1
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Khandelwal P, Joshi A, Mathur A, Puraswani M, Gurjar BS, Sinha A, Hari P, Faruq M, Bagga A. Variants in complement genes are uncommon in patients with anti-factor H autoantibody-associated atypical hemolytic uremic syndrome. Pediatr Nephrol 2023; 38:2659-2668. [PMID: 36622444 DOI: 10.1007/s00467-022-05862-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coexisting genetic variants in patients with anti-factor H (FH)-associated atypical hemolytic uremic syndrome (aHUS) have implications for therapy. We estimated the prevalence of complement genetic variants in children with anti-FH aHUS from a prospective nationwide cohort and determined if significant genetic variants impact long-term kidney outcomes. METHODS Of 436 patients in the database, 77 consecutive patients, 21 with a relapse and 9 with kidney failure and/or death were included. Targeted sequencing, using a 27-gene panel including CFH, CFI, CFB, C3, CD46, PLG, DGKE, and THBD and multiplex ligation-dependent probe amplification of CFH-CFHR region, was performed. The adverse outcome was eGFR < 30 ml/min/1.73 m2 or death. RESULTS Patients had high anti-FH titers 5670 (2177-13,545) AU/ml, relapsing course (42.1%), and adverse outcomes (19.6%). Variants, chiefly of unknown significance, were found in 7 (6.5%; 95% CI 3.1-13.2%); a pathogenic variant was found in one patient. Homozygous deletion of CFHR1 was present in 91.6% compared to 9.8% in 184 healthy controls. Plasma exchanges and immunosuppression showed a trend of improving outcomes, independent of genetic defects (HR 0.32; P = 0.070). Meta-analysis of 18 studies (384 patients) showed that the pooled prevalence of pathogenic and likely pathogenic variants was 3% (95% CI 0-8%). Of 37 total variants in the meta-analysis, 7 (18.9%) each were pathogenic and likely pathogenic; others were variants of unknown significance. CONCLUSIONS Significant variants in complement regulatory genes are rare in patients with anti-FH-associated aHUS. Irrespective of genetic defects, plasma exchanges and immunosuppression showed a statistical trend to improved outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aditi Joshi
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Aradhana Mathur
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Bahadur Singh Gurjar
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Mohammed Faruq
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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2
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Abstract
Complement is an evolutionarily conserved system which is important in the defense against microorganisms and also in the elimination of modified or necrotic elements of the body. Complement is activated in a cascade type manner and activation and all steps of cascade progression are tightly controlled and regulatory interleaved with many processes of inflammatory machinery. Overshooting of the complement system due to dysregulation can result in the two prototypes of primary complement mediated renal diseases: C3 glomerulopathy and thrombotic microangiopathy. Apart from these, complement also is highly activated in many other inflammatory native kidney diseases, such as membranous nephropathy, ANCA-associated necrotizing glomerulonephritis, and IgA nephropathy. Moreover, it likely plays an important role also in the transplant setting, such as in antibody-mediated rejection or in hematopoietic stem cell transplant associated thrombotic microangiopathy. In this review, these glomerular disorders are discussed with regard to the role of complement in their pathogenesis. The consequential, respective clinical trials for complement inhibitory therapy strategies for these diseases are described.
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3
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Java A, Baciu P, Widjajahakim R, Sung YJ, Yang J, Kavanagh D, Atkinson J, Seddon J. Functional Analysis of Rare Genetic Variants in Complement Factor I ( CFI) using a Serum-Based Assay in Advanced Age-related Macular Degeneration. Transl Vis Sci Technol 2020; 9:37. [PMID: 32908800 PMCID: PMC7453046 DOI: 10.1167/tvst.9.9.37] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/26/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Factor I (FI) is a serine protease regulator of the complement system. Genetic variants in CFI are associated with advanced age-related macular degeneration (AAMD). However, the clinical and functional impact of these variants is unknown. This study assessed the functional significance of rare CFI variants using a serum-based assay. Methods Carriers of rare variants with (n = 78) and without AAMD (n = 28), and noncarriers with (n = 49) and without AMD (n = 44) were evaluated. Function of FI was determined by measuring the proteolytic cleavage of C3b to iC3b, using the cofactor protein, Factor H. Results CFI variants were categorized into three groups based on antigenic and functional assessments. Type 1 variants (n = 18) in 35 patients with AAMD demonstrated low serum FI levels and a corresponding decrease in FI function. Type 2 variants (n = 6) in 7 individuals demonstrated normal serum FI antigenic levels but reduced degradation of C3b to iC3b. Type 3 variants (n = 15) in 64 individuals demonstrated normal antigenic levels and degradation of C3b to iC3b. However, iC3b generation was low when measured per unit of FI. Thus most rare CFI variants demonstrate either low antigenic levels (type 1) or normal levels but reduced function (types 2 or 3). Conclusions Results provide for the first time a comprehensive functional assessment in serum of CFI rare genetic variants and further establish FI's key role in the pathogenesis of AAMD. Translational Relevance Stratifying patients in the clinic with a rare CFI variant will facilitate screening and targeting patients most likely to benefit from complement therapies.
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Affiliation(s)
- Anuja Java
- Divisions of Nephrology and Rheumatology, Department of Medicine, Washington University, St. Louis, MO, USA
| | | | - Rafael Widjajahakim
- Department of Ophthalmology and Visual Sciences, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Yun Ju Sung
- Department of Psychiatry and Division of Biostatistics Washington University School of Medicine in St. Louis, MO, USA
| | | | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - John Atkinson
- Divisions of Nephrology and Rheumatology, Department of Medicine, Washington University, St. Louis, MO, USA
| | - Johanna Seddon
- Department of Ophthalmology and Visual Sciences, University of Massachusetts School of Medicine, Worcester, MA, USA
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4
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Weiss AJ, Kronforst K. Renal failure, respiratory distress, and an atypical purpuric rash in a full-term infant with omphalocele and hypospadias: Answers. Pediatr Nephrol 2019; 34:2339-2342. [PMID: 31236666 DOI: 10.1007/s00467-019-04275-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Aaron J Weiss
- McGaw Medical Center of Northwestern University, Chicago, IL, USA. .,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 45, 225 E Chicago Ave., Chicago, IL, 60611, USA.
| | - Kenny Kronforst
- McGaw Medical Center of Northwestern University, Chicago, IL, USA. .,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 45, 225 E Chicago Ave., Chicago, IL, 60611, USA.
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5
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A review of thrombotic microangiopathies in multiple myeloma. Leuk Res 2019; 85:106195. [DOI: 10.1016/j.leukres.2019.106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
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6
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Jlajla H, Dehman F, Jallouli M, Khedher R, Ayadi I, Zerzeri Y, Laadhar L, Sfar I, Mahfoudh A, Gorgi Y, Cheour E, Zouaghi K, Gargah T, Kallel Sellami M. Molecular basis of complement factor I deficiency in Tunisian atypical haemolytic and uraemic syndrome patients. Nephrology (Carlton) 2019; 24:357-364. [PMID: 29292855 DOI: 10.1111/nep.13217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2017] [Indexed: 01/07/2023]
Abstract
AIM The aim of the present study was to characterize the molecular basis of complement factor I deficiency in Tunisian atypical haemolytic and uremic syndrome patients with low factor I levels. METHODS Six adults and seven children were enrolled in this study. Complement factor I levels were assessed by a homemade sandwich ELISA and ranged between 12.5% and 60%. Genomic DNA was amplified by way of a polymerase chain reaction using intronic primers flanking the 13 coding exons. Sequencing of amplified products was carried out by the dye terminator sequencing method. Molecular study was performed on parental samples for three dead paediatric patients. The control group consisted of 100 healthy Tunisian donors. RESULTS We identified a total of 13 substitutions and one insertion: seven in introns, four in exons and three in UTR. The new mutations were c.-132G > C, c.71 + 181 T > A in 5'UTR and intron 1, respectively. Three intronic polymorphisms were predicted to have impact on splicing events: c.482 + 6C > T, c.884-42_884-41insTTAAA (rs34422850) and c.1429 + 33 A > G (rs9998151). They were three missense mutations leading to a p.Ile 357Met, p.Ile416Leu and p.GLu548Gln. p.Ile 357Met was found in two patients and one relative. Half of the patients had associated mutation and/or polymorphisms. CONCLUSION This is the first genetic study in Tunisian and Maghrebin atypical haemolytic and uraemic syndrome patients. The high occurrence of Ile357Met mutation may reflect a founding effect. Functional impact of the two new mutations c.-132G > C and c.71 + 181A > T have to be studied. Association of simultaneous genetic abnormalities may explain the variability of atypical haemolytic and uraemic syndrome, penetrance and disease phenotype.
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Affiliation(s)
- Hend Jlajla
- Department of Immunology, La Rabta Hospital, Tunis, Tunisia.,Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia.,Faculty of Sciences, Carthage University, Bizerte, Tunisia
| | - Fatma Dehman
- Department of Immunology, La Rabta Hospital, Tunis, Tunisia.,Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia
| | - Manel Jallouli
- Department of Paediatrics, Charles Nicolle Hospital, Tunis, Tunisia
| | - Rania Khedher
- Department of Nephrology, La Rabta Hospital, Tunis, Tunisia
| | - Imen Ayadi
- Department of Immunology, La Rabta Hospital, Tunis, Tunisia.,Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia.,Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Yosr Zerzeri
- Department of Immunology, La Rabta Hospital, Tunis, Tunisia.,Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia
| | - Lilia Laadhar
- Department of Immunology, La Rabta Hospital, Tunis, Tunisia.,Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia.,Faculty of Medicine, El Manar University, Tunis, Tunisia
| | - Imen Sfar
- Faculty of Medicine, El Manar University, Tunis, Tunisia.,Department of Immunology, Charles Nicolle Hospital, Tunis, Tunisia
| | | | - Yosr Gorgi
- Faculty of Medicine, El Manar University, Tunis, Tunisia.,Department of Immunology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Elhem Cheour
- Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia
| | - Karim Zouaghi
- Faculty of Medicine, El Manar University, Tunis, Tunisia.,Department of Nephrology, La Rabta Hospital, Tunis, Tunisia
| | - Tahar Gargah
- Faculty of Medicine, El Manar University, Tunis, Tunisia.,Department of Paediatrics, Charles Nicolle Hospital, Tunis, Tunisia
| | - Maryam Kallel Sellami
- Department of Immunology, La Rabta Hospital, Tunis, Tunisia.,Research Laboratory of Immuno-Rheumatology (LR05 SP01), La Rabta Hospital, Tunis, Tunisia.,Faculty of Medicine, El Manar University, Tunis, Tunisia
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7
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Schönauer R, Seidel A, Grohmann M, Lindner TH, Bergmann C, Halbritter J. Deleterious Impact of a Novel CFH Splice Site Variant in Atypical Hemolytic Uremic Syndrome. Front Genet 2019; 10:465. [PMID: 31156713 PMCID: PMC6530248 DOI: 10.3389/fgene.2019.00465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/30/2019] [Indexed: 12/21/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a heterogeneous disorder characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and acute kidney injury (AKI). In about 50% of cases, pathogenic variants in genes involved in the innate immune response including complement factors complement factor H (CFH), CFI, CFB, C3, and membrane co-factor protein (MCP/CD46) put patients at risk for uncontrolled activation of the alternative complement pathway. As aHUS is characterized by incomplete penetrance and presence of additional triggers for disease manifestation, genetic variant interpretation is challenging and streamlined functional variant evaluation is urgently needed. Here, we report the case of a 27-year-old female without previous medical and family history who presented with confusion, petechial bleeding, and anuric AKI. Kidney biopsy revealed glomerular thrombotic microangiopathy (TMA). Targeted next generation sequencing identified a paternally transmitted novel heterozygous splice site variant in the CFH gene [c.3134-2A>G; p.Asp1045_Thr1053del] which resulted in a partial in-frame deletion of exon 20 transcript as determined by cDNA analysis. On the protein level, the concomitant loss of 9 amino acids in the short consensus repeat (SCR) domains 17 and 18 of CFH includes a highly conserved cysteine residue, which is assumed to be essential for proper structural folding and protein function. Treatment with steroids, plasmapheresis, and the complement inhibitor eculizumab led to complete hematological and clinical remission after several months and stable renal function up to 6 years later. In conclusion, genetic investigation for pathogenic variants and evaluation of their functional impact, in particular in the case of splice site variants, is clinically relevant and enables not only better molecular understanding but helps to guide therapy with complement inhibitors.
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Affiliation(s)
- Ria Schönauer
- Division of Nephrology, University Hospital Leipzig, Leipzig, Germany
| | - Anna Seidel
- Division of Nephrology, University Hospital Leipzig, Leipzig, Germany
| | - Maik Grohmann
- Center for Human Genetics, Bioscientia, Ingelheim, Germany
| | - Tom H Lindner
- Division of Nephrology, University Hospital Leipzig, Leipzig, Germany
| | | | - Jan Halbritter
- Division of Nephrology, University Hospital Leipzig, Leipzig, Germany
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8
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Raina R, Krishnappa V, Blaha T, Kann T, Hein W, Burke L, Bagga A. Atypical Hemolytic-Uremic Syndrome: An Update on Pathophysiology, Diagnosis, and Treatment. Ther Apher Dial 2018; 23:4-21. [PMID: 30294946 DOI: 10.1111/1744-9987.12763] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/25/2018] [Indexed: 12/25/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS), a rare variant of thrombotic microangiopathy, is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. The condition is associated with poor clinical outcomes with high morbidity and mortality. Atypical HUS predominantly affects the kidneys but has the potential to cause multi-organ system dysfunction. This uncommon disorder is caused by a genetic abnormality in the complement alternative pathway resulting in over-activation of the complement system and formation of microvascular thrombi. Abnormalities of the complement pathway may be in the form of mutations in key complement genes or autoantibodies against specific complement factors. We discuss the pathophysiology, clinical manifestations, diagnosis, complications, and management of aHUS. We also review the efficacy and safety of the novel therapeutic agent, eculizumab, in aHUS, pregnancy-associated aHUS, and aHUS in renal transplant patients.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General and Akron Children's Hospital, Akron, OH, USA.,Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA
| | - Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA.,Northeast Ohio Medical University, Rootstown, OH, USA
| | - Taryn Blaha
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Taylor Kann
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - William Hein
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Linda Burke
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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9
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Cidon EU, Martinez PA, Hickish T. Gemcitabine-induced haemolytic uremic syndrome, although infrequent, can it be prevented: A case report and review of literature. World J Clin Cases 2018; 6:531-537. [PMID: 30397609 PMCID: PMC6212612 DOI: 10.12998/wjcc.v6.i12.531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/08/2018] [Accepted: 10/09/2018] [Indexed: 02/05/2023] Open
Abstract
Gemcitabine is an antineoplastic used to treat several malignancies including pancreatic cancer. Its toxicity profile is well known with myelotoxicity, increased vascular permeability and peripheral oedema as most frequent adverse events. However, several cases of acute renal failure have been reported and haemolytic uremic syndrome (HUS) seems to be the underlying process. The cause of HUS remains unknown but its consequences can be lethal. Therefore, a high grade of suspicion is crucial to diagnose it and promptly treat it. This hopefully will reduce its morbidity. HUS is characterized by progressive renal failure associated with microangiopathic haemolytic anaemia and thrombocytopenia. The primary event is damage to endothelial cells and thrombotic microangiopathy (TMA) is the histopathological lesion. TMA affects mainly renal microvasculature. However, some cases evolve with central nervous or cardiovascular systems involvement. We present here a case of gemcitabine-induced HUS, with renal and cardiovascular system affected at the time of diagnosis which to our knowledge this is the first time of such case to be reported.
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Affiliation(s)
- Esther U Cidon
- Department of Medical Oncology, Royal Bournemouth and Christchurch Hospital NHS Foundation Trust, Bournemouth BH7 7DW, United Kingdom
| | - Pilar A Martinez
- Department of Oncology, Clinical University Hospital, Valladolid 47003, Spain
| | - Tamas Hickish
- Department of Medical Oncology, Royal Bournemouth and Christchurch Hospital NHS Foundation Trust and Bournemouth University, Bournemouth BH7 7DW, United Kingdom
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10
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Geerlings MJ, Volokhina EB, de Jong EK, van de Kar N, Pauper M, Hoyng CB, van den Heuvel LP, den Hollander AI. Genotype-phenotype correlations of low-frequency variants in the complement system in renal disease and age-related macular degeneration. Clin Genet 2018; 94:330-338. [PMID: 29888403 PMCID: PMC6175426 DOI: 10.1111/cge.13392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/24/2018] [Accepted: 06/03/2018] [Indexed: 12/28/2022]
Abstract
Genetic alterations in the complement system have been linked to a variety of diseases, including atypical hemolytic uremic syndrome (aHUS), C3 glomerulopathy (C3G), and age‐related macular degeneration (AMD). We performed sequence analysis of the complement genes complement factor H (CFH), complement factor I (CFI), and complement C3 (C3) in 866 aHUS/C3G and 697 AMD patients. In total, we identified 505 low‐frequency alleles, representing 121 unique variants, of which 51 are novel. CFH contained the largest number of unique low‐frequency variants (n = 64; 53%), followed by C3 (n = 32; 26%) and CFI (n = 25; 21%). A substantial number of variants were found in both patients groups (n = 48; 40%), while 41 (34%) variants were found only in aHUS/C3G and 32 (26%) variants were AMD specific. Genotype‐phenotype correlations between the disease groups identified a higher frequency of protein altering alleles in short consensus repeat 20 (SCR20) of factor H (FH), and in the serine protease domain of factor I (FI) in aHUS/C3G patients. In AMD, a higher frequency of protein‐altering alleles was observed in SCR3, SCR5, and SCR7 of FH, the SRCR domain of FI, and in the MG3 domain of C3. In conclusion, we observed a substantial overlap of variants between aHUS/C3G and AMD; however, there is a distinct clustering of variants within specific domains.
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Affiliation(s)
- M J Geerlings
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E B Volokhina
- Radboud university medical center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Department of Pediatric Nephrology, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E K de Jong
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N van de Kar
- Radboud university medical center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Department of Pediatric Nephrology, Nijmegen, The Netherlands
| | - M Pauper
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C B Hoyng
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L P van den Heuvel
- Radboud university medical center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Department of Pediatric Nephrology, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pediatrics, Department of Growth and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - A I den Hollander
- Department of Ophthalmology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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Kernan KF, Ghaloul-Gonzalez L, Shakoory B, Kellum JA, Angus DC, Carcillo JA. Adults with septic shock and extreme hyperferritinemia exhibit pathogenic immune variation. Genes Immun 2018; 20:520-526. [PMID: 29977033 PMCID: PMC6320733 DOI: 10.1038/s41435-018-0030-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/05/2018] [Accepted: 03/16/2018] [Indexed: 01/20/2023]
Abstract
Post-hoc subgroup analysis of the negative trial of
interleukin-1β receptor antagonist (IL1RA) for septic shock suggested
that patients with features of macrophage activation syndrome (MAS) experienced
a 50% relative risk reduction for mortality with treatment. Here we seek
a genetic basis for this differential response. From 1341 patients enrolled in
the ProCESS trial of early goal directed therapy for septic shock, we selected 6
patients with MAS features and the highest ferritin, for whole exome sequencing
(mean 24,030.7 ηg/ml, +/SEM 7,411.1). Eleven rare (minor allele
frequency <5%) pathogenic or likely pathogenic variants causal
for the monogenic disorders of Familial Hemophagocytic Lymphohistiocytosis,
atypical Hemolytic Uremic Syndrome, Familial Mediterranean Fever, and
Cryopyrin-associated Periodic Fever were identified. In these conditions, seven
of the identified variants are currently targeted with IL1RA and four with
anti-C5 antibody. Gene-targeted precision medicine may benefit this subgroup of
patients with septic shock and pathogenic immune variation.
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Affiliation(s)
- Kate F Kernan
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek C Angus
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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12
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Timmermans SAMEG, Abdul-Hamid MA, Potjewijd J, Theunissen ROMFIH, Damoiseaux JGMC, Reutelingsperger CP, van Paassen P. C5b9 Formation on Endothelial Cells Reflects Complement Defects among Patients with Renal Thrombotic Microangiopathy and Severe Hypertension. J Am Soc Nephrol 2018; 29:2234-2243. [PMID: 29858281 DOI: 10.1681/asn.2018020184] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 04/25/2018] [Indexed: 01/08/2023] Open
Abstract
Background Severe hypertension can induce thrombotic microangiopathy (TMA) in the renal vasculature, the occurrence of which has been linked to mechanical stress to the endothelium. Complement defects may be the culprit of disease in patients who present with severe renal disease and often progress to ESRD, despite BP control.Methods We studied a well defined cohort of 17 patients with hypertension-associated TMA to define the prevalence of complement defects by a specific ex vivo serum-based microvascular endothelial cell assay.Results Compared with normal human serum and samples from patients with hypertensive arterionephrosclerosis, 14 of 16 (87.5%) serum samples collected at presentation from 16 patients with hypertension-associated TMA induced abnormal C5b9 formation on microvascular endothelial cells. We detected rare variants in complement genes in eight of 17 (47%) patients. ESRD occurred in 14 of 17 (82%) patients, and recurrent TMA after transplant occurred in seven of 11 (64%) donor kidneys. Eculizumab improved the renal function in three patients and prevented TMA recurrence in an allograft recipient.Conclusions These observations point to complement defects as the key causative factor of ESRD and recurrent TMA after transplant in patients presenting with severe hypertension. Complement defects can be identified by measurements of complement activation on microvascular endothelial cells, which should substantially influence treatment and prognosis.
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Affiliation(s)
| | | | | | | | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands; and
| | - Chris P Reutelingsperger
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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13
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Recurrent structural variation, clustered sites of selection, and disease risk for the complement factor H ( CFH) gene family. Proc Natl Acad Sci U S A 2018; 115:E4433-E4442. [PMID: 29686068 DOI: 10.1073/pnas.1717600115] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Structural variation and single-nucleotide variation of the complement factor H (CFH) gene family underlie several complex genetic diseases, including age-related macular degeneration (AMD) and atypical hemolytic uremic syndrome (AHUS). To understand its diversity and evolution, we performed high-quality sequencing of this ∼360-kbp locus in six primate lineages, including multiple human haplotypes. Comparative sequence analyses reveal two distinct periods of gene duplication leading to the emergence of four CFH-related (CFHR) gene paralogs (CFHR2 and CFHR4 ∼25-35 Mya and CFHR1 and CFHR3 ∼7-13 Mya). Remarkably, all evolutionary breakpoints share a common ∼4.8-kbp segment corresponding to an ancestral CFHR gene promoter that has expanded independently throughout primate evolution. This segment is recurrently reused and juxtaposed with a donor duplication containing exons 8 and 9 from ancestral CFH, creating four CFHR fusion genes that include lineage-specific members of the gene family. Combined analysis of >5,000 AMD cases and controls identifies a significant burden of a rare missense mutation that clusters at the N terminus of CFH [P = 5.81 × 10-8, odds ratio (OR) = 9.8 (3.67-Infinity)]. A bipolar clustering pattern of rare nonsynonymous mutations in patients with AMD (P < 10-3) and AHUS (P = 0.0079) maps to functional domains that show evidence of positive selection during primate evolution. Our structural variation analysis in >2,400 individuals reveals five recurrent rearrangement breakpoints that show variable frequency among AMD cases and controls. These data suggest a dynamic and recurrent pattern of mutation critical to the emergence of new CFHR genes but also in the predisposition to complex human genetic disease phenotypes.
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14
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Michels MAHM, van de Kar NCAJ, Okrój M, Blom AM, van Kraaij SAW, Volokhina EB, van den Heuvel LPWJ. Overactivity of Alternative Pathway Convertases in Patients With Complement-Mediated Renal Diseases. Front Immunol 2018; 9:612. [PMID: 29670616 PMCID: PMC5893837 DOI: 10.3389/fimmu.2018.00612] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 03/12/2018] [Indexed: 01/06/2023] Open
Abstract
Overactivation of the alternative pathway of the complement system is associated with the renal diseases atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy (C3G). C3 nephritic factors (C3NeF) play an important role in C3G pathogenesis by stabilizing the key enzymatic complex of complement, the C3 convertase. However, the reliability of assays detecting these autoantibodies is limited. Therefore, in this study, we validated and optimized a prototype hemolytic method for robust detection and characterization of factors causing convertase overactivity in large patient cohorts. The assay assesses convertase activity directly in the physiological milieu of serum and therefore is not restricted to detection of stabilizing autoantibodies such as C3NeF but may also reveal genetic variants resulting in prolonged convertase activity. We first defined clear cutoff values based on convertase activity in healthy controls. Next, we evaluated 27 C3G patient samples and found 16 positive for prolonged convertase activity, indicating the presence of factors influencing convertase stability. In three patients, the overactive convertase profile was persistent over disease course while in another patient the increased stability normalized in remission. In all these four patients, the convertase-stabilizing activity resided in the purified immunoglobulin (Ig) fraction, demonstrating the autoantibody nature. By contrast, the Igs of a familial aHUS patient carrying the complement factor B mutation p.Lys323Glu did not reveal convertase stabilization. However, in serum prolonged convertase activity was observed and segregated with the mutation in both affected and unaffected family members. In conclusion, we present a robust and reliable method for the detection, characterization, and evaluation over time of factors prolonging convertase activity (C3NeF or certain mutations) in patient cohorts. This assay may provide new insights in disease pathogenesis and may contribute to the development of more personalized treatment strategies.
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Affiliation(s)
- Marloes A H M Michels
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marcin Okrój
- Department of Medical Biotechnology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, Gdańsk, Poland
| | - Anna M Blom
- Medical Protein Chemistry, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sanne A W van Kraaij
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lambertus P W J van den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Pediatrics/Pediatric Nephrology and Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
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15
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Gurjar BS, Manikanta Sriharsha T, Bhasym A, Prabhu S, Puraswani M, Khandelwal P, Saini H, Saini S, Verma AK, Chatterjee P, Guchhait P, Bal V, George A, Rath S, Sahu A, Sharma A, Hari P, Sinha A, Bagga A. Characterization of genetic predisposition and autoantibody profile in atypical haemolytic-uraemic syndrome. Immunology 2018; 154:663-672. [PMID: 29485195 PMCID: PMC6050217 DOI: 10.1111/imm.12916] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 12/25/2022] Open
Abstract
We previously reported that Indian paediatric patients with atypical haemolytic-uraemic syndrome (aHUS) showed high frequencies of anti-complement factor H (FH) autoantibodies that are correlated with homozygous deletion of the genes for FH-related proteins 1 and 3 (FHR1 and FHR3) (FHR1/3-/- ). We now report that Indian paediatric aHUS patients without anti-FH autoantibodies also showed modestly higher frequencies of the FHR1/3-/- genotype. Further, when we characterized epitope specificities and binding avidities of anti-FH autoantibodies in aHUS patients, most anti-FH autoantibodies were directed towards the FH cell-surface anchoring polyanionic binding site-containing C-terminal short conservative regions (SCRs) 17-20 with higher binding avidities than for native FH. FH SCR17-20-binding anti-FH autoantibodies also bound the other cell-surface anchoring polyanionic binding site-containing region FH SCR5-8, at lower binding avidities. Anti-FH autoantibody avidities correlated with antibody titres. These anti-FH autoantibody characteristics did not differ between aHUS patients with or without the FHR1/3-/- genotype. Our data suggest a complex matrix of interactions between FHR1-FHR3 deletion, immunomodulation and anti-FH autoantibodies in the aetiopathogenesis of aHUS.
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Affiliation(s)
| | | | - Angika Bhasym
- Regional Centre for BiotechnologyFaridabadIndia
- Department of BiotechnologyManipal Academy of Higher EducationManipalIndia
| | - Savit Prabhu
- Paediatric Biology CentreTranslational Health Science and Technology InstituteFaridabadIndia
| | - Mamta Puraswani
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Priyanka Khandelwal
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Himanshi Saini
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Savita Saini
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | | | | | | | - Vineeta Bal
- National Institute of ImmunologyNew DelhiIndia
- Paediatric Biology CentreTranslational Health Science and Technology InstituteFaridabadIndia
| | - Anna George
- National Institute of ImmunologyNew DelhiIndia
| | - Satyajit Rath
- National Institute of ImmunologyNew DelhiIndia
- Paediatric Biology CentreTranslational Health Science and Technology InstituteFaridabadIndia
- Agharkar Research InstitutePuneIndia
| | - Arvind Sahu
- National Centre for Cell ScienceS. P. Pune University CampusPuneIndia
| | - Amita Sharma
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Pankaj Hari
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Aditi Sinha
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Arvind Bagga
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
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16
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Duineveld C, Verhave JC, Berger SP, van de Kar NC, Wetzels JF. Living Donor Kidney Transplantation in Atypical Hemolytic Uremic Syndrome: A Case Series. Am J Kidney Dis 2017; 70:770-777. [DOI: 10.1053/j.ajkd.2017.06.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/26/2017] [Indexed: 11/11/2022]
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17
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Bruel A, Kavanagh D, Noris M, Delmas Y, Wong EKS, Bresin E, Provôt F, Brocklebank V, Mele C, Remuzzi G, Loirat C, Frémeaux-Bacchi V, Fakhouri F. Hemolytic Uremic Syndrome in Pregnancy and Postpartum. Clin J Am Soc Nephrol 2017; 12:1237-1247. [PMID: 28596415 PMCID: PMC5544502 DOI: 10.2215/cjn.00280117] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pregnancy is associated with various forms of thrombotic microangiopathy, including hemolytic uremic syndrome. A previous small French study suggested that pregnancy-associated hemolytic uremic syndrome was to be included in the spectrum of atypical hemolytic uremic syndrome linked to complement alternative pathway dysregulation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We sought to retrospectively analyze the presentation, outcome, and frequency of complement alternative pathway gene variants in a larger international (France, United Kingdom, Italy) cohort of patients with pregnancy-associated hemolytic uremic syndrome. RESULTS Eighty-seven patients with pregnancy-associated hemolytic uremic syndrome were included. Hemolytic uremic syndrome occurred mainly during the first pregnancy (58%) and in the postpartum period (76%). At diagnosis, 56 (71%) patients required dialysis. Fifty-six (78%) patients underwent plasma exchanges, 21 (41%) received plasma infusions, and four (5%) received eculizumab. During follow-up (mean duration of 7.2 years), 41 (53%) patients reached ESRD, 15 (19%) had CKD, and 18 (28%) patients experienced hemolytic uremic syndrome relapse. Twenty-four patients (27%) received a kidney transplant and a recurrence of hemolytic uremic syndrome occurred in 13 (54%) patients. Variants in complement genes were detected in 49 (56%) patients, mainly in the CFH (30%) and CFI genes (9%). CONCLUSIONS Pregnancy-associated hemolytic uremic syndrome and atypical hemolytic uremic syndrome nonrelated to pregnancy have the same severity at onset and during follow-up and the same frequency of complement gene variants.
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Affiliation(s)
- Alexandra Bruel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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18
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Song D, Liu XR, Chen Z, Xiao HJ, Ding J, Sun SZ, Liu HY, Guo WY, Wang SX, Yu F, Zhao MH. The clinical and laboratory features of Chinese Han anti-factor H autoantibody-associated hemolytic uremic syndrome. Pediatr Nephrol 2017; 32:811-822. [PMID: 28035470 DOI: 10.1007/s00467-016-3562-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-complement factor H (CFH) autoantibody-associated hemolytic uremic syndrome (HUS) is a severe sub-type of HUS. METHODS We assessed the clinical and renal pathological features, circulating complement levels, and genetic background of Chinese pediatric patients with this sub-type of HUS. Thirty-three consecutive patients with acute kidney injury who tested positive for serum anti-CFH autoantibodies were enrolled in this study. RESULTS All of the eight patients who underwent renal biopsies presented with changes typical of thrombotic microangiopathy, especially changes in chronic characteristics. Compared to patients in remission and normal control subjects, patients with acute disease had significantly lower plasma CFH levels and significantly higher plasma complement 3a (C3a), C5a, and terminal complement complex (SC5b-9) levels. The CFH-anti-CFH immunoglobin G (IgG) circulating immunocomplex (CFH-CIC) titers were more closely correlated with CFH plasma levels than anti-CFH IgG levels. Of the 22 patients, four (18%) were homozygous for CFHR3-1Δ and ten were heterozygous for CFHR1 or CFHR3 deletions. Most patients responded well to a combination of plasma and immunosuppressive therapies, with a remission rate of 87%. At the end of the follow-up, nine patients reached the combined end-points, including two with end-stage renal disease and seven with relapses. CONCLUSION Plasma C3a, C5a, and SC5b-9 levels predicted disease activity in anti-CFH autoantibody-associated HUS patients enrolled in this study. These patients responded well to plasma therapy combined with immunosuppression.
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Affiliation(s)
- Di Song
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Xiao-Rong Liu
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China.
| | - Zhi Chen
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China
| | - Hui-Jie Xiao
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Shu-Zhen Sun
- Department of Pediatrics, Shandong Provincial Hospital affiliated with Shandong University, Jinan, People's Republic of China
| | - Hong-Yan Liu
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Wei-Yi Guo
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China.
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.
- Department of Nephrology, Peking University International Hospital, Beijing, 102206, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
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19
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Adult Post-Kidney Transplant Familial Atypical Hemolytic Uremic Syndrome Successfully Treated With Eculizumab: A Case Report and Literature Review. Am J Ther 2017; 23:e1110-5. [PMID: 25486517 DOI: 10.1097/mjt.0000000000000133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hemolytic uremic syndrome is the triad of nonimmune microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. When not associated with enteric infection, it is classified as atypical hemolytic uremic syndrome (aHUS) and carries a worse outcome with high mortality rate and up to 50% of the survivors will end up with end-stage renal disease. Renal transplant was restricted to a very small percentage of patients due to high recurrence rate posttransplant that approaches 90%. Our case describes a posttransplant adult patient with familial aHUS whom was successfully treated with eculizumab. We also reviewed all other reported cases of adult posttransplant aHUS, both familial and sporadic, which were treated with eculizumab. In summary, eculizumab might expand the utility of renal transplant for patients with end-stage renal disease due to aHUS.
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20
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Timmermans SAMEG, Abdul-Hamid MA, Vanderlocht J, Damoiseaux JGMC, Reutelingsperger CP, van Paassen P. Patients with hypertension-associated thrombotic microangiopathy may present with complement abnormalities. Kidney Int 2017; 91:1420-1425. [PMID: 28187980 DOI: 10.1016/j.kint.2016.12.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/24/2016] [Accepted: 12/08/2016] [Indexed: 12/11/2022]
Abstract
Thrombotic microangiopathy (TMA) is a pattern of endothelial damage that can be found in association with diverse clinical conditions such as malignant hypertension. Although the pathophysiological mechanisms differ, accumulating evidence links complement dysregulation to various TMA syndromes and in particular the atypical hemolytic uremic syndrome. Here, we evaluated the role of complement in nine consecutive patients with biopsy-proven renal TMA attributed to severe hypertension. Profound hematologic symptoms of TMA were uncommon. In six out of nine patients, we found mutations C3 in three, CFI in one, CD46 in one, and/or CFH in two patients either with or without the risk CFH-H3 haplotype in four patients. Elevated levels of the soluble C5b-9 and renal deposits of C3c and C5b-9 along the vasculature and/or glomerular capillary wall, confirmed complement activation in vivo. In contrast to patients without genetic defects, patients with complement defects invariably progressed to end-stage renal disease, and disease recurrence after kidney transplantation seems common. Thus, a subset of patients with hypertension-associated TMA falls within the spectrum of complement-mediated TMA, the prognosis of which is poor. Hence, testing for genetic complement abnormalities is warranted in patients with severe hypertension and TMA on renal biopsy to adopt suitable treatment options and prophylactic measures.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Myrurgia A Abdul-Hamid
- Department of Pathology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Joris Vanderlocht
- Department of Transplantation Immunology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Chris P Reutelingsperger
- Deptartment of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Centre, Maastricht, the Netherlands.
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Westra D, Volokhina EB, van der Molen RG, van der Velden TJAM, Jeronimus-Klaasen A, Goertz J, Gracchi V, Dorresteijn EM, Bouts AHM, Keijzer-Veen MG, van Wijk JAE, Bakker JA, Roos A, van den Heuvel LP, van de Kar NCAJ. Serological and genetic complement alterations in infection-induced and complement-mediated hemolytic uremic syndrome. Pediatr Nephrol 2017; 32:297-309. [PMID: 27718086 PMCID: PMC5203860 DOI: 10.1007/s00467-016-3496-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND The role of complement in the atypical form of hemolytic uremic syndrome (aHUS) has been investigated extensively in recent years. As the HUS-associated bacteria Shiga-toxin-producing Escherichia coli (STEC) can evade the complement system, we hypothesized that complement dysregulation is also important in infection-induced HUS. METHODS Serological profiles (C3, FH, FI, AP activity, C3d, C3bBbP, C3b/c, TCC, αFH) and genetic profiles (CFH, CFI, CD46, CFB, C3) of the alternative complement pathway were prospectively determined in the acute and convalescent phase of disease in children newly diagnosed with STEC-HUS or aHUS. Serological profiles were compared with those of 90 age-matched controls. RESULTS Thirty-seven patients were studied (26 STEC-HUS, 11 aHUS). In 39 % of them, including 28 % of STEC-HUS patients, we identified a genetic and/or acquired complement abnormality. In all patient groups, the levels of investigated alternative pathway (AP) activation markers were elevated in the acute phase and normalized in remission. The levels were significantly higher in aHUS than in STEC-HUS patients. CONCLUSIONS In both infection-induced HUS and aHUS patients, complement is activated in the acute phase of the disease but not during remission. The C3d/C3 ratio displayed the best discrepancy between acute and convalescent phase and between STEC-HUS and aHUS and might therefore be used as a biomarker in disease diagnosis and monitoring. The presence of aberrations in the alternative complement pathway in STEC-HUS patients was remarkable, as well.
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Affiliation(s)
- Dineke Westra
- Department of Pediatric Nephrology (804), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Elena B Volokhina
- Department of Pediatric Nephrology (804), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Renate G van der Molen
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thea J A M van der Velden
- Department of Pediatric Nephrology (804), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Annelies Jeronimus-Klaasen
- Department of Pediatric Nephrology (804), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Joop Goertz
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Valentina Gracchi
- Department of Pediatric Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Eiske M Dorresteijn
- Department of Pediatric Nephrology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Antonia H M Bouts
- Department of Pediatric Nephrology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mandy G Keijzer-Veen
- Department of Pediatric Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Joanna A E van Wijk
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jaap A Bakker
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anja Roos
- Department of Medical Microbiology and Immunology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Lambert P van den Heuvel
- Department of Pediatric Nephrology (804), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Department of Pediatrics, Department of Growth and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology (804), Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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22
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Cheong HI, Jo SK, Yoon SS, Cho H, Kim JS, Kim YO, Koo JR, Park Y, Park YS, Shin JI, Yoo KH, Oh D. Clinical Practice Guidelines for the Management of Atypical Hemolytic Uremic Syndrome in Korea. J Korean Med Sci 2016; 31:1516-28. [PMID: 27550478 PMCID: PMC4999392 DOI: 10.3346/jkms.2016.31.10.1516] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/10/2016] [Indexed: 12/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare syndrome characterized by micro-angiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. The major pathogenesis of aHUS involves dysregulation of the complement system. Eculizumab, which blocks complement C5 activation, has recently been proven as an effective agent. Delayed diagnosis and treatment of aHUS can cause death or end-stage renal disease. Therefore, a diagnosis that differentiates aHUS from other forms of thrombotic microangiopathy is very important for appropriate management. These guidelines aim to offer recommendations for the diagnosis and treatment of patients with aHUS in Korea. The guidelines have largely been adopted from the current guidelines due to the lack of evidence concerning the Korean population.
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Affiliation(s)
- Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Sung Soo Yoon
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Young Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Ja Ryong Koo
- Division of Nephrology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong, Korea
| | - Yong Park
- Division of Hematology, Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, School of Medicine, CHA University, Seongnam, Korea.
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23
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Durey MAD, Sinha A, Togarsimalemath SK, Bagga A. Anti-complement-factor H-associated glomerulopathies. Nat Rev Nephrol 2016; 12:563-78. [PMID: 27452363 DOI: 10.1038/nrneph.2016.99] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atypical haemolytic uraemic syndrome (aHUS), an important cause of acute kidney injury, is characterized by dysregulation of the complement pathway, frequent need for dialysis, and progression to end-stage renal disease. Autoantibodies against complement factor H (FH), the main plasma regulatory protein of the alternative pathway of the complement system, account for a considerable proportion of children with aHUS. The autoantibodies are usually associated with the occurrence of a homozygous deletion in the genes encoding the FH-related proteins FHR1 and FHR3. High levels of autoantibodies, noted at the onset of disease and during relapses, induce functional deficiency of FH, whereas their decline, in response to plasma exchanges and/or immunosuppressive therapy, is associated with disease remission. Management with plasma exchange and immunosuppression is remarkably effective in inducing and maintaining remission in aHUS associated with FH autoantibodies, whereas terminal complement blockade with eculizumab is considered the most effective therapy in other forms of aHUS. Anti-FH autoantibodies are also detected in a small proportion of patients with C3 glomerulopathies, which are characterized by chronic glomerular injury mediated by activation of the alternative complement pathway and predominant C3 deposits on renal histology.
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Affiliation(s)
- Marie-Agnes Dragon Durey
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 15 rue de l'ecole de medecine, 75006 Paris, France.,Université Paris Descartes, Paris, France.,Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Shambhuprasad Kotresh Togarsimalemath
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 15 rue de l'ecole de medecine, 75006 Paris, France.,Université Paris Descartes, Paris, France
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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24
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Gleeson PJ, Wilson V, Cox TE, Sharma SD, Smith-Jackson K, Strain L, Lappin D, McHale T, Kavanagh D, Goodship THJ. Chromosomal rearrangement-A rare cause of complement factor I associated atypical haemolytic uraemic syndrome. Immunobiology 2016; 221:1124-30. [PMID: 27268256 DOI: 10.1016/j.imbio.2016.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/30/2016] [Accepted: 05/08/2016] [Indexed: 10/21/2022]
Abstract
Chromosomal rearrangements affecting the genes encoding complement factor H and the factor H related proteins have been described in aHUS patients. To date such disorders have not been described in other aHUS associated genes. We describe here a heterozygous 875,324bp deletion encompassing the gene (CFI) encoding complement factor I and ten other genes. The index case presented with aHUS and did not recover renal function. No abnormalities were detected on Sanger sequencing of CFI but a low factor I level led to a multiplex ligation-dependent probe amplification assay being undertaken. This showed a complete heterozygous deletion of CFI. The extent of the deletion and the breakpoint was defined. In the Newcastle aHUS cohort we have identified and report here 32 different CFI variants in 56 patients but to date this is the only deletion that we have identified. This finding although rare does suggest that screening for chromosomal rearrangements affecting CFI should be undertaken in all aHUS patients particularly if the factor I level is unexplainably low.
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Affiliation(s)
- Patrick J Gleeson
- Departments of Nephrology and Histopathology, University Hospital Galway, Galway, Ireland
| | - Valerie Wilson
- Northern Molecular Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Thomas E Cox
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Seema D Sharma
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Kate Smith-Jackson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Lisa Strain
- Northern Molecular Genetics Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Lappin
- Departments of Nephrology and Histopathology, University Hospital Galway, Galway, Ireland
| | - Teresa McHale
- Departments of Nephrology and Histopathology, University Hospital Galway, Galway, Ireland
| | - David Kavanagh
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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25
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Genetic analysis and functional characterization of novel mutations in a series of patients with atypical hemolytic uremic syndrome. Mol Immunol 2016; 71:10-22. [DOI: 10.1016/j.molimm.2016.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/19/2015] [Accepted: 01/02/2016] [Indexed: 11/21/2022]
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26
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Emirova K, Volokhina E, Tolstova E, van den Heuvel B. Recovery of renal function after long-term dialysis and resolution of cardiomyopathy in a patient with aHUS receiving eculizumab. BMJ Case Rep 2016; 2016:bcr-2015-213928. [PMID: 26880823 DOI: 10.1136/bcr-2015-213928] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We present the case of a 18-month-old girl with renal and cardiac manifestations of atypical haemolytic uraemic syndrome (aHUS), and a novel complement factor H mutation. Transient haematological remission was achieved with intensive plasmapheresis, but cardiac function deteriorated and renal function was not restored. Initiation of eculizumab after 6 months of dialysis significantly improved organ function. At 43 months after presentation, haematological values had normalised and cardiac function had improved. Dialysis was discontinued after 10 months (the longest reported time in a patient with aHUS) and the estimated glomerular filtration rate had recovered to 70 mL/min/1.73 m(2). In conclusion, treatment of aHUS with eculizumab, even after long-term dialysis, can significantly improve renal function. Discontinuation of dialysis and resolution of cardiac function has implications on the potential recovery and treatment choice of such patients. Earlier initiation of eculizumab, however, might have prevented the irreversible renal sclerosis and cardiac dysfunction.
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Affiliation(s)
- Khadizha Emirova
- The AI Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Elena Volokhina
- Department of Paediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Evgenia Tolstova
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bert van den Heuvel
- Department of Paediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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27
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Adjustment of Eculizumab Dosage Pattern in Patients with Atypical Hemolytic Uremic Syndrome with Suboptimal Response to Standard Treatment Pattern. Case Rep Nephrol 2016; 2016:7471082. [PMID: 28025630 PMCID: PMC5153492 DOI: 10.1155/2016/7471082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/11/2016] [Accepted: 11/02/2016] [Indexed: 11/17/2022] Open
Abstract
In patients with atypical hemolytic uremic syndrome (aHUS), complement blocking by eculizumab rapidly halts the process of thrombotic microangiopathy and it is associated with clear long-term hematologic and renal improvements. Eculizumab treatment consists of a 4-week initial phase with weekly IV administration of 900 mg doses, followed by a maintenance phase with a 1,200 mg dose in the fifth week and every 14±2 days thereafter. We present three patients with aHUS and suboptimal response to eculizumab treatment at the usual administration dosage who showed hematologic and renal improvements after an adjustment in the eculizumab treatment protocol.
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28
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Bhatia D, Khandelwal P, Sinha A, Hari P, Cheong HI, Bagga A. Incomplete penetrance of CD46 mutation causing familial atypical hemolytic uremic syndrome. Pediatr Nephrol 2015; 30:2215-20. [PMID: 26307634 DOI: 10.1007/s00467-015-3189-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 07/25/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) secondary to homozygous mutations in CD46 is uncommon. While heterozygous individuals may remain asymptomatic, homozygous mutations with severely depleted CD46 surface expression without disease manifestation is rare. METHODS We report on two siblings with features suggestive of hemolytic uremic syndrome. Estimation of CD46 expression by flow cytometry and gene sequencing were performed in members of this family. RESULTS Three siblings, two of whom were symptomatic, had markedly decreased (<10%) cell surface expression of CD46 and homozygous splice site mutation (IVS2 + 2 T > G) in the CD46 gene; the other 10-year-old sibling was asymptomatic. The illness was preceded by dengue shock syndrome in the index case. Both parents and two other siblings were heterozygous for this CD46 mutation. CONCLUSIONS Homozygous IVS2 + 2 T > G mutation in CD46 gene, similar to heterozygous mutation, may be clinically silent at least during childhood. The role of antecedent infections in triggering the disease requires further examination.
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Affiliation(s)
- Divya Bhatia
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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29
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Blasco Pelicano M, Rodríguez de Córdoba S, Campistol Plana JM. Síndrome hemolítico urémico atípico. Med Clin (Barc) 2015; 145:438-45. [DOI: 10.1016/j.medcli.2014.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/25/2014] [Accepted: 08/29/2014] [Indexed: 12/15/2022]
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30
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Campistol JM, Arias M, Ariceta G, Blasco M, Espinosa L, Espinosa M, Grinyó JM, Macía M, Mendizábal S, Praga M, Román E, Torra R, Valdés F, Vilalta R, Rodríguez de Córdoba S. An update for atypical haemolytic uraemic syndrome: diagnosis and treatment. A consensus document. Nefrologia 2015; 35:421-47. [PMID: 26456110 DOI: 10.1016/j.nefro.2015.07.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a clinical entity defined as the triad of nonimmune haemolytic anaemia, thrombocytopenia, and acute renal failure, in which the underlying lesions are mediated by systemic thrombotic microangiopathy (TMA). Different causes can induce the TMA process that characterizes HUS. In this document we consider atypical HUS (aHUS) a sub-type of HUS in which the TMA phenomena are the consequence of the endotelial damage in the microvasculature of the kidneys and other organs due to a disregulation of the activity of the complement system. In recent years, a variety of aHUs-related mutations have been identified in genes of the the complement system, which can explain approximately 60% of the aHUS cases, and a number of mutations and polymorphisms have been functionally characterized. These findings have stablished that aHUS is a consequence of the insufficient regulation of the activiation of the complement on cell surfaces, leading to endotelial damage mediated by C5 and the complement terminal pathway. Eculizumab is a monoclonal antibody that inhibits the activation of C5 and blocks the generation of the pro-inflammatory molecule C5a and the formation of the cell membrane attack complex. In prospective studies in patients with aHUS, the use of Eculizumab has shown a fast and sustained interruption of the TMA process and it has been associated with significative long-term improvements in renal function, the interruption of plasma therapy and important reductions in the need of dialysis. According to the existing literature and the accumulated clinical experience, the Spanish aHUS Group published a consensus document with recommendations for the treatment of aHUs (Nefrologia 2013;33[1]:27-45). In the current online version of this document, we update the aetiological classification of TMAs, the pathophysiology of aHUS, its differential diagnosis and its therapeutic management.
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Affiliation(s)
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
| | - Miguel Blasco
- Servicio de Nefrología, Hospital Clínic, Barcelona, España
| | - Laura Espinosa
- Servicio de Nefrología Pediátrica, Hospital La Paz, Madrid, España
| | - Mario Espinosa
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, España
| | - Josep M Grinyó
- Servicio de Nefrología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Manuel Macía
- Servicio de Nefrología, Hospital Virgen de la Candelaria, Santa Cruz de Tenerife, España
| | | | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Elena Román
- Servicio de Nefrología Pediátrica, Hospital La Fe, Valencia, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Fundació Puigvert, Barcelona, España
| | - Francisco Valdés
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, España
| | - Ramón Vilalta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
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31
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Mallett A, Hughes P, Szer J, Tuckfield A, Van Eps C, Cambell SB, Hawley C, Burke J, Kausman J, Hewitt I, Parnham A, Ford S, Isbel N. Atypical haemolytic uraemic syndrome treated with the complement inhibitor eculizumab: the experience of the Australian compassionate access cohort. Intern Med J 2015; 45:1054-65. [DOI: 10.1111/imj.12864] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 07/19/2015] [Indexed: 02/03/2023]
Affiliation(s)
- A. Mallett
- Department of Renal Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - P. Hughes
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - J. Szer
- Department of Clinical Haematology and BMT Service; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - A. Tuckfield
- Department of Clinical Haematology and BMT Service; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - C. Van Eps
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - S. B. Cambell
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - C. Hawley
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - J. Burke
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - J. Kausman
- Department of Nephrology; The Royal Children's Hospital Melbourne; Melbourne Victoria Australia
| | - I. Hewitt
- Department of Nephrology; Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - A. Parnham
- Department of Nephrology; Gold Coast Hospital; Gold Coast Queensland Australia
| | - S. Ford
- Department of Nephrology; Monash Medical Centre; Melbourne Victoria Australia
| | - N. Isbel
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
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32
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Volokhina EB, Westra D, van der Velden TJAM, van de Kar NCAJ, Mollnes TE, van den Heuvel LP. Complement activation patterns in atypical haemolytic uraemic syndrome during acute phase and in remission. Clin Exp Immunol 2015; 181:306-13. [PMID: 25079699 DOI: 10.1111/cei.12426] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2014] [Indexed: 02/01/2023] Open
Abstract
Atypical haemolytic uraemic syndrome (aHUS) is associated with (genetic) alterations in alternative complement pathway. Nevertheless, comprehensive evidence that the complement system in aHUS patients is more prone to activation is still lacking. Therefore, we performed a thorough analysis of complement activation in acute phase and in remission of this disease. Complement activation patterns of the aHUS patients in acute phase and in remission were compared to those of healthy controls. Background levels of complement activation products C3b/c, C3bBbP and terminal complement complex (TCC) were measured using enzyme-linked immunosorbent assay (ELISA) in ethylenediamine tetraacetic acid (EDTA) plasma. In vitro-triggered complement activation in serum samples was studied using zymosan-coating and pathway-specific assay. Furthermore, efficiencies of the C3b/c, C3bBbP and TCC generation in fluid phase during spontaneous activation were analysed. Patients with acute aHUS showed elevated levels of C3b/c (P < 0·01), C3bBbP (P < 0·0001) and TCC (P < 0·0001) in EDTA plasma, while values of patients in remission were normal, compared to those of healthy controls. Using data from a single aHUS patient with complement factor B mutation we illustrated normalization of complement activation during aHUS recovery. Serum samples from patients in remission showed normal in vitro patterns of complement activation and demonstrated normal kinetics of complement activation in the fluid phase. Our data indicate that while aHUS patients have clearly activated complement in acute phase of the disease, this is not the case in remission of aHUS. This knowledge provides important insight into complement regulation in aHUS and may have an impact on monitoring of these patients, particularly when using complement inhibition therapy.
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Affiliation(s)
- E B Volokhina
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - D Westra
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - T J A M van der Velden
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - N C A J van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - T E Mollnes
- Department of Immunology, Oslo University Hospital, Oslo, Norway.,K. G. Jebsen IRC, University of Oslo, Oslo, Norway.,Research Laboratory, Nordland Hospital, Bodø, Norway.,Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - L P van den Heuvel
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
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33
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Davin JC, van de Kar NCAJ. Advances and challenges in the management of complement-mediated thrombotic microangiopathies. Ther Adv Hematol 2015; 6:171-85. [PMID: 26288712 PMCID: PMC4530367 DOI: 10.1177/2040620715577613] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Complement activation plays a major role in several renal pathophysiological conditions. The three pathways of complement lead to C3 activation, followed by the formation of the anaphylatoxin C5a and the terminal membrane attack complex (MAC) in blood and at complement activating surfaces, lead to a cascade of events responsible for inflammation and for the induction of cell lysis. In case of ongoing uncontrolled complement activation, endothelial cells activation takes place, leading to events in which at the end thrombotic microangiopathy can occur. Atypical haemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy characterized by excessive complement activation on the surface of the microcirculation. It is a severe, rare disease which leads to end-stage renal failure (ESRF) and/or to death in more than 50% of patients without treatment. In the first decade of the second millennium, huge progress in understanding the aetiology of this disease was made, which paved the way to better treatment. First, protocols of plasma therapy for treatment, prevention of relapses and for renal transplantation in those patients were set up. Secondly, in some severe cases, combined kidney and liver transplantation was reported. Finally, at the end of this decade, the era of complement inhibitors, as anti-C5 monoclonal antibody (anti-C5 mAb) began. The past five years have seen growing evidence of the favourable effect of anti-C5 mAb in aHUS which has made this drug the first-line treatment in this disease. The possible complication of meningococcal infection needs appropriate vaccination before its use. Unfortunately, the worldwide use of anti-C5 mAb is limited by its very high price. In the future, extension of indications for anti-C5 mAb use, the elaboration of generics and of mAbs directed towards other complement factors of the terminal pathway of the complement system might succeed in reducing the cost of this new valuable therapeutic approach and render it available worldwide for patients from all social classes.
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Affiliation(s)
- Jean-Claude Davin
- Paediatric Nephrology Department, Emma Children's Hospital-Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam Z-O, The Netherlands
| | - Nicole C A J van de Kar
- Department of Paediatric Nephrology, Radboud University Medical Centre, Amalia Children's Hospital, Nijmegen, The Netherlands
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34
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Liszewski MK, Atkinson JP. Complement regulator CD46: genetic variants and disease associations. Hum Genomics 2015; 9:7. [PMID: 26054645 PMCID: PMC4469999 DOI: 10.1186/s40246-015-0029-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 05/26/2015] [Indexed: 12/23/2022] Open
Abstract
Membrane cofactor protein (MCP; CD46) is an ubiquitously expressed complement regulatory protein that protects host cells from injury by complement. This type-I membrane glycoprotein serves as a cofactor for the serine protease factor I to mediate inactivation of C3b and C4b deposited on host cells. More than 60 disease-associated mutations in MCP have now been identified. The majority of the mutations are linked to a rare thrombotic microangiopathic-based disease, atypical hemolytic uremic syndrome (aHUS), but new putative links to systemic lupus erythematosus, glomerulonephritis, and pregnancy-related disorders among others have also been identified. This review summarizes our current knowledge of disease-associated mutations in this complement inhibitor.
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Affiliation(s)
- M Kathryn Liszewski
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, 660 South Euclid, Saint Louis, MO, 63110, USA.
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, 660 South Euclid, Saint Louis, MO, 63110, USA.
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35
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Nester CM, Barbour T, de Cordoba SR, Dragon-Durey MA, Fremeaux-Bacchi V, Goodship THJ, Kavanagh D, Noris M, Pickering M, Sanchez-Corral P, Skerka C, Zipfel P, Smith RJH. Atypical aHUS: State of the art. Mol Immunol 2015; 67:31-42. [PMID: 25843230 DOI: 10.1016/j.molimm.2015.03.246] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 12/12/2022]
Abstract
Tremendous advances in our understanding of the thrombotic microangiopathies (TMAs) have revealed distinct disease mechanisms within this heterogeneous group of diseases. As a direct result of this knowledge, both children and adults with complement-mediated TMA now enjoy higher expectations for long-term health. In this update on atypical hemolytic uremic syndrome, we review the clinical characteristics; the genetic and acquired drivers of disease; the broad spectrum of environmental triggers; and current diagnosis and treatment options. Many questions remain to be addressed if additional improvements in patient care and outcome are to be achieved in the coming decade.
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Affiliation(s)
- Carla M Nester
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Division of Nephrology, Stead Family Department of Pediatrics, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Thomas Barbour
- Centre for Complement and Inflammation Research, Department of Medicine, Imperial College, London W12 0NN, UK
| | | | - Marie Agnes Dragon-Durey
- Assistance Publique - Hopitaux de Paris, Service d'Immunologie Biologique, Hopital Europeen Georges Pompidou, Paris, France
| | - Veronique Fremeaux-Bacchi
- Assistance Publique - Hopitaux de Paris, Service d'Immunologie Biologique, Hopital Europeen Georges Pompidou, Paris, France
| | - Tim H J Goodship
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - David Kavanagh
- Assistance Publique - Hopitaux de Paris, Service d'Immunologie Biologique, Hopital Europeen Georges Pompidou, Paris, France
| | - Marina Noris
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Ranica, Bergamo, Italy
| | - Matthew Pickering
- Centre for Complement and Inflammation Research, Department of Medicine, Imperial College, London W12 0NN, UK
| | - Pilar Sanchez-Corral
- Unidad de Investigación and Ciber de Enfermedades Raras, Hospital Universitario de La Paz_IdiPAZ, Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Christine Skerka
- Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Peter Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany; Friedrich Schiller University, Jena, Germany
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Division of Nephrology, Stead Family Department of Pediatrics, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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36
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Kavanagh D, Yu Y, Schramm EC, Triebwasser M, Wagner EK, Raychaudhuri S, Daly MJ, Atkinson JP, Seddon JM. Rare genetic variants in the CFI gene are associated with advanced age-related macular degeneration and commonly result in reduced serum factor I levels. Hum Mol Genet 2015; 24:3861-70. [PMID: 25788521 PMCID: PMC4459386 DOI: 10.1093/hmg/ddv091] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/09/2015] [Indexed: 12/13/2022] Open
Abstract
To assess a potential diagnostic and therapeutic biomarker for age-related macular degeneration (AMD), we sequenced the complement factor I gene (CFI) in 2266 individuals with AMD and 1400 without, identifying 231 individuals with rare genetic variants. We evaluated the functional impact by measuring circulating serum factor I (FI) protein levels in individuals with and without rare CFI variants. The burden of very rare (frequency <1/1000) variants in CFI was strongly associated with disease (P = 1.1 × 10−8). In addition, we examined eight coding variants with counts ≥5 and saw evidence for association with AMD in three variants. Individuals with advanced AMD carrying a rare CFI variant had lower mean FI compared with non-AMD subjects carrying a variant (P < 0.001). Further new evidence that FI levels drive AMD risk comes from analyses showing individuals with a CFI rare variant and low FI were more likely to have advanced AMD (P = 5.6 × 10−5). Controlling for covariates, low FI increased the risk of advanced AMD among those with a variant compared with individuals without advanced AMD with a rare CFI variant (OR 13.6, P = 1.6 × 10−4), and also compared with control individuals without a rare CFI variant (OR 19.0, P = 1.1 × 10−5). Thus, low FI levels are strongly associated with rare CFI variants and AMD. Enhancing FI activity may be therapeutic and measuring FI provides a screening tool for identifying patients who are most likely to benefit from complement inhibitory therapy.
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Affiliation(s)
- David Kavanagh
- Institute of Genetic Medicine, Newcastle University, International Centre for Life, Newcastle upon Tyne, UK
| | - Yi Yu
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, MA, USA
| | - Elizabeth C Schramm
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Triebwasser
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Erin K Wagner
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, MA, USA
| | - Soumya Raychaudhuri
- Partners HealthCare Center for Personalized Genetic Medicine, Boston, MA, USA, Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA, Division of Genetics, Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Mark J Daly
- Partners HealthCare Center for Personalized Genetic Medicine, Boston, MA, USA, Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA, Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Johanna M Seddon
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, MA, USA, Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA and Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, MA, USA
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37
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Verhave JC, Wetzels JFM, van de Kar NCAJ. Novel aspects of atypical haemolytic uraemic syndrome and the role of eculizumab. Nephrol Dial Transplant 2014; 29 Suppl 4:iv131-41. [PMID: 25165180 DOI: 10.1093/ndt/gfu235] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The haemolytic uraemic syndrome (HUS) is part of a spectrum of thrombotic microangiopathies. The most common etiologies of HUS are the ones seen in childhood caused by an infection of Shiga toxin-producing Escherichia coli, HUS caused by an infection with Streptococcus pneumoniae and HUS due to abnormalities in the alternative pathway of the complement system. In the past decade, enormous progress has been made in understanding the pathogenesis in the latter group of patients. The analysis of genes that encode for complement regulatory proteins and the development of assays for measuring the activity of ADAMTS13 and the detection of antibodies against factor H contributed significantly to the diagnostic tools in patients with HUS. These assays have made it possible to clearly differentiate between thrombotic thrombocytopenic purpura and various forms of HUS. With the introduction of eculizumab, a monoclonal anti-C5 inhibitor, in the clinical arena as effective treatment of most complement-mediated forms of HUS, a new era of treatment in HUS has begun. We review the recent advances in HUS, with the focus on treatment. We discuss unsolved questions, which should be addressed in future studies.
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Affiliation(s)
- Jacobien C Verhave
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole C A J van de Kar
- Department of Paediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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Syndrome hémolytique et urémique atypique : pour qui l’éculizumab ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0928-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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39
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Parikova A, Fronek JP, Viklicky O. Living-donor kidney transplantation for atypical haemolytic uremic syndrome with pre-emptive eculizumab use. Transpl Int 2014; 28:366-9. [DOI: 10.1111/tri.12440] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alena Parikova
- Department of Nephrology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Jiri P Fronek
- Department of Transplant Surgery; Institute for Clinical and Experimental Medicine; Prague Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology; Institute for Clinical and Experimental Medicine; Prague Czech Republic
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40
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Abstract
Hemolytic uremic syndrome (HUS) is a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. The atypical form of HUS is a disease characterized by complement overactivation. Inherited defects in complement genes and acquired autoantibodies against complement regulatory proteins have been described. Incomplete penetrance of mutations in all predisposing genes is reported, suggesting that a precipitating event or trigger is required to unmask the complement regulatory deficiency. The underlying genetic defect predicts the prognosis both in native kidneys and after renal transplantation. The successful trials of the complement inhibitor eculizumab in the treatment of atypical HUS will revolutionize disease management.
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Affiliation(s)
- David Kavanagh
- The Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK.
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41
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Marinozzi MC, Vergoz L, Rybkine T, Ngo S, Bettoni S, Pashov A, Cayla M, Tabarin F, Jablonski M, Hue C, Smith RJ, Noris M, Halbwachs-Mecarelli L, Donadelli R, Fremeaux-Bacchi V, Roumenina LT. Complement factor B mutations in atypical hemolytic uremic syndrome-disease-relevant or benign? J Am Soc Nephrol 2014; 25:2053-65. [PMID: 24652797 DOI: 10.1681/asn.2013070796] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a genetic ultrarare renal disease associated with overactivation of the alternative pathway of complement. Four gain-of-function mutations that form a hyperactive or deregulated C3 convertase have been identified in Factor B (FB) ligand binding sites. Here, we studied the functional consequences of 10 FB genetic changes recently identified from different aHUS cohorts. Using several tests for alternative C3 and C5 convertase formation and regulation, we identified two gain-of-function and potentially disease-relevant mutations that formed either an overactive convertase (M433I) or a convertase resistant to decay by FH (K298Q). One mutation (R178Q) produced a partially cleaved protein with no ligand binding or functional activity. Seven genetic changes led to near-normal or only slightly reduced ligand binding and functional activity compared with the most common polymorphism at position 7, R7. Notably, none of the algorithms used to predict the disease relevance of FB mutations agreed completely with the experimental data, suggesting that in silico approaches should be undertaken with caution. These data, combined with previously published results, suggest that 9 of 15 FB genetic changes identified in patients with aHUS are unrelated to disease pathogenesis. This study highlights that functional assessment of identified nucleotide changes in FB is mandatory to confirm disease association.
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Affiliation(s)
- Maria Chiara Marinozzi
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Laura Vergoz
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Tania Rybkine
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Stephanie Ngo
- Assistance Publique-Hôpitaux de Paris, Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Serena Bettoni
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Bergamo, Italy
| | - Anastas Pashov
- Molecular Medicine, Stephan Angelov Institute of Microbiology, Bulgarian Academy of Sciences, Sofia, Bulgaria
| | - Mathieu Cayla
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Fanny Tabarin
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Mathieu Jablonski
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Christophe Hue
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Richard J Smith
- Molecular Otolaryngology and Renal Research Laboratories and Rare Renal Disease Clinic, Departments of Pediatrics and Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa; and
| | - Marina Noris
- Laboratory of Immunology and Genetics of Transplantation and Rare Diseases, Mario Negri Institute for Pharmacological Research, Ranica, Bergamo, Italy
| | - Lise Halbwachs-Mecarelli
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France
| | - Roberta Donadelli
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Bergamo, Italy
| | - Veronique Fremeaux-Bacchi
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Assistance Publique-Hôpitaux de Paris, Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Lubka T Roumenina
- Institut National de la Santé et de la Recherche Médicale UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, Paris, France; Université Paris Descartes Sorbonne Paris-Cité, Paris, France; Université Pierre et Marie Curie (Paris-6), Paris, France;
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Abstract
CD46 is an important regulator of the complement system by preventing unwanted deposition of the complement activation products and opsonins C3b/C4b onto self-tissue. Recently, intracellular signals mediated by CD46 activation on several distinct human cell types have demonstrated that CD46 also plays decisive roles in immuneregulation. The growing recognition of CD46 as key regulator in several vital biological processes, led to increased demand in sensitive methods for monitoring CD46 expression and changes thereof on cells and in tissues. Here we describe a method, which allows for studying CD46 expression on the surface of cells using specific antibodies in combination with fluorescence-activated cell sorting (FACS) analysis.
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Affiliation(s)
- Martin Kolev
- Division of Transplantation Immunology and Mucosal Biology, MRC Centre for Transplantation, King's College London, Guy's Hospital, London, UK
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43
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Boon CJ, van de Ven JP, Hoyng CB, den Hollander AI, Klevering BJ. Cuticular drusen: Stars in the sky. Prog Retin Eye Res 2013; 37:90-113. [DOI: 10.1016/j.preteyeres.2013.08.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 08/14/2013] [Accepted: 08/19/2013] [Indexed: 12/24/2022]
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Haerynck F, Stordeur P, Vandewalle J, Van Coster R, Bordon V, De Baets F, Schelstraete P, Javaux C, Bouvry MR, Fremeaux-Bacchi V, Dehoorne J. Complete Factor I Deficiency Due to Dysfunctional Factor I with Recurrent Aseptic Meningo-Encephalitis. J Clin Immunol 2013; 33:1293-301. [DOI: 10.1007/s10875-013-9944-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 09/30/2013] [Indexed: 11/29/2022]
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45
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Cooper DN, Krawczak M, Polychronakos C, Tyler-Smith C, Kehrer-Sawatzki H. Where genotype is not predictive of phenotype: towards an understanding of the molecular basis of reduced penetrance in human inherited disease. Hum Genet 2013; 132:1077-130. [PMID: 23820649 PMCID: PMC3778950 DOI: 10.1007/s00439-013-1331-2] [Citation(s) in RCA: 407] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 06/15/2013] [Indexed: 02/06/2023]
Abstract
Some individuals with a particular disease-causing mutation or genotype fail to express most if not all features of the disease in question, a phenomenon that is known as 'reduced (or incomplete) penetrance'. Reduced penetrance is not uncommon; indeed, there are many known examples of 'disease-causing mutations' that fail to cause disease in at least a proportion of the individuals who carry them. Reduced penetrance may therefore explain not only why genetic diseases are occasionally transmitted through unaffected parents, but also why healthy individuals can harbour quite large numbers of potentially disadvantageous variants in their genomes without suffering any obvious ill effects. Reduced penetrance can be a function of the specific mutation(s) involved or of allele dosage. It may also result from differential allelic expression, copy number variation or the modulating influence of additional genetic variants in cis or in trans. The penetrance of some pathogenic genotypes is known to be age- and/or sex-dependent. Variable penetrance may also reflect the action of unlinked modifier genes, epigenetic changes or environmental factors. At least in some cases, complete penetrance appears to require the presence of one or more genetic variants at other loci. In this review, we summarize the evidence for reduced penetrance being a widespread phenomenon in human genetics and explore some of the molecular mechanisms that may help to explain this enigmatic characteristic of human inherited disease.
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Affiliation(s)
- David N. Cooper
- Institute of Medical Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN UK
| | - Michael Krawczak
- Institute of Medical Informatics and Statistics, Christian-Albrechts University, 24105 Kiel, Germany
| | | | - Chris Tyler-Smith
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA UK
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46
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Wong EKS, Goodship THJ, Kavanagh D. Complement therapy in atypical haemolytic uraemic syndrome (aHUS). Mol Immunol 2013; 56:199-212. [PMID: 23810412 PMCID: PMC3899040 DOI: 10.1016/j.molimm.2013.05.224] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 05/10/2013] [Indexed: 12/22/2022]
Abstract
Central to the pathogenesis of atypical haemolytic uraemic syndrome (aHUS) is over-activation of the alternative pathway of complement. Inherited defects in complement genes and autoantibodies against complement regulatory proteins have been described. The use of plasma exchange to replace non-functioning complement regulators and hyper-functional complement components in addition to the removal of CFH-autoantibodies made this the ‘gold-standard’ for management of aHUS. In the last 4 years the introduction of the complement inhibitor Eculizumab has revolutionised the management of aHUS. In this review we shall discuss the available literature on treatment strategies to date.
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Affiliation(s)
- Edwin K S Wong
- The Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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47
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Kemper C, Köhl J. Novel roles for complement receptors in T cell regulation and beyond. Mol Immunol 2013; 56:181-90. [PMID: 23796748 DOI: 10.1016/j.molimm.2013.05.223] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 05/20/2013] [Indexed: 12/16/2022]
Abstract
Complement receptors are expressed on cells of the innate and the adaptive immune system. They play important roles in pathogen and danger sensing as they translate the information gathered by complement fluid phase sensors into cellular responses. Further, they control complement activation on viable and apoptotic host cells, clearance of immune complexes and mediate opsonophagocytosis. More recently, evidence has accumulated that complement receptors form a complex network with other innate receptors systems such as the Toll-like receptors, the Notch signaling system, IgG Fc receptors and C-type lectin receptors contributing to the benefit and burden of innate and adaptive immune responses in autoimmune and allergic diseases as well as in cancer and transplantation. Here, we will discuss recent developments and emerging concepts of complement receptor activation and regulation with a particular focus on the differentiation, maintenance and contraction of effector and regulatory T cells.
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Affiliation(s)
- Claudia Kemper
- Division of Transplant Immunology and Mucosal Biology, MRC Centre for Transplantation, King's College London, Guy's Hospital, London, UK.
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48
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Kolev M, Le Friec G, Kemper C. The role of complement in CD4+ T cell homeostasis and effector functions. Semin Immunol 2013; 25:12-9. [DOI: 10.1016/j.smim.2013.04.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 04/30/2013] [Indexed: 01/22/2023]
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49
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Fremeaux-Bacchi V, Fakhouri F, Garnier A, Bienaimé F, Dragon-Durey MA, Ngo S, Moulin B, Servais A, Provot F, Rostaing L, Burtey S, Niaudet P, Deschênes G, Lebranchu Y, Zuber J, Loirat C. Genetics and outcome of atypical hemolytic uremic syndrome: a nationwide French series comparing children and adults. Clin J Am Soc Nephrol 2013; 8:554-62. [PMID: 23307876 DOI: 10.2215/cjn.04760512] [Citation(s) in RCA: 487] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Atypical hemolytic uremic syndrome (aHUS) is a rare complement-mediated kidney disease that was first recognized in children but also affects adults. This study assessed the disease presentation and outcome in a nationwide cohort of patients with aHUS according to the age at onset and the underlying complement abnormalities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 214 patients with aHUS were enrolled between 2000 and 2008 and screened for mutations in the six susceptibility factors for aHUS and for anti-factor H antibodies. RESULTS Onset of aHUS occurred as frequently during adulthood (58.4%) as during childhood (41.6%). The percentages of patients who developed the disease were 23%, 40%, 70%, and 98% by age 2, 18, 40, and 60 years, respectively. Mortality was higher in children than in adults (6.7% versus 0.8% at 1 year) (P=0.02), but progression to ESRD after the first aHUS episode was more frequent in adults (46% versus 16%; P<0.001). Sixty-one percent of patients had mutations in their complement genes. The renal outcome was not significantly different in adults regardless of genetic background. Only membrane cofactor protein (MCP) and undetermined aHUS were less severe in children than adults. The frequency of relapse after 1 year was 92% in children with MCP-associated HUS and approximately 30% in all other subgroups. CONCLUSION Mortality rate was higher in children than adults with aHUS, but renal prognosis was worse in adults than children. In children, the prognosis strongly depends on the genetic background.
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Affiliation(s)
- Véronique Fremeaux-Bacchi
- Service d'Immunologie Biologique, Hôpital Europeén Georges Pompidou, 20-40 rue Leblanc, Paris cedex 15, France.
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50
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Wang FM, Yu F, Tan Y, Song D, Zhao MH. Serum complement factor H is associated with clinical and pathological activities of patients with lupus nephritis. Rheumatology (Oxford) 2012; 51:2269-77. [PMID: 22956549 DOI: 10.1093/rheumatology/kes218] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate serum complement factor H (CFH) and its associations with clinical and pathological features in patients with LN. METHODS Serum CFH was detected in 241 LN patients, 38 active and 11 inactive patients with SLE without clinical evidence of renal involvement and 51 normal controls. Serum CFH autoantibodies and CFH Tyr402His were screened in the 241 LN patients. CFH deposition in kidneys was detected in some patients. RESULTS Serum CFH levels in patients with LN at active phase were significantly lower than in 38 SLE patients or in normal controls. No serum anti-CFH autoantibodies were detected in patients with LN, and there was no significant difference in CFH Tyr402His distribution between patients with LN and normal controls. Glomerular expression of CFH was stronger than in normal controls. Serum CFH levels were mildly negatively associated with SLEDAI scores (r = -0.204, P = 0.001) and positively associated with serum C3 (r = 0.367, P < 0.001) and haemoglobulin levels (r = 0.193, P = 0.003). Patients with LN class III, subclass IV-S and those with thrombotic microangiopathy had the lowest serum CFH. CONCLUSION Serum CFH levels were associated with disease activity of LN.
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Affiliation(s)
- Feng-mei Wang
- Department of Medicine, Renal Division, Peking University First Hospital, Beijing, China
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