemolytic anemia of the Hapten-drug adsorptionor autoimmune type

Complement alone

Cold agglutinin syndromeWarm antibody autoimmune hemolytic anemia (IgM with a large thermal amplitude)Paroxysmal cold hemoglobinuriaDrug-immune hemolytic anemia: immune complex type

IgG+complement Warm antibody autoimmune hemolytic anemiaDrug-immune hemolytic anemia: autoimmune type (rare)

Williams hematology. 8th 2010

14

ALUR TERAPI AIHA :

15

16ALUR TERAPI COLD AIHAExpert Rev. Hematol. 4(6), 607–618 (2011)

COLD AIHA TRANSIEN

TRANFUSI PRC Bila Perlu

ANTIBIOTIK infeksi bakteri definitif

(M. pneumonia)

KORTIKOSTEROID jangka pendek (3 mg)

Pada AIHA berat

HINDARI PAPARAN DINGIN

COLD AIHA KRONIK

TERAPI INFEKSIVAKSINASI

ASAM FOLAT

WAIT & WATCH

TRANSFUSI PRCprewarmed

TERAPI RITUXIMAB±FLUDARABIN

KRONIK AKTIF atauRELAPS+SIMPTOMATIF

YA

TIDAK

17

PREDNISON : 1-1.5mg/kg/hari (2-3minggu)IV metilpred 250-1000mg (1-3hr) anemia berat

PREDNISON ↑ : 2mg/kg/hari± danazol (2 minggu)

PREDNISON ↓ mulai minggu 4

TAPERING-STOP PREDNISON (6-12bln)

TERGANTUNG PREDNISON

SPLENEKTOMI RITUXIMAB

SPLENEKTOMIRITUXIMABIMUNOSUPRESAN (Aza, Cy, MMF, Cic)

Gagal Respon

Respon

Gagal

Respon Gagal Respon Gagal

atau

Gagal

ALUR TERAPI WARM AIHAExpert Rev. Hematol. 4(6), 607–618 (2011)

KESIMPULAN :

1. Klinis AIHA mirip anemia hemolitik lainnya kerjasama klinisi dan praktisi lab dalam diagnosis

2. Penatalaksanaan AIHA belum berdasar evidence based / RCT. Masing-masing center mengembangkan guideline sendiri.

3. Penatalaksanan berdasar tipe AIHA (cold atau warm) serta penyakit yang mendasari

4. Terapi lini pertama : kortikosteroidTerapi lini kedua : splenektomi atau rituximabTerapi lini ketiga : azatriopin, siklosporin, siklofosfamid, MMF

18

Terima Kasih

Expert Rev. Hematol. 4(6), 607–618 (2011)

20

Expert Rev. Hematol. 1(2), (2008)

Blood Reviews (2008) 22, 17–31

L.D. Petz, Immune hemolytic anemias , Elsevier. 2nd ed. 2004

L.D. Petz, Immune hemolytic anemias , Elsevier. 2nd ed. 2004

L.D. Petz, Immune hemolytic anemias , Elsevier. 2nd ed. 2004

L.D. PetzImmune hemolytic anemias

Elsevier. 2nd ed. 2004

27

Criteria for complete response (CR) for AIHA : resolution of both anemia (Hb 13g/dL [males], 12g/dL [females]) and signs of hemolysis off all therapy for at least 4 weeks after treatment.

A partial response (PR) :a stable increase in hemoglobin level of at least 2 g/dL and discontinuation of concomitant therapy.

haematologica 2005; 90:1273-1274

Monoclonal antibodies are produced in the following main forms:· Murine – 100% mouse protein· Chimeric – approximately 65% human and 35% mouse protein· Humanized – 95% human and 5% mouse protein· Fully human – 100% human protein

An antibody is a protein used by the immune system to identify and neutralize foreign objects like bacteria and viruses. Each antibody recognizes a specific antigen unique to its target.

Monoclonal antibodies (mAb) are antibodies that are identical because they were produced by one type of immune cell, all clones of a single parent cell.

Polyclonal antibodies are antibodies that are derived from different cell lines.

Current Trends in Monoclonal Antibody Development and Manufacturing2010, Springer

28

Therapeutic monoclonal antibodies: from the bench to the clinic, 2009, John Wiley&Sons 29

Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490-1498.

Cellular and molecular immunology, Abbas, 6th ed, 2007, Elsevier 31

CD20 is a transmembrane protein with four predicted hydrophobic regions that cross the membrane and two extracellular loops. It is a B-cell marker that is expressed from the pre-B-cell stage until the plasma cell stage. CD20 is not expressed on stem cells or plasma cells. Although the exact function of CD20 is still not completely understood, data indicate that it is possibly a Ca2þ channel (Bubien et al. 1993) and may be involved in B-cell growth and activation (Tedder et al. 1985). CD20 is also expressed in more than 90 percent of B-cell non-Hodgkin’s lymphomas and 10 to 15 percent of chronic lymphocytic leukemia B-cells (Almasri et al. 1992; Anderson et al. 1984).

Its antigen, CD52, is a small (21 to 28 kDa) glycosylphosphatidylinositol-anchored cell surface glycoprotein. CD52 is highly expressed (500,000 molecules/cell on lymphocytes) on B- and T-cells, as well as in monocytes, macrophages, eosinophils, natural killer cells, dendritic cells, and epithelial cells of the male reproductive tractTherapeutic monoclonal antibodies: from the bench to the clinic2009, John Wiley&Sons

32

CD20 ideal target bagi terapi CLL

33

34

Surface Molecule Targets on B Cells

slg

HLA-DR

CD52CD20

CD23

B lymphocyte

Adapted from Press O, et al. Cancer J Sci Am. 1998:4(suppl 2):s19–s26, and M Hallek.

Molecule Target mAb

HLA-DR Hu1D10

CD20 CDCADCCCaChannel

Rituximab

Ofatumumab

GA-101

CD22

CD23 FceRII Lumiliximab

CD25Denileukin diflitoxin

CD37 Tetraspan

CD38 ADP-riboC Humax-CD38

CD52 GPI-linked Alemtuzumab

CD80 Co-stim Galiximab

35

.

36

.

37

Cellular and molecular immunology, Abbas, 6th ed, 2007, Elsevier

38

Cellular and molecular immunology, Abbas, 6th ed, 2007, Elsevier

39

Anti-CD20: Mechanism of Action

Antibody-Dependent Cell-Mediated Cytotoxicity (ADCC)

Complement-dependentCytotoxicityComplement-dependentCytotoxicity

FcRIIIACD20

CD20MAC

ApoptosisApoptosis

.Anti-CD20 antibody

Macrophage, monocyte, NK cell

University of Rochester Medical Center, 2009 40

.

.

.

.

The structural-functional classification of cytokines Mechanical Stretch and Cytokines, Springer 2011

No Cytokine family Subfamilies and ligands Main biological functions

1 Interferons (IFN)

Interferons type I: IFNα, β,δ, κ, ω, τInterferon type II: IFNγInterferons type III: IFNλ1(IL-29), IFNλ2 (IL-28A),IFNλ3 (IL-28B)

Antiviral, antiproliferative,Immunomodulating action

2Hemopoietic cell Growth factors

Stem cells factor (kit-ligand,steel factor), Flt-3 ligand,G-CSF,M-CSF, IL-7,IL-11Ligands of gp140 receptorsubunit: IL-3, IL-5,GM-CSFErythropoietin, Thrombopoietin

Stimulation of different cell precursor types proliferation and differentiation in bone marrow, hematopoiesis Activation

3

Superfamilyof interleukin-1 (IL-1)and fibroblast Growth factor (FGF)

FGF family: acid FGF, basic FGF, FGF3-FGF23IL-1 family (F1–11): IL-1α,IL-1β, IL-1 receptor antagonist, IL-18, IL-33, IL-37 and others

Activation of fibroblast and epithelial cell Proliferation Proinflammatory effect, activation of specificImmunity

4Tumor necrosis factor (TNF) family

TNF, lymphotoxin α and β,Fas-ligand and others

Proinflammatory action, apoptosis regulation and immune cell intercellular Interaction

5 Interleukin-6 family

Ligands of gp130: IL-6, IL-11, IL-31,oncostatin-M, cardiotropin-1, leukemia inhibitory factor, ciliary neurotrophic factor

Proinflammatory and immunoregulatory Action

6 Chemokines Subclasses: SS, SHS, SH3S, S Different leukocyte types chemotaxis Regulation

7 Interleukin-10 family IL-10, -19, -20, -22, -24, -26Immunosupressive action, inflammation and tumor growthRegulation

8 Interleukin-12 family IL-12, -23, -27, -35 Regulation of T-helper differentiation

9

Cytokines of T-helperclones and lymphocytefunction regulators

T-helpers type I: IL-2, IL-15, IL-21, IFNγ, TNF, T-helpers type II: IL-4,IL-5, IL-10, IL-13Ligands of IL-2 receptorγ-chain: IL-15, IL-21

Activation of cell ImmunityActivation of humoral immunity,Immunomodulation EffectsDifferentiation, proliferation andfunctional activity stimulation ofdifferent types of lymphocytes, DC, NK-cells, macrophages and others

10 Interleukin-17 family IL-17A, B, C, D, E, FProinflammatory cytokine synthesis Activation

11

Superfamily of nervegrowth factor (NGF),platelet derivinggrowth factor (PDGF)and transforminggrowth factor (TGF)

NGF, brain neurotrophicFactor. PDGF, vascular endothelialgrowth factors (VEGF), TGFβ, activins, inhibins, nodal, bone morphogenicproteins, mullerian inhibitory substance

Regulation of inflammation,angiogenesis, neuron functioning,Embryonic development andtissue regeneration

12Epidermal growth factor (EGF) family EGF, TGFα and others

Stimulation of different cell type proliferation

13Insulin-like growth factor (IGF) family IGF-I, IGF-II

Stimulation of different cell type proliferation

The structural-functional classification of cytokinesNo Cytokine family Subfamilies and ligands Main biological functions

6 Chemokines Subclasses: SS, SHS, SH3S, S Different leukocyte types chemotaxis Regulation

7 Interleukin-10 family IL-10, -19, -20, -22, -24, -26Immunosupressive action, inflammation and tumor growthRegulation

8 Interleukin-12 family IL-12, -23, -27, -35 Regulation of T-helper differentiation

9

Cytokines of T-helperclones and lymphocytefunction regulators

T-helpers type I: IL-2, IL-15, IL-21, IFNγ, TNF, T-helpers type II: IL-4,IL-5, IL-10, IL-13Ligands of IL-2 receptorγ-chain: IL-15, IL-21

Activation of cell ImmunityActivation of humoral immunity,Immunomodulation EffectsDifferentiation, proliferation andfunctional activity stimulation ofdifferent types of lymphocytes, DC, NK-cells, macrophages and others

10 Interleukin-17 family IL-17A, B, C, D, E, FProinflammatory cytokine synthesis Activation

11

Superfamily of nervegrowth factor (NGF),platelet derivinggrowth factor (PDGF)and transforminggrowth factor (TGF)

NGF, brain neurotrophicFactor. PDGF, vascular endothelialgrowth factors (VEGF), TGFβ, activins, inhibins, nodal, bone morphogenicproteins, mullerian inhibitory substance

Regulation of inflammation,angiogenesis, neuron functioning,Embryonic development andtissue regeneration

12Epidermal growth factor (EGF) family EGF, TGFα and others

Stimulation of different cell type proliferation

13Insulin-like growth factor (IGF) family IGF-I, IGF-II

Stimulation of different cell type proliferation

43

DIRECT COOMB TEST POSITIVE

Autoantibodies directed at RBC antigens (warm autoimmune hemolytic anemia [WAIHA], cold agglutinin syndrome [CAS])

Alloantibodies in a patient who was recently transfused antigen-positive RBCs (acute or delayed hemolytic transfusion reaction [AHTR, DHTR])

Passively transfused alloantibodies against the patient’s RBCs resulting from plasma-containing components (platelet component) or a plasma derivative (intravenous immunoglobulin [IVIG] or Rh immune globulin [RhIg])

Alloantibodies in the maternal circulation which cross the placenta and coat the fetal RBCs (hemolytic disease of the fetus and newborn [HDFN])Antibodies against drugs which bind to the RBC membrane (penicillin)Absorbed proteins (IgG) which attach to altered RBC membrane or RBCs modified by drugs (cephalosporins)

Immune complex or complement binding to RBCs after drug administration secondary to a drug/anti-drug interaction (quinidine, phenacetin)

Nonspecific uptake of protein, usually IgG (patients with hypergammaglobulinemia or recipients of high dose IVIG)

Antibodies derived from passenger lymphocytes as a result of either solid organ or HPC transplantation

Direct antiglobulin Test, Elsevier. 2009

De Novo Pathway

Salvage Pathway

Ribose 5P + ATP

PRPP synthetase

5-Phosphoribosyl-1-pyrophosphate (PRPP)

IMP

GMPGTP

RNA

GlycoproteinSynthesis

dGDPdGTP

DNAGuanine

HGPRTase

IMPD (Inosine Monophosphate Dehydrogenase)

Mycophenolic Mofetil acid(CELLCEPT)

CellCept©: Mechanism of Action

Guanosin nukleotida

Definition of Autoimmune

• Misperceptions of the immune system in the human body can not

distinguish whether the antigens in the body comes from outside or within

the patient's body itself.

• (Self and non self), so that the result will damage the immune system is

our body's own tissue, a condition termed as autoimmune diseases.

(Guntur, 2006)

Auto-immune Diseases

Failure of SELF RECOGNITION Failure of SELF TOLERANCE TOLERANCE

• CENTRAL (Death of self reactive lymphocytes)

• PERIPHERAL (anergy, suppression by T-cells, deletion by apoptosis, sequestration (Ag masking))

STRONG GENETIC PREDISPOSITION OFTEN RELATED TO OTHER AUTOIMMUNE DISEASES OFTEN TRIGGERED BY INFECTIONS

(Guntur, 2006)

Pathogenesis of Autoimmunity Genetic predisposition and environmental factors relevant

• Immunoglobulins, T cell receptors, major histocompatibilty complex T Cell Bypass- The requirement of T cells to activate B cells in order to

produce large amounts of antibodies is bypassed Molecular Mimicry- An exogenous antigen shares structural similarities with

host antigen and when an antibody is produced, it can bind to host antigen Idiotype Cross Reaction- A cross reaction between the idiotype (molecule

recognized by antigen) on an antiviral antibody and a host cell receptor for

the virus in question Cytokine Dysregulation- Certain cytokines have a role in the prevention of

the exaggeration of pro-inflammatory immune response Dendritic Cell Apoptosis- Defective dendritic cells can lead to inappropriate

systemic lymphocyte activation and a decline in self tolerance

(Guntur, 2006)

Calculation of normal transfusion requirements for a 70-kg male whose marrow is producing no RBCsNormal RBC volume = 30 mL/kg = 2100 mLIf the patient’s hemoglobin is 10 g/dL (two thirds of normal), the RBC volume is 1400 mL.If RBC survival is 100 days, 14 mL of RBCs must be replaced daily to maintain a hemoglobin of 10 g/dL.Because RBCs obtained from a blood donor are of all ages, average survival of transfused RBCs will be about 50 days.Therefore, to maintain a hemoglobin of 10 g/dL, 28 mL would have to be transfused daily, or 196 mL/wk.Each unit of RBCs contains about 180 mL of RBCs. Thus, about 1 unit of RBCs per week is a normal transfusion requirement for an adult producing no RBCs.In the absence of bleeding, a significantly increased transfusion requirement indicates hemolysis, i.e., a short RBC survival time of transfused RBCs.

L.D. Petz, Immune hemolytic anemias , Elsevier. 2nd ed. 2004

Plasmapheresis is a form of therapy to separate plasma from blood, remove pathogenic substances from plasma, and either replace it with substitution fluid or purify it. There are four main types of membrane plasmapheresis:plasma exchange (PE)double filtration plasmapheresis (DFPP)plasma adsorption (PA)immunoadsorption (IA).

FASE UJI KETERANGAN

Studi Preklinik Invitro utk menguji efikasi, toksisitas dan farmakokinetik

Fase 0 Uji pertama pada manusia (10-15 org)Farmakodinamik dan kinetik

Fase I 20-100 orgUji keamanan, dosis, efikasi obat

Fase IIKonfirmasi dari fase I dg subyek lebih besar (20-300 org)Uji keamanan, dosis, efikasi obat

Fase III RCT, multicenter, 300-3000 orgPerbandingan dengan gold standar tx

Fase IV Post Marketing Surveillance TrialEfek jangka panjang

Adapted from Clinicaltrials.gov, 2009 http://www.nlm.nih.gov/services/ctphases.html 52

Peran TGF beta

Peter Ten Dijke. Smad Signal Transduction Smads in Proliferation, Differentiation and Disease. Springer, 2006

5454

LPS bp

CD 14

IL 6

TNF -

IL -1

IL 8

APC

CD 4+ TCR

IFN -

SUPER ANTIGEN

IL - 10 IL - 4IL - 5IL - 6

Ig

NO ICAM -1

a

gTH - 2TH - 1

B cell

CD 8+

LPS

IMUNOCOM

SEPSIS

MOD

SHOCK

SEPTIC

IL-2

CSF

Compl.

N

NK

(Guntur, 2006)

C3a, C5a

PGE 2

TLR 4

TLR2

C7a MHC II

PAI-1

Imunopatogenesis

Kortikosteroid

54

5555

MD-2CD14

LPS bp

TLR4

My D88

TRAF6IRAK

NF-KB

ENDOTOKSIN

M

NIK/MKK

IKK

Target Genes

- Insulin Treatment

Guntur, 2008

- Metformin- Low dos Kortikosteroid

- Statin- ACE Inhibitor- AG II Blocker

- Anti ROS- NO

- Bradikinin

- Oestrogen

TNF-IL-6 IL-12

IL-1

IL-8

TGFβ-1

CYTOKINES

55

5656Dorren 200556

Biome-chanical

PCh

Cyto C

Jalur Zainal