Immune mediated disease Flashcards
What percent of dogs with IMHA display a non-regenerative anemia on presentation?
30%
What are non-immune mediated causes of spherocytosis?
- Oxidative damage (zinc, acetaminophen)
- Pyruvate kinase deficiency
- Hypersplenism
- Envenomation
- Disorders associated with RBC fragmentation (endocarditis, hemangiosarcoma)
- Dyserythropoiesis
- Transfusion
How many spherocytes per hpf is supportive of IMHA?
> 5 per 100x field = 63% sensitivity, 93% specificity
3-4/hpf = 74% sensitivity and 81% specificity so can be suggestive of IMHA if other causes of spherocytes are eliminated
Is a PCV or hematocrit more reliable in cases of IMHA?
PCV - agglutination can falsely decrease the automated hematocrit
How is the saline agglutination test performed?
4 drops of saline, 1 drop of blood = 100% specificity
If results are equivocal, can wash the RBCs in saline (1:4 ratio) 3 times and see if agglutination persists
What is another name for a Coombs test?
Direct antiglobulin test (DAT)
What is the sensitivity and specificity of a Coombs test for the diagnosis of IMHA?
Sensitivity around 80%, specificity 95-100%
How does lipemia affect RBCs?
Increases erythrocyte fragility, which can increase artifactual hemolysis
What are the proposed mechanisms for the development of IMHA in dogs infected with B. gibsoni?
- Babesia infects RBCs, which may lead to antibodies targeting the organism destroying the RBC too
- Oxidative injury may lead to damage of uninfected erythrocytes, exposing antigens that are normally hidden
- Antibodies form against RBC membranes after silica acid residues are removed
Name two protozoan parasites other than Babesia that can trigger IMHA
Rangelia
Theileria
A high level of evidence exists for what organism causing IMHA in cats?
Mycoplasma haemofelis
What drug has the highest degree of evidence for inducing IMHA in dogs?
Cefazedone
What drug has the highest degree of evidence for inducing IMHA in cats?
Propylthiouracil
What are we supposed to call primary IMHA now?
Non-associative IMHA
Packed RBC transfusions given to dogs with IMHA should be no older than what? Why?
- 7-10 days
- Increased age of pRBC was associated with increased risk of mortality in dogs with hemolysis
Why are pRBCs preferred over bovine hemoglobin solutions for dogs with IMHA?
- BHS scavenge nitric oxide, potentially causing vasoconstriction and hypertension
- BHS exert a greater oncotic pressure, this increasing intravascular volume and hypertension
If a dog with IMHA is started on >2mg/kg/day of prednisone, when should the dose be decreased?
Within the first 1-2 weeks, as long as HCT is stable or increasing
What two clinicopathologic abnormalities were identified as predictors of mortality in IMHA patients?
Increased bilirubin
Increased BUN/urea
Does the consensus statement recommend IVIG?
Only as a salvage measure if a dog is not responding to 1-2 weeks of treatment with 2 immunosuppressive drugs
For IMHA patients, when should the dose of prednisone be tapered and by how much?
When the PCV is stable and >30% for 2 weeks after starting treatment, decrease prednisone by 25% (can decrease by up to 50% if on a secondary agent)
What monitoring should be performed while a patient is on azathioprine?
CBC and chem every 2 weeks for the first 2 months, then every 1-2 months
When are prophylactic antibiotics recommended for neutropenia?
<1000 cells/uL
In patients with severe neutropenia persisting for more than 1 week, what drug can be considered?
Recombinant granulocyte colony stimulating factor
What is the relapse rate for IMHA?
11-15% based on retrospective studies
Thromboprophylaxis should be provided to all dogs with IMHA except…
Dogs with severe thrombocytopenia (<30K)
What antithrombotic drug is recommended first for IMHA? If that isn’t available, what is recommended next?
- Unfractionated heparin with individual dose adjustment
- LWM heparin OR oral Xa inhibitor recommended second
How long should antithrombotics be continued in IMHA patients?
Until the patient is in remission and off prednisone OR until they have been in remission for 6 months with no other risk factors for thrombosis
In a retrospective study, what dog breeds were predisposed to developing PIMA?
Whippets, Miniature Dachshunds, Lurchers
What percent of dogs with PIMA ultimately responded to treatment? What was associated with improved survival?
- Erythroid regeneration in 88%, remission in 62%
- Corrected reticulocyte percentage >0.2 associated with improved survival
Cell free DNA was increased in dogs with IMHA compared to controls. What might cause this increase and why is it concerning?
- May be caused by cell death and release of neutrophil extracellular traps
- Cell free DNA has prothrombotic properties
What is a hallmark feature of bone marrow histopathology in dogs with PIMA?
Rubriphagocytosis
Dogs with PIMA develop a regenerative response after a median of how many days of immunosuppression? When is remission achieved?
Regeneration: 30 days
Remission: 60 days
What drug is capable of inhibiting canine complement-mediated hemolysis in vitro?
C1-esterase inhibitor
What cardiac biomarker is increased in dogs with IMHA on presentation and decreases with treatment?
Troponin I
Primary IMHA is most commonly diagnosed in what age cat?
2-6 years of age
What were negative prognostic indicators in cats with IMHA?
Higher bilirubin, older cats
What is IgG4 related disease?
Diffuse IgG4 positive lymphoplasmacytic infiltrates lead to increased serum concentrations of IgG4, peripheral eosinophilia, tumorous swellings, obliterative phlebitis, and fibrosis
What arm of the immune system mediates most autoimmune diseases?
Th2 cells - results in the production of autoantibodies
What antibody class is involved in most cases of IMHA? What is its half life?
IgG - half life is one week
How do glucocorticoids affect gene transcription?
- Enter the cell by passive diffusion
- Interact with glucocorticoids receptors in the cytosol
- Leads to a conformational change in the receptor and release of an activated complex => nucleus
- Activated complex binds to short DNA sequences called glucocorticoid response elements => modification of gene transcription
Name 5 ways that glucocorticoids suppress the immune system
- Inhibit production and release of cytokines, chemokines
- Impair macrophage activity by influencing the expression and function of Fc receptors
- Decrease macrophage antigen processing/presentation
- Reduce the numbers of lymphocytes
- Decrease migration of inflammatory cells from the blood into tissues
Describe the mechanism of action of cyclosporine
- Enters the cytosol and complexes with cyclophilin
- This complex then binds and inhibits calcineurin, thus inhibiting calcineurin’s calcium-stimulated phosphatase
- Without this dephosphorylation, NFAT is not activated
- NFAT is needed for nuclear transcription of cytokines, like IL-2
- IL-2 is needed for the activation and proliferation of T cells => inhibits T cell function
What enzyme metabolizes cyclosporine in the liver?
Cytochrome P450
When measuring blood cyclosporine levels, when should samples be obtained?
Peak - 2 hours after dosing
Trough - right before the next dose
What is the active metabolite of azathioprine?
6-mercaptopurine
What is the mechanism of action of azathioprine?
Purine analogue
- 6 mercaptopurine resembles adenine and guanine, so it is alternately inserted during the S phase of cell division
- Leads to ribonucleic acid miscoding => disruption of RNA and DNA synthesis and mitosis
Why are lymphocytes more sensitive to inhibition of purine and pyrimidine synthesis?
Lymphocytes lack a salvage pathway for the synthesis of purines and pyrimidine and are reliant on de novo synthesis of these nucleotides (unlike other cell lines)
What breed has lower thiopurine methytransferase activity and is therefore at higher risk of azathioprine toxicity?
Giant Schnauzers
What breed has higher thiopurine methytransferase activity and therefore may need higher doses of azathioprine to be effective?
Alaskan Malamute
What is the active metabolite of mycophenolate mofetil?
Mycophenolic acid
What is the mechanism of action of mycophenolate?
Inhibits inosine monophosphate dehydrogenase - enzyme necessary for de novo purine synthesis
- Inhibits both B and T cell proliferation/clonal expansion in the S phase of the cell cycle
- Suppresses B cell antibody formation
- Induces apoptosis of activated T cells
What isoform of inosine monophosphate dehydrogenase is primarily affected by mycophenolate?
Type 2 isoform (5 fold greater affinity) - found in activated lymphocytes
What nucleotide is primarily depleted by inhibition of inosine monophosphate dehydrogenase?
Guanosine
What is the mechanism of action of leflunomide?
Reversibly inhibits dihydro-orotate dehydrogenase - enzyme needed for de novo pyrimidine synthesis
What is the mechanism of action of alkylating agents?
- Cross-link DNA, thus interfering with DNA replication and RNA transcription
- Toxic to both resting and dividing cells (cell cycle nonspecific)
Name 2 alkylating agents that are commonly used for immune suppression in veterinary medicine
- Chlorambucil
- Cyclophosphamide
What metabolite of cyclophosphamide results in sterile hemorrhagic cystitis?
Acrolein
What drug has a primary immunosuppressive effect against macrophages?
Liposomal clodronate
What glucocorticoid has negligible mineralocorticoid activity and may be preferred in situations where water retention is detrimental?
Dexamethasone