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Rodríguez de Córdoba S. Genetic variability shapes the alternative pathway complement activity and predisposition to complement-related diseases. Immunol Rev 2023; 313:71-90. [PMID: 36089777 PMCID: PMC10086816 DOI: 10.1111/imr.13131] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The implementation of next-generation sequencing technologies has provided a sharp picture of the genetic variability in the components and regulators of the alternative pathway (AP) of the complement system and has revealed the association of many AP variants with different rare and common diseases. An important finding that has emerged from these analyses is that each of these complement-related diseases associate with genetic variants altering specific aspects of the activation and regulation of the AP. These genotype-phenotype correlations have provided valuable insights into their pathogenic mechanisms with important diagnostic and therapeutic implications. While genetic variants in coding regions and structural variants are reasonably well characterized and occasionally have been instrumental to uncover unknown features of the complement proteins, data about complement expressed quantitative trait loci are still very limited. A crucial task for future studies will be to identify these quantitative variations and to determine their impact in the overall activity of the AP. This is fundamental as it is now clear that the consequences of genetic variants in the AP are additive and that susceptibility or resistance to disease is the result of specific combinations of genetic variants in different complement components and regulators ("complotypes").
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2
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Kawano N, Abe T, Ikeda N, Nagahiro Y, Kawano S, Tochigi T, Nakaike T, Yamashita K, Kubo K, Yamanaka A, Terasaka S, Marutsuka K, Mashiba K, Kikuchi I, Shimoda K, Matsumoto M, Ochiai H. Clinical features and outcomes of four atypical hemolytic uremic syndrome cases at a single institution in Miyazaki Prefecture from 2015 to 2019. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although atypical hemolytic uremic syndrome (aHUS) is a life-threatening clinical entity that was characterized by thrombotic microangiopathy (TMA) with the activation of the complement system and the efficient treatment of eculizumab, the clinical features of aHUS have been unclear because of the rare incidence.
Case presentation
We retrospectively analyzed 4 aHUS cases at a single institution during 2015–2019. Here, we presented 4 aHUS cases with renal transplantation (one case), influenza/acute interstitial pneumonia/disseminated intravascular coagulation (two cases), and severe fever with thrombocytopenia syndrome (one case), respectively. Initial clinical symptoms were microangiopathic hemolytic anemia (four cases), renal dysfunction (four cases), thrombocytopenia (four cases), and pulmonary hemorrhage (three cases) consisted with TMA features. Subsequent further examinations ruled out thrombotic thrombocytopenic purpura, Shiga toxin-producing E.coli-induced hemolytic uremic syndrome, and secondary TMA. Taken these findings together, we made the clinical diagnosis of aHUS. Furthermore, all cases also presented the high levels of plasma soluble C5b-9 (871.1 ng/ml, 1144.3 ng/ml, 929.2 ng/ml, and 337.5 ng/ml), suggesting persistent activation of complementary system. Regarding the treatment, plasma exchange (PE) (four cases) and eculizumab (two cases) therapy were administered for aHUS cases. Consequently, case 2 and case 4 were still alive with 768 days and 235 days, respectively. The other two cases were dead at 34 days and 13 days, respectively. Finally, although the previous reported genetic pathogenetic mutations were not detected in our cases, multiple genetic variants of complement factors were detected as CFH (H402Y, E936D), and THBD (A473V) in case 1, CFH (V62I, H402Y, V837I) in case 2, and CFH (H402Y, E 936D) and THBD (A473V) in case 3, CFH (V62I, H402Y, E936D) and THBD (473V) in case 4, respectively.
Conclusions
Because of still high mortality in our study, an urgent diagnosis of aHUS and subsequent immediate treatment including PE and eculizumab should be essential in clinical practice. Furthermore, the multiple genetic variants and the triggers may be related to one of the pathogenesis of aHUS. Thus, we assume that such a case-oriented study would be highly useful to the physicians who directly care for aHUS cases in clinical practice.
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Chikungunya virus as a trigger for different renal disorders: an exploratory study. J Nephrol 2022; 35:1437-1447. [PMID: 35119686 DOI: 10.1007/s40620-022-01256-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/11/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Chikungunya virus was detected in cases of acute chikungunya fever in renal tissue. However, chikungunya virus-related kidney injury still lacks characterization, and it is unknown whether the kidneys are reservoirs for the virus. We sought to detect histopathological changes and viral antigens in renal tissue, and to evaluate kidney injury markers in different phases of chikungunya fever. METHODS Two groups were evaluated in this exploratory study: patients with biopsy-proven kidney injury established after chikungunya fever, and patients with post-chikungunya fever chronic joint manifestations without known kidney injury, in whom we actively searched for kidney injury markers. RESULTS In the first group, 15 patients had kidney injury 0.5-24 months after chikungunya fever. The most frequent histopathological diagnoses were glomerular lesions. No viral antigens were detected in renal tissue. High-risk genotypes were detected in patients with atypical hemolytic uremic syndrome and focal and segmental glomerulosclerosis. In the second group, 114 patients had post-chikungunya fever joint manifestations on average for 35.6 months. Mean creatinine and proteinuria were 0.9 mg/dl and 71.5 mg/day, respectively. One patient had isolated hematuria. There was no indication for renal biopsy in this group. CONCLUSIONS Several histopathological features were found after chikungunya fever, without virus detection in renal tissue. These findings suggest that chikungunya virus may trigger kidney lesions with varying degrees of severity at different stages of infection. However, the probability that this virus replicates in the renal tissue seems unlikely.
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4
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Okamura H, Nakamae H, Shindo T, Ohtani K, Hidaka Y, Ohtsuka Y, Makuuchi Y, Kuno M, Takakuwa T, Harada N, Nishimoto M, Nakashima Y, Koh H, Hirose A, Nakamae M, Wakamiya N, Hino M, Inoue N. Early Elevation of Complement Factor Ba Is a Predictive Biomarker for Transplant-Associated Thrombotic Microangiopathy. Front Immunol 2021; 12:695037. [PMID: 34326846 PMCID: PMC8315095 DOI: 10.3389/fimmu.2021.695037] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a fatal complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Previous reports suggest that TA-TMA is caused by complement activation by complement-related genetic variants; however, this needs to be verified, especially in adults. Here, we performed a nested case-control study of allo-HSCT-treated adults at a single center. Fifteen TA-TMA patients and 15 non-TA-TMA patients, matched according to the propensity score, were enrolled. Based on a previous report showing an association between complement-related genes and development of TA-TMA, we first sequenced these 17 genes. Both cohorts harbored several genetic variants with rare allele frequencies; however, there was no difference in the percentage of patients in the TA-TMA and non-TA-TMA groups with the rare variants, or in the average number of rare variants per patient. Second, we measured plasma concentrations of complement proteins. Notably, levels of Ba protein on Day 7 following allo-HSCT were abnormally and significantly higher in TA-TMA than in non-TA-TMA cases, suggesting that complement activation via the alternative pathway contributes to TA-TMA. All other parameters, including soluble C5b-9, on Day 7 were similar between the groups. The levels of C3, C4, CH50, and complement factors H and I in the TA-TMA group after Day 28 were significantly lower than those in the non-TA-TMA group. Complement-related genetic variants did not predict TA-TMA development. By contrast, abnormally high levels of Ba on Day 7 did predict development of TA-TMA and non-relapse mortality. Thus, Ba levels on Day 7 after allo-HSCT are a sensitive and prognostic biomarker of TA-TMA.
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Affiliation(s)
- Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Takero Shindo
- Hematology/Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsuki Ohtani
- Department of Clinical Neutrition, Rakuno Gakuen University, Ebetsu, Japan.,The Japanese Association for Complement Research, Wakayama, Japan
| | - Yoshihiko Hidaka
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Yasufumi Ohtsuka
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Yosuke Makuuchi
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masatomo Kuno
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Teruhito Takakuwa
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Naonori Harada
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Asao Hirose
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Mika Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Nobutaka Wakamiya
- The Japanese Association for Complement Research, Wakayama, Japan.,Department of Medicine and Physiology, Rakuno Gakuen University, Ebetsu, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Norimitsu Inoue
- The Japanese Association for Complement Research, Wakayama, Japan.,Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
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5
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Wu D, Chen J, Ling C, Chen Z, Fan J, Sun Q, Meng Q, Liu X. Clinical and Genetic Characteristics of Atypical Hemolytic Uremic Syndrome in Children: A Chinese Cohort Study. Nephron Clin Pract 2021; 145:415-427. [PMID: 33873197 DOI: 10.1159/000513009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare but critical illness. To this date, few studies have reported on the disease in Chinese children. METHODS We studied a Chinese pediatric cohort to delineate the clinical characteristics, genotypes, and prognosis. Ninety-one patients with aHUS were enrolled in this study. RESULTS Fifty-nine children (64.8%) had anti-complement-factor-H autoantibody-associated aHUS (anti-CFH aHUS). Of these children, 21 (46.7%) had complement factor-H-related protein 1 (CFHR1) homozygous deletion, and most patients with CFHR1 homozygous deletion also had complement factor-H-related protein 3 (CFHR3) homozygous deletions (76.2%). Using gene sequencing of 15 candidate genes, we identified 14 genetic variants in 46 aHUS patients, including 5 pathogenic or like pathogenic variants and 9 variants of uncertain significance. The average follow-up time was 46.1 ± 28 months. Among patients with anti-CFH aHUS, there was a correlation between CFHR1 homozygous deletion and patients with persistent proteinuria (odds ratio [OR] 6.954, 95% confidence interval [CI] 1.033-46.821, p = 0.046). As of the last follow-up, ESRD or deaths occurred in 3.6% of the children with anti-CFH aHUS and 26.7% of children with aHUS who were negative for anti-CFH. CONCLUSIONS Anti-complement-factor-H antibody positivity is the main cause of morbidity in Chinese children with aHUS. There may be a correlation between CFHR1 homozygous deletion and persistent proteinuria. Comprehensive assessment of anti-CFH antibodies and genetic variants is essential for the management of aHUS children.
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Affiliation(s)
- Dan Wu
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiahui Chen
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chen Ling
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhi Chen
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Fan
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qiang Sun
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qun Meng
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaorong Liu
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
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6
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Minato S, Iijima H, Nakao H, Nishi K, Hidaka Y, Inoue N, Kubota M, Ishiguro A. Anti-complement factor H (CFH) antibodies and a novel CFH gene mutation in an atypical hemolytic uremic syndrome patient with complement activation of the classical pathway. Immunol Med 2021; 44:274-277. [PMID: 33784485 DOI: 10.1080/25785826.2021.1905303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease caused by overactivation of the complement alternative pathway. aHUS involves the presence of antibodies against complement factor H and its mutations in the complement genes. A 2-month-old boy presented with discoid rash, hemolytic anemia, thrombocytopenia, multiple antibodies, and hypocomplementemia with a very low level of C4 (< 3 mg/dL), indicating activation of the complement pathway, together fulfilling the systemic lupus erythematosus (SLE) criteria of the American College of Rheumatology at 5 months of age. However, most of these findings normalized spontaneously without any intervention. Further investigations revealed a high level of anti-complement factor H antibodies and a novel heterozygous missense mutation (p.Glu1172Ala, located in exon 22) in a complement gene, CFH. At 2 years of age, his SLE-like symptoms have not recurred, but hematuria and schistocytes were persistent. Eventually, aHUS was diagnosed rather than SLE. Our findings suggest that multiple antibody complex, including anti-complement factor H antibody, may temporarily activate the classical pathway, resulting in SLE-like findings.
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Affiliation(s)
- Sonoko Minato
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan.,Center for Postgraduate Education and Training, NCCHD, Tokyo, Japan
| | - Hiroyuki Iijima
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Hiro Nakao
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Kentaro Nishi
- Division of Nephrology and Rheumatology, NCCHD, Tokyo, Japan
| | - Yoshihiko Hidaka
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Norimitsu Inoue
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Mitsuru Kubota
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, NCCHD, Tokyo, Japan.,Division of Hematology, NCCHD, Tokyo, Japan
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7
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Okabe M, Kobayashi A, Marumoto H, Koike K, Yamamoto I, Kawamura T, Tsuboi N, Yokoo T. Renal Damage in Recurrent Atypical Hemolytic Uremic Syndrome Associated with C3 p.Ile1157Thr Gene Mutation. Intern Med 2021; 60:917-922. [PMID: 33087669 PMCID: PMC8024950 DOI: 10.2169/internalmedicine.5716-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with atypical hemolytic uremic syndrome (aHUS) associated with a C3 p.Ile1157Thr mutation show a relatively high renal survival and low mortality rates, but renal histopathological findings after recurrence have been rarely reported. A 30-year-old man with a C3 p.Ile1157Thr mutation experienced a third recurrence of thrombotic microangiopathies with neurological and gastrointestinal disorders. A renal biopsy performed during the recovery phase of acute kidney injury revealed collapsed glomeruli and arteriolar vacuolization. Approximately 10% of glomeruli were globally sclerotic, despite the absence of arterio-/arteriolo-sclerosis. These findings suggest substantial progression of irreversible injuries in multiple organs, including kidneys, which occurs in aHUS patients with repeated thrombotic microangiopathies.
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Affiliation(s)
- Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Arisa Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Hirokazu Marumoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
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8
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Wada H, Shiraki K, Matsumoto T, Shimpo H, Yamashita Y, Shimaoka M. The evaluation of a scoring system for diagnosing atypical hemolytic uremic syndrome. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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9
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Genetic and molecular evidence for complement dysregulation in patients with HELLP syndrome. Thromb Res 2020; 196:167-174. [PMID: 32890900 DOI: 10.1016/j.thromres.2020.08.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/14/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND HELLP (Hemolysis, elevated liver enzymes and low platelets) syndrome is a severe and acute pregnancy-related disorder that occurs in approximately 2.5 per 1000 deliveries and represents a major cause of maternal and perinatal morbidity and mortality. This syndrome has been suggested to be a microangiopathy and delivery is the only effective treatment. OBJECTIVES The aim of this study was to investigate the pathophysiology of HELLP syndrome by simultaneously exploring complement, haemostasis, autoimmunity and inflammation in relation to the clinical outcome. METHODS We investigated 19 HELLP patients at the time of diagnosis and 3 months after delivery, for complement function, haemostasis and inflammation with immunoenzymatic methods. Complement-related gene variants were also analyzed by next generation sequencing and multiplex ligation-dependent probe amplification. Nineteen age-matched healthy pregnant women served as controls. RESULTS At diagnosis, HELLP patients, compared to controls, showed significantly higher plasma levels of SC5b-9 (median 710 ng/ml [range 216-1499] vs 253 ng/ml [19-371], P < 0.0001) and of C5a (20.8 ng/ml [5.6-27.5] vs 12.7 ng/ml [3.2-24.6]; P = 0.004), which decreased three months after delivery (SC5b9: 190 ng/ml [83-446] vs 160 ng/ml [107-219]; C5a: 9.28 ng/ml [2.3-21.6] vs 10.7 ng/ml [2.5-21.2]). A significantly higher frequency of genetic variants involving complement regulatory genes was also observed (52.6% vs 15.8%; P = 0.016). Moreover, at HELLP diagnosis, patients showed increased coagulation markers (fragment F1 + 2 and D-dimer; P = 0.0001) while both patients and controls had high thrombin-generation potential that decreased after delivery. CONCLUSIONS In the pathophysiology of HELLP syndrome, complement dysregulation, in addition to coagulation activation, is involved and may represent a potential target for treatment with the aim of delaying delivery.
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10
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Fujita Y, Terashita M, Yazawa M, Yamasaki Y, Imamura T, Kibayashi J, Sawai T, Hidaka Y, Ohtani K, Inoue N, Shibagaki Y. Eculizumab for Severe Thrombotic Microangiopathy Secondary to Surgical Invasive Stress and Bleeding. Intern Med 2020; 59:93-99. [PMID: 31902910 PMCID: PMC6995713 DOI: 10.2169/internalmedicine.3315-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is an extremely rare condition caused by an excessive activation of the complement pathway based on genetic or acquired dysfunctions in complement regulation, leading to thrombotic microangiopathy (TMA). A complement-amplifying condition (CAC) can trigger aHUS occurrence along with complement abnormality. We herein report a case of severe TMA after laparoscopic myomectomy in a healthy woman. This case was eventually diagnosed as complement-mediated TMA secondary to surgical invasive stress as a CAC, with no definitive diagnosis of aHUS despite a genetic test. The patient fully recovered after several eculizumab administrations.
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Affiliation(s)
- Yoko Fujita
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Maho Terashita
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yukitaka Yamasaki
- Department of Infectious Disease, St. Marianna University School of Medicine, Japan
| | - Tomonori Imamura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Police Hospital, Japan
| | | | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Japan
| | - Yoshihiko Hidaka
- Department of Molecular Genetics, Wakayama Medical University, Japan
- The Japanese Association for Complement Research, Japan
| | - Katsuki Ohtani
- The Japanese Association for Complement Research, Japan
- Department of Food and Health Sciences, Rakuno Gakuen University, Japan
| | - Norimitsu Inoue
- Department of Molecular Genetics, Wakayama Medical University, Japan
- The Japanese Association for Complement Research, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
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11
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Mira FS, Nunes AL, Elvas AR, Oliveira N. Atypical haemolytic uremic syndrome from multiple missenses to a full-blown disease. BMJ Case Rep 2019; 12:12/6/e230026. [PMID: 31253663 DOI: 10.1136/bcr-2019-230026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 72-year-old woman was admitted to the hospital because of dorsal, lumbar and lower abdomen pain that had started 4 days before. She had a history of age-related macular degeneration (treated with intraocular bevacizumab). Blood tests showed anaemia, thrombocytopaenia, acute kidney injury, elevated liver enzymes and total bilirubin (mainly because of the indirect fraction). Viral serologies and ADAMTS13 activity levels were normal, and stool testing was negative for Escherichia coli-producing Shiga toxins. E. coli was isolated in urine. Atypical haemolytic uremic syndrome triggered by a urinary tract infection or by the vascular endothelial growth factor-inhibitor bevacizumab were the most likely hypothesis. The patient started urgent plasmapheresis and dialysis that lasted for a total of 18 days. There was complete remission and recovery of kidney function allowing for treatment discontinuation, and she was discharged home. After 6 months of follow-up, she shows no signs of relapse.
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Affiliation(s)
- Filipe Santos Mira
- Nephrology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Nephrology, Faculty of Medicine, Coimbra, Portugal
| | - Ana Luísa Nunes
- Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Ana Rita Elvas
- Internal Medicine, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Nuno Oliveira
- Nephrology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal.,Nephrology, Faculty of Medicine, Coimbra, Portugal
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12
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Valoti E, Alberti M, Iatropoulos P, Piras R, Mele C, Breno M, Cremaschi A, Bresin E, Donadelli R, Alizzi S, Amoroso A, Benigni A, Remuzzi G, Noris M. Rare Functional Variants in Complement Genes and Anti-FH Autoantibodies-Associated aHUS. Front Immunol 2019; 10:853. [PMID: 31118930 PMCID: PMC6504697 DOI: 10.3389/fimmu.2019.00853] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/02/2019] [Indexed: 01/06/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by microangiopathic hemolytic anemia, thrombocytopenia and renal failure. It is caused by genetic or acquired defects of the complement alternative pathway. Factor H autoantibodies (anti-FHs) have been reported in 10% of aHUS patients and are associated with the deficiency of factor H-related 1 (FHR1). However, FHR1 deficiency is not enough to cause aHUS, since it is also present in about 5% of Caucasian healthy subjects. In this study we evaluated the prevalence of genetic variants in CFH, CD46, CFI, CFB, C3, and THBD in aHUS patients with anti-FHs, using healthy subjects with FHR1 deficiency, here defined “supercontrols,” as a reference group. “Supercontrols” are more informative than general population because they share at least one risk factor (FHR1 deficiency) with aHUS patients. We analyzed anti-FHs in 305 patients and 30 were positive. The large majority were children (median age: 7.7 [IQR, 6.6–9.9] years) and 83% lacked FHR1 (n = 25, cases) due to the homozygous CFHR3-CFHR1 deletion (n = 20), or the compound heterozygous CFHR3-CFHR1 and CFHR1-CFHR4 deletions (n = 4), or the heterozygous CFHR3-CFHR1 deletion combined with a frameshift mutation in CFHR1 that generates a premature stop codon (n = 1). Of the 960 healthy adult subjects 48 had the FHR1 deficiency (“supercontrols”). Rare likely pathogenetic variants in CFH, THBD, and C3 were found in 24% of cases (n = 6) compared to 2.1% of the “supercontrols” (P-value = 0.005). We also found that the CFH H3 and the CD46GGAAC haplotypes are not associated with anti-FHs aHUS, whereas these haplotypes are enriched in aHUS patients without anti-FHs, which highlights the differences in the genetic basis of the two forms of the disease. Finally, we confirm that common infections are environmental factors that contribute to the development of anti-FHs aHUS in genetically predisposed individuals, which fits with the sharp peak of incidence during scholar-age. Further studies are needed to fully elucidate the complex genetic and environmental factors underlying anti-FHs aHUS and to establish whether the combination of anti-FHs with likely pathogenetic variants or other risk factors influences disease outcome and response to therapies.
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Affiliation(s)
- Elisabetta Valoti
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Marta Alberti
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Paraskevas Iatropoulos
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Rossella Piras
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Caterina Mele
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Matteo Breno
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Alessandra Cremaschi
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Elena Bresin
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Roberta Donadelli
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Alizzi
- Azienda Ospedaliera-Universitaria, Città della Salute e della Scienza and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Azienda Ospedaliera-Universitaria, Città della Salute e della Scienza and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ariela Benigni
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.,'L. Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Atypical Hemolytic Uremic Syndrome With the p.Ile1157Thr C3 Mutation Successfully Treated With Plasma Exchange and Eculizumab: A Case Report. Crit Care Explor 2019; 1:e0008. [PMID: 32166254 PMCID: PMC7063875 DOI: 10.1097/cce.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. To describe a case of atypical hemolytic uremic syndrome induced by influenza A infection with the p.Ile1157Thr C3 mutation.
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14
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Tseng MH, Tsai JD, Tsai IJ, Huang SM, Huang JL, Fan WL, Lee HJ, Wu TW, Lin SH. Whole-exome sequencing detects mutations in pediatric patients with atypical hemolytic uremic syndrome in Taiwan. Clin Chim Acta 2019; 494:143-150. [PMID: 30905589 DOI: 10.1016/j.cca.2019.03.1623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/16/2019] [Accepted: 03/20/2019] [Indexed: 12/30/2022]
Abstract
Although atypical hemolytic uremic syndrome (aHUS) is a genetic disorder, molecular defects are detected in only 60% of patients. We aim to dissect the genetic background by whole exome sequence and the clinical characteristics of pediatric patients with aHUS. Ten patients (6 male and 4 female) with mean age 5.2 ± 5.0 years were enrolled. The age at onset ranged from 2 days to 11 years. Eighteen different mutations (17 missense, 2 nonsense, and 11 novel) on 7 complement and 3 coagulation genes were detected in all patients. The majority of mutation was heterozygous and S1191L on CFH were the recurrent mutation. Sixty percent of patients had multiple genetic mutations. Nine mutations were associated with genes known to be implicated in aHUS (CFH, CFI, CD46, CFHR5, and DGKE), while 4 and 5 mutations were detected on complement- (C8B, C9, and MASP1) and coagulation-associated (VWF and CD36) genes, respectively. CD36 may be a candidate gene act as disease modifier for aHUS through the contribution of thrombosis by impairing the interaction with TSP-1 and ADAMTS 13 shown in simulation model. Genetic defects on both complement and coagulation pathways play pathogenic roles on aHUS. CD36 may be a novel candidate gene act as disease modifier of aHUS.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Pediatrics, Xiamen Chang Gung Hospital, Ximen, China
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taipei, Taiwan
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Jing-Long Huang
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Lang Fan
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hwei-Jen Lee
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, US
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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15
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Yoshida Y, Kato H, Ikeda Y, Nangaku M. Pathogenesis of Atypical Hemolytic Uremic Syndrome. J Atheroscler Thromb 2018; 26:99-110. [PMID: 30393246 PMCID: PMC6365154 DOI: 10.5551/jat.rv17026] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a type of thrombotic microangiopathy (TMA) defined by thrombocytopenia, microangiopathic hemolytic anemia, and renal failure. aHUS is caused by uncontrolled complement activation in the alternative pathway (AP). A variety of genetic defects in complement-related factors or acquired autoantibodies to the complement regulators have been found in 50 to 60% of all cases. Recently, however, the classification and diagnosis of aHUS are becoming more complicated. One reason for this is that some factors, which have not been regarded as complement-related factors, have been reported as predisposing factors for phenotypic aHUS. Given that genotype is highly correlated with the phenotype of aHUS, careful analysis of underlying genetic abnormalities or acquired factors is needed to predict the prognosis or to decide an optimal treatment for the disease. Another reason is that complement dysregulation in the AP have also been found in a part of other types of TMA such as transplantation-related TMA and pregnancy-related complication. Based on these findings, it is now time to redefine aHUS according to the genetic or acquired background of abnormalities.Here, we review the pathogeneses and the corresponding phenotypes of aHUS and complement-related TMAs.
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Affiliation(s)
- Yoko Yoshida
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
| | - Hideki Kato
- Department of Prevention of Diabetes and Lifestyle-Related Diseases Graduate School of Medicine, the University of Tokyo
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
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16
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Zhao W, Ding Y, Lu J, Zhang T, Chen D, Zhang H, Zeng C, Liu Z, Chen H. Genetic analysis of the complement pathway in C3 glomerulopathy. Nephrol Dial Transplant 2018; 33:1919-1927. [PMID: 29566171 DOI: 10.1093/ndt/gfy033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 01/12/2018] [Indexed: 01/28/2023] Open
Abstract
Background C3 glomerulopathy often presents with a membranoproliferative glomerulonephritis (MPGN) pattern, and is principally caused by unrestricted activation of the complement alternative pathway. Genetic abnormalities of the complement system critically implicate in the pathogenesis of C3 glomerulopathy, but a systemic profile remains open, especially in Asia. Methods In this study, we completed a comprehensive screen of 11 candidate alternative pathway genes by using targeted genomic enrichment and massively parallel sequencing on 43 patients with sporadic C3 glomerulopathy, which were classified as dense deposit disease (DDD; n = 10) and C3 glomerulonephritis (C3GN; n = 33) cases. An additional 24 patients with immune complex-mediated MPGN were also enrolled. Results In total, 4 novel and 16 rare variants were identified: one was classified as likely pathogenic, and the remaining 19 were of uncertain significance. Three variants reportedly led to functional deficiency with supporting evidences. Variants in the CFH, CFI, CD46 and C3 genes were most frequently detected. A defective control of the complement alternative pathway due to hereditary abnormalities was found at frequencies of 50%, 27% and 17% in DDD, C3GN and immune complex-mediated MPGN, respectively. Irrespective of histological type, the patients with likely pathogenic and uncertain significant variants were clinically similar to those without. Conclusions Accurate genetic screening can give rise to progress in understanding the pathogenesis of C3 glomerulopathy, and the correct assignment of pathogenicity classification is of great importance for better patient care and prognostic or therapeutic advice.
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Affiliation(s)
- Weiwei Zhao
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yin Ding
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,Division of Nephrology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Jianping Lu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,Division of Nephrology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Tao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dacheng Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,Division of Nephrology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Huimei Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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17
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Matsumoto T, Toyoda H, Amano K, Hirayama M, Ishikawa E, Fujimoto M, Ito M, Ohishi K, Katayama N, Yoshida Y, Matsumoto M, Kawamura N, Ikejiri M, Kawakami K, Miyata T, Wada H. Clinical Manifestation of Patients With Atypical Hemolytic Uremic Syndrome With the C3 p.I1157T Variation in the Kinki Region of Japan. Clin Appl Thromb Hemost 2018; 24:1301-1307. [PMID: 29695177 PMCID: PMC6714784 DOI: 10.1177/1076029618771750] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The gain-of-function variation p.I1157T in C3 was previously identified in 8 patients with atypical hemolytic uremic syndrome (aHUS) at Mie University Hospital. In the present study, we identified another 11 patients with aHUS with this variation, including 10 pediatric patients (onset age: 1-16 years). The variation seems to be geographically concentrated around Mie Prefecture in Japan. Fifteen of the 19 patients with aHUS experienced infection as probable triggering events. All 19 patients had renal dysfunction. Seven patients, including 2 from the previous study and 5 from the present study, were treated with eculizumab, with all showing a good response with hematological normalization. Among the 5 eculizumab-treated patients in the present study, 3 had an ambiguous diagnosis of aHUS due to low-grade hemolysis even with elevated levels of lactate dehydrogenase and bilirubin. In those cases, in-house targeted DNA sequencing identified the C3 p.I1157T variation carriers, which enabled the early initiation of treatment with eculizumab. The present study supports the early introduction of eculizumab in patients with aHUS, especially pediatric patients.
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Affiliation(s)
- Takeshi Matsumoto
- 1 Division of Blood Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Hidemi Toyoda
- 2 Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Keishirou Amano
- 2 Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masahiro Hirayama
- 2 Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Eiji Ishikawa
- 3 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mika Fujimoto
- 3 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- 3 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kohshi Ohishi
- 1 Division of Blood Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Naoyuki Katayama
- 4 Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoko Yoshida
- 5 Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Masanori Matsumoto
- 5 Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | | | - Makoto Ikejiri
- 7 Central Laboratory, Mie University Hospital, Tsu, Japan
| | - Keiki Kawakami
- 8 Department of Hematology, Suzuka General Hospital, Suzuka, Japan
| | - Toshiyuki Miyata
- 9 Departments of Molecular Pathogenesis and Cerebrovascular Medicine, National Central and Cardiovascular Center, Suita, Japan
| | - Hideo Wada
- 10 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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18
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Fujisawa M, Kato H, Yoshida Y, Usui T, Takata M, Fujimoto M, Wada H, Uchida Y, Kokame K, Matsumoto M, Fujimura Y, Miyata T, Nangaku M. Clinical characteristics and genetic backgrounds of Japanese patients with atypical hemolytic uremic syndrome. Clin Exp Nephrol 2018; 22:1088-1099. [PMID: 29511899 PMCID: PMC6437120 DOI: 10.1007/s10157-018-1549-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/22/2018] [Indexed: 01/08/2023]
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is caused by complement overactivation, and its presentation and prognosis differ according to the underlying molecular defects. The aim of this study was to characterize the genetic backgrounds of aHUS patients in Japan and to elucidate the associations between their genetic backgrounds, clinical findings, and outcomes. Methods We conducted a nationwide epidemiological survey of clinically diagnosed aHUS patients and examined 118 patients enrolled from 1998 to 2016 in Japan. We screened variants of seven genes related to complement and coagulation, as well as positivity for anti-CFH antibodies, and assessed clinical manifestations, laboratory findings, and clinical course. Results The most frequent genetic abnormalities were in C3 (31%) and the frequency of CFH variants was relatively low (10%) compared to Western countries. The predominant variant in this cohort was C3 p.I1157T (23%), which was related to favorable outcomes despite frequent relapses. A total of 72% of patients received plasma therapy, while 42% were treated with eculizumab. The prognosis of Japanese aHUS patients was relatively favorable, with a total mortality rate of 5.4% and a renal mortality rate of 15%. Conclusions The common occurrence of genotype C3, especially the p.I1157T variant was the characteristic of the genetic backgrounds of Japanese aHUS patients that differed from those of Caucasian patients. In addition, the favorable prognosis of patients with the unique C3 p.I1157T variant indicates that understanding the clinical characteristics of individual gene alterations is important for predicting prognosis and determining therapeutic strategies in aHUS. Electronic supplementary material The online version of this article (10.1007/s10157-018-1549-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Madoka Fujisawa
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideki Kato
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yoko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomoko Usui
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Munenori Takata
- Clinical Research Support Center (CresCent), The University of Tokyo, Tokyo, Japan
| | - Mika Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yumiko Uchida
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | | | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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19
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Bitzan M, Zieg J. Influenza-associated thrombotic microangiopathies. Pediatr Nephrol 2018; 33:2009-2025. [PMID: 28884355 PMCID: PMC6153504 DOI: 10.1007/s00467-017-3783-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/11/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022]
Abstract
Thrombotic microangiopathy (TMA) refers to phenotypically similar disorders, including hemolytic uremic syndromes (HUS) and thrombotic thrombocytopenic purpura (TTP). This review explores the role of the influenza virus as trigger of HUS or TTP. We conducted a literature survey in PubMed and Google Scholar using HUS, TTP, TMA, and influenza as keywords, and extracted and analyzed reported epidemiological and clinical data. We identified 25 cases of influenza-associated TMA. Five additional cases were linked to influenza vaccination and analyzed separately. Influenza A was found in 83%, 10 out of 25 during the 2009 A(H1N1) pandemic. Two patients had bona fide TTP with ADAMTS13 activity <10%. Median age was 15 years (range 0.5-68 years), two thirds were male. Oligoanuria was documented in 81% and neurological involvement in 40% of patients. Serum C3 was reduced in 5 out of 14 patients (36%); Coombs test was negative in 7 out of 7 and elevated fibrin/fibrinogen degradation products were documented in 6 out of 8 patients. Pathogenic complement gene mutations were found in 7 out of 8 patients tested (C3, MCP, or MCP combined with CFB or clusterin). Twenty out of 24 patients recovered completely, but 3 died (12%). Ten of the surviving patients underwent plasma exchange (PLEX) therapy, 5 plasma infusions. Influenza-mediated HUS or TTP is rare. A sizable proportion of tested patients demonstrated mutations associated with alternative pathway of complement dysregulation that was uncovered by this infection. Further research is warranted targeting the roles of viral neuraminidase, enhanced virus-induced complement activation and/or ADAMTS13 antibodies, and rational treatment approaches.
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Affiliation(s)
- Martin Bitzan
- Division of Nephrology, The Montreal Children's Hospital, McGill University Health Centre, 1001, boul. Décarie-Room B RC.6651, Montréal, QC, H4A 3J1, Canada.
| | - Jakub Zieg
- 0000 0004 1937 116Xgrid.4491.8Department of Pediatric Nephrology, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
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20
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Ding Y, Zhao W, Zhang T, Qiang H, Lu J, Su X, Wen S, Xu F, Zhang M, Zhang H, Zeng C, Liu Z, Chen H. A haplotype in CFH family genes confers high risk of rare glomerular nephropathies. Sci Rep 2017; 7:6004. [PMID: 28729648 PMCID: PMC5519609 DOI: 10.1038/s41598-017-05173-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/24/2017] [Indexed: 12/15/2022] Open
Abstract
Despite distinct renal lesions, a series of rare glomerular nephropathies are reportedly mediated by complement overactivation. Genetic variations in complement genes contribute to disease risk, but the relationship of genotype to phenotype has not been straightforward. Here, we screened 11 complement genes from 91 patients with atypical hemolytic uremic syndrome (aHUS), C3 glomerulopathy (C3G) and membranoproliferative glomerulonephritis type I (MPGN I), and identified the concomitant presence of three missense variations located within the human complement Factor H (CFH) gene cluster. The three variations, rs55807605, rs61737525 and rs57960694, have strong linkage disequilibrium; subsequent haplotype analysis indicated that ATA increased the susceptibility of these renal diseases. In silico analysis, the CFHR3 rs61737525-T risk allele altered the physical and structural properties and generated a reduction in binding affinity of the CFHR3/C3b complex. Surface plasmon resonance (SPR) binding analysis further demonstrated the substitution induced a decrease of two orders of magnitude in C3b-binding properties, with a declined cofactor activity in fluid phase. These data suggest that the haplotype carrying the causative allele behaves as a partial C3 convertase deficiency, predisposing individuals to diverse pathologic lesions underlying complement overactivation. Such genotype-phenotype discrepancies allow better understanding about these nephropathies mediated by genetic complement disorders.
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Affiliation(s)
- Yin Ding
- Devision of Nephrology, Jinling Hospital, Southern Medical University, Nanjing, 210016, China.,National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Weiwei Zhao
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Tao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Hao Qiang
- Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, 210009, China
| | - Jianping Lu
- Devision of Nephrology, Jinling Hospital, Southern Medical University, Nanjing, 210016, China.,National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Xin Su
- Center of Drug Discovery, State Key Laboratory of Natural Medicines, China Pharmaceutical University, Nanjing, 210009, China
| | - Shuzhen Wen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Mingchao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China
| | - Zhihong Liu
- Devision of Nephrology, Jinling Hospital, Southern Medical University, Nanjing, 210016, China. .,National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China.
| | - Huimei Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210016, China.
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21
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Fidalgo T, Martinho P, Pinto CS, Oliveira AC, Salvado R, Borràs N, Coucelo M, Manco L, Maia T, Mendes MJ, Del Orbe Barreto R, Corrales I, Vidal F, Ribeiro ML. Combined study of ADAMTS13 and complement genes in the diagnosis of thrombotic microangiopathies using next-generation sequencing. Res Pract Thromb Haemost 2017; 1:69-80. [PMID: 30046676 PMCID: PMC6058207 DOI: 10.1002/rth2.12016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/15/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The 2 main forms of thrombotic microangiopathy (TMA) are thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). Deficiency of ADAMTS13 and dysregulation of the complement pathway result in TTP and aHUS, respectively; however, overlap of their clinical characteristics makes differential diagnosis challenging. OBJECTIVES AND METHODS We aimed to develop a TMA diagnosis workflow based on ADAMTS13 activity and screening of ADAMTS13 and complement genes using a custom next-generation sequencing (NGS) gene panel. PATIENTS For this, from a cohort of 154 Portuguese patients with acute TMA, the genotype-phenotype correlations were analyzed in 7 hereditary TTP (ADAMTS13 activity <10%, no inhibitor), 36 acquired TTP (ADAMTS13 activity <10%, presence of an inhibitor), and in 34 presumable aHUS. RESULTS In total, 37 different rare variants, 8 of which novel (in ADAMTS13,CFH, and CD46), were identified across 7 genes. Thirteen TTP patients were homozygous (n=6), compound heterozygous (n=2), and heterozygous (n=5) for 11 ADAMTS13 variants (6 pathogenic mutations). Among the 34 aHUS patients, 17 were heterozygous for 23 variants in the different complement genes with distinct consequences, ranging from single pathogenic mutations associated with complete disease penetrance to benign variants that cause aHUS only when combined with other variants and/or CFH and CD46 risk haplotypes or CFHR1-3 deletion. CONCLUSIONS Our study provides evidence of the usefulness of the NGS panel as an excellent technology that enables more rapid diagnosis of TMA, and is a valuable asset in clinical practice to discriminate between TTP and aHUS.
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Affiliation(s)
- Teresa Fidalgo
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Patrícia Martinho
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Catarina S. Pinto
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Ana C. Oliveira
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Ramon Salvado
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Nina Borràs
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - Margarida Coucelo
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Licínio Manco
- Research Centre for Anthropology and Health (CIAS), Department of Life SciencesUniversity of CoimbraCoimbraPortugal
| | - Tabita Maia
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - M. João Mendes
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | | | - Irene Corrales
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - Francisco Vidal
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - M. Letícia Ribeiro
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
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van Hoeve K, Vandermeulen C, Van Ranst M, Levtchenko E, van den Heuvel L, Mekahli D. Occurrence of atypical HUS associated with influenza B. Eur J Pediatr 2017; 176:449-454. [PMID: 28110418 DOI: 10.1007/s00431-017-2856-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 12/29/2016] [Accepted: 01/10/2017] [Indexed: 12/27/2022]
Abstract
UNLABELLED Hemolytic uremic syndrome (HUS) is a disease characterized by thrombotic microangiopathy with a triad of non-immune hemolytic anemia, thrombocytopenia, and renal impairment. Approximately 10% of cases of HUS are classified as atypical (aHUS). While today many genetically forms of aHUS pathology are known, only about 50% of carriers precipitate the disease. The reason remains unclear, and triggering events like intercurrent infections have been postulated. In rare cases, influenza A is the known trigger of aHUS; however, no cases of influenza B have been reported. CONCLUSION We describe for the first time that influenza B strain as a trigger for aHUS in children with primary hereditary forms. We also showed in our three cases that immunization appears to be safe; however, this needs to be confirmed in a larger cohort. What is Known: • Known triggers of aHUS are infectious specimen. • Influenza A-associated aHUS cases are rarely published. What is New: • aHUS can be triggered by influenza B virus infection. • Influenza vaccination of patients with aHUS appears safe.
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Affiliation(s)
- Karen van Hoeve
- Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Corinne Vandermeulen
- University Vaccinology Center, KU Leuven - University of Leuven, 3000, Leuven, Belgium
| | - Marc Van Ranst
- Department of Microbiology and Immunology, KU Leuven - Rega Institute, 3000, Leuven, Belgium
| | - Elena Levtchenko
- Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Laboratory of Pediatrics, KU Leuven - University of Leuven, 3000, Leuven, Belgium
| | | | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Laboratory of Pediatrics, KU Leuven - University of Leuven, 3000, Leuven, Belgium
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Kobbe R, Schild R, Christner M, Oh J, Loos S, Kemper MJ. Case report - atypical hemolytic uremic syndrome triggered by influenza B. BMC Nephrol 2017; 18:96. [PMID: 28320387 PMCID: PMC5358041 DOI: 10.1186/s12882-017-0512-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/15/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Influenza A infections have been described to cause secondary hemolytic uremic syndrome and to trigger atypical hemolytic uremic syndrome (aHUS) in individuals with an underlying genetic complement dysregulation. To date, influenza B has not been reported to trigger aHUS. CASE PRESENTATION A 6-month-old boy presented with hemolytic uremic syndrome triggered by influenza B infection. Initially the child recovered spontaneously. When he relapsed Eculizumab treatment was initiated, resulting in complete and sustained remission. A pathogenic mutation in membrane cofactor protein (MCP) was detected. CONCLUSION Influenza B is a trigger for aHUS and might be underreported as such. Influenza vaccination may protect patients at risk.
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Affiliation(s)
- Robin Kobbe
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany.
| | - Raphael Schild
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany
| | - Martin Christner
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany
| | - Jun Oh
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany
| | - Sebastian Loos
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany
| | - Markus J Kemper
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246, Hamburg, Germany
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No association between dysplasminogenemia with p.Ala620Thr mutation and atypical hemolytic uremic syndrome. Int J Hematol 2016; 104:223-7. [PMID: 27194432 DOI: 10.1007/s12185-016-2021-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/06/2016] [Accepted: 05/08/2016] [Indexed: 12/29/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS), a form of thrombotic microangiopathy, is caused by the uncontrolled activation of the alternative pathway of complement on the cell surface that leads to microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. A recent genetic analysis of aHUS patients identified deleterious mutations not only in complement or complement regulatory genes but also in the plasminogen gene, suggesting that subnormal plasminogen activity may be related to the degradation of thrombi in aHUS. Dysplasminogenemia, which is caused by a genetic variant in the plasminogen gene, PLG:p.Ala620Thr, is commonly observed in the northeast Asian populations, including Japanese. To examine the association between dysplasminogenemia and aHUS, we genotyped PLG:p.Ala620Thr in 103 Japanese patients with aHUS. We identified five aHUS patients with PLG:p.Ala620Thr; the minor allele frequency (MAF) was thus 0.024. The MAF in the patient group was not significantly different from those obtained from a general Japanese population (MAF = 0.020) and the Japanese genetic variation HGDV database (MAF = 0.021) (P = 0.62 and 0.61, respectively). We concluded that, although carriers with PLG:p.Ala620Thr show low plasminogen activity, this is not a predisposing variant for aHUS and that individuals of dysplasminogenemia are not at significantly increased risk of aHUS.
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Disease Recurrence After Early Discontinuation of Eculizumab in a Patient With Atypical Hemolytic Uremic Syndrome With Complement C3 I1157T Mutation. J Pediatr Hematol Oncol 2016; 38:e137-9. [PMID: 26840081 DOI: 10.1097/mph.0000000000000505] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Eculizumab, terminal complement inhibitor, has become the frontline treatment for atypical hemolytic uremic syndrome (aHUS). However, the optimal treatment schedule has not yet been established. We describe here an aHUS patient with a mutation of C3 I1157T who achieved remission with eculizumab and suffered a recurrence after eculizumab discontinuation, a clinical situation that has not been previously described in patients with C3 mutation. A 9-year-old male experienced an onset of aHUS after viral gastroenteritis and was treated with hemodialysis. At 13 years of age he developed bacterial enterocolitis due to Campylobacter jejuni and experienced a recurrence of aHUS. Eculizumab was initiated on day 4 after disease onset resulting in recovering laboratory parameters. The patient received eculizumab for 5 months before its discontinuation. Second relapse induced by bacterial pharyngitis was confirmed 4 months after eculizumab discontinuation and prompt eculizumab reinitiation resulted in rapid remission. The patients carrying mutations in CFH or C3 have a high frequency of relapse and worse prognosis. More than 50% of aHUS relapses occurred during the first year after the onset. Therefore, long-term treatment with eculizumab is appropriate in patients with aHUS who have experienced a relapse or have mutations associated with poor prognosis.
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Siomou E, Gkoutsias A, Serbis A, Kollios K, Chaliasos N, Frémeaux-Bacchi V. aHUS associated with C3 gene mutation: a case with numerous relapses and favorable 20-year outcome. Pediatr Nephrol 2016; 31:513-7. [PMID: 26572892 DOI: 10.1007/s00467-015-3267-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/02/2015] [Accepted: 11/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is frequently associated with gene mutations in complement-regulatory proteins and activators. Different complement C3 gene mutations have been associated with different outcomes in aHUS. CASE-DIAGNOSIS/TREATMENT We report the case of a 21-year-old male with a C3 heterozygous gene mutation (p.Ile1157Thr) who developed aHUS at the age of 10 months and had six relapses, the last at the age of 14.5 years. Each relapse was characterized by an apparent predominance of hematological manifestations with milder renal involvement and was followed by complete recovery, with creatinine values and hematological parameters usually recovering after the 3rd to 6th day of hospitalization. The patient was treated with plasma infusion, apart from the initial and the last episode, when dialysis was needed. Twenty years after the onset, he retains normal renal function, with no proteinuria or hypertension. One similar case of highly recurrent aHUS carrying the same C3 mutation as our patient with recovery of renal function has been previously reported. CONCLUSIONS We further support that aHUS associated with the p.Ile1157Thr C3 mutation may be highly recurrent, but with recovered renal function. The prevalent p.Ile1157Thr C3 gene mutation has variable disease manifestations and both severe and milder renal phenotypes have been found.
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Affiliation(s)
- Ekaterini Siomou
- Department of Pediatrics, Ioannina University Hospital, Stavros Niarchos Avenue, GR-45 500, Ioannina, Greece.
| | - Athanasios Gkoutsias
- Department of Pediatrics, Ioannina University Hospital, Stavros Niarchos Avenue, GR-45 500, Ioannina, Greece
| | - Anastasios Serbis
- Department of Pediatrics, Ioannina University Hospital, Stavros Niarchos Avenue, GR-45 500, Ioannina, Greece
| | - Konstantinos Kollios
- Third Department of Pediatrics, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Nikolaos Chaliasos
- Department of Pediatrics, Ioannina University Hospital, Stavros Niarchos Avenue, GR-45 500, Ioannina, Greece
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Genetic variations in complement factors in patients with congenital thrombotic thrombocytopenic purpura with renal insufficiency. Int J Hematol 2016; 103:283-91. [DOI: 10.1007/s12185-015-1933-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/10/2015] [Accepted: 12/28/2015] [Indexed: 12/11/2022]
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Yasuda S, Yamamoto M, Fukuda T, Ohtsuka Y, Miura O. Postoperative Atypical Hemolytic Uremic Syndrome Treated Successfully with Eculizumab. Intern Med 2016; 55:1171-5. [PMID: 27150874 DOI: 10.2169/internalmedicine.55.5955] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare type of HUS associated with dysregulation of the alternative complement pathway. We herein report the findings of a 43-year-old woman who developed aHUS two days after myomectomy. The serum C3 level was low and the sheep erythrocyte hemolytic assay showed a moderate hemolysis. The renal insufficiency progressed despite performing plasma exchange therapy, although a partial hematological response was observed. Thus, the patient was subsequently treated with the anti-C5 antibody eculizumab, which promptly improved and normalized the renal function. Although aHUS after surgery has rarely been reported, it needs to be promptly recognized and treated with eculizumab to prevent irreversible renal damage.
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Affiliation(s)
- Shunichiro Yasuda
- Department of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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Miyata T, Uchida Y, Ohta T, Urayama K, Yoshida Y, Fujimura Y. Atypical haemolytic uraemic syndrome in a Japanese patient with DGKE genetic mutations. Thromb Haemost 2015; 114:862-3. [PMID: 26018111 DOI: 10.1160/th15-01-0007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/23/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Toshiyuki Miyata
- Dr. Toshiyuki Miyata, Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan, Tel.: +81 6 6833 5012, Fax: +81 6 6835 1176, E-mail:
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31
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de Córdoba SR. Complement genetics and susceptibility to inflammatory disease. Lessons from genotype-phenotype correlations. Immunobiology 2015; 221:709-14. [PMID: 26004345 DOI: 10.1016/j.imbio.2015.05.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
Abstract
Different genome-wide linkage and association studies performed during the last 15 years have associated mutations and polymorphisms in complement genes with different diseases characterized by tissue damage and inflammation. These are complex disorders in which genetically susceptible individuals usually develop the pathology as a consequence of environmental triggers. Although complement dysregulation is a common feature of these pathologies, how the disease phenotype is determined is only partly understood. One way to advance understanding is to focus the research in the analysis of the peculiar genotype-phenotype correlations that characterize some of these diseases. I will review here how understanding the functional consequences of these disease-associated complement genetic variants is providing us with novel insights into the underpinning complement biology and a better knowledge of the pathogenic mechanisms underlying each of these pathologies. These advances have important therapeutic and diagnostic implications.
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32
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Yoshida Y, Miyata T, Matsumoto M, Shirotani-Ikejima H, Uchida Y, Ohyama Y, Kokubo T, Fujimura Y. A novel quantitative hemolytic assay coupled with restriction fragment length polymorphisms analysis enabled early diagnosis of atypical hemolytic uremic syndrome and identified unique predisposing mutations in Japan. PLoS One 2015; 10:e0124655. [PMID: 25951460 PMCID: PMC4423893 DOI: 10.1371/journal.pone.0124655] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 03/17/2015] [Indexed: 01/19/2023] Open
Abstract
For thrombotic microangiopathies (TMAs), the diagnosis of atypical hemolytic uremic syndrome (aHUS) is made by ruling out Shiga toxin-producing Escherichia coli (STEC)-associated HUS and ADAMTS13 activity-deficient thrombotic thrombocytopenic purpura (TTP), often using the exclusion criteria for secondary TMAs. Nowadays, assays for ADAMTS13 activity and evaluation for STEC infection can be performed within a few hours. However, a confident diagnosis of aHUS often requires comprehensive gene analysis of the alternative complement activation pathway, which usually takes at least several weeks. However, predisposing genetic abnormalities are only identified in approximately 70% of aHUS. To facilitate the diagnosis of complement-mediated aHUS, we describe a quantitative hemolytic assay using sheep red blood cells (RBCs) and human citrated plasma, spiked with or without a novel inhibitory anti-complement factor H (CFH) monoclonal antibody. Among 45 aHUS patients in Japan, 24% (11/45) had moderate-to-severe (≥50%) hemolysis, whereas the remaining 76% (34/45) patients had mild or no hemolysis (<50%). The former group is largely attributed to CFH-related abnormalities, and the latter group has C3-p.I1157T mutations (16/34), which were identified by restriction fragment length polymorphism (RFLP) analysis. Thus, a quantitative hemolytic assay coupled with RFLP analysis enabled the early diagnosis of complement-mediated aHUS in 60% (27/45) of patients in Japan within a week of presentation. We hypothesize that this novel quantitative hemolytic assay would be more useful in a Caucasian population, who may have a higher proportion of CFH mutations than Japanese patients.
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Affiliation(s)
- Yoko Yoshida
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | | | - Yumiko Uchida
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshifumi Ohyama
- Molecular and Cellular Biology Laboratory, Graduate School of Medical Life Science, Yokohama City University, Yokohama, Japan
| | - Tetsuro Kokubo
- Molecular and Cellular Biology Laboratory, Graduate School of Medical Life Science, Yokohama City University, Yokohama, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
- * E-mail:
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Martínez-Barricarte R, Heurich M, López-Perrote A, Tortajada A, Pinto S, López-Trascasa M, Sánchez-Corral P, Morgan BP, Llorca O, Harris CL, Rodríguez de Córdoba S. The molecular and structural bases for the association of complement C3 mutations with atypical hemolytic uremic syndrome. Mol Immunol 2015; 66:263-73. [PMID: 25879158 PMCID: PMC4503813 DOI: 10.1016/j.molimm.2015.03.248] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/18/2015] [Accepted: 03/24/2015] [Indexed: 01/28/2023]
Abstract
Mutations in C3 have been associated with aHUS and other glomerulopathies. aHUS-associated C3 mutants R592W, R161W, and I1157T impair regulation by MCP, but not by FH. EM analysis provides the structural basis for the functional impairment of the R161W and I1157T mutants. Data supports aHUS-associated C3 mutations selectively affect complement regulation on surfaces.
Atypical hemolytic uremic syndrome (aHUS) associates with complement dysregulation caused by mutations and polymorphisms in complement activators and regulators. However, the reasons why some mutations in complement proteins predispose to aHUS are poorly understood. Here, we have investigated the functional consequences of three aHUS-associated mutations in C3, R592W, R161W and I1157T. First, we provide evidence that penetrance and disease severity for these mutations is modulated by inheritance of documented “risk” haplotypes as has been observed with mutations in other complement genes. Next, we show that all three mutations markedly reduce the efficiency of factor I-mediated C3b cleavage when catalyzed by membrane cofactor protein (MCP), but not when catalyzed by factor H. Biacore analysis showed that each mutant C3b bound sMCP (recombinant soluble MCP; CD46) at reduced affinity, providing a molecular basis for its reduced cofactor activity. Lastly, we show by electron microscopy structural analysis a displacement of the TED domain from the MG ring in C3b in two of the C3 mutants that explains these defects in regulation. As a whole our data suggest that aHUS-associated mutations in C3 selectively affect regulation of complement on surfaces and provide a structural framework to predict the functional consequences of the C3 genetic variants found in patients.
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Affiliation(s)
- Rubén Martínez-Barricarte
- Centro Investigaciones Biológicas, Ramiro de Maeztu 9, 28040 Madrid, Spain; Ciber de Enfermedades Raras, Ramiro de Maeztu 9, 28040 Madrid, Spain
| | - Meike Heurich
- Institute of Infection & Immunity, School of Medicine, Cardiff University Heath Park, Cardiff CF14 4XN, United Kingdom
| | | | - Agustin Tortajada
- Centro Investigaciones Biológicas, Ramiro de Maeztu 9, 28040 Madrid, Spain; Ciber de Enfermedades Raras, Ramiro de Maeztu 9, 28040 Madrid, Spain
| | - Sheila Pinto
- Centro Investigaciones Biológicas, Ramiro de Maeztu 9, 28040 Madrid, Spain; Ciber de Enfermedades Raras, Ramiro de Maeztu 9, 28040 Madrid, Spain
| | - Margarita López-Trascasa
- Unidad de Inmunología, Hospital Universitario La Paz-IdiPAZ, and Ciber de Enfermedades Raras. Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Pilar Sánchez-Corral
- Unidad de Investigación, Hospital Universitario La Paz-IdiPAZ, and Ciber de Enfermedades Raras. Paseo de la Castellana 261, 28046 Madrid, Spain
| | - B Paul Morgan
- Institute of Infection & Immunity, School of Medicine, Cardiff University Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Oscar Llorca
- Centro Investigaciones Biológicas, Ramiro de Maeztu 9, 28040 Madrid, Spain
| | - Claire L Harris
- Institute of Infection & Immunity, School of Medicine, Cardiff University Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Santiago Rodríguez de Córdoba
- Centro Investigaciones Biológicas, Ramiro de Maeztu 9, 28040 Madrid, Spain; Ciber de Enfermedades Raras, Ramiro de Maeztu 9, 28040 Madrid, Spain.
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Mapping interactions between complement C3 and regulators using mutations in atypical hemolytic uremic syndrome. Blood 2015; 125:2359-69. [PMID: 25608561 DOI: 10.1182/blood-2014-10-609073] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/07/2015] [Indexed: 01/22/2023] Open
Abstract
The pathogenesis of atypical hemolytic uremic syndrome (aHUS) is strongly linked to dysregulation of the alternative pathway of the complement system. Mutations in complement genes have been identified in about two-thirds of cases, with 5% to 15% being in C3. In this study, 23 aHUS-associated genetic changes in C3 were characterized relative to their interaction with the control proteins factor H (FH), membrane cofactor protein (MCP; CD46), and complement receptor 1 (CR1; CD35). In surface plasmon resonance experiments, 17 mutant recombinant proteins demonstrated a defect in binding to FH and/or MCP, whereas 2 demonstrated reduced binding to CR1. In the majority of cases, decreased binding affinity translated to a decrease in proteolytic inactivation (known as cofactor activity) of C3b via FH and MCP. These results were used to map the putative binding regions of C3b involved in the interaction with MCP and CR1 and interrogated relative to known FH binding sites. Seventy-six percent of patients with C3 mutations had low C3 levels that correlated with disease severity. This study expands our knowledge of the functional consequences of aHUS-associated C3 mutations relative to the interaction of C3 with complement regulatory proteins mediating cofactor activity.
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Postoperative atypical hemolytic uremic syndrome associated with complement c3 mutation. Case Rep Nephrol 2014; 2014:784943. [PMID: 25431709 PMCID: PMC4241332 DOI: 10.1155/2014/784943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/11/2014] [Accepted: 10/14/2014] [Indexed: 12/17/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) can be distinguished from typical or Shiga-like toxin-induced HUS. The clinical outcome is unfavorable; up to 50% of affected patients progress to end-stage renal failure and 25% die during the acute phase. Multiple conditions have been associated with aHUS, including infections, drugs, autoimmune conditions, transplantation, pregnancy, and metabolic conditions. aHUS in the nontransplant postsurgical period, however, is rare. An 8-month-old boy underwent surgical repair of tetralogy of Fallot. Neurological disturbances, acute renal failure, thrombocytopenia, and microangiopathic hemolytic anemia developed 25 days later, and aHUS was diagnosed. Further evaluation revealed that his complement factor H (CFH) level was normal and that anti-FH antibodies were not detected in his plasma. Sequencing of his CFH, complement factor I, membrane cofactor protein, complement factor B, and thrombomodulin genes was normal. His ADAMTS-13 (a disintegrin-like and metalloprotease with thrombospondin-1 repeats 13) activity was also normal. However, he had a potentially causative mutation (R425C) in complement component C3. Restriction fragment length polymorphism analysis revealed that his father and aunt also had this mutation; however, they had no symptoms of aHUS. We herein report a case of aHUS that developed after cardiovascular surgery and was caused by a complement C3 mutation.
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New functional and structural insights from updated mutational databases for complement factor H, Factor I, membrane cofactor protein and C3. Biosci Rep 2014; 34:BSR20140117. [PMID: 25188723 PMCID: PMC4206863 DOI: 10.1042/bsr20140117] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
aHUS (atypical haemolytic uraemic syndrome), AMD (age-related macular degeneration) and other diseases are associated with defective AP (alternative pathway) regulation. CFH (complement factor H), CFI (complement factor I), MCP (membrane cofactor protein) and C3 exhibited the most disease-associated genetic alterations in the AP. Our interactive structural database for these was updated with a total of 324 genetic alterations. A consensus structure for the SCR (short complement regulator) domain showed that the majority (37%) of SCR mutations occurred at its hypervariable loop and its four conserved Cys residues. Mapping 113 missense mutations onto the CFH structure showed that over half occurred in the C-terminal domains SCR-15 to -20. In particular, SCR-20 with the highest total of affected residues is associated with binding to C3d and heparin-like oligosaccharides. No clustering of 49 missense mutations in CFI was seen. In MCP, SCR-3 was the most affected by 23 missense mutations. In C3, the neighbouring thioester and MG (macroglobulin) domains exhibited most of 47 missense mutations. The mutations in the regulators CFH, CFI and MCP involve loss-of-function, whereas those for C3 involve gain-of-function. This combined update emphasizes the importance of the complement AP in inflammatory disease, clarifies the functionally important regions in these proteins, and will facilitate diagnosis and therapy. A new compilation of 324 mutations in four major proteins from the complement alternative pathway reveals mutational hotspots in factor H and complement C3, and less so in factor I and membrane cofactor protein. Their associations with function are discussed.
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