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Bouwmeester RN, Engel LJ, Altena W, Renette C, van Daelen C, van Kempen E, de Wildt R, van de Kar NC. Living with Atypical Hemolytic Uremic Syndrome in the Netherlands: Patient and Family Perspective. Kidney Int Rep 2024; 9:2189-2197. [PMID: 39081735 PMCID: PMC11284443 DOI: 10.1016/j.ekir.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) poses a significant health challenge due to its rarity and severity within the spectrum of thrombotic microangiopathy. Despite efforts to optimize and personalize health care for patients with aHUS, understanding the individual experiences, needs, and desires of patients with aHUS and their relatives remains limited. Methods Here, we present a nationwide, exploratory, qualitative interview study with a direct content analysis approach. In-depth interviews and a 6-week evaluation were audio-recorded and conducted using a semistructured topic guide, based on the Institute for Positive Health (IPH) model. Results Analysis of 10 interviews involving 6 patients with aHUS and 13 relatives revealed the prevalence of long-term disease symptoms in adult patients, notably fatigue, which significantly impacted daily functioning. Moreover, the resilience demonstrated by patients and their relatives was noteworthy; however, the acute phase of aHUS and the unpredictable nature of disease recurrence could profoundly affect mental well-being. The emotional toll of aHUS is pervasive, with feelings of fear, guilt, and trauma persisting across disease phases in both patients and relatives. Challenges in medical care, including delays in diagnosis and the need for personalized and uniform protocols, were highlighted. Support was deemed crucial, indicating the necessity for enhancements in the accessibility to comprehensible disease information and psychological counseling. Finally, complexities surrounding genetic testing and carriership were discussed. Conclusion This study underscores the profound, enduring, and multifaced impact of aHUS. The insights gleaned from the experiences and needs of patients with aHUS and their relatives could lay the foundation for development and implementation of more personalized innovations in aHUS health care.
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Affiliation(s)
- Romy N. Bouwmeester
- Radboud University Medical Center, Amalia Children’s Hospital, Department of Pediatric Nephrology, Nijmegen, Netherlands
| | - Leonie J. Engel
- Radboud University Medical Center, Amalia Children’s Hospital, Department of Pediatric Nephrology, Nijmegen, Netherlands
| | - Wim Altena
- Dutch Kidney Patients Association, Bussum, Netherlands
| | | | - Clim van Daelen
- Dutch Kidney Patients Association, Bussum, Netherlands
- The Netherlands Patients Federation, Utrecht, Netherlands
| | | | | | - Nicole C.A.J. van de Kar
- Radboud University Medical Center, Amalia Children’s Hospital, Department of Pediatric Nephrology, Nijmegen, Netherlands
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2
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Shah M, El Chaer F, Ho DY, El Boghdadly Z. Managing infectious challenges in the age of molecular-targeted therapies for adult hematological malignancies. Transpl Infect Dis 2024; 26:e14283. [PMID: 38698640 DOI: 10.1111/tid.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 05/05/2024]
Abstract
Over the last decade, the therapeutic landscape for hematological malignancies (HMs) has witnessed a remarkable surge in the development of novel biological and small-molecule-targeted immunomodulatory agents. These therapies have drastically improved survival, but some come at the cost of increased risk of bacterial, viral, and/or fungal infections and on-target off-tumor immunological side effects. To mitigate such risks, physicians must be well informed about infectious complications and necessary preventive measures, such as screening, vaccinations, and antimicrobial prophylaxis. Furthermore, physicians should be vigilant about the noninfectious side effects of these agents that can mimic infections and understand their potential drug-drug interactions with antimicrobials. Strengthening and harmonizing the current surveillance and reporting system for drug-associated infections in real-world settings is essential to better ascertain the potential infections associated with these agents. In this review, we aimed to summarize the infection risks associated with novel agents used for specific HMs and outline recommended strategies for monitoring and prophylaxis.
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Affiliation(s)
- Manan Shah
- Division of Hematology and Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, Virginia, USA
| | - Dora Y Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, Virginia, USA
| | - Zeinab El Boghdadly
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
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3
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Fattizzo B, Rampi N, Barcellini W. Vaccinations in hematological patients in the era of target therapies: Lesson learnt from SARS-CoV-2. Blood Rev 2023; 60:101077. [PMID: 37029066 PMCID: PMC10043962 DOI: 10.1016/j.blre.2023.101077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/14/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023]
Abstract
Novel targeting agents for hematologic diseases often exert on- or off-target immunomodulatory effects, possibly impacting on response to anti-SARS-CoV-2 vaccinations and other vaccines. Agents that primarily affect B cells, particularly anti-CD20 monoclonal antibodies (MoAbs), Bruton tyrosine kinase inhibitors, and anti-CD19 chimeric antigen T-cells, have the strongest impact on seroconversion. JAK2, BCL-2 inhibitors and hypomethylating agents may hamper immunity but show a less prominent effect on humoral response to vaccines. Conversely, vaccine efficacy seems not impaired by anti-myeloma agents such as proteasome inhibitors and immunomodulatory agents, although lower seroconversion rates are observed with anti-CD38 and anti-BCMA MoAbs. Complement inhibitors for complement-mediated hematologic diseases and immunosuppressants used in aplastic anemia do not generally affect seroconversion rate, but the extent of the immune response is reduced under steroids or anti-thymocyte globulin. Vaccination is recommended prior to treatment or as far as possible from anti-CD20 MoAb (at least 6 months). No clearcut indications for interrupting continuous treatment emerged, and booster doses significantly improved seroconversion. Cellular immune response appeared preserved in several settings.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Nicolò Rampi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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4
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Ispasanie E, Muri L, Schmid M, Schubart A, Thorburn C, Zamurovic N, Holbro T, Kammüller M, Pluschke G. In vaccinated individuals serum bactericidal activity against B meningococci is abrogated by C5 inhibition but not by inhibition of the alternative complement pathway. Front Immunol 2023; 14:1180833. [PMID: 37457736 PMCID: PMC10349132 DOI: 10.3389/fimmu.2023.1180833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Several diseases caused by the dysregulation of complement activation can be treated with inhibitors of the complement components C5 and/or C3. However, complement is required for serum bactericidal activity (SBA) against encapsulated Gram-negative bacteria. Therefore, C3 and C5 inhibition increases the risk of invasive disease, in particular by Neisseria meningitidis. As inhibitors against complement components other than C3 and C5 may carry a reduced risk of infection, we compared the effect of inhibitors targeting the terminal pathway (C5), the central complement component C3, the alternative pathway (FB and FD), and the lectin pathway (MASP-2) on SBA against serogroup B meningococci. Methods Serum from adults was collected before and after vaccination with the meningococcal serogroup B vaccine 4CMenB and tested for meningococcal killing. Since the B capsular polysaccharide is structurally similar to certain human polysaccharides, 4CMenB was designed to elicit antibodies against meningococcal outer membrane proteins. Results While only a few pre-vaccination sera showed SBA against the tested B meningococcal isolates, 4CMenB vaccination induced potent complement-activating IgG titers against isolates expressing a matching allele of the bacterial cell surface-exposed factor H-binding protein (fHbp). SBA triggered by these cell surface protein-specific antibodies was blocked by C5 and reduced by C3 inhibition, whereas alternative (factor B and D) and lectin (MASP-2) pathway inhibitors had no effect on the SBA of post-4CMenB vaccination sera. Discussion Compared to the SBA triggered by A,C,W,Y capsule polysaccharide conjugate vaccination, SBA against B meningococci expressing a matching fHbp allele was remarkably resilient against the alternative pathway inhibition.
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Affiliation(s)
- Emma Ispasanie
- Swiss Tropical and Public Health Institute, Molecular Immunology Unit, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Lukas Muri
- Swiss Tropical and Public Health Institute, Molecular Immunology Unit, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Marc Schmid
- Swiss Tropical and Public Health Institute, Molecular Immunology Unit, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Anna Schubart
- Novartis Institutes for Biomedical Research, Department Autoimmunity, Transplantation and Inflammation, Basel, Switzerland
| | | | - Natasa Zamurovic
- Novartis Institutes for Biomedical Research, Translational Medicine-Preclinical Safety, Basel, Switzerland
| | - Thomas Holbro
- Global Drug Development, Novartis Pharma AG, Basel, Switzerland
| | - Michael Kammüller
- Novartis Institutes for Biomedical Research, Translational Medicine-Preclinical Safety, Basel, Switzerland
| | - Gerd Pluschke
- Swiss Tropical and Public Health Institute, Molecular Immunology Unit, Basel, Switzerland
- University of Basel, Basel, Switzerland
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5
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Girmenia C, Barcellini W, Bianchi P, Di Bona E, Iori AP, Notaro R, Sica S, Zanella A, De Vivo A, Barosi G, Risitano A. Management of infection in PNH patients treated with eculizumab or other complement inhibitors: Unmet clinical needs. Blood Rev 2023; 58:101013. [PMID: 36117056 DOI: 10.1016/j.blre.2022.101013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/21/2022] [Accepted: 09/01/2022] [Indexed: 11/02/2022]
Abstract
This article presents the results of group discussion among an ad hoc constituted panel of experts aimed at identifying and addressing unmet clinical needs (UCNs) in the management of infectious risk associated with eculizumab or new terminal complement inhibitors (CIs) in paroxysmal nocturnal hemoglobinuria (PNH). With the Delphi technique, the most clinically relevant UCNs in PNH patients candidate to or on terminal CI were selected. They resulted to be: optimizing the infection prevention measures; developing non pharmacological infectious risk-mitigation strategies; improving the management of disease exacerbation during infectious complications. For each of these issues consensus opinions were provided and, when appropriate, proposals for advancement in clinical practice were addressed. The hope is that this comprehensive overview will serve to improve the practice of CIs therapy and inform the design and implementation of new studies in the field.
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Affiliation(s)
- Corrado Girmenia
- Hematology, Department of Hematology, Oncology and Dermatology, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
| | - Wilma Barcellini
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit, Milan, Italy
| | - Paola Bianchi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit, Milan, Italy
| | - Eros Di Bona
- Division of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Anna Paola Iori
- Department of Hematology, Oncology and Dermatology, Azienda Policlinico Umberto I, Rome, Italy
| | - Rosario Notaro
- Azienda Ospedaliera Universitaria Careggi, Firenze, Italy; Instituto per lo Studio, la Prevenzione e la Rete Oncologica, Firenze, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Alberto Zanella
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico Hematology Unit, Pathophysiology of Anemias Unit, Milan, Italy
| | - Antonio De Vivo
- Hematology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Giovanni Barosi
- Center for the Study of Myeloifbrosis, IRCCS policlinico S. Matteo Foundation, Pavia, Italy
| | - Antonio Risitano
- Federico II University of Naples, Naples, Italy; AORN Moscati, Avellino, Italy
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Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
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Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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7
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Vonbrunn E, Büttner-Herold M, Amann K, Daniel C. Complement Inhibition in Kidney Transplantation: Where Are We Now? BioDrugs 2023; 37:5-19. [PMID: 36512315 PMCID: PMC9836999 DOI: 10.1007/s40259-022-00567-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/14/2022]
Abstract
Kidney transplantation is a life-saving strategy for patients with end-stage renal disease. Although progress has been made in the field of transplantation medicine in recent decades in terms of surgical techniques and immunosuppression, long-term organ survival remains a challenge. Also, for reasons of organ shortage, there is an unmet need for new therapeutic approaches to improve the long-term survival of transplants. There is increasing evidence that the complement system plays a crucial role in various pathological events after transplantation, including ischemia/reperfusion injury as well as rejection episodes. The complement system is part of the innate immune system and plays a crucial role in the defense against pathogens but is also involved in tissue homeostasis. However, the tightly regulated complement system can become dysregulated or activated by non-infectious stimuli, then targeting the organism's own cells and leading to inflammatory tissue damage that exacerbates injury. In this review, we will highlight the role of the complement system after transplantation and discuss ongoing and potential therapeutic approaches.
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Affiliation(s)
- Eva Vonbrunn
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Krankenhausstr. 8-10, 91054 Erlangen, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Krankenhausstr. 8-10, 91054 Erlangen, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Krankenhausstr. 8-10, 91054 Erlangen, Germany
| | - Christoph Daniel
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Krankenhausstr. 8-10, 91054 Erlangen, Germany
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8
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Muri L, Schubart A, Thorburn C, Zamurovic N, Holbro T, Kammüller M, Pluschke G, Ispasanie E. Inhibition of the different complement pathways has varying impacts on the serum bactericidal activity and opsonophagocytosis against Haemophilus influenzae type b. Front Immunol 2022; 13:1020580. [PMID: 36578495 PMCID: PMC9791579 DOI: 10.3389/fimmu.2022.1020580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022] Open
Abstract
Defense against Haemophilus influenzae type b (Hib) is dependent on antibodies and complement, which mediate both serum bactericidal activity (SBA) and opsonophagocytosis. Here we evaluated the influence of capsule-specific antibodies and complement inhibitors targeting the central component C3, the alternative pathway (AP; fB, fD), the lectin pathway (LP; MASP-2) and the terminal pathway (C5) on both effector functions. Findings may be relevant for the treatment of certain diseases caused by dysregulation of the complement system, where inhibitors of complement factors C3 or C5 are used. Inhibitors against other complement components are being evaluated as potential alternative treatment options that may carry a reduced risk of infection by encapsulated bacteria. Serum and reconstituted blood of healthy adults were tested for bactericidal activity before and after vaccination with the Hib capsule-conjugate vaccine ActHIB. Most sera had bactericidal activity prior to vaccination, but vaccination significantly enhanced SBA titers. Independently of the vaccination status, both C3 and C5 inhibition abrogated SBA, whereas inhibition of the LP had no effect. AP inhibition had a major inhibitory effect on SBA of pre- vaccination serum, but vaccination mitigated this inhibition for all disease isolates tested. Despite this, SBA-mediated killing of some Hib isolates remained retarded. Even for the most serum-resistant isolate, SBA was the dominating defense mechanism in reconstituted whole blood, as addition of blood cells to the serum did not enhance bacterial killing. Limited Fc receptor-mediated opsonophagocytosis was unmasked when bacterial killing by the membrane attack complex was blocked. In the presence of C3 or C5 inhibitors, addition of post-vaccination, but not of pre-vaccination serum to the blood cells triggered opsonophagocytosis, leading to suppression of bacterial multiplication. Taken together, our data indicate that for host defense against Hib, killing by SBA is more efficient than by blood cell opsonophagocytosis. However, additional defense mechanisms, such as bacterial clearance by spleen and liver, may play an important role in preventing Hib-mediated sepsis, in particular for Hib isolates with increased serum-resistance. Results indicate potentially improved safety profile of AP inhibitors over C3 and C5 inhibitors as alternative therapeutic agents in patients with increased susceptibility to Hib infection.
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Affiliation(s)
- Lukas Muri
- Molecular Immunology Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland,University of Basel, Basel, Switzerland
| | - Anna Schubart
- Department Autoimmunity, Transplantation and Inflammation, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | | | - Natasa Zamurovic
- Translational Medicine-Preclinical Safety, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Thomas Holbro
- Global Drug Development, Novartis Pharma AG, Basel, Switzerland
| | - Michael Kammüller
- Translational Medicine-Preclinical Safety, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Gerd Pluschke
- Molecular Immunology Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland,University of Basel, Basel, Switzerland,*Correspondence: Gerd Pluschke,
| | - Emma Ispasanie
- Molecular Immunology Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland,University of Basel, Basel, Switzerland
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9
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Bouwmeester RN, Duineveld C, Wijnsma KL, Bemelman FJ, van der Heijden JW, van Wijk JA, Bouts AH, van de Wetering J, Dorresteijn E, Berger SP, Gracchi V, van Zuilen AD, Keijzer-Veen MG, de Vries AP, van Rooij RW, Engels FA, Altena W, de Wildt R, van Kempen E, Adang EM, ter Avest M, ter Heine R, Volokhina EB, van den Heuvel LP, Wetzels JF, van de Kar NC. Early Eculizumab Withdrawal in Patients With Atypical Hemolytic Uremic Syndrome in Native Kidneys Is Safe and Cost-Effective: Results of the CUREiHUS Study. Kidney Int Rep 2022; 8:91-102. [PMID: 36644349 PMCID: PMC9832049 DOI: 10.1016/j.ekir.2022.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction The introduction of eculizumab has improved the outcome in patients with atypical hemolytic uremic syndrome (aHUS). The optimal treatment strategy is debated. Here, we report the results of the CUREiHUS study, a 4-year prospective, observational study monitoring unbiased eculizumab discontinuation in Dutch patients with aHUS after 3 months of therapy. Methods All pediatric and adult patients with aHUS in native kidneys and a first-time eculizumab treatment were evaluated. In addition, an extensive cost-consequence analysis was conducted. Results A total of 21 patients were included in the study from January 2016 to October 2020. In 17 patients (81%), a complement genetic variant or antibodies against factor H were identified. All patients showed full recovery of hematological thrombotic microangiopathy (TMA) parameters after the start of eculizumab. A renal response was noted in 18 patients. After a median treatment duration of 13.6 weeks (range 2.1-43.9), eculizumab was withdrawn in all patients. During follow-up (80.7 weeks [0.0-236.9]), relapses occurred in 4 patients. Median time to first relapse was 19.5 (14.3-53.6) weeks. Eculizumab was reinitiated within 24 hours in all relapsing patients. At last follow-up, there were no chronic sequelae, i.e., no clinically relevant increase in serum creatinine (sCr), proteinuria, and/or hypertension in relapsing patients. The low sample size and event rate did not allow to determine predictors of relapse. However, relapses only occurred in patients with a likely pathogenic variant. The cost-effectiveness analysis revealed that the total medical expenses of our population were only 30% of the fictive expenses that would have been made when patients received eculizumab every fortnight. Conclusion It is safe and cost-effective to discontinue eculizumab after 3 months of therapy in patients with aHUS in native kidneys. Larger data registries are needed to determine factors associated with suboptimal kidney function recovery during eculizumab treatment, factors to predict relapses, and long-term outcomes of eculizumab discontinuation.
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Affiliation(s)
- Romy N. Bouwmeester
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands,Correspondence: Romy N. Bouwmeester, Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kioa L. Wijnsma
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Frederike J. Bemelman
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Joanna A.E. van Wijk
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Antonia H.M. Bouts
- Department of Pediatric Nephrology, Amsterdam University Medical Center, Emma Children’s Hospital, Amsterdam, the Netherlands
| | | | - Eiske Dorresteijn
- Department of Pediatric Nephrology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Stefan P. Berger
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Valentina Gracchi
- Department of Pediatric Nephrology, University Medical Center Groningen, University of Groningen, Beatrix Children’s Hospital, Groningen, the Netherlands
| | - Arjan D. van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mandy G. Keijzer-Veen
- Department of Pediatric Nephrology, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Aiko P.J. de Vries
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roos W.G. van Rooij
- Department of Pediatric Nephrology, Leiden University Medical Center, Willem-Alexander Children’s Hospital, Leiden, the Netherlands
| | - Flore A.P.T. Engels
- Department of Pediatric Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Wim Altena
- Dutch Kidney Patient Association, Bussum, the Netherlands
| | - Renée de Wildt
- Dutch Kidney Patient Association, Bussum, the Netherlands
| | - Evy van Kempen
- Dutch Kidney Patient Association, Bussum, the Netherlands
| | - Eddy M. Adang
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Mendy ter Avest
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Rob ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Elena B. Volokhina
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Lambertus P.W.J. van den Heuvel
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Nicole C.A.J. van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
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10
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Dunn S, Brocklebank V, Bryant A, Carnell S, Chadwick TJ, Johnson S, Kavanagh D, Lecouturier J, Malina M, Moloney E, Oluboyede Y, Weetman C, Wong EKS, Woodward L, Sheerin N. Safety and impact of eculizumab withdrawal in patients with atypical haemolytic uraemic syndrome: protocol for a multicentre, open-label, prospective, single-arm study. BMJ Open 2022; 12:e054536. [PMID: 36123058 PMCID: PMC9486193 DOI: 10.1136/bmjopen-2021-054536] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/15/2021] [Accepted: 08/18/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Atypical haemolytic uraemic syndrome (aHUS) is a rare, life-threatening disease caused by excessive activation of part of the immune system called complement. Eculizumab is an effective treatment, controlling aHUS in 90% of patients. Due to the risk of relapse, lifelong treatment is currently recommended. Eculizumab treatment is not without problems, foremost being the risk of severe meningococcal infection, the burden of biweekly intravenous injections and the high cost.This paper describes the design of the Stopping Eculizumab Treatment Safely in aHUS trial that aims to establish whether a safety monitoring protocol, including the reintroduction of eculizumab for those who relapse, could be a safe, alternative treatment strategy for patients with aHUS. METHODS AND ANALYSIS This is a multicentre, non-randomised, open-label study of eculizumab withdrawal with continuous monitoring of thrombotic microangiopathy-related serious adverse events using the Bayes factor single-arm design. 30 patients will be recruited to withdraw from eculizumab and have regular blood and urine tests for 24 months, to monitor for disease activity. If relapse occurs, treatment will be restarted within 24 hours of presentation. 20 patients will remain on treatment and complete health economic questionnaires only. An embedded qualitative study will explore the views of participants. ETHICS AND DISSEMINATION A favourable ethical opinion and approval was obtained from the North East-Tyne & Wear South Research Ethics Committee. Outcomes will be disseminated via peer-reviewed articles and conference presentations. TRIAL REGISTRATION NUMBER EudraCT number: 2017-003916-37 and ISRCTN number: ISRCTN17503205.
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Affiliation(s)
- Sarah Dunn
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Victoria Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas J Chadwick
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jan Lecouturier
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Health Economics, Optimax Access, Newcastle upon Tyne, UK
| | - Yemi Oluboyede
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Weetman
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Edwin Kwan Soon Wong
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Len Woodward
- aHUS Alliance Global Action, Newcastle upon Tyne, UK
| | - Neil Sheerin
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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11
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Martire B, Ottaviano G, Sangerardi M, Sgrulletti M, Chini L, Dellepiane RM, Montin D, Rizzo C, Pignata C, Marseglia GL, Moschese V. Vaccinations in Children and Adolescents Treated With Immune-Modifying Biologics: Update and Current Developments. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1485-1496. [PMID: 35085809 DOI: 10.1016/j.jaip.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
Treatment with immune-modifying biologics has positively impacted disease control and quality of life in many patients with immune-mediated disorders. However, the higher susceptibility to common and opportunistic pathogens is of concern. Thus, immunization strategies to control vaccine-preventable diseases represent a critical issue in this population. However, limited data exist on the safety, immunogenicity, and efficacy of available vaccines in patients on biologics, particularly in children. Here, according to published literature and real-life experience and practice, we report the interim indications of the Italian Society of Pediatric Allergology and Immunology (SIAIP) Vaccine Committee and of the Italian Primary Immunodeficiency Network (IPINet) Centers on immunization of children and adolescents receiving biologics. Our aim is to provide a practical guidance for the clinician to ensure optimal protection for patients and the community.
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Affiliation(s)
- Baldassarre Martire
- Pediatrics and Neonatology Unit, Maternal-Infant Department, Monsignor A. R. Dimiccoli Hospital, Barletta, Italy.
| | - Giorgio Ottaviano
- Molecular and Cellular Immunology Unit, Great Ormond Street Institute of Child Health, University College of London, London, UK
| | - Maria Sangerardi
- Department of Pediatrics and Emergency, Pediatric Hospital, Policlinico - University of Bari, Bari, Italy
| | - Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, University of Rome, Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Loredana Chini
- Pediatric Immunopathology and Allergology Unit, University of Rome, Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Rosa Maria Dellepiane
- Pediatric Intermediate Care Unit, Scientific Institute for Research, Hospitalization and Healthcare Foundation (IRCSS); Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Montin
- Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Caterina Rizzo
- Innovation and Clinical Pathways Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences-Section of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, IRCCS Foundation, Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, University of Rome, Tor Vergata, Policlinico Tor Vergata, Rome, Italy
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12
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Complement gene variant effect on relapse of complement-mediated thrombotic microangiopathy after eculizumab cessation. Blood Adv 2022; 7:340-350. [PMID: 35533258 PMCID: PMC9881046 DOI: 10.1182/bloodadvances.2021006416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Eculizumab is effective for complement-mediated thrombotic microangiopathy (CM-TMA), also known as atypical hemolytic uremic syndrome. Although lifelong therapy had been suggested, discontinuation does not universally lead to relapse. Comprehensive data evaluating risk factors for recurrence following discontinuation are limited. Our aim was to systematically review available literature assessing the role of complement genetic variants in this setting. Reports on CM-TMA and eculizumab withdrawal published before 1 January 2021, were included. Key reasons for patient exclusion were no follow-up after drug withdrawal and patients lacking complement genetic testing. Two-hundred eighty patients from 40 publications were included. Median age was 28 years, and 25 patients had a known history of renal transplant. Complement genetic variants were identified in 60%, most commonly in CFH (n = 59) and MCP/CD46 (n = 38). Of patients with a complement gene variant, 51.3% had ≥1 likely pathogenic/pathogenic variant whereas the remaining had variants of uncertain significance (VUS). Overall relapse rate after therapy discontinuation was 29.6%. Relapse rate was highest among patients with CFH variants and MCP/CD46 variants in canonical splice regions. VUS (P < .001) and likely pathogenic/pathogenic variants (P < .001) were associated with increased relapse. Presence of a renal allograft (P = .009); decreasing age (P = .029); and detection of variants in CFH (P < .001), MCP/CD46 (P < .001), or C3 (P < .001) were all independently associated with relapse after eculizumab discontinuation. Eculizumab discontinuation is appropriate in specific patients with CM-TMA. Caution should be exerted when attempting such a strategy in patients with high risk of recurrence, including a subgroup of patients with MCP/CD46 variants.
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13
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Willerton L, Lucidarme J, Walker A, Lekshmi A, Clark SA, Walsh L, Bai X, Lee-Jones L, Borrow R. Antibiotic resistance among invasive Neisseria meningitidis isolates in England, Wales and Northern Ireland (2010/11 to 2018/19). PLoS One 2021; 16:e0260677. [PMID: 34843604 PMCID: PMC8629238 DOI: 10.1371/journal.pone.0260677] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022] Open
Abstract
Invasive meningococcal disease (IMD), caused by Neisseria meningitidis, can have a fatality rate as high as 10%, even with appropriate treatment. In the UK, penicillin is administered to patients in primary care whilst third generation cephalosporins, cefotaxime and ceftriaxone, are administered in secondary care. The first-choice antibiotic for chemoprophylaxis of close contacts is ciprofloxacin, followed by rifampicin. Immunocompromised individuals are often recommended antibiotic chemoprophylaxis and vaccination due to a greater risk of IMD. Resistance to antibiotics among meningococci is relatively rare, however reduced susceptibility and resistance to penicillin are increasing globally. Resistance to third generation cephalosporins is seldom reported, however reduced susceptibility to both cefotaxime and ceftriaxone has been observed. Rifampicin resistance has been reported among meningococci, mainly following prophylaxis, and ciprofloxacin resistance, whilst uncommon, has also been reported across the globe. The Public Health England Meningococcal Reference Unit receives and characterises the majority of isolates from IMD cases in England, Wales and Northern Ireland. This study assessed the distribution of antibiotic resistance to penicillin, rifampicin, ciprofloxacin and cefotaxime among IMD isolates received at the MRU from 2010/11 to 2018/19 (n = 4,122). Out of the 4,122 IMD isolates, 113 were penicillin-resistant, five were ciprofloxacin-resistant, two were rifampicin-resistant, and one was cefotaxime-resistant. Penicillin resistance was due to altered penA alleles whilst rifampicin and ciprofloxacin resistance was due to altered rpoB and gyrA alleles, respectively. Cefotaxime resistance was observed in one isolate which had an altered penA allele containing additional mutations to those harboured by the penicillin-resistant isolates. This study identified several isolates with resistance to antibiotics used for current treatment and prophylaxis of IMD and highlights the need for continued surveillance of resistance among meningococci to ensure continued effective use.
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Affiliation(s)
- Laura Willerton
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Jay Lucidarme
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Andrew Walker
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Aiswarya Lekshmi
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Stephen A. Clark
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Lloyd Walsh
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Xilian Bai
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Lisa Lee-Jones
- Life Sciences Department, Manchester Metropolitan University, Manchester, United Kingdom
| | - Ray Borrow
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, United Kingdom
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14
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Muri L, Ispasanie E, Schubart A, Thorburn C, Zamurovic N, Holbro T, Kammüller M, Pluschke G. Alternative Complement Pathway Inhibition Abrogates Pneumococcal Opsonophagocytosis in Vaccine-Naïve, but Not in Vaccinated Individuals. Front Immunol 2021; 12:732146. [PMID: 34707606 PMCID: PMC8543009 DOI: 10.3389/fimmu.2021.732146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023] Open
Abstract
To assess the relative contribution of opsonisation by antibodies, classical and alternative complement pathways to pneumococcal phagocytosis, we analyzed killing of pneumococci by human blood leukocytes collected from vaccine-naïve and PCV13-vaccinated subjects. With serotype 4 pneumococci as model, two different physiologic opsonophagocytosis assays based on either hirudin-anticoagulated whole blood or on washed cells from EDTA-anticoagulated blood reconstituted with active serum, were compared. Pneumococcal killing was measured in the presence of inhibitors targeting the complement components C3, C5, MASP-2, factor B or factor D. The two assay formats yielded highly consistent and comparable results. They highlighted the importance of alternative complement pathway activation for efficient opsonophagocytic killing in blood of vaccine-naïve subjects. In contrast, alternative complement pathway inhibition did not affect pneumococcal killing in PCV13-vaccinated individuals. Independent of amplification by the alternative pathway, even low capsule-specific antibody concentrations were sufficient to efficiently trigger classical pathway mediated opsonophagocytosis. In heat-inactivated or C3-inhibited serum, high concentrations of capsule-specific antibodies were required to trigger complement-independent opsonophagocytosis. Our findings suggest that treatment with alternative complement pathway inhibitors will increase susceptibility for invasive pneumococcal infection in non-immune subjects, but it will not impede pneumococcal clearance in vaccinated individuals.
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Affiliation(s)
- Lukas Muri
- Molecular Immunology Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Emma Ispasanie
- Molecular Immunology Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Anna Schubart
- Translational Medicine-Preclinical Safety, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | | | - Natasa Zamurovic
- Translational Medicine-Preclinical Safety, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Thomas Holbro
- Novartis Pharma AG, Global Drug Development, Basel, Switzerland
| | - Michael Kammüller
- Translational Medicine-Preclinical Safety, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Gerd Pluschke
- Molecular Immunology Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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15
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Cruz DS, da Silva Santos M, Santos B. Cost-Utility Analysis of Eculizumab for the Treatment of Paroxysmal Nocturnal Hemoglobinuria from the Perspective of the Brazilian Public Health System. Value Health Reg Issues 2021; 26:113-125. [PMID: 34332185 DOI: 10.1016/j.vhri.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 01/12/2021] [Accepted: 03/22/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To perform a first cost-utility analysis of eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria from the perspective of the Brazilian Unified Health System. METHODS A Markov decision model was developed for 35-year-old patients with symptomatic paroxysmal nocturnal hemoglobinuria. We used a cycle length of one month and a time horizon of 20 years. The effectiveness measure was the quality-adjusted life year (QALY). Data were extracted from clinical trials, historical cohorts, and Unified Health System databases. Resource use and costs were estimated from the perspective of the Unified Health System. Deterministic and probabilistic sensitivity analyses were performed. RESULTS The estimated gain in effectiveness with the use of eculizumab was 1.08 QALY through the incremental cost of R$10,959,375.95. The incremental cost-effectiveness ratio was R$10,139,542.84 per QALY, being 331.92 times greater than the Brazilian gross domestic product per capita. In the deterministic sensitivity analysis, the parameters related to the utilities of health states were associated with greater impact in the model. The results of the probabilistic sensitivity analysis with 1000 simulations evidence that 100% of the simulations were not considered cost-effective with the arbitrated willingness to pay R$30,548.40 and R$91,645.20 per QALY. CONCLUSIONS The gain in effectiveness with the use of eculizumab was modest, associated with an unjustifiable incremental cost. Therefore, eculizumab is not a cost-effective drug compared with the current standard of care in the treatment of paroxysmal nocturnal hemoglobinuria from the Brazilian Unified Health System perspective.
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Affiliation(s)
- Daniela Souza Cruz
- Secretaria da Câmara de Regulação do Mercado de Medicamentos, Agência Nacional de Vigilância Sanitária, Brasília, Brasil.
| | | | - Braulio Santos
- Instituto Nacional de Cardiologia, Rio de Janeiro, Brasil
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16
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Infectious Challenges with Novel Antibody–Based Therapies. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Infectious Risks Associated with Biologics Targeting Janus Kinase-Signal Transducer and Activator of Transcription Signaling and Complement Pathway for Inflammatory Diseases. Infect Dis Clin North Am 2021; 34:271-310. [PMID: 32444011 DOI: 10.1016/j.idc.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The recognition of the role of complement and Janus kinase (JAK)-dependent cytokines in the pathogenesis of inflammatory and immune-mediated disorders has revolutionized the treatment of a myriad of rheumatological and inflammatory diseases. C5 inhibitors and Janus kinase inhibitors have emerged as attractive therapeutic options. Because of the blockage of immune pathways, these targeted therapies carry an increased risk of infection. This article reviews the mechanism of action and the approved and off-label indications of the agents with most clinical experience within this drug classes. It discusses the associated risks of infection, proposing screening, prevention, and risk mitigation strategies.
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18
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Different approaches to long-term treatment of aHUS due to MCP mutations: a multicenter analysis. Pediatr Nephrol 2021; 36:463-471. [PMID: 32715379 PMCID: PMC7815604 DOI: 10.1007/s00467-020-04714-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening microangiopathy, frequently causing kidney failure. Inhibition of the terminal complement complex with eculizumab is the only licensed treatment but mostly requires long-term administration and risks severe side effects. The underlying genetic cause of aHUS is thought to influence the severity of initial and recurring episodes, with milder courses in patients with mutations in membrane cofactor protein (MCP). METHODS Twenty pediatric cases of aHUS due to isolated heterozygous MCP mutations were reported from 12 German pediatric nephrology centers to describe initial presentation, timing of relapses, treatment, and kidney outcome. RESULTS The median age of onset was 4.6 years, with a female to male ratio of 1:3. Without eculizumab maintenance therapy, 50% (9/18) of the patients experienced a first relapse after a median period of 3.8 years. Kaplan-Meier analysis showed a relapse-free survival of 93% at 1 year. Four patients received eculizumab long-term treatment, while 3 patients received short courses. We could not show a benefit from complement blockade therapy on long term kidney function, independent of short-term or long-term treatment. To prevent 1 relapse with eculizumab, the theoretical number-needed-to-treat (NNT) was 15 for the first year and 3 for the first 5 years after initial presentation. CONCLUSION Our study shows that heterozygous MCP mutations cause aHUS with a risk of first relapse of about 10% per year, resulting in large NNTs for prevention of relapses with eculizumab. More studies are needed to define an optimal treatment schedule for patients with MCP mutations to minimize the risks of the disease and treatment.
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19
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Sahebnasagh A, Avan R, Saghafi F, Mojtahedzadeh M, Sadremomtaz A, Arasteh O, Tanzifi A, Faramarzi F, Negarandeh R, Safdari M, Khataminia M, Rezai Ghaleno H, Habtemariam S, Khoshi A. Pharmacological treatments of COVID-19. Pharmacol Rep 2020; 72:1446-1478. [PMID: 32816200 PMCID: PMC7439639 DOI: 10.1007/s43440-020-00152-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023]
Abstract
The viral infection due to the new coronavirus or coronavirus disease 2019 (COVID-19), which was reported for the first time in December 2019, was named by the World Health Organization (WHO) as Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV2), because of the very similar genome and also its related symptoms to SARS-CoV1. The ongoing COVID-19 pandemic with significant mortality, morbidity, and socioeconomic impact is considered by the WHO as a global public health emergency. Since there is no specific treatment available for SARS-CoV2 infection, and or COVID-19, several clinical and sub-clinical studies are currently undertaken to find a gold-standard therapeutic regimen with high efficacy and low side effect. Based on the published scientific evidence published to date, we summarized herein the effects of different potential therapies and up-to-date clinical trials. The review is intended to help readers aware of potentially effective COVID-19 treatment and provide useful references for future studies.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Razieh Avan
- Department of Clinical Pharmacy, Medical Toxicology and Drug Abuse Research Center (MTDRC), Faculty of Pharmacy, Birjand University of Medical Sciences, Birjand, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mojataba Mojtahedzadeh
- Department of Clinical Pharmacy, Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Afsaneh Sadremomtaz
- XB20 Drug Design, Groningen Research Institute of Pharmacy, University of Groningen, 9700 AD Groningen, The Netherlands
| | - Omid Arasteh
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Asal Tanzifi
- Sepanta Faragene Azma Research Laboratory. Co. LTD., Gorgan, Iran
- Department of Parasitology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Faramarzi
- Clinical Pharmacy Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Negarandeh
- Student Research Committee, Department of Pharmaceutics, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammadreza Safdari
- Department of Orthopedic Surgery, Faculty of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Masoud Khataminia
- Student Research Committee, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Rezai Ghaleno
- Department of Surgery, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Solomon Habtemariam
- Pharmacognosy Research Laboratories and Herbal Analysis Services, University of Greenwich, Central Avenue, Chatham-Maritime, Kent, ME4 4TB UK
| | - Amirhosein Khoshi
- Department of Clinical Biochemistry, School of Medicine, North Khorasan University of Medical Sciences, Arkan roadway, Bojnurd, Iran
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20
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Soler-Garcia A, Fernández de Sevilla M, Abad R, Esteva C, Alsina L, Vázquez J, Muñoz-Almagro C, Noguera-Julian A. Meningococcal Serogroup B Disease in Vaccinated Children. J Pediatric Infect Dis Soc 2020; 9:454-459. [PMID: 31634404 DOI: 10.1093/jpids/piz071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/27/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neisseria meningitidis serogroup B (MenB) is the most frequent cause of invasive meningococcal disease (IMD) in Spain. The multicomponent vaccine against MenB (4CMenB) was approved in Spain in January 2014. METHODS We present 4 cases of children who developed MenB-associated IMD despite previous vaccination with 4CMenB. Extensive immunologic diagnostic work-up was performed in order to rule out any immunodeficiency. Also, molecular characterization of the MenB strain was conducted to determine whether bacterial antigens matched vaccine antigens. RESULTS Among the 4 patients (2 girls), 2 had previous risk factors for IMD (recurrent bacterial meningitis of unknown origin and treatment with eculizumab). All patients developed meningitis, but only 2 developed septic shock; they were all cured without sequelae. No other primary or secondary immunodeficiencies were detected. MenB sequence type 213 was identified in 3 cases. With the exception of neisserial heparin-binding antigen peptide 465 present in 1 isolate, the rest of the isolated strains harbored vaccine antigen variants that did not match antigen variants included in the vaccine. CONCLUSIONS We present 4 children who developed MenB-associated IMD despite previous vaccination with 4CMenB. In 2 cases, the antibodies induced by 4CMenB likely were not effective against the isolated strains. A high level of suspicion for IMD seems advisable regardless of the patient's vaccination history.
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Affiliation(s)
- Aleix Soler-Garcia
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Pediàtrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Mariona Fernández de Sevilla
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Pediàtrica, Hospital Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Raquel Abad
- Unidad de Neisseria, Listeria y Bordetella, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Esteva
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Pediàtrica, Hospital Sant Joan de Déu, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Laia Alsina
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Pediàtrica, Hospital Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Julio Vázquez
- Unidad de Neisseria, Listeria y Bordetella, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Muñoz-Almagro
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Pediàtrica, Hospital Sant Joan de Déu, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain.,Departament de Medicina, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Pediàtrica, Hospital Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
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21
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Willerton L, Lucidarme J, Campbell H, Caugant DA, Claus H, Jacobsson S, Ladhani SN, Mölling P, Neri A, Stefanelli P, Taha MK, Vogel U, Borrow R. Geographically widespread invasive meningococcal disease caused by a ciprofloxacin resistant non-groupable strain of the ST-175 clonal complex. J Infect 2020; 81:575-584. [PMID: 32858070 DOI: 10.1016/j.jinf.2020.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/26/2020] [Accepted: 08/08/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Invasive meningococcal disease (IMD) caused by non-serogroupable (NG) strains mainly affects immunocompromised individuals. Reduced susceptibility to penicillin in meningococci is increasing in Europe but ciprofloxacin resistance remains rare. In 2019, three travel-related meningococcal disease cases caused by a ciprofloxacin-resistant NG strain were identified in England, leading Germany to report four additional IMD cases (2016 to 2019). We describe these and newly identified cases and characterise the strain responsible. METHODS Cases were identified as part of national surveillance and by analysing available genomes using PubMLST tools. RESULTS Of the cases identified in England in 2019, two geographically distinct cases developed conjunctivitis after returning from Mecca (Kingdom of Saudi Arabia) and a third linked case presented with IMD. Of the four cases from Germany, three occurred in asylum seekers - two familial and a further geographically distinct case. Further IMD cases were identified in Italy (n = 2; 2017-2018), Sweden (n = 1; 2016) and England (n = 1; 2015). A single ST-175 clonal complex (cc175) strain with genosubtype P1.22-11,15-25 was responsible. Decreased susceptibility to penicillin was widespread with three ciprofloxacin resistant subclusters. Constituent isolates were potentially covered by subcapsular vaccines. CONCLUSION This disease associated NG cc175 strain exhibits resistance to antibiotics commonly used to prevent IMD but is potentially covered by subcapsular (meningococcal B) vaccines.
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Affiliation(s)
- Laura Willerton
- Meningococcal Reference Unit, Public Health England, Manchester, UK.
| | - Jay Lucidarme
- Meningococcal Reference Unit, Public Health England, Manchester, UK
| | - Helen Campbell
- Immunisation and Countermeasures Division, Public Health England, London, UK
| | - Dominique A Caugant
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Heike Claus
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Susanne Jacobsson
- National Reference Laboratory for Neisseria meningitidis, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Shamez N Ladhani
- Immunisation and Countermeasures Division, Public Health England, London, UK; Paediatric Infectious Diseases Research Group, St George's University of London, London, United Kingdom
| | - Paula Mölling
- National Reference Laboratory for Neisseria meningitidis, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Arianna Neri
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Paola Stefanelli
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Muhamed-Kheir Taha
- Invasive Bacterial Infections Unit and WHO collaborating Centre for meningitis, Institut Pasteur, Paris, France
| | - Ulrich Vogel
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Ray Borrow
- Meningococcal Reference Unit, Public Health England, Manchester, UK
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22
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Jodele S, Köhl J. Tackling COVID-19 infection through complement-targeted immunotherapy. Br J Pharmacol 2020; 178:2832-2848. [PMID: 32643798 PMCID: PMC7361469 DOI: 10.1111/bph.15187] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/09/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
The complement system is an ancient part of innate immunity sensing highly pathogenic coronaviruses by mannan‐binding lectin (MBL) resulting in lectin pathway activation and subsequent generation of the anaphylatoxins (ATs) C3a and C5a as important effector molecules. Complement deposition on endothelial cells and high blood C5a serum levels have been reported in COVID‐19 patients with severe illness, suggesting vigorous complement activation leading to systemic thrombotic microangiopathy (TMA). Complement regulator gene variants prevalent in African‐Americans have been associated with a higher risk for severe TMA and multi‐organ injury. Strikingly, severe acute respiratory syndrome Coronavirus 2 (SARS‐CoV‐2)‐infected African‐Americans suffer from high mortality. These findings allow us to apply our knowledge from other complement‐mediated diseases to COVID‐19 infection to better understand severe disease pathogenesis. Here, we discuss the multiple aspects of complement activation, regulation, crosstalk with other parts of the immune system, and the options to target complement in COVID‐19 patients to halt disease progression and death.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jörg Köhl
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
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23
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McQuillen DP, Ram S. No Good Deed Goes Unpunished: Eculizumab and Invasive Neisserial Infections. Clin Infect Dis 2020; 69:601-603. [PMID: 30418552 DOI: 10.1093/cid/ciy959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/07/2018] [Indexed: 02/07/2023] Open
Affiliation(s)
- Daniel P McQuillen
- Center for Infectious Diseases and Prevention, Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington.,Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester
| | - Sanjay Ram
- Center for Infectious Diseases and Prevention, Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington.,Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester
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24
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Raina R, Grewal MK, Radhakrishnan Y, Tatineni V, DeCoy M, Burke LLG, Bagga A. Optimal management of atypical hemolytic uremic disease: challenges and solutions. Int J Nephrol Renovasc Dis 2019; 12:183-204. [PMID: 31564951 PMCID: PMC6732511 DOI: 10.2147/ijnrd.s215370] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a chronic life threatening condition that arises from genetic abnormalities resulting in uncontrolled complement amplifying activity. The introduction of eculizumab, the humanized monoclonal antibody, has brought about a paradigm shift in the management of aHUS. However, there are many knowledge gaps, diagnostic issues, access and cost issues, and patient or physician challenges associated with the use of this agent. Limited data on the natural history of aHUS along with the underlying genetic mutations make it difficult to predict the relapses and thereby raising concerns about the appropriate duration and monitoring of treatment. In this review, we discuss the safety and efficacy of eculizumab in patients with aHUS and its associated challenges.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | - Manpreet K Grewal
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | | | - Vineeth Tatineni
- Department of Internal Medicine, Summa Health, Akron City Hospital, Akron, OH, USA
| | - Meredith DeCoy
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Linda LG Burke
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Arvind Bagga
- Division of Paediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
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25
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Schröder-Braunstein J, Kirschfink M. Complement deficiencies and dysregulation: Pathophysiological consequences, modern analysis, and clinical management. Mol Immunol 2019; 114:299-311. [PMID: 31421540 DOI: 10.1016/j.molimm.2019.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/31/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023]
Abstract
Complement defects are associated with an enhanced risk of a broad spectrum of infectious as well as systemic or local inflammatory and thrombotic disorders. Inherited complement deficiencies have been described for virtually all complement components but can be mimicked by autoantibodies, interfering with the activity of specific complement components, convertases or regulators. While being rare, diseases related to complement deficiencies are often severe with a frequent but not exclusive manifestation during childhood. Whereas defects of early components of the classical pathway significantly increase the risk of autoimmune disorders, lack of components of the terminal pathway as well as of properdin are associated with an enhanced susceptibility to meningococcal infections. The impaired synthesis or function of C1 inhibitor results in the development of hereditary angioedema (HAE). Furthermore, complement dysregulation causes renal disorders such as atypical hemolytic uremic syndrome (aHUS) or C3 glomerulopathy (C3G) but also age-related macular degeneration (AMD). While paroxysmal nocturnal hemoglobinuria (PNH) results from the combined deficiency of the regulatory complement proteins CD55 and CD59, which is caused by somatic mutation of a common membrane anchor, isolated CD55 or CD59 deficiency is associated with the CHAPLE syndrome and polyneuropathy, respectively. Here, we provide an overview on clinical disorders related to complement deficiencies or dysregulation and describe diagnostic strategies required for their comprehensive molecular characterization - a prerequisite for informed decisions on the therapeutic management of these disorders.
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Affiliation(s)
- Jutta Schröder-Braunstein
- University of Heidelberg, Institute of Immunology, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Michael Kirschfink
- University of Heidelberg, Institute of Immunology, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
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26
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Deterioration in Clinical Status Is Not Enough to Suspend Eculizumab: A Genetic Complement-Mediated Atypical Hemolytic Uremic Syndrome Case Report. Case Rep Nephrol 2019; 2019:9264824. [PMID: 31360562 PMCID: PMC6652041 DOI: 10.1155/2019/9264824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 11/17/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Mutations in CFI gene coding for complement regulation factors and in THBD gene coding for endothelial cell receptor thrombomodulin could predispose to the disease and hypertension can trigger the onset. Case Presentation A 51-year-old female patient who had received kidney transplant eighteen years ago presented with hypertensive peak and hemolysis pattern. Normal ADAMTS13 levels as well as negative culture and serology for Shiga-toxin excluded, respectively, thrombotic thrombocytopenic purpura (TTP) and typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS). In suspicion of aHUS, we administered eculizumab and hemodialysis sessions were started as the patient showed severe renal failure. After an initial response, the patient developed cerebral hemorrhage. After last eculizumab administration, according to hematological parameters, an unsatisfactory response was observed: given the worsening clinical scenario, we withdrew eculizumab. Pathogenic mutations in CFI and THBD genes were found. After eculizumab reinitiation, looking at hemolysis indexes, we observed a suboptimal response as well as an otherwise adequate renal one: renal graft function was recovered despite persistence of hemolysis signs, after 6 months on regular dialysis. Conclusion For the first time, we report an aHUS case in which a peculiar combination of mutations in CFI and THBD is found. We describe the importance of continuing eculizumab despite deterioration of patient's clinical conditions.
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27
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Nolfi-Donegan D, Konar M, Vianzon V, MacNeil J, Cooper J, Lurie P, Sedivy J, Wang X, Granoff DM, McNamara L. Fatal Nongroupable Neisseria meningitidis Disease in Vaccinated Patient Receiving Eculizumab. Emerg Infect Dis 2019; 24. [PMID: 30015608 PMCID: PMC6056112 DOI: 10.3201/eid2408.180228] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Patients receiving eculizumab have an increased risk for meningococcal disease, but most reported cases are attributable to encapsulated meningococcal strains. We describe a case in which a nongroupable meningococcal strain, which rarely causes disease in healthy persons, caused fatal disease in an eculizumab recipient despite meningococcal vaccination.
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28
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Wijnsma KL, Duineveld C, Wetzels JFM, van de Kar NCAJ. Eculizumab in atypical hemolytic uremic syndrome: strategies toward restrictive use. Pediatr Nephrol 2019; 34:2261-2277. [PMID: 30402748 PMCID: PMC6794245 DOI: 10.1007/s00467-018-4091-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 12/19/2022]
Abstract
With the introduction of the complement C5-inhibitor eculizumab, a new era was entered for patients with atypical hemolytic uremic syndrome (aHUS). Eculizumab therapy very effectively reversed thrombotic microangiopathy and reduced mortality and morbidity. Initial guidelines suggested lifelong treatment and recommended prophylactic use of eculizumab in aHUS patients receiving a kidney transplant. However, there is little evidence to support lifelong therapy or prophylactic treatment in kidney transplant recipients. Worldwide, there is an ongoing debate regarding the optimal dose and duration of treatment, particularly in view of the high costs and potential side effects of eculizumab. An increasing but still limited number of case reports and small cohort studies suggest that a restrictive treatment regimen is feasible. We review the current literature and focus on the safety and efficacy of restrictive use of eculizumab. Our current treatment protocol is based on restrictive use of eculizumab. Prospective monitoring will provide more definite proof of the feasibility of such restrictive treatment.
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Affiliation(s)
- Kioa L. Wijnsma
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Caroline Duineveld
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands ,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
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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29
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Terano C, Ishikura K, Hamada R, Yoshida Y, Kubota W, Okuda Y, Shinozuka S, Harada R, Iyoda S, Fujimura Y, Hamasaki Y, Hataya H, Honda M. Practical issues in using eculizumab for children with atypical haemolytic uraemic syndrome in the acute phase: A review of four patients. Nephrology (Carlton) 2018; 23:539-545. [PMID: 28387984 DOI: 10.1111/nep.13054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/14/2017] [Accepted: 04/05/2017] [Indexed: 11/28/2022]
Abstract
AIM Recently eculizumab, a monoclonal antibody to C5, was found to improve the disease course of atypical haemolytic uraemic syndrome (aHUS) and has been recommended as the first line treatment by an international consensus guideline. However, several practical issues in the use of eculizumab for the acute phase of aHUS have yet to be resolved. METHODS Children who received eculizumab with diagnosis of aHUS between March 2010 and December 2015 at Tokyo Metropolitan Children's Medical Center were enrolled. aHUS was diagnosed according to the haemolytic uraemic syndrome (HUS) criteria after excluding Shiga toxin-inducing Escherichia coli (STEC) -associated HUS and thrombocytopaenic purpura. We retrieved and analyzed data from the electronic medical records at our institution. RESULTS We reviewed four patients with suspected aHUS. Eculizumab was discontinued in one patient in whom STEC-HUS was later diagnosed. Treatment was continued in the remaining three patients without recurrence. Practical issues included difficulty in diagnosing aHUS, particularly in the acute phase, risk of infection by encapsulated organisms, especially Neisseria meningitis, and infusion reaction. In addition to issues relating to the acute phase, discontinuing eculizumab in stable patients in the chronic phase must be considered. CONCLUSION Eculizumab, the first line treatment for children with aHUS, is usually effective. However, certain problems associated with its use require caution to be exercised. As clinical information on eculizumab are still very limited, and the rationale for its long-term use has yet to be established, physicians are advised to exercise care when using eculizumab to manage aHUS.
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Affiliation(s)
- Chikako Terano
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan.,Division of Nephrology and Rheumatology, National Center for Child Health and Development, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Yasuhiro Yoshida
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Japan
| | - Wataru Kubota
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Japan
| | - Shunsuke Shinozuka
- Department of Pediatrics, National Hospital Organization Saitama National Hospital, Japan
| | - Ryoko Harada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Sunao Iyoda
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan.,Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
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30
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Martinón-Torres F, Bernatowska E, Shcherbina A, Esposito S, Szenborn L, Marti MC, Hughes S, Faust SN, Gonzalez-Granado LI, Yu LM, D'Agostino D, Calabresi M, Toneatto D, Snape MD. Meningococcal B Vaccine Immunogenicity in Children With Defects in Complement and Splenic Function. Pediatrics 2018; 142:peds.2017-4250. [PMID: 30068713 DOI: 10.1542/peds.2017-4250] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The capsular group B meningococcal vaccine (4CMenB) is recommended for children with complement deficiencies, asplenia, and splenic dysfunction; however, data on the immunogenicity of 4CMenB in these "at-risk" children are missing. METHODS Participants aged 2 to 17 years in Italy, Spain, Poland, the United Kingdom, and Russia with complement deficiencies, asplenia, or splenic dysfunction received 2 doses of 4CMenB 2 months apart, as did healthy children in the control group. Exogenous and endogenous human complement serum bactericidal activity (SBA) was determined at baseline and 1 month after the second immunization against 4 test strains: H44/76 (assessing vaccine antigen factor H binding protein), 5/99 (Neisserial adhesion A), NZ98/254 (Porin A), and M10713 (Neisserial heparin binding antigen). RESULTS Of 239 participants (mean age 10.3 years, 45% female), 40 children were complement deficient (9 eculizumab therapy, 4 terminal-chain deficiencies, 27 "other"), 112 children had asplenia or splenic dysfunction (8 congenital asplenia, 8 functional asplenia, 96 splenectomy), and 87 children were in the control group. After immunization, the proportions of complement-deficient participants with exogenous complement SBA titers ≥1:5 were 87% (H44/76), 95% (5/99), 68% (NZ98/254), and 73% (M10713), compared with 97%, 100%, 86%, and 94%, respectively, for asplenic children and 98%, 99%, 83%, and 99% for children in the control group. When testing with endogenous complement, strain-specific bactericidal activity was evident in only 1 eculizumab-treated participant and 1 terminal chain complement-deficient participant. CONCLUSIONS 4CMenB administration is similarly immunogenic in healthy children and those with asplenia or splenic dysfunction. The significance of the trend to lower responses of SBA titers in complement-deficient children (especially those with terminal chain complement deficiency or those on eculizumab therapy) must be determined by ongoing surveillance for vaccine failures.
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Affiliation(s)
- Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases, Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ewa Bernatowska
- Department of Immunology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Anna Shcherbina
- Research and Clinical Centre of Pediatric Hematology, Oncology and Immunology named after Dmitry Rogachev, Moscow, Russian Federation
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Leszek Szenborn
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Stephen Hughes
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Saul N Faust
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Luis I Gonzalez-Granado
- Immunodeficiencies Unit, Department of Pediatrics, University Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (i+12) and Associate Professor of Pediatrics, Complutense University of Madrid, Madrid, Spain
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences and
| | | | | | | | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom; .,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
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31
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Heesterbeek DAC, Angelier ML, Harrison RA, Rooijakkers SHM. Complement and Bacterial Infections: From Molecular Mechanisms to Therapeutic Applications. J Innate Immun 2018; 10:455-464. [PMID: 30149378 PMCID: PMC6784045 DOI: 10.1159/000491439] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022] Open
Abstract
Complement is a complex protein network of plasma, and an integral part of the innate immune system. Complement activation results in the rapid clearance of bacteria by immune cells, and direct bacterial killing via large pore-forming complexes. Here we review important recent discoveries in the complement field, focusing on interactions relevant for the defense against bacteria. Understanding the molecular interplay between complement and bacteria is of great importance for future therapies for infectious and inflammatory diseases. Antibodies that support complement-dependent bacterial killing are of interest for the development of alternative therapies to treat infections with antibiotic-resistant bacteria. Furthermore, a variety of novel therapeutic complement inhibitors have been developed to prevent unwanted complement activation in autoimmune inflammatory diseases. A better understanding of how such inhibitors may increase the risk of bacterial infections is essential if such therapies are to be successful.
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Affiliation(s)
- Dani A C Heesterbeek
- Department of Medical Microbiology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Mathieu L Angelier
- Department of Medical Microbiology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Richard A Harrison
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
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32
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Gunawansa N, Rathore R, Sharma A, Halawa A. Vaccination practices in End Stage Renal Failure and Renal Transplantation; Review of current guidelines and recommendations. World J Transplant 2018; 8:68-74. [PMID: 29988933 PMCID: PMC6033742 DOI: 10.5500/wjt.v8.i3.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/02/2018] [Accepted: 03/13/2018] [Indexed: 02/05/2023] Open
Abstract
Due to the increased burden of infectious complications following solid organ transplantation, vaccination against common pathogens is a hugely important area of discussion and application in clinical practice. Reduction in infectious complications will help to reduce morbidity and mortality post-transplantation. Immunisation history is invaluable in the work-up of potential recipients. Knowledge of the available vaccines and their use in transplant recipients, donors and healthcare providers is vital in the delivery of quality care to transplant recipients. This article will serve as an aide-memoire to transplant physicians and health care professionals involved in managing transplant recipients as it provides an overview of different types of vaccines, timing of vaccination, vaccines contraindicated post solid organ transplantation and travel vaccines.
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Affiliation(s)
- Nalaka Gunawansa
- National Institute of Nephrology Dialysis and Transplantation, Sri Lanka and Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool 111, United Kingdom
| | - Roshni Rathore
- Department of Renal, University Hospitals of Coventry and Warwickshire and Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool 111, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool and Royal Liverpool University Hospital, Liverpool 111, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool and Royal Liverpool University Hospital, Liverpool 111, United Kingdom
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33
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Reher D, Fuhrmann V, Kluge S, Nierhaus A. A rare case of septic shock due to Neisseria meningitidis serogroup B infection despite prior vaccination in a young adult with paroxysmal nocturnal haemoglobinuria receiving eculizumab. Vaccine 2018; 36:2507-2509. [DOI: 10.1016/j.vaccine.2018.03.087] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 12/11/2022]
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Winthrop KL, Mariette X, Silva JT, Benamu E, Calabrese LH, Dumusc A, Smolen JS, Aguado JM, Fernández-Ruiz M. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors). Clin Microbiol Infect 2018; 24 Suppl 2:S21-S40. [PMID: 29447987 DOI: 10.1016/j.cmi.2018.02.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection. IMPLICATIONS Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.
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Affiliation(s)
- K L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA.
| | - X Mariette
- Department of Rheumatology, Hôpitaux Universitaire Paris-Sud, Université Paris-Sud, INSERM U1184, Paris, France
| | - J T Silva
- Department of Infectious Diseases, University Hospital of Badajoz, Fundación para La Formación e Investigación de Los Profesionales de La Salud (FundeSalud), Badajoz, Spain
| | - E Benamu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - L H Calabrese
- Department of Rheumatic and Immunological Diseases, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH, USA
| | - A Dumusc
- Department of Rheumatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - J S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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Infections associated with the use of eculizumab: recommendations for prevention and prophylaxis. Curr Opin Infect Dis 2018; 29:319-29. [PMID: 27257797 DOI: 10.1097/qco.0000000000000279] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Eculizumab inhibits complement effector functions and has significantly impacted the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. However, the risks of potentially life-threatening infections, notably with Neisseria spp. in addition to its cost, are major challenges in clinical practice. In this review, we characterize and summarize the infectious complications reported with the use of eculizumab in the context of its typical and expanding indications. RECENT FINDINGS Use of eculizumab is rapidly extending to the fields of transplantation and neurology. Eculizumab has been primarily associated with an increased risk of meningococcal infections. Immunization against its commonest serotypes (ABCWY) is now possible with the advent of the meningococcal B vaccine. A combined ABCWY vaccine is underway. Preventive strategies against breakthrough Neisseria infections should also include chemoprophylaxis. Less is known about the association of eculizumab with other infections as recently reported. Surrogate markers of complement blockade, notably CH50, and eculizumab efficacy may help in the risk assessment of infection. SUMMARY Eculizumab has opened new horizons in the treatment of complement-mediated disorders. Prophylactic and immunization strategies against the risk of Nesseria spp. infections are sound and feasible. The use of eculizumab is expanding beyond complement-mediated diseases to transplantation and neurological disorders. Further research is needed to better define and stratify the risk of infection and prevention strategies in patients with the latter indications.
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Post-eculizumab meningococcaemia in vaccinated patients. Clin Microbiol Infect 2018; 24:89-90. [DOI: 10.1016/j.cmi.2017.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 11/18/2022]
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Hall V, Johnson D, Torresi J. Travel and biologic therapy: travel-related infection risk, vaccine response and recommendations. J Travel Med 2018; 25:4934912. [PMID: 29635641 DOI: 10.1093/jtm/tay018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 03/01/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Biologic therapy has revolutionized the management of refractory chronic autoimmune and auto-inflammatory disease, as well as several malignancies, providing rapid symptomatic relief and/or disease remission. Patients receiving biologic therapies have an improved quality of life, facilitating travel to exotic destinations and potentially placing them at risk of a range of infections. For each biologic agent, we review associated travel-related infection risk and expected travel vaccine response and effectiveness. METHODS A PUBMED search [vaccination OR vaccine] AND/OR ['specific vaccine'] AND/OR [immunology OR immune response OR response] AND [biologic OR biological OR biologic agent] was performed. A review of the literature was performed in order to develop recommendations on vaccination for patients in receipt of biologic therapy travelling to high-risk travel destinations. RESULTS There is a paucity of literature in this area, however, it is apparent that travel-related infection risk is increased in patients on biologic therapy and when illness occurs they are at a higher risk of complication and hospitalization. Patients in receipt of biologic agents are deemed as having a high level of immunosuppression-live vaccines, including the yellow fever vaccine, are contraindicated. Inactivated vaccines are considered safe; however, vaccine response can be attenuated by the patient's biologic therapy, thereby resulting in reduced vaccine effectiveness and protection. CONCLUSIONS Best practice requires a collaborative approach between the patient's primary healthcare physician, relevant specialist and travel medicine expert, who should all be familiar with the immunosuppressive and immunomodulatory effects resulting from the biologic therapies. Timing of vaccines should be carefully planned, and if possible, vaccination provided well before established immunosuppression.
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Affiliation(s)
- Victoria Hall
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia
| | - Douglas Johnson
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia.,Department of General Medicine, Austin Health, Heidelberg, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Joseph Torresi
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia.,Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.,Eastern Infectious Diseases and Travel Medicine, Knox Private Hospital, Boronia, VIC, Australia
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40
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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41
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Parikh SR, Lucidarme J, Bingham C, Warwicker P, Goodship T, Borrow R, Ladhani SN. Meningococcal B Vaccine Failure With a Penicillin-Resistant Strain in a Young Adult on Long-Term Eculizumab. Pediatrics 2017; 140:peds.2016-2452. [PMID: 28864711 DOI: 10.1542/peds.2016-2452] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 11/24/2022] Open
Abstract
We describe a case of invasive meningococcal disease due to a vaccine-preventable and penicillin-resistant strain in a fully immunized young adult on long-term complement inhibitor therapy and daily penicillin chemoprophylaxis. Eculizumab is a humanized monoclonal antibody that binds human complement C5 protein and inhibits the terminal complement pathway. It is currently recommended for the treatment of complement-mediated thrombotic microangiopathies. An unwanted complication of inhibiting complement, however, is an increased risk of invasive meningococcal disease. Here, we report the first case of meningococcal group B vaccine failure in a young adult receiving eculizumab for atypical hemolytic uremic syndrome. She developed invasive meningococcal disease due to a vaccine-preventable and penicillin-resistant meningococcal group B strain 4 months after receiving 2 doses of meningococcal group B vaccine while on oral penicillin prophylaxis against meningococcal infection.
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Affiliation(s)
- Sydel R Parikh
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, United Kingdom
| | - Jay Lucidarme
- Vaccine Evaluation Unit, Public Health England, Manchester, United Kingdom
| | - Coralie Bingham
- Exeter Kidney Unit, Royal Devon and Exeter Hospital, Devon, United Kingdom
| | - Paul Warwicker
- Lister Renal Unit, Lister Hospital, Hertfordshire, United Kingdom
| | - Tim Goodship
- Institute of Human Genetics, Newcastle University, Newcastle, United Kingdom; and
| | - Ray Borrow
- Vaccine Evaluation Unit, Public Health England, Manchester, United Kingdom
| | - Shamez N Ladhani
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, United Kingdom; .,St George's University of London, London, United Kingdom
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42
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Konar M, Granoff DM. Eculizumab treatment and impaired opsonophagocytic killing of meningococci by whole blood from immunized adults. Blood 2017; 130. [PMID: 28630122 PMCID: PMC5561903 DOI: 10.1182/blood-2017-05-781450] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Eculizumab, a humanized anti-complement C5 monoclonal antibody (mAb) for treatment of paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome, blocks the terminal complement pathway required for serum bactericidal activity (SBA). Because treated patients are at >1000-fold increased risk of meningococcal disease, vaccination is recommended; whether vaccination can protect by opsonophagocytic activity in the absence of SBA is not known. Meningococci were added to anticoagulated blood from 12 healthy adults vaccinated with meningococcal serogroup B and serogroup A, C, W, Y vaccines. Bacterial survival was measured after 3-hour incubation in the presence of eculizumab or control complement factor D inhibitor ACH-4471, which blocks the complement alternative pathway (AP) and is in phase 2 development for treatment of PNH. In the absence of inhibitors, colony formation units (CFUs) per milliliter in blood from all 12 immunized subjects decreased from ∼4000 at time 0 to sterile cultures at 3 hours. In the presence of eculizumab, there was a >22-fold increase in geometric mean CFUs per milliliter (90 596 and 114 683 CFU/mL for serogroup B and C strains, respectively; P < .0001 compared with time 0). In the presence of ACH-4471, there was a >12-fold decrease (23 and 331 CFU/mL, respectively; P < .0001). The lack of meningococci killing by blood containing eculizumab resulted from inhibition of release of C5a, a C5 split product needed for upregulation of phagocytosis. The results provide an explanation for the large number of cases of meningococcal disease in immunized patients being treated with eculizumab and suggest that vaccination may provide better protection against meningococcal disease in patients treated with an AP-specific inhibitor.
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Affiliation(s)
- Monica Konar
- Center for Immunobiology and Vaccine Development, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Dan M Granoff
- Center for Immunobiology and Vaccine Development, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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44
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Hawkins KL, Hoffman M, Okuyama S, Rowan SE. A Case of Fulminant Meningococcemia: It Is All in the Complement. Case Rep Infect Dis 2017; 2017:6093695. [PMID: 28808592 PMCID: PMC5541820 DOI: 10.1155/2017/6093695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/24/2017] [Accepted: 06/14/2017] [Indexed: 12/25/2022] Open
Abstract
Eculizumab is a novel monoclonal antibody that inhibits complement-mediated hemolysis in patients with paroxysmal nocturnal hemoglobinuria (PNH). Complement deficiency is a well-known risk factor for meningococcal infection. We describe a case of a young patient with PNH treated with eculizumab who presented with a life-threatening case of nongroupable meningococcemia. As this new biologic agent becomes more widely prescribed, providers should be aware of the increased risk of meningococcemia. In addition to vaccination, providers may consider the use of oral penicillin for antibiotic prophylaxis against Neisseria meningitidis in these cases of functional complement deficiency.
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Affiliation(s)
- Kellie L. Hawkins
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | - Mariah Hoffman
- Denver Health and Hospital Authority, Denver, CO, USA
- Division of Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sonia Okuyama
- Denver Health and Hospital Authority, Denver, CO, USA
- Division of Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah E. Rowan
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
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45
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is a disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury. The histopathologic lesions of aHUS include thrombotic microangiopathy involving the glomerular capillaries and thrombosis involving arterioles or interlobar arteries. Extra-renal manifestations occur in up to 20% of patients. The majority of aHUS is caused by complement system defects impairing ordinary regulatory mechanisms. Activating events therefore lead to unbridled, ongoing complement activity producing widespread endothelial injury. Pathologic mutations include those resulting in loss-of-function in a complement regulatory gene (CFH, CFI, CD46 or THBD) or gain-of-function in an effector gene (CFB or C3). Treatment with the late complement inhibitor, eculizumab – a monoclonal antibody directed against C5 – is effective.
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Affiliation(s)
- Kuixing Zhang
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Yuxin Lu
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Kevin T Harley
- Department of Internal Medicine, Division of Nephrology and Hypertension, Irvine School of Medicine, University of California, Orange, CA, USA
| | - Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
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46
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Gianchecchi E, Piccini G, Torelli A, Rappuoli R, Montomoli E. An unwanted guest:Neisseria meningitidis– carriage, risk for invasive disease and the impact of vaccination with insight on Italy incidence. Expert Rev Anti Infect Ther 2017; 15:689-701. [DOI: 10.1080/14787210.2017.1333422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Giulia Piccini
- VisMederi Srl, Siena, Italy
- Department of Life Sciences, University of Siena, Siena, Italy
| | - Alessandro Torelli
- VisMederi Srl, Siena, Italy
- Department of Life Sciences, University of Siena, Siena, Italy
| | | | - Emanuele Montomoli
- VisMederi Srl, Siena, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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47
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Volokhina E, Wijnsma K, van der Molen R, Roeleveld N, van der Velden T, Goertz J, Sweep F, Brüggemann RJ, Wetzels J, van de Kar N, van den Heuvel L. Eculizumab Dosing Regimen in Atypical HUS: Possibilities for Individualized Treatment. Clin Pharmacol Ther 2017; 102:671-678. [DOI: 10.1002/cpt.686] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 01/30/2023]
Affiliation(s)
- E Volokhina
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - K Wijnsma
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - R van der Molen
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - N Roeleveld
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
- Department of Health Evidence; Radboud University Medical Center; Nijmegen The Netherlands
| | - T van der Velden
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - J Goertz
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - F Sweep
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - RJ Brüggemann
- Department of Pharmacy; Radboud University Medical Center; Nijmegen The Netherlands
| | - J Wetzels
- Department of Nephrology; Radboud University Medical Center; Nijmegen The Netherlands
| | - N van de Kar
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - L van den Heuvel
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Pediatrics; University Hospitals Leuven; Leuven Belgium
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48
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Rosain J, Hong E, Fieschi C, Martins PV, El Sissy C, Deghmane AE, Ouachée M, Thomas C, Launay D, de Pontual L, Suarez F, Moshous D, Picard C, Taha MK, Frémeaux-Bacchi V. Strains Responsible for Invasive Meningococcal Disease in Patients With Terminal Complement Pathway Deficiencies. J Infect Dis 2017; 215:1331-1338. [DOI: 10.1093/infdis/jix143] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/23/2017] [Indexed: 12/17/2022] Open
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49
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Abstract
Thrombocytopenia is a commonly encountered hematologic problem in inpatient and ambulatory medicine. The many underlying mechanisms of thrombocytopenia include pseudothrombocytopenia, splenic sequestration, and marrow underproduction and destruction. This article presents the known causes of thrombocytopenia, a framework for evaluation, and brief descriptions of management in a case-based format.
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Affiliation(s)
- Eun-Ju Lee
- Division of Hematology, Weill Cornell Medical College, New York, NY, USA
| | - Alfred Ian Lee
- Section of Hematology, Yale Cancer Center, Yale University School of Medicine, 333 Cedar Street, Box 208021, New Haven, CT 06520, USA.
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50
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Okumi M, Tanabe K. Prevention and treatment of atypical haemolytic uremic syndrome after kidney transplantation. Nephrology (Carlton) 2017; 21 Suppl 1:9-13. [PMID: 26988663 DOI: 10.1111/nep.12776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Atypical haemolytic uraemic syndrome is a rare disorder characterized by an over-activated, dysregulated alternative complement pathway due to genetic mutation and environmental triggers. Atypical haemolytic uraemic syndrome is a serious, life-threatening disease characterized by thrombotic microangiopathy, which causes haemolytic anaemia, thrombocytopaenia, and acute renal failure. Since recurrences of atypical haemolytic uraemic syndrome frequently lead to end-stage kidney disease even in renal allografts, kidney transplantation for patients with end-stage kidney disease secondary to atypical haemolytic uraemic syndrome has long been contraindicated. However, over the past several years, advancements in the management of atypical haemolytic uraemic syndrome have allowed successful kidney transplantation in these patients. The key factor of this success is eculizumab, a humanized anti-C5 monoclonal antibody, which inhibits terminal membrane-attack complex formation and thrombotic microangiopathy progression. In the setting of kidney transplantation, there are different possible triggers of post-transplant atypical haemolytic uraemic syndrome recurrence, such as brain-death related injury, ischaemia-reperfusion injury, infections, the use of immunosuppressive drugs, and rejection. Principal strategies are to prevent endothelial damage that could potentially activate alternative complement pathway activation and subsequently lead to atypical haemolytic uraemic syndrome recurrence in kidney allograft. Published data shows that prophylactic eculizumab therapy is highly effective for the prevention of post-transplant atypical haemolytic uraemic syndrome recurrence, and prompt treatment with eculizumab as soon as recurrence is diagnosed is important to maintain renal allograft function. Further study to determine the optimal dosing and duration of prophylactic therapy and treatment of post-transplant atypical haemolytic uraemic syndrome recurrence is needed.
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Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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