The Oklahoma TTP-HUS Registry enrolled 360 consecutive patients, 1989–2006, who had a clinical or renal biopsy diagnosis of an initial episode of TTP-HUS and a request for plasma exchange treatment (PEX). 47 (13%) appeared to have a drug-associated etiology determined by the use of a drug previously reported to be associated with TTP or HUS.

Patient CharacteristicsQuinine (n=23)Ticlopidine (n=2)Clopidogrel (n=1)Calcineurin inhibitors (n=5)Chemotherapy (n=16)
*median; ‡seizure, stroke, coma, focal abnormalities anytime during the course; †most abnormal values at diagnosis ± 7 days, median; **defined by ↑ Cr ≥0.5 mg/dL x 2 days or Cr ≥4.0 and dialysis; §only for patients who received PEX 
Age* (years) 61 68 17 52 57 
Female (%) 96% 50% 100% 60% 69% 
Race (% white) 96% 50% 100% 100% 94% 
Time from last dose* 3 days 3 days 0 days 1 day 105 days 
Severe neurologic abnormalities (%)‡ 30% 50% 0% 40% 6% 
Platelet count†(/μL ) 26 6 81 35 38 
Hematocrit†(%) 23 23 13 21 22 
LDH†(U/L) 2143 2120 581 1346 805 
Creatinine†(mg/dL) 7.0 4.0 1.6 7.0 4.5 
Acute renal failure (%)** 91% 0% 0% 40% 38% 
Response to PEX§ 95% (21/22) NA 100% (1/1) 25% (1/4) 47% (7/15) 
Death (30 days) 13% 50% 0% 20% 13% 
Death (1 year) 13% 50% 0% 20% 69% 
Patient CharacteristicsQuinine (n=23)Ticlopidine (n=2)Clopidogrel (n=1)Calcineurin inhibitors (n=5)Chemotherapy (n=16)
*median; ‡seizure, stroke, coma, focal abnormalities anytime during the course; †most abnormal values at diagnosis ± 7 days, median; **defined by ↑ Cr ≥0.5 mg/dL x 2 days or Cr ≥4.0 and dialysis; §only for patients who received PEX 
Age* (years) 61 68 17 52 57 
Female (%) 96% 50% 100% 60% 69% 
Race (% white) 96% 50% 100% 100% 94% 
Time from last dose* 3 days 3 days 0 days 1 day 105 days 
Severe neurologic abnormalities (%)‡ 30% 50% 0% 40% 6% 
Platelet count†(/μL ) 26 6 81 35 38 
Hematocrit†(%) 23 23 13 21 22 
LDH†(U/L) 2143 2120 581 1346 805 
Creatinine†(mg/dL) 7.0 4.0 1.6 7.0 4.5 
Acute renal failure (%)** 91% 0% 0% 40% 38% 
Response to PEX§ 95% (21/22) NA 100% (1/1) 25% (1/4) 47% (7/15) 
Death (30 days) 13% 50% 0% 20% 13% 
Death (1 year) 13% 50% 0% 20% 69% 
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Calcineurin inhibitors were cyclosporine (3) and tacrolimus (2); chemotherapy agents were mitomycin C (11), gemcitabine (2), gemcitabine/taxotere (1), pentostatin (1), and BCNU (1). 32 patients, including patients in all 5 drugs categories, had ADAMTS13 activity measured; all were ≥ 25%. Patients were predominantly women (81%), similar to patients with severe ADAMTS13 deficiency, and almost all white (94%), distinct from patients with severe ADAMTS13 deficiency (

J Thromb Haemost 2005;3:1432
). The short interval between exposure to quinine, ticlopidine, and clopidogrel and the diagnosis of TTP-HUS was consistent with an acute, immune-mediated mechanism, while the long interval between chemotherapy exposure and diagnosis of TTP-HUS was consistent with a cumulative dose-dependent toxicity. Calcineurin inhibitor-induced TTP-HUS has previously been described as dose-dependent toxicity. Although PEX was requested for all patients, 5 were not treated: 3 died before PEX was begun (quinine, ticlopidine, cyclosporine); 1 responded to plasma infusion (ticlopidine); 1 refused treatment and died (mitomycin C). Response to PEX, defined as achieving a platelet count ≥150,000/mL, occurred in 96% of patients following quinine or clopidogrel compared to 42% of patients following calcineurin inhibitors or chemotherapy. Death within 30 days, attributed to TTP-HUS, occurred with all drugs except clopidogrel; death at 1 year increased only among patients treated with chemotherapy, caused by their metastatic malignancy.

Conclusions:

  1. Quinine was the most common drug associated with TTP-HUS.

  2. Drug-associated TTP-HUS appears to have 2 distinct etiologic mechanisms:

    • acute and potentially immune-mediated reactions (quinine, ticlopidine, clopidogrel) and

    • cumulative, dose-dependent toxicity (calcineurin inhibitors, chemotherapy agents).

  3. Although the role of PEX in the recovery of patients with drug-associated TTP-HUS is unclear, PEX may be appropriate initial treatment since some patients appear to respond and since a drug-associated etiology cannot be certain when patients initially present.

Topics:
hemolytic-uremic syndrome, purpura, thrombus, treatment outcome, uremia syndrome, chemotherapy regimen, quinine, clopidogrel, ticlopidine, calcineurin inhibitors

Author notes

Disclosure: No relevant conflicts of interest to declare.

2007, The American Society of Hematology
2007
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