Thrombotic thrombocytopenic purpura :

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1 Thrombotic thrombocytopenic purpura : From pathophysiology to targeted therapies Paul Coppo paul.coppo@sat.aphp.fr Hematology Department - Hôpital Saint-Antoine AP-HP et Université Pierre & Marie Curie Reference Center for Thrombotic Microangiopathies Journées de Néphrologie N Jean Hamburger 19 avril 2011

THROMBOTIC MICROANGIOPATHIES Microangiopathic hemolytic anemia (< 12 à 13 g/dl) Peripheral thrombocytopenia (< 150x10 9 /L) Organ failure of variable severity PTT Acquired

2 THROMBOTIC MICROANGIOPATHIES Microangiopathic hemolytic anemia (< 12 à 13 g/dl) Peripheral thrombocytopenia (< 150x10 9 /L) Organ failure of variable severity PTT Acquired secondary «idiopathic» 4 cases / million hab /y Hereditary SHU STEC+ Atypical 2-4 cases / million hab /y Other entities - HELLP Sd - CAPS - Malignant AHT - Cancers - Transplantation

3 THROMBOTIC MICROANGIOPATHIES Microangiopathic hemolytic anemia (< 12 à 13 g/dl) Peripheral thrombocytopenia (< 150x10 9 /L) Organ failure of variable severity PTT Acquired secondary «idiopathic» 4 cases / million hab /y Hereditary SHU STEC+ Atypical 2-4 cases / million hab /y Other entities - HELLP Sd - CAPS - Malignant AHT - Cancers - Transplantation

4 Pathophysiology of acquired TTP Willebrand factor Moake et al., N Engl J Med, J Clin Invest, Furlan et al., Blood, Tsai et al., Blood, 1996 Unusually large multimers VWF multimers kda ADAMTS13 Low molecular weight multimers 500 kda NHP TTP HMW Antibodies Antibodies vwf A3 Met843 TTP Unusually large multimers A2 Tyr842 A1 ADAMTS13

5 Pathophysiology of acquired TTP Willebrand factor Moake et al., N Engl J Med, J Clin Invest, Furlan et al., Blood, Tsai et al., Blood, 1996 Unusually large multimers VWF multimers kda ADAMTS13 Low molecular weight multimers 500 kda NHP TTP HMW Antibodies Antibodies vwf A3 Met843 TTP Unusually ually large multimers dyn/cm 2 A2 Tyr842 ADAMTS13 A1 Platelet adhesion dyn/cm 2

6 TTP and ADAMTS13 Zheng et al, J Biol Chem Fujikawa et al, Blood Gerritsen et al, Blood Levy et al, Nature 2001 Monochain glycoprotein of 150/190 kda (1427 aa) Metalloproteinase, ADAMTS family : ADAMTS13 PS Propeptide Catalytic domaine (binding site with Ca 2+ /Zn 2+ ) Disintegrin-like domain TSP-1 Cys-rich domain (RGDS) SPACER TSP-1 domains 2 CUB domains Gene: chromosome 9q34 Synthesis: Liver, endothelial cells Plasmatic concentration = 1 µg/ml. Half-life life = 3 days Mutations (hereditary form) Autoantibodies (acquired form)

7 CONTRIBUTION OF ANIMAL MODELS Model of acquired TTP in non-human primate : major role humoral immunity Feys et al., Blood 2010 Balb/c mice ADAMTS13 Anti-ADAMTS13 (3H9) monoclonal Antibodies (Metalloproteinase domain) Versus 5C11 (Non inhibitory anti-adamts13 MoAb) Baboon (Papio ursinus) 2 infusions (600 µg/kg) / day 2 days 6 baboons (3H9) 5 baboons (5C11)

8 CONTRIBUTION OF ANIMAL MODELS Model of acquired TTP in non-human primate : major role humoral immunity Feys et al., Blood 2010 Balb/c mice ADAMTS13 Anti-ADAMTS13 (3H9) monoclonal Antibodies (Metalloproteinase domain) Versus 5C11 (Non inhibitory anti-adamts13 MoAb) Baboon (Papio ursinus) 2 infusions (600 µg/kg) / day 2 days 6 baboons (3H9) 5 baboons (5C11) Thrombocytopenia within 24h Microangiopathic hemolytic anemia from 24h Sacrified at day 4

anti-adamts13 MoAb) Baboon (Papio ursinus) 2 infusions (600 µg/kg) / day 2 days 6 baboons (3H9) 5 baboons (5C11) Prolonged

9 CONTRIBUTION OF ANIMAL MODELS Model of acquired TTP in non-human primate : major role humoral immunity Feys et al., Blood 2010 Balb/c mice ADAMTS13 Anti-ADAMTS13 (3H9) monoclonal Antibodies (Metalloproteinase domain) Versus 5C11 (Non inhibitory anti-adamts13 MoAb) Baboon (Papio ursinus) 2 infusions (600 µg/kg) / day 2 days 6 baboons (3H9) 5 baboons (5C11) Prolonged infusion (12 days) Myocardial injury Troponin T at D6 Thrombocytopenia within 24h Microangiopathic hemolytic anemia from 24h (reversible) Sacrified at day 4

10 SUSCEPTIBILITY GENES INVOLVED IN AUTOIMMUNE TTP Allele DRB1 *01 Acquired TTP n (%) Controls n (%) TMA control group n (%) 10 (17) 23 (35) 8 (23) p * (1) p* (2) p* (3) Usual frequency of the allele : 13.5% to 24.5%, *03 6 (10) 11 (17) 6 (17) *04 *07 5 (8) 21 (32) 9 (26) 12 (20) 14 (22) 9 (26) Asia Pacific islands Subsahelian Africa *08 3 (5) 3 (5) 5 (14) *09 3 (5) 1 (2) 1 (3) *10 5 (8) 2 (3) 1 (3) *11 35 (59) 14 (22) 7 (20) *12 4 (7) 2 (3) 2 (6) *13 10 (17) 11 (17) 7 (20) *14 2 (3) 3 (5) 2 (6) *15 13 (22) 13 (20) 9 (26) DQB1 *03 46 (77) 92 (54) 18 (46) CNR-MAT, J Thromb Haemost 2010

11 SUSCEPTIBILITY GENES INVOLVED IN AUTOIMMUNE TTP Allele DRB1 *01 Acquired TTP n (%) Controls n (%) TMA control group n (%) 10 (17) 23 (35) 8 (23) p * (1) p* (2) p* (3) Usual frequency of the allele : 13.5% to 24.5%, *03 6 (10) 11 (17) 6 (17) *04 *07 5 (8) 21 (32) 9 (26) 12 (20) 14 (22) 9 (26) Asia Pacific islands Subsahelian Africa *08 3 (5) 3 (5) 5 (14) *09 3 (5) 1 (2) 1 (3) *10 *11 5 (8) 2 (3) 1 (3) 35 (59) 14 (22) 7 (20) Incidence of DRB1*11 allele : (pairing /ethnical group) *12 *13 4 (7) 2 (3) 2 (6) 10 (17) 11 (17) 7 (20) Caucasians vs controls: *14 2 (3) 3 (5) 2 (6) % vs 22%, p=10-7 *15 13 (22) 13 (20) 9 (26) OR = 7.8, CI95% = DQB1 *03 46 (77) 92 (54) 18 (46) CNR-MAT, J Thromb Haemost 2010

12 Acquired TTP as a consequence of an efficient immune response against infections? HLA DRB1*11, DQB1*03 - Protection against tuberculosis - Better clearance of hepatitis C virus HLA DRB1*04 Dubaniewicz et al., 2005 Osafo-Addo et al., 2008 Renou et al., 2002 Harris et al., 2008 Singh et al., Increased risk of tuberculosis - Increased risk of severe malaria Le paludisme dans le monde jusqu au 19è siècle

13 Acquired TTP as a consequence of an efficient immune response against infections? HLA DRB1*11, DQB1*03 - Protection against tuberculosis - Better clearance of hepatitis C virus HLA DRB1*04 - Increased risk of tuberculosis - Increased risk of severe malaria Dubaniewicz et al., 2005 Osafo-Addo et al., 2008 Renou et al., 2002 Harris et al., 2008 Singh et al., 2007 Tuberculosis and plasmodium exist since at least 3 million years in East Africa Le paludisme dans le monde jusqu au 19è siècle Infectious diseases that have co-evolved with human kind Co-evolution Efficient immunity against TB, malaria, HCV Anti-infectious immunity vs self-tolerance

14 Conclusion Proposed model ADAMTS13 Co-stimulation

15 Conclusion Proposed model DRB1*11-DQB1*03 (Infectious selection pressure?) ADAMTS13 Co-stimulation

16 Conclusion Proposed model Spacer domaine DRB1*11-DQB1*03 (Infectious selection pressure?) (Arg660-Tyr661-Tyr 665) ADAMTS13 Co-stimulation

17 Conclusion Proposed model Spacer domaine DRB1*11-DQB1*03 (Infectious selection pressure?) (Arg660-Tyr661-Tyr 665) ADAMTS13 Anti-ADAMTS13 Abs - Anti-spacer (Arg660-Tyr661-Tyr 665) - VH 1-69: preferential gene Co-stimulation

18 Conclusion Proposed model Spacer domaine DRB1*11-DQB1*03 (Infectious selection pressure?) (Arg660-Tyr661-Tyr 665) ADAMTS13 Infections TLR Anti-ADAMTS13 Abs - Anti-spacer (Arg660-Tyr661-Tyr 665) - VH 1-69: preferential gene Co-stimulation

19 Conclusion Proposed model Spacer domaine DRB1*11-DQB1*03 (Infectious selection pressure?) (Arg660-Tyr661-Tyr 665) A3 A2 A1 ADAMTS13 Infections TLR Endothelial activation Anti-ADAMTS13 Abs - Anti-spacer (Arg660-Tyr661-Tyr 665) - VH 1-69: preferential gene Co-stimulation

20 Conclusion Proposed model Spacer domaine DRB1*11-DQB1*03 (Infectious selection pressure?) (Arg660-Tyr661-Tyr 665) A3 A2 A1 ADAMTS13 Infections TLR Endothelial activation Anti-ADAMTS13 Abs - Anti-spacer (Arg660-Tyr661-Tyr 665) - VH 1-69: preferential gene Co-stimulation

21 Conclusion Proposed model Spacer domaine DRB1*11-DQB1*03 (Infectious selection pressure?) (Arg660-Tyr661-Tyr 665) A3 A2 A1 ADAMTS13 Infections TLR Endothelial activation Anti-ADAMTS13 Abs - Anti-spacer (Arg660-Tyr661-Tyr 665) - VH 1-69: preferential gene Co-stimulation Acquired TTP: a relevant model to study the role of infections in the loss of tolerance of the immune system and loss of endothelial homeostasy

22 With standard treatment : Treatment of TTP : current results Remission ~ 85% CNR - MAT, Br J Haematol 2006 Death rate 10-20% Relapse rate 20-30% Flare-up episodes : ~ 50% of patients : Complications liées aux EP PE Refractoriness : ~ 10% of cases : PE Howard et al., Transfusion 2006

23 Rituximab in acquired idiopathic TTP Promising results from case series/case reports Ahmad et al., Am J Hematol 2004 Koulova et al., Am J Hematol 2005 Reddy et al., Ann Hematol 2005 Kosugi et al., Int J Hematol 2005 Galbusera et al., Blood 2005 Fakhouri et al., Blood 2005 Prevention of relapses Increase of ADAMTS13 levels Well tolerated Gianfaldoni et al., J Chemother 2005 Darabi et Berg, Am J Clin Pathol 2006 Scully et al., Br J Haematol 2006 Elliott et al., Eur J Haematol 2009 To be evaluated in patients with a suboptimal response

24 TTP in suboptimal response; role of rituximab Start of standard treatment Standard treatment Maintenance treatment Follow-up Inclusion Day 1 Day x Day x+14 Day 30 Month 3 Month 6 Month 9 Month 12 Rituximab Day 5 to day x B B B B B Day x Day X+1 Day X+2 Day X+3 Day X+4 Day X+5 Day X+6 Day X+7 Day X+8 Day X+9 Day X+10 Day X+11 Day X+12 Day X+13 Day X+14 PE R X X X X X X X X X X X X X X X Dx Dx+3 Dx+7 Dx+14 B B B B B ADAMTS13 actvity; Abs Residual peripheral B-lymphocytes

25 RESPONSE TO TREATMENT Proportion d'individus non normalisés Thrombocytopenic patients Traitement R.moins Group R+ Traitement R.plus Group R- P= % Durée Time (nombre (days) de jours) R+ (N=21) R- (N=53) P Steroids administration 15 (71%) 42 (79%) 0.68 Platelet count recovery at D35 (%) 21 (100%) 41 (77%) <0.02 Mean plasma volume (ml/kg) 891± ±

26 RESPONSE TO TREATMENT Proportion d'individus non normalisés Thrombocytopenic patients Traitement R.moins Group R+ Traitement R.plus Group R- P= % Durée Time (nombre (days) de jours) R+ (N=21) R- (N=53) P Steroids administration 15 (71%) 42 (79%) 0.68 Platelet count recovery at D35 (%) 21 (100%) 41 (77%) <0.02 Mean plasma volume (ml/kg) 891± ± Mean time to platelet count recovery after the first rituximab infusion: 12 ± 6,7 days Platelet count (G/l) D1 D4 D7 0 rituximab D10 D13 D16 Time D19 D22 D25 D28 D31

27 RESPONSE TO TREATMENT Proportion d'individus non normalisés Thrombocytopenic patients Traitement R.moins Group R+ Traitement R.plus Group R- P= % Durée Time (nombre (days) de jours) R+ (N=21) R- (N=53) P Steroids administration 15 (71%) 42 (79%) 0.68 Platelet count recovery at D35 (%) 21 (100%) 41 (77%) <0.02 Mean plasma volume (ml/kg) 891± ± Mean time to platelet count recovery after the first rituximab infusion: 12 ± 6,7 days Platelet count (G/l) D1 D4 D7 0 Cyclophosphamide Splenectomy? N-acetylcysteine rituximab D10 D13 D16 Time D19 D22 D25 D28 D31

28 ADAMTS13 activity and B-cell depletion ADAMTS13 activity (%) P=0.01 P=0.02 P=0.003 P=0.12 P= Months Circulating B-Lymphocytes (%) D1 D4 D8 D15 D22 D30 M3 M6 M9 M12 Anti-ADAMTS13 antibodies (U/ml) P=0.64 P=0.003 P=0.007 P=0.04 Group R+ Group R- P= Months Time after rituximab administration Relapse after immune reconstitution Prevention of relapses during ~ 12 months Froissart et al., submitted

29 KEY POINTS Rituximab in TTP in suboptimal response : 1. Allows to prevent late-onset responses ( > 1 month) 2. Is not efficient immediately (only after ~ 15 days); does not prevent early deaths 3. Does not systematically prevent late-onset relapses (when B-cell reconstitution occurs) (> 1 year)

30 UNRESOLVED QUESTIONS - Optimal dose and schedule of rituximab administration? Adaptation of rituximab infusions according to residual B-lymphocytes - Evaluation of B-cell repopulation after rituximab? Early CD19 + /CD5 + lymphocytes Memory CD27 + lymphocytes PTTRITUX2 study - Role of a preemptive treatment with rituximab

31 Preemptive treatment with rituximab I. 22 patients received a preemptive treatment with rituximab Median number of episodes of PTT before rituximab : 2 [1-14] Previous treatments : - Vincristine - Splenectomy 4 patients (18%) : > 1 cycle of rituximab: 4 cycles (1 case) at 1,4 y - 3,4 y - 5 y 6,5 y 3 cycles (1 case) at 1,3 y - 5 y - 6 y then CPM 2 cycles (2 case) at 1 y - 2,7 y ; 2,5 y - 4,2 y 18 patients (82%) : 1 unique cycle of rituximab 18 episodes: 4 infusions 11 episodes: 1 to 3 infusions (1/w, 375 mg/m 2 ) ADAMTS13: 81% [0% 113%] at 2 y of treatment [6,3 months 4,4 y] Median follow-up : 3,5 y [3 months 7,5 y] 6 patients with a severe acquired deficiency w/o preemptive treatment: 3/6 relapses No relapse +++ Splenectomy Rituximab Death (relapse)

32 Preemptive treatment with rituximab II. TTP RTX RTX RTX RTX ADAMTS13 Anti-ADAMTS13 Abs B-Lymphocytes ADAMTS13 activity (%) Anti-ADAMTS13 antibodies (U:mL) y 2 y 3 y 4 y 5 y 6 y 7 y B-Lymphocytes (%) Who will require long term infusions of rituximab? Tachyphylaxy? Short term and long term infectious complications?

33 Forthcoming targeted therapies ADAMTS13 Future treatment: recombinant ADAMTS13 + rituximab ± plasmapheresis ± steroids?

34 Conclusion Perspectives: Treatment of TMA in 2011 Diagnosis of TMA = Treatment in emergency +++ Daily PE 60 ml/kg folates + Intensive care ±Steroids Avoid platelet infusions Réponse Platelet count recovery > 2 d Progressive tapering, then stop PE sessions

35 Conclusion Perspectives: Treatment of TMA in 2011 Diagnosis of TMA = Treatment in emergency +++ Daily PE 60 ml/kg folates + Intensive care ±Steroids Avoid platelet infusions Réponse Platelet count recovery > 2 d Suboptimal response by D5 Progressive tapering, then stop PE sessions TTP: Rituximab SplX - CPM HUS: Complement blockers

CNR Coppo P. Buffet M. Malot S. Vernant JP. Galicier L. Centre de Référence R Maladies Rares MAT Rondeau E. Ronco P. Deschênes G. Guidet B. Mira JP. Azoulay E. Brivet F. Regnier B.

Tours Nivet H. Reims Wynckel A Rouen Clabault K. Montpellier Bordessoule D Provôt t F. Toulouse Pourrat J. Marseille Poullin P. Lyon CNR-MAT.com Nantes Hamidou M. Pouteil-Noble C.

36 CNR Coppo P. Buffet M. Malot S. Vernant JP. Galicier L. Centre de Référence R Maladies Rares MAT Rondeau E. Ronco P. Deschênes G. Guidet B. Mira JP. Azoulay E. Brivet F. Regnier B. Veyradier A. Frémeaux meaux-bacchi V. Strasbourg Herbrecht R. Amiens Choukroun G. Bordeaux Gruson D. Clerm.-Ferrand Limoges Palcoux JB. Caen Ramakers M. Lille Rennes Vigneaux C. Tours Nivet H. Reims Wynckel A Rouen Clabault K. Montpellier Bordessoule D Provôt t F. Toulouse Pourrat J. Marseille Poullin P. Lyon CNR-MAT.com Nantes Hamidou M. Pouteil-Noble C. Dijon Mousson C. Rossi JF Réunion Zunic P. Rennes Nantes La RéunionR Caen Poitiers Bordeaux Amiens Rouen Tours Limoges Toulouse Lille Reims Paris Clermont- Ferrand Dijon Lyon Montpellier Marseille Strasbourg Mulhouse

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