Abstract
Simple SummaryThis review analyzes the occurrence, clinical characteristics, and prognostic impact and treatment of autoimmune hemolytic anemia (AIHA) in chronic lymphocytic leukemia (CLL). Autoimmune hemolytic anemia is observed in about 10% of CLL. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity, so the different mechanisms are well described in this review which also focuses on drugs associated to CLL-AIHA and on difficulties to diagnose it. There is a comprehensive revision of the main published casistics and then of the treatments; in particular the paper analyzes the main chemo-immunotherapeutic agents used in this setting. Since the therapy depends on the presence and severity of clinical symptoms, disease status, and comorbidities, treatment is nowadays more individualized in CLL and also in CLL-AIHA. Patients not responding to corticosteroids and rituximab are treated with CLL-specific drugs as per current guidelines according to age and comorbidities and new targeted agents against BCR and BCL-2 which can be given orally and have few side effects, are very effective both in progressive CLL and in situations such as AIHA.Chronic lymphocytic leukemia (CLL) patients have a greater predisposition to develop autoimmune complications. The most common of them is autoimmune hemolytic anemia (AIHA) with a frequency of 7–10% of cases. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity. CLL B-cells have damaged apoptosis, produce less immunoglobulins, and could be responsible for antigen presentation and releasing inflammatory cytokines. CLL B-cells can act similar to antigen-presenting cells activating self-reactive T helper cells and may induce T-cell subsets imbalance, favoring autoreactive B-cells which produce anti-red blood cells autoantibodies. Treatment is individualized and it depends on the presence and severity of clinical symptoms, disease status, and comorbidities. Corticosteroids are the standardized first-line treatment; second-line treatment comprises rituximab. Patients not responding to corticosteroids and rituximab should be treated with CLL-specific drugs as per current guidelines according to age and comorbidities. New targeted drugs (BTK inhibitors and anti BCL2) are recently used after or together with steroids to manage AIHA. In the case of cold agglutinin disease, rituximab is preferred, because steroids are ineffective. Management must combine supportive therapies, including vitamins; antibiotics and heparin prophylaxis are indicated in order to minimize infectious and thrombotic risk.
Highlights
Chronic lymphocytic leukemia (CLL) is one of the most common types of leukemia in the western world, representing approximately 20% of all hematological diagnoses [1]
“Active disease” criteria are progressive bone marrow failure manifested by anemia and/or thrombocytopenia; bulky, or progressive, or symptomatic hepato-splenomegaly and/or lymphadenopathies; progressive lymphocytosis with an increase of more than 50% in 2 months or rapid lymphocyte doubling time (LDT); symptomatic or functional extranodal involvement; autoimmune complications not controlled by steroids; constitutional symptoms such as significant fatigue, night sweats for more than
In the context of CLL, the diagnosis of autoimmune hemolytic anemia (AIHA) could be difficult because blood parameters such as hemoglobin, hemolytic markers, and direct antiglobulin test (DAT) which are relevant for AIHA may be altered by CLL progression or concomitant treatment
Summary
CLL is one of the most common types of leukemia in the western world, representing approximately 20% of all hematological diagnoses [1]. CLL is a malignant lymphoid neoplasm characterized by progressive accumulation of functionally incompetent lymphocytes, which are usually monoclonal in origin. CLL has an extremely heterogeneous clinical course, ranging from years of stable disease to rapidly progressive disease [2]. Early-stage asymptomatic CLL patients do not require immediate therapeutic intervention but only observation; treatment is necessary for patients with advanced disease or when “active disease” is observed. “Active disease” criteria are progressive bone marrow failure manifested by anemia and/or thrombocytopenia; bulky, or progressive, or symptomatic hepato-splenomegaly and/or lymphadenopathies; progressive lymphocytosis with an increase of more than 50% in 2 months or rapid lymphocyte doubling time (LDT); symptomatic or functional extranodal involvement (skin, kidney, lung, spine); autoimmune complications not controlled by steroids; constitutional symptoms such as significant fatigue, night sweats for more than. 1 month, unintentional weight loss more than 10% during the previous 6 months, fevers for more than 2 weeks without evidence of infection [3,4,5]
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