PRİMER İMMÜN TROMBOSİTOPENİDE ARTMIŞ RETİKÜLER LİF DERECESİ

Öz

AMAÇ: Primer immün trombositopenide (İTP) kemik iliği fibrozu, trombopoeitin reseptör agonist tedavileri sırasında fibrozisli vakalar bildirildiğinden ilgi odağı haline gelmiştir, ancak hastaların tanı anında fibrozis durumunu değerlendiren az sayıda çalışma vardı. Bu çalışmanın amacı İTP'li hastalarda kemik iliği fibrozisinin özellikle tedaviye yanıt ve prognoza etkisini değerlendirmektir. GEREÇ VE YÖNTEM: Hastaların kemik iliği retikülin lif derecesi, hemoglobin, trombosit, yaş, cinsiyet, komorbiditeleri, başvuru sırasında hepatit ve otoimmün belirteçleri, yanıt, remisyon durumu ve remisyon süresi ve tedaviler hastaların tıbbi dosyalarından kaydedildi ve her parametre, İTP'li 53 hastada retiküler lif derecesi ile bir ilişki açısından değerlendirildi. BULGULAR: Hastaların %79,3’ünde kemik iliği retikülin içeriği derece 1 veya daha fazlaydı. Kemik iliği retiküler lif derecesi ile tanı anında toplam kan sayımı, birinci, ikinci ve üçüncü basamak tedaviye yanıt süreleri, tedavi sonrası trombosit sayıları ve iki tedavi hattı arasındaki süre, yaş, cinsiyet, komorbidite varlığı, antinükleer antikor pozitifliği ve yanıt oranı ve süresi arasında anlamlı bir ilişki bulunmadı. Tanı anındaki trombosit sayısı ile yaş arasında anlamlı ve pozitif korelasyon (p<0,05), tanı anındaki beyaz kan ve nötrofil sayısı ile yaş arasında istatistiksel olarak anlamlı ve negatif korelasyon vardı (p<0,05). SONUÇ: İTP'li hastalarda ilk kez daha yüksek dereceli fibrozis bulundu. ITP ve otoimmün fibrozis arasındaki bağlantıyı doğrulamak için kemik iliği biyopsilerinin takip edildiği prospektif çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• Primer immün trombositopenide (İTP)
• Retiküler lif
• Prognoz

INCREASED RETICULAR FIBER GRADE IN PRIMARY IMMUNE THROMBOCYTOPENIA

Öz

OBJECTIVE: Bone marrow fibrosis in primary immune thrombocytopenia (ITP) has become a centre of attention since cases with fibrosis were reported during trombopoeitin receptor agonist therapies but, there have been few studies evaluating the fibrosis status of the patients at diagnosis. The aim of the study was to evaluate the impact of marrow fibrosis on especially response to treatment and prognosis in patients with ITP. MATERIAL AND METHODS: Bone marrow reticulin fiber grade, haemoglobin, platelets, age, sex, co-morbidities of the patients, hepatitis and autoimmune markers on admission, response, remission status and duration of remission and treatments were recorded from medical files of the patients and each parameter was evaluated for an association with reticular fiber grade in 53 patients with ITP. RESULTS: 79.3% of patients had marrow reticulin content grade 1 or more. No significant correlations were found between bone marrow reticular fiber grade and total blood count at diagnosis, response times to the first, second- and third-line treatment, platelet counts after treatment and time between two treatment lines, age, gender, presence of comorbidity and antinuclear antibody positivity and response rate and time. There was a significant and positive correlation between platelet count at diagnosis and age (p<0.05) and, there was a statistically significant and negative correlation between white blood and neutrophil count at diagnosis and age (p<0.05) CONCLUSIONS: For the first time, higher grade of fibrosis was found in patients with ITP. Prospective studies with follow-up bone marrow biopsies are needed to validate the link between ITP and autoimmune fibrosis.

Anahtar Kelimeler

• Primary Immune Thrombocytopenia (ITP)
• Reticular fiber
• Prognosis.

Kaynakça

1. 1. Moulis G, Palmaro A, Montastruc JL, et al. Epidemiology of incident immune thrombocytopenia: a nationwide population-based study in France. Blood. 2014;20;124(22):3308-15.
2. 2. Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019;10;3(23):3829-3866.
3. 3. Lambert MP, Gernsheimer TB. Clinical updates in adult immune thrombocytopenia Blood. 2017:25;129(21):2829-35.
4. 4. Palandri F, Polverelli N, Sollazzo D, et al. Have splenectomy rate and main outcomes of ITP changed after the introduction of new treatments? A monocentric study in the outpatient setting during 35 years. Am J Hematol. 2016;91(4): 267-72.
5. 5. Ahmed R, Devasia AJ, Viswabandya A, et al. Long-term outcome following splenectomy for chronic and persistent immune thrombocytopenia (ITP) in adults and children: Splenectomy in ITP. Ann Hematol. 2016;95(9):1429-34.
6. 6. Chugh S, Darvish-Kazem S, Lim W, et al. Rituximab plus standard of care for treatment of primary immune thrombocytopenia: a systematic review and meta-analysis. Lancet Haematol. 2015;2(2):75-81.
7. 7. Wong RSM, Saleh MN, Khelif A, et al. Safety and efficacy of long-term treatment of chronic/persistent ITP with eltrombopag: final results of the EXTEND study. 2017; 7;130(23):2527-36.
8. 8. Bidika E, Fayyaz H, Salib M, et al. Romiplostim and Eltrombopag in Immune Thrombocytopenia as a Second-Line Treatment. Cureus. 2020(21);12(8): e9920.

9. 9. Ghanima W, Cooper N, Rodeghiero F, et al. Thrombopoietin receptor agonists: ten years later. Haematologica. 2019;104(6):1112-23.
10. 10. Cines DB, Gernsheimer T, Wasser J, et al. Integrated analysis of long-term safety in patients with chronic immune thrombocytopaenia (ITP) treated with the thrombopoietin (TPO) receptor agonist romiplostim. Int J Hematol. 2015;102(3):259-70.
11. 11. Brynes RK, Wong RS, Thein MM, et al. A 2-Year, Longitudinal, Prospective Study of the Effects of Eltrombopag on Bone Marrow in Patients with Chronic Immune Thrombocytopenia. Acta Haematol. 2017;137(2):66- 72.
12. 12. Rizvi H, Butler T, Calaminici M, et al. United Kingdom immune thrombocytopenia registry: retrospective evaluation of bone marrow fibrosis in adult patients with primary immune thrombocytopenia and correlation with clinical findings. Br J Haematol. 2015;169(4):590-4.
13. 13. Ettrup MS, Jensen AØ, Engebjerg MC, et al. Bone marrow reticulin and collagen content in patients with adult chronic immune thrombocytopenic purpura: a Danish nationwide study. Am J Hematol. 2010;85(12):930-4.
14. 14. Mufti G, Bagg A, Hasserjian RP, et al. Bone marrow reticulin in patients with immune thrombocytopenic purpura. Presented at the 48th Annual Meeting of the American Society of Hematology, Orlando, Florida.2016:(12);9-12.
15. 15. Thiele J, Kvasnicka HM, Facchetti F, et al. European consensus on grading bone marrow fibrosis and assessment of cellularity. Haematologica. 2005;90(8):1128-32.
16. 16. Zhang HY, Hou M, Zhang XH,et al. [The diagnostic value of platelet glycoprotein-specific autoantibody detection in idiopathic thrombocytopenic purpura]. 2004;12(2):204-6.
17. 17. Chang M, Nakagawa PA, Williams SA, et al. Immune thrombocytopenic purpura (ITP) plasma and purified ITP monoclonal autoantibodies inhibit megakaryocytopoiesis in vitro. Blood. 2003;102(3):887-95.
18. 18. Leytin V, Mykhaylov S, Starkey AF, et al. Intravenous immunoglobulin inhibits anti-glycoprotein IIb-induced platelet apoptosis in a murine model of immune thrombocytopenia. Br J Haematol. 2006;133(1):78-82.
19. 19. Marcellino B, El Jamal SM, Mascarenhas JO. Distinguishing autoimmune myelofibrosis from primary myelofibrosis. Clin Adv Hematol Oncol. 2018;16(9):619-26.
20. 20. Hasselbalch HC. The role of cytokines in the initiation and progression of myelofibrosis. Cytokine Growth Factor Rev. 2013;24(2):133-45.
21. 21. Mbonu I, Sossou C, Nnaoma CB, et al. A Case of Systemic Lupus Erythematosus Presenting as Autoimmune Myelofibrosis. Am J Case Rep. 2019;(20):937-940.
22. 22. Barcellini W, Iurlo A, Radice T, et al. Increased prevalence of autoimmune phenomena in myelofibrosis: relationship with clinical and morphological characteristics, and with immunoregulatory cytokine patterns. Leuk Res. 2013;37(11):1509-15.
23. 23. Pundole X, Konoplev S, Oo TH, Lu H. Autoimmune myelofibrosis and systemic lupus erythematosus in a middle-aged male presenting only with severe anemia: a case report. Medicine (Baltimore). 2015;94(19):741.
24. 24. Rocha AM, Souza C, Rocha GA, et al. The levels of IL-17A and of the cytokines involved in Th17 cell commitment are increased in patients with chronic immune thrombocytopenia. Haematologica. 2011;96(10):1560-4.
25. 25. Mahlknecht U, Kaiser S. Age-related changes in peripheral blood counts in humans. Exp Ther Med. 2010;1(6):1019-25.
26. 26. Park B, Lee YJ. Inverse association of testosterone and sex hormone binding globulin levels with leukocyte count in middle-aged and elderly men. Aging Male. 2018;21(3):176-81.
27. 27. Karolczak K, Konieczna L, Kostka T, et al. Testosterone and dihydrotestosterone reduce platelet activation and reactivity in older men and women. Aging (Albany NY). 2018;10(5):902-29.
28. 28. Teofili L, Giona F, Martini M, et al. Thrombopoietin receptor activation, thrombopoietin mimetic drugs, and hereditary thrombocytosis: remarks on bone marrow fibrosis. J Clin Oncol. 2010;28(19): e317-8.