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Sándor N, Schneider AE, Matola AT, Barbai VH, Bencze D, Hammad HH, Papp A, Kövesdi D, Uzonyi B, Józsi M. The human factor H protein family - an update. Front Immunol 2024; 15:1135490. [PMID: 38410512 PMCID: PMC10894998 DOI: 10.3389/fimmu.2024.1135490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/08/2024] [Indexed: 02/28/2024] Open
Abstract
Complement is an ancient and complex network of the immune system and, as such, it plays vital physiological roles, but it is also involved in numerous pathological processes. The proper regulation of the complement system is important to allow its sufficient and targeted activity without deleterious side-effects. Factor H is a major complement regulator, and together with its splice variant factor H-like protein 1 and the five human factor H-related (FHR) proteins, they have been linked to various diseases. The role of factor H in inhibiting complement activation is well studied, but the function of the FHRs is less characterized. Current evidence supports the main role of the FHRs as enhancers of complement activation and opsonization, i.e., counter-balancing the inhibitory effect of factor H. FHRs emerge as soluble pattern recognition molecules and positive regulators of the complement system. In addition, factor H and some of the FHR proteins were shown to modulate the activity of immune cells, a non-canonical function outside the complement cascade. Recent efforts have intensified to study factor H and the FHRs and develop new tools for the distinction, quantification and functional characterization of members of this protein family. Here, we provide an update and overview on the versatile roles of factor H family proteins, what we know about their biological functions in healthy conditions and in diseases.
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Affiliation(s)
- Noémi Sándor
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
| | | | | | - Veronika H. Barbai
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Dániel Bencze
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Hani Hashim Hammad
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Alexandra Papp
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Dorottya Kövesdi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
| | - Barbara Uzonyi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
| | - Mihály Józsi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
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2
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Abstract
Uncontrolled alternative pathway activation is the primary driver of several diseases, and it contributes to the pathogenesis of many others. Consequently, diagnostic tests to monitor this arm of the complement system are increasingly important. Defects in alternative pathway regulation are strong risk factors for disease, and drugs that specifically block the alternative pathway are entering clinical use. A range of diagnostic tests have been developed to evaluate and monitor the alternative pathway, including assays to measure its function, expression of alternative pathway constituents, and activation fragments. Genetic studies have also revealed many disease-associated variants in alternative pathway genes that predict the risk of disease and prognosis. Newer imaging modalities offer the promise of non-invasively detecting and localizing pathologic complement activation. Together, these various tests help in the diagnosis of disease, provide important prognostic information, and can help guide therapy with complement inhibitory drugs.
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Affiliation(s)
- Joshua M. Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Veronique Fremeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Immunology Biology and INSERM UMRS1138, Centre de Recherche des Cordeliers, Team "Inflammation, Complement and Cancer", Paris, France
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3
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Rodríguez de Córdoba S. Genetic variability shapes the alternative pathway complement activity and predisposition to complement-related diseases. Immunol Rev 2023; 313:71-90. [PMID: 36089777 PMCID: PMC10086816 DOI: 10.1111/imr.13131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The implementation of next-generation sequencing technologies has provided a sharp picture of the genetic variability in the components and regulators of the alternative pathway (AP) of the complement system and has revealed the association of many AP variants with different rare and common diseases. An important finding that has emerged from these analyses is that each of these complement-related diseases associate with genetic variants altering specific aspects of the activation and regulation of the AP. These genotype-phenotype correlations have provided valuable insights into their pathogenic mechanisms with important diagnostic and therapeutic implications. While genetic variants in coding regions and structural variants are reasonably well characterized and occasionally have been instrumental to uncover unknown features of the complement proteins, data about complement expressed quantitative trait loci are still very limited. A crucial task for future studies will be to identify these quantitative variations and to determine their impact in the overall activity of the AP. This is fundamental as it is now clear that the consequences of genetic variants in the AP are additive and that susceptibility or resistance to disease is the result of specific combinations of genetic variants in different complement components and regulators ("complotypes").
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4
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Favi E, Molinari P, Alfieri C, Castellano G, Ferraresso M, Cresseri D. Case report: Eculizumab plus obinutuzumab induction in a deceased donor kidney transplant recipient with DEAP-HUS. Front Immunol 2022; 13:1073808. [PMID: 36591301 PMCID: PMC9795842 DOI: 10.3389/fimmu.2022.1073808] [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: 10/18/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022] Open
Abstract
The wide-spread use of the anti-complement component 5 monoclonal antibody (moAb) eculizumab has greatly reduced the incidence of relapsing atypical hemolytic uremic syndrome (aHUS) after kidney transplantation (KT). However, the optimal management of aHUS transplant candidates with anti-Complement Factor H (CFH) antibodies remains debated. In these patients, the benefits of chronic eculizumab administration should be weighed against the risk of fatal infections, repeated hospital admissions, and excessive costs. We report the case of a 45-year-old female patient with CFHR1/CFHR3 homozygous deletion-associated aHUS who underwent deceased-donor KT despite persistently elevated anti-CFH antibody titers. As induction and aHUS prophylaxis, she received a combination of eculizumab and obinutuzumab, a humanized type 2 anti-CD20 moAb. The post-operative course was uneventful. After 1-year of follow-up, she is doing well with excellent allograft function, undetectable anti-CFH antibodies, sustained B-cell depletion, and no signs of aHUS activity. A brief review summarizing current literature on the topic is also included. Although anecdotal, our experience suggests that peri-operative obinutuzumab administration can block anti-CFH antibodies production safely and effectively, thus ensuring long-lasting protection from post-transplant aHUS relapse, at a reasonable cost. For the first time, we have demonstrated in vivo that obinutuzumab B-cell depleting properties are not significantly affected by eculizumab-induced complement inhibition.
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Affiliation(s)
- Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy,*Correspondence: Evaldo Favi,
| | - Paolo Molinari
- Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Alfieri
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy,Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Castellano
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy,Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Donata Cresseri
- Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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5
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Overview on the role of complement-specific autoantibodies in diseases. Mol Immunol 2022; 151:52-60. [PMID: 36084516 DOI: 10.1016/j.molimm.2022.08.011] [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: 05/25/2022] [Revised: 08/03/2022] [Accepted: 08/15/2022] [Indexed: 11/24/2022]
Abstract
The complement system is recognized as a major pathogenic or contributing factor in an ever-growing number of diseases. In addition to inherited factors, autoantibodies to complement proteins have been detected in various systemic and organ-specific disorders. These include antibodies directed against complement components, regulators and receptors, but also protein complexes such as autoantibodies against complement convertases. In some cases, the autoantibodies are relatively well characterized and a pathogenic role is incurred and their detection has diagnostic value. In other cases, the relevance of the autoantibodies is rather unclear. This review summarizes what we know of complement specific autoantibodies in diseases and identifies unresolved questions regarding their functional effect and relevance.
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6
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Raina R, Sethi SK, Dragon-Durey MA, Khooblall A, Sharma D, Khandelwal P, Shapiro R, Boyer O, Yap HK, Bagga A, Licht C. Systematic review of atypical hemolytic uremic syndrome biomarkers. Pediatr Nephrol 2022; 37:1479-1493. [PMID: 35118546 DOI: 10.1007/s00467-022-05451-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Observing biomarkers that affect alternative pathway dysregulation components may be effective in obtaining a new and more rapid diagnostic portrayal of atypical hemolytic uremic syndrome. We have conducted a systematic review on the aHUS biomarkers: C3, C5a, C5b-9, factor B, complement factor B, H, and I, CH50, AH50, D-dimer, as well as anti-CFH antibodies. METHODS An exhaustive literature search was conducted for aHUS patient population plasma/serum, collected/reported at the onset of diagnosis. A total of 60 studies were included with the data on 837 aHUS subjects, with at least one biomarker reported. RESULTS The biomarkers C3 [mean (SD): 72.1 (35.0), median: 70.5 vs. reference range: 75-175 mg/dl, n = 752]; CH50 [28.3 (32.1), 24.3 vs. 30-75 U/ml, n = 63]; AH50 [27.6% (30.2%), 10% vs. ≥ 46%, n = 23]; and CFB [13.1 (6.6), 12.4, vs. 15.2-42.3 mg/dl, n = 19] were lower among aHUS subjects as compared with the reference range. The biomarkers including C4 [mean (SD): 20.4 (9.5), median: 20.5 vs. reference range: 14-40 mg/dl, n = 343]; C4d [7.2 (6.5), 4.8 vs. ≤ 9.8 μg/ml, n = 108]; CFH [40.2 (132.3), 24.5 vs. 23.6-43.1 mg/dl, n = 123 subjects]; and CFI [8.05 (5.01), 6.55 mg/dl vs. 4.4-18.1 mg/dl, n = 38] were all observed to be within the reference range among aHUS subjects. The biomarkers C5a [mean (SD): 54.9 (32.9), median: 48.8 vs. reference range: 10.6-26.3 mg/dl, n = 117]; C5b-9 [466.0 (401.4), 317 (186-569.7) vs. ≤ 250 ng/ml, n = 174]; Bb [2.6 (2.1), 1.9 vs. ≤ 1.6 μg/ml, n = 77] and D-dimer [246 (65.05), 246 vs. < 2.2 ng/ml, 2, n = 2 subjects] were higher among patients with aHUS compared with the reference range. CONCLUSION If a comprehensive complement profile were built using our data, aHUS would be identified by low levels of C3, CH50, AH50, and CFB along with increased levels of C5a, C5b-9, Bb, anti-CFH autoantibodies, and D-dimer. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
| | - Sidharth K Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | | | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Divya Sharma
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Olivia Boyer
- Service de Néphrologie Pédiatrique, AP-HP, Centre de Référence de maladies rénales rares de l'enfant et de l'adulte (MARHEA), Hôpital Necker - Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France.,Institut Imagine, Laboratoire des maladies rénales héréditaires, INSERM UMR 1163, Université de Paris, Paris, France
| | - Hui Kim Yap
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Kent Ridge, Singapore.,Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Christoph Licht
- Cell Biology Program, SickKids Research Institute, Toronto, ON, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
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7
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Complement Factor H related protein 1 and immune inflammatory disorders. Mol Immunol 2022; 145:43-49. [DOI: 10.1016/j.molimm.2022.03.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
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8
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Yokoo T, Tanabe A, Yoshida Y, Caaveiro JMM, Nakakido M, Ikeda Y, Fujimura Y, Matsumoto M, Entzminger K, Maruyama T, Okumura CJ, Nangaku M, Tsumoto K. Antibody recognition of complement Factor H reveals a flexible loop involved in Atypical Hemolytic Uremic Syndrome pathogenesis. J Biol Chem 2022; 298:101962. [PMID: 35452676 PMCID: PMC9127587 DOI: 10.1016/j.jbc.2022.101962] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/15/2022] [Accepted: 04/16/2022] [Indexed: 11/28/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a disease associated with dysregulation of the immune complement system, especially of the alternative pathway (AP). Complement factor H (CFH), consisting of 20 domains called CCP1-20, downregulates the AP as a cofactor for mediating C3 inactivation by complement factor I (CFI). However, anomalies related to CFH are known to cause excessive complement activation and cytotoxicity. In aHUS, mutations and the presence of anti-CFH autoantibodies (AAbs) have been reported as plausible causes of CFH dysfunction, and it is known that CFH-related aHUS carries a high probability of end-stage renal disease. Elucidating the detailed functions of CFH at the molecular level will help to understand aHUS pathogenesis. Herein, we used biophysical data to reveal that a heavy-chain antibody fragment, termed VHH4, recognized CFH with high affinity. Hemolytic assays also indicated that VHH4 disrupted the protective function of CFH on sheep erythrocytes. Furthermore, X-ray crystallography revealed that VHH4 recognized the Leu1181-Leu1189CCP20 loop, a known anti-CFH AAbs epitope. We next analyzed the dynamics of the C-terminal region of CFH, and showed that the epitopes recognized by anti-CFH AAbs and VHH4 were the most flexible regions in CCP18-20. Finally, we conducted mutation analyses to elucidate the mechanism of VHH4 recognition of CFH, and revealed that VHH4 inserts Trp1183CCP20 residue of CFH into the pocket formed by the complementary determining region 3 loop. These results suggested that anti-CFH AAbs may adopt a similar molecular mechanism to recognize the flexible loop of Leu1181-Leu1189CCP20, leading to aHUS pathogenesis.
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Affiliation(s)
- Takanori Yokoo
- Department of Chemistry and Biotechnology, School of Engineering, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8656, Japan
| | - Aki Tanabe
- Department of Bioengineering, School of Engineering, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Yoko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Jose M M Caaveiro
- Department of Global Healthcare, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Makoto Nakakido
- Department of Chemistry and Biotechnology, School of Engineering, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8656, Japan; Department of Bioengineering, School of Engineering, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Kevin Entzminger
- Abwiz Bio Inc, 9823 Pacific Heights Blvd, Ste J, San Diego, California, 92121, USA
| | - Toshiaki Maruyama
- Abwiz Bio Inc, 9823 Pacific Heights Blvd, Ste J, San Diego, California, 92121, USA
| | - C J Okumura
- Abwiz Bio Inc, 9823 Pacific Heights Blvd, Ste J, San Diego, California, 92121, USA
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Kouhei Tsumoto
- Department of Chemistry and Biotechnology, School of Engineering, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8656, Japan; Department of Bioengineering, School of Engineering, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan; The institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan.
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9
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Irmscher S, Zipfel SLH, Halder LD, Ivanov L, Gonzalez-Delgado A, Waldeyer C, Seiffert M, Brunner FJ, von der Heide M, Löschmann I, Wulf S, Czamara D, Papac-Milicevic N, Strauß O, Lorkowski S, Reichenspurner H, Holers MV, Banda NK, Zeller T, Binder EB, Binder CJ, Wiech T, Zipfel PF, Skerka C. Factor H-related protein 1 (FHR-1) is associated with atherosclerotic cardiovascular disease. Sci Rep 2021; 11:22511. [PMID: 34795372 PMCID: PMC8602345 DOI: 10.1038/s41598-021-02011-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 10/29/2021] [Indexed: 02/08/2023] Open
Abstract
Atherosclerotic cardiovascular disease (ACVD) is a lipid-driven inflammatory disease and one of the leading causes of death worldwide. Lipid deposits in the arterial wall lead to the formation of plaques that involve lipid oxidation, cellular necrosis, and complement activation, resulting in inflammation and thrombosis. The present study found that homozygous deletion of the CFHR1 gene, which encodes the plasma complement protein factor H-related protein 1 (FHR-1), was protective in two cohorts of patients with ACVD, suggesting that FHR-1 accelerates inflammation and exacerbates the disease. To test this hypothesis, FHR-1 was isolated from human plasma and was found to circulate on extracellular vesicles and to be deposited in atherosclerotic plaques. Surface-bound FHR-1 induced the expression of pro-inflammatory cytokines and tissue factor in both monocytes and neutrophils. Notably, plasma concentrations of FHR-1, but not of factor H, were significantly (p < 0.001) elevated in patients with ACVD, and correlated with the expression of the inflammation markers C-reactive protein, apolipoprotein serum amyloid protein A, and neopterin. FHR-1 expression also significantly correlated with plasma concentrations of low-density lipoprotein (LDL) (p < 0.0001) but not high-density lipoprotein (HDL). Taken together, these findings suggest that FHR-1 is associated with ACVD.
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Affiliation(s)
- Sarah Irmscher
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.,Institute of Cell Biochemistry, Hannover Medical School, Hannover, Germany
| | - Svante L H Zipfel
- Clinic for Heart and Visceral Surgery, University Heart and Vascular Center Hamburg, Medical University Hamburg-Eppendorf, Hamburg, Germany
| | - Luke D Halder
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Lia Ivanov
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Andres Gonzalez-Delgado
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Christoph Waldeyer
- Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Medical University Hamburg-Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Moritz Seiffert
- Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Medical University Hamburg-Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Fabian J Brunner
- Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Medical University Hamburg-Eppendorf, Hamburg, Germany
| | - Monika von der Heide
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Ina Löschmann
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Sonia Wulf
- Institute of Pathology, Medical University Hamburg-Eppendorf, Hamburg, Germany
| | - Darina Czamara
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany
| | | | - Olaf Strauß
- Department of Ophthalmology, Charité -University Medicine Berlin, a Corporate Member of Free University, Humboldt-University and the Berlin Institute of Health, Berlin, Germany
| | - Stefan Lorkowski
- Institute for Nutritional Sciences, Friedrich Schiller University, Jena, Germany
| | - Hermann Reichenspurner
- Clinic for Heart and Visceral Surgery, University Heart and Vascular Center Hamburg, Medical University Hamburg-Eppendorf, Hamburg, Germany
| | - Michael V Holers
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, United States of America
| | - Nirmal K Banda
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, United States of America
| | - Tania Zeller
- Department of General and Interventional Cardiology, University Heart and Vascular Center Hamburg, Medical University Hamburg-Eppendorf, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK) Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Elisabeth B Binder
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany
| | - Christoph J Binder
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thorsten Wiech
- Institute of Pathology, Medical University Hamburg-Eppendorf, Hamburg, Germany
| | - Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.,Faculty of Biosciences, Friedrich Schiller University, Jena, Germany
| | - Christine Skerka
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.
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10
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Abstract
The complement cascade is an evolutionary ancient innate immune defense system, playing a major role in the defense against infections. Its function in maintaining host homeostasis on activated cells has been emphasized by the crucial role of its overactivation in ever growing number of diseases, such as atypical hemolytic uremic syndrome (aHUS), autoimmune diseases as systemic lupus erythematosus (SLE), C3 glomerulopathies (C3GN), age-related macular degeneration (AMD), graft rejection, Alzheimer disease, and cancer, to name just a few. The last decade of research on complement has extended its implication in many pathological processes, offering new insights to potential therapeutic targets and asserting the necessity of reliable, sensitive, specific, accurate, and reproducible biomarkers to decipher complement role in pathology. We need to evaluate accurately which pathway or role should be targeted pharmacologically, and optimize treatment efficacy versus toxicity. This chapter is an introduction to the role of complement in human diseases and the use of complement-related biomarkers in the clinical practice. It is a part of a book intending to give reliable and standardized methods to evaluate complement according to nowadays needs and knowledge.
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11
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Lemaire M, Noone D, Lapeyraque AL, Licht C, Frémeaux-Bacchi V. Inherited Kidney Complement Diseases. Clin J Am Soc Nephrol 2021; 16:942-956. [PMID: 33536243 PMCID: PMC8216622 DOI: 10.2215/cjn.11830720] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the past 20 years, we have witnessed tremendous advances in our ability to diagnose and treat genetic diseases of the kidney caused by complement dysregulation. Staggering progress was realized toward a better understanding of the genetic underpinnings and pathophysiology of many forms of atypical hemolytic uremic syndrome (aHUS) and C3-dominant glomerulopathies that are driven by complement system abnormalities. Many of these seminal discoveries paved the way for the design and characterization of several innovative therapies, some of which have already radically improved patients' outcomes. This review offers a broad overview of the exciting developments that have occurred in the recent past, with a particular focus on single-gene (or Mendelian), complement-driven aHUS and C3-dominant glomerulopathies that should be of interest to both nephrologists and kidney researchers. The discussion is restricted to genes with robust associations with both aHUS and C3-dominant glomerulopathies (complement factor H, complement component 3, complement factor H-related proteins) or only aHUS (complement factor B, complement factor I, and membrane cofactor protein). Key questions and challenges are highlighted, along with potential avenues for future directions.
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Affiliation(s)
- Mathieu Lemaire
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada,Cell Biology Program, SickKids Research Institute, Toronto, Ontario, Canada,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Laure Lapeyraque
- Division of Nephrology, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada,Department of Pediatrics, Faculty of Medicine, University of Montréal, Québec, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada,Cell Biology Program, SickKids Research Institute, Toronto, Ontario, Canada,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Laboratory of Immunology, Paris, France
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12
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Outcomes of a clinician-directed protocol for discontinuation of complement inhibition therapy in atypical hemolytic uremic syndrome. Blood Adv 2021; 5:1504-1512. [PMID: 33683339 DOI: 10.1182/bloodadvances.2020003175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022] Open
Abstract
Terminal complement inhibition is the standard of care for atypical hemolytic uremic syndrome (aHUS). The optimal duration of complement inhibition is unknown, although indefinite therapy is common. Here, we present the outcomes of a physician-directed eculizumab discontinuation and monitoring protocol in a prospective cohort of 31 patients that started eculizumab for acute aHUS (and without a history of renal transplant). Twenty-five (80.6%) discontinued eculizumab therapy after a median duration on therapy of 2.37 (interquartile range: 1.06, 9.70) months. Eighteen patients discontinued per protocol and 7 because of nonadherence. Of these, 5 (20%) relapsed; however, relapse rate was higher in the case of nonadherence (42.8%) vs clinician-directed discontinuation and monitoring (11.1%). Four of 5 patients who relapsed were successfully retreated without a decline in renal function. One patient died because of recurrent aHUS and hypertensive emergency in the setting of nonadherence. Nonadherence to therapy (odds ratio, 8.25; 95% confidence interval, 1.02-66.19; P = .047) was associated with relapse, whereas the presence of complement gene variants (odds ratio, 1.39; 95% confidence interval, 0.39-4.87; P = .598) was not significantly associated with relapse. Relapse occurred in 40% (2 of 5) with a CFH or MCP variant, 33.3% (2 of 6) with other complement variants, and 0% (0 of 6) with no variants (P = .217). There was no decline in mean glomerular filtration rate from the date of stopping eculizumab until end of follow-up. In summary, eculizumab discontinuation with close monitoring is safe in most patients, with low rates of aHUS relapse and effective salvage with eculizumab retreatment in the event of recurrence.
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13
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Uzonyi B, Szabó Z, Trojnár E, Hyvärinen S, Uray K, Nielsen HH, Erdei A, Jokiranta TS, Prohászka Z, Illes Z, Józsi M. Autoantibodies Against the Complement Regulator Factor H in the Serum of Patients With Neuromyelitis Optica Spectrum Disorder. Front Immunol 2021; 12:660382. [PMID: 33986750 PMCID: PMC8111293 DOI: 10.3389/fimmu.2021.660382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune inflammatory disease of the central nervous system (CNS), characterized by pathogenic, complement-activating autoantibodies against the main water channel in the CNS, aquaporin 4 (AQP4). NMOSD is frequently associated with additional autoantibodies and antibody-mediated diseases. Because the alternative pathway amplifies complement activation, our aim was to evaluate the presence of autoantibodies against the alternative pathway C3 convertase, its components C3b and factor B, and the complement regulator factor H (FH) in NMOSD. Four out of 45 AQP4-seropositive NMOSD patients (~9%) had FH autoantibodies in serum and none had antibodies to C3b, factor B and C3bBb. The FH autoantibody titers were low in three and high in one of the patients, and the avidity indexes were low. FH-IgG complexes were detected in the purified IgG fractions by Western blot. The autoantibodies bound to FH domains 19-20, and also recognized the homologous FH-related protein 1 (FHR-1), similar to FH autoantibodies associated with atypical hemolytic uremic syndrome (aHUS). However, in contrast to the majority of autoantibody-positive aHUS patients, these four NMOSD patients did not lack FHR-1. Analysis of autoantibody binding to FH19-20 mutants and linear synthetic peptides of the C-terminal FH and FHR-1 domains, as well as reduced FH, revealed differences in the exact binding sites of the autoantibodies. Importantly, all four autoantibodies inhibited C3b binding to FH. In conclusion, our results demonstrate that FH autoantibodies are not uncommon in NMOSD and suggest that generation of antibodies against complement regulating factors among other autoantibodies may contribute to the complement-mediated damage in NMOSD.
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Affiliation(s)
- Barbara Uzonyi
- MTA-ELTE Immunology Research Group, Eötvös Loránd Research Network (ELKH), Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary.,Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Zsóka Szabó
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Eszter Trojnár
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Satu Hyvärinen
- Department of Bacteriology and Immunology, Medicum, and Immunobiology Research Program Unit, University of Helsinki and Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Katalin Uray
- MTA-ELTE Research Group of Peptide Chemistry, Eötvös Loránd Research Network (ELKH), ELTE Eötvös Loránd University, Budapest, Hungary
| | - Helle H Nielsen
- Department of Neurology, Odense University Hospital and Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Anna Erdei
- MTA-ELTE Immunology Research Group, Eötvös Loránd Research Network (ELKH), Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary.,Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - T Sakari Jokiranta
- Department of Bacteriology and Immunology, Medicum, and Immunobiology Research Program Unit, University of Helsinki and Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Zoltán Prohászka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital and Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - Mihály Józsi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary.,MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary.,MTA-ELTE Complement Research Group, Eötvös Loránd Research Network (ELKH), Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
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14
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Chaturvedi S, Braunstein EM, Brodsky RA. Antiphospholipid syndrome: Complement activation, complement gene mutations, and therapeutic implications. J Thromb Haemost 2021; 19:607-616. [PMID: 32881236 PMCID: PMC8080439 DOI: 10.1111/jth.15082] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome (APS) is an acquired thromboinflammatory disorder characterized by the presence of antiphospholipid antibodies as well as an increased frequency of venous or arterial thrombosis and/or obstetrical morbidity. The spectrum of disease varies from asymptomatic to a severe form characterized by widespread thrombosis and multiorgan failure, termed catastrophic APS (CAPS). CAPS affects only about ∼1% of APS patients, often presents as a thrombotic microangiopathy and has a fulminant course with >40% mortality, despite the best available therapy. Animal models have implicated complement in the pathophysiology of thrombosis in APS, with more recent data from human studies confirming the interaction between the coagulation and complement pathways. Activation of the complement cascade via antiphospholipid antibodies can cause cellular injury and promote coagulation via multiple mechanisms. Finally, analogous to classic complement-mediated diseases such as atypical hemolytic uremic syndrome, a subset of patients with APS may be at increased risk for development of CAPS because of the presence of germline variants in genes crucial for complement regulation. Together, these data make complement inhibition an attractive and potentially lifesaving therapy to mitigate morbidity and mortality in severe thrombotic APS and CAPS.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Avila Bernabeu AI, Cavero Escribano T, Cao Vilarino M. Atypical Hemolytic Uremic Syndrome: New Challenges in the Complement Blockage Era. Nephron Clin Pract 2020; 144:537-549. [PMID: 32950988 DOI: 10.1159/000508920] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare cause of thrombotic microangiopathy (TMA), characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and multisystem end organ involvement, most commonly affecting the kidney. Diagnosis is clinical, after exclusion of other TMA causes. Primary aHUS arises from genetic abnormalities, resulting in uncontrolled complement activity, while a variety of clinical scenarios cause secondary aHUS, including infection, pregnancy, malignancy, autoimmune disease, and medications. They can also induce a temporary complement deregulation with an overlap between both scenarios, which can make differential diagnosis difficult. Primary aHUS can be sporadic or familial and is associated with a high rate of progression to ESRD. Many aHUS patients relapse in the native or transplanted kidneys, leading to kidney failure. The introduction of eculizumab has changed the prognosis of aHUS, by inducing hematologic remission, improving or stabilizing kidney functions, and preventing graft failure. The early institution of appropriate therapy can prevent multiorgan damage, so is essential to recognize and differentiate the TMA syndromes. Eculizumab is considered now the first-line treatment, and it is recommended lifelong therapy. However, the high cost of therapy has led to make efforts to develop precise complement functional and genetic studies that help physicians to determine the appropriate duration of eculizumab therapy. Nowadays, more studies are needed to select candidates to adjustment of therapy.
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16
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Li X, Hao Z, Liu X, Li W. Deficiency of Mouse FHR-1 Homolog, FHR-E, Accelerates Sepsis, and Acute Kidney Injury Through Enhancing the LPS-Induced Alternative Complement Pathway. Front Immunol 2020; 11:1123. [PMID: 32636836 PMCID: PMC7316958 DOI: 10.3389/fimmu.2020.01123] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/07/2020] [Indexed: 11/26/2022] Open
Abstract
Alternative complement pathway (AP) plays an important role in the development of sepsis, which is life threatening. Deficiency of factor H-related protein 1 (FHR-1), which is a regulator of AP, has been considered as a susceptible factor for atypical hemolytic uremic syndrome (aHUS) and other types of nephropathy when an inducer such as infection exists. However, the underlying mechanism of the disease development is largely unknown. There is no report on CFHR1 gene knockout in any animal infection model and its function in vivo is still unclear. Here, a Cfhr1 knockout mouse was generated for investigating AP in sepsis and sepsis-induced acute kidney injury (AKI). We found that murine FHR-1 homolog (FHR-E) deficiency enhanced lipopolysaccharide (LPS)-induced AP activation both in vitro and in vivo and that Cfhr1 knockout mice exhibited more severe sepsis and AKI in response to LPS challenge. These results indicated that FHR-E deficiency promoted LPS-induced sepsis and AKI through AP over-activation, providing a mouse model for studying AP regulation and sepsis. This study revealed the function of FHR-E in vivo, which may further provide hints to the pathogenesis of FHR-1 deficiency-related diseases by enhancing LPS-induced AP activation.
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Affiliation(s)
- Xiangru Li
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China.,MOE Key Laboratory of Major Diseases in Children, Beijing, China.,Genetics and Birth Defects Control Center, National Center for Children's Health, Beijing, China
| | - Zhenhua Hao
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China.,MOE Key Laboratory of Major Diseases in Children, Beijing, China.,Genetics and Birth Defects Control Center, National Center for Children's Health, Beijing, China
| | - Xiaorong Liu
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wei Li
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China.,MOE Key Laboratory of Major Diseases in Children, Beijing, China.,Genetics and Birth Defects Control Center, National Center for Children's Health, Beijing, China
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17
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Anti-complement factor H autoantibodies may be protective in lupus nephritis. Clin Chim Acta 2020; 508:1-8. [PMID: 32387092 DOI: 10.1016/j.cca.2020.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/22/2020] [Accepted: 05/04/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study aimed to investigate the role of anti-CFH autoantibodies in lupus nephritis based on a well-defined cohort. METHODS One hundred twenty patients with biopsy-proven active lupus nephritis were collected as the discovery cohort, sixty patients served as the validation cohort, thirty-four patients with SLE without renal involvement (NR-SLE) were as disease controls, and thirty healthy donors were also included. The anti-CFH autoantibodies and IgG subclasses were detected by ELISA, and epitopes were evaluated by western blot. Anti-CFH autoantibodies were purified by affinity chromatography column, and the interference on the biofunctions of CFH was further studied by the C3b binding assay and cofactor activity assay in vitro. RESULTS The prevalence of anti-CFH autoantibodies in lupus nephritis was significantly higher than that in healthy controls (8.3% (10/120) vs. 0% (0/30), P = 0.017), and no significant difference was found between the discovery and the validation group (8.3% (10/120) vs. 11.7% (7/60), P = 0.268) or the discovery and the NR-SLE group (8.3% (10/120) vs. 11.8% (4/34), P = 0.231). The subclass was mainly IgG2 (7/10), and major epitopes were in the middle (8/10 in SCRs 11-14) and N-terminal (7/10 in SCRs 1-4) regions of CFH. Patients with anti-CFH autoantibodies had a significantly lower prevalence of acute kidney injury (0% (0/10) vs. 40.0%(4/10), P = 0.025), lower serum creatinine levels (0.76 (0.40, 1.06) vs. 1.43 (0.46, 11.15), mg/dL, P = 0.023), and higher hemoglobin levels (113.8 ± 24.63 vs. 90.0 ± 22.53, g/L, P = 0.037) than those who were negative after further stratified analysis. A functional study showed that anti-CFH autoantibodies purified from patients with lupus nephritis could improve the binding between CFH and C3b, and also enhance the cofactor activity of CFH in vitro. CONCLUSIONS Anti-CFH autoantibodies were detected in patients with lupus nephritis in approximately 10% of patients with polyepitopes and IgG2 subclass predominance. Patients with anti-CFH autoantibodies presented with milder renal damage, and the purified autoantibodies could enhance the C3b binding and CFI cofactor activity of CFH in vitro, which suggested a protective role in the lupus nephritis.
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18
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Kerboua KE, Djenouhat K. Complementology's foundation: The 100-year anniversary of the Nobel Prize to Jules Bordet. J Immunoassay Immunochem 2020; 41:106-116. [PMID: 31747841 DOI: 10.1080/15321819.2019.1689999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The discovery of the complement system was associated with the creation of medical serodiagnosis in the early 20th century. Its biotechnological applications, usable even a century after its development by Jules Bordet, preceded for decades the proof of its biochemical rather than biophysical nature. Complement science has begun to emerge, thanks to the labs of Michael Heidelberger and his student Manfred Martin Mayer. Complementology had known difficult moments like the suicide of Louis Pillemer by swallowing the reagents of his laboratory following the criticisms of his discovery by Robert A. Nelson, Jr., in March 1957, at the Walter Reed Army Institute. This alternative complement pathway continues to revolutionize medicine by its implications as the principal component of immunosurveillance and as an amplification loop for plasma proteolytic cascades. Moreover, the drug designed in pathologies related to this pathway, eculizumab, was the most expensive drug in the world at the beginning of its marketing. Complementology promises great hopes in inflammatory and degenerative diseases, regenerative medicine, transplantation, and vector nanotechnology and as a diagnostic tool primarily in transplantation and inflammatory imaging. The moral and historical responsibility requires to make known this legacy to the new generation of doctors and scientists and also the technicians of the clinical laboratory of complementology throughout the world.
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Affiliation(s)
- Kheir Eddine Kerboua
- Laboratory of Immunology, Faculty of Medicine, University of Kasdi Merbah Ouargla, ouargla, Algeria
| | - Kamal Djenouhat
- Laboratory of Immunology, Faculty of Medicine, University of Youcef Benkhadda Algiers, Algiers, Algeria
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19
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Regulation of regulators: Role of the complement factor H-related proteins. Semin Immunol 2019; 45:101341. [PMID: 31757608 DOI: 10.1016/j.smim.2019.101341] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/07/2019] [Accepted: 10/24/2019] [Indexed: 01/15/2023]
Abstract
The complement system, while being an essential and very efficient effector component of innate immunity, may cause damage to the host and result in various inflammatory, autoimmune and infectious diseases or cancer, when it is improperly activated or regulated. Factor H is a serum glycoprotein and the main regulator of the activity of the alternative complement pathway. Factor H, together with its splice variant factor H-like protein 1 (FHL-1), inhibits complement activation at the level of the central complement component C3 and beyond. In humans, there are also five factor H-related (FHR) proteins, whose function is poorly characterized. While data indicate complement inhibiting activity for some of the FHRs, there is increasing evidence that FHRs have an opposite role compared with factor H and FHL-1, namely, they enhance complement activation directly and also by competing with the regulators FH and FHL-1. This review summarizes the current stand and recent data on the roles of factor H family proteins in health and disease, with focus on the function of FHR proteins.
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20
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Mitrovic S, Hertig A, Fautrel B. Reply to the Letter: 'Thrombotic microangiopathy in adult-onset Still's disease: the story is just beginning'. Expert Rev Clin Immunol 2019; 15:1125-1126. [PMID: 31623457 DOI: 10.1080/1744666x.2019.1682893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Stéphane Mitrovic
- Department of Rheumatology, AP-HP, Hôpital de La Pitié Salpêtrière, Sorbonne Université, Paris, France.,Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Alexandre Hertig
- Department of Renal Transplantation, AP-HP, Hôpital de La Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Bruno Fautrel
- Department of Rheumatology, AP-HP, Hôpital de La Pitié Salpêtrière, Sorbonne Université, Paris, France.,Faculté de Médecine et Institut Pierre Louis d'Epidémiologie et Santé publique, Sorbonne Université, Paris, France.,CRI-IMIDIATE, a FCRIN Clinical Research Network, France
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21
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Serum FHR1 binding to necrotic-type cells activates monocytic inflammasome and marks necrotic sites in vasculopathies. Nat Commun 2019; 10:2961. [PMID: 31273197 PMCID: PMC6609651 DOI: 10.1038/s41467-019-10766-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/31/2019] [Indexed: 12/22/2022] Open
Abstract
Persistent inflammation is a hallmark of many human diseases, including anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and atherosclerosis. Here, we describe a dominant trigger of inflammation: human serum factor H-related protein FHR1. In vitro, this protein selectively binds to necrotic cells via its N-terminus; in addition, it binds near necrotic glomerular sites of AAV patients and necrotic areas in atherosclerotic plaques. FHR1, but not factor H, FHR2 or FHR3 strongly induces inflammasome NLRP3 in blood-derived human monocytes, which subsequently secrete IL-1β, TNFα, IL-18 and IL-6. FHR1 triggers the phospholipase C-pathway via the G-protein coupled receptor EMR2 independent of complement. Moreover, FHR1 concentrations of AAV patients negatively correlate with glomerular filtration rates and associate with the levels of inflammation and progressive disease. These data highlight an unexpected role for FHR1 during sterile inflammation, may explain why FHR1-deficiency protects against certain diseases, and identifies potential targets for treatment of auto-inflammatory diseases.
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22
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Tsai HM. Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndromes. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00042-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Abstract
The complement system is a part of the immune system implicated in host defense against pathogens and damaged cells and Factor H is the main regulatory protein of this powerful enzymatic cascade. Autoantibodies directed against Factor H (anti-FH antibodies) are implicated in different pathologies mainly atypical hemolytic and uremic syndrome and C3 glomerulopathies. The detection and quantification of these autoantibodies are crucial for the clinical management of the patients.Anti-Factor H antibodies are detected and quantified by an ELISA assay. The aim of this chapter is to describe the procedure to determine anti-FH autoantibodies and to provide information about their biological significance.
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24
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Yoshida Y, Kato H, Ikeda Y, Nangaku M. Pathogenesis of Atypical Hemolytic Uremic Syndrome. J Atheroscler Thromb 2018; 26:99-110. [PMID: 30393246 PMCID: PMC6365154 DOI: 10.5551/jat.rv17026] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a type of thrombotic microangiopathy (TMA) defined by thrombocytopenia, microangiopathic hemolytic anemia, and renal failure. aHUS is caused by uncontrolled complement activation in the alternative pathway (AP). A variety of genetic defects in complement-related factors or acquired autoantibodies to the complement regulators have been found in 50 to 60% of all cases. Recently, however, the classification and diagnosis of aHUS are becoming more complicated. One reason for this is that some factors, which have not been regarded as complement-related factors, have been reported as predisposing factors for phenotypic aHUS. Given that genotype is highly correlated with the phenotype of aHUS, careful analysis of underlying genetic abnormalities or acquired factors is needed to predict the prognosis or to decide an optimal treatment for the disease. Another reason is that complement dysregulation in the AP have also been found in a part of other types of TMA such as transplantation-related TMA and pregnancy-related complication. Based on these findings, it is now time to redefine aHUS according to the genetic or acquired background of abnormalities.Here, we review the pathogeneses and the corresponding phenotypes of aHUS and complement-related TMAs.
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Affiliation(s)
- Yoko Yoshida
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
| | - Hideki Kato
- Department of Prevention of Diabetes and Lifestyle-Related Diseases Graduate School of Medicine, the University of Tokyo
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
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25
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Raina R, Krishnappa V, Blaha T, Kann T, Hein W, Burke L, Bagga A. Atypical Hemolytic-Uremic Syndrome: An Update on Pathophysiology, Diagnosis, and Treatment. Ther Apher Dial 2018; 23:4-21. [PMID: 30294946 DOI: 10.1111/1744-9987.12763] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/25/2018] [Indexed: 12/25/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS), a rare variant of thrombotic microangiopathy, is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. The condition is associated with poor clinical outcomes with high morbidity and mortality. Atypical HUS predominantly affects the kidneys but has the potential to cause multi-organ system dysfunction. This uncommon disorder is caused by a genetic abnormality in the complement alternative pathway resulting in over-activation of the complement system and formation of microvascular thrombi. Abnormalities of the complement pathway may be in the form of mutations in key complement genes or autoantibodies against specific complement factors. We discuss the pathophysiology, clinical manifestations, diagnosis, complications, and management of aHUS. We also review the efficacy and safety of the novel therapeutic agent, eculizumab, in aHUS, pregnancy-associated aHUS, and aHUS in renal transplant patients.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General and Akron Children's Hospital, Akron, OH, USA.,Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA
| | - Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA.,Northeast Ohio Medical University, Rootstown, OH, USA
| | - Taryn Blaha
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Taylor Kann
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - William Hein
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Linda Burke
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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26
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Bitzan M, Hammad RM, Bonnefoy A, Al Dhaheri WS, Vézina C, Rivard GÉ. Acquired thrombotic thrombocytopenic purpura with isolated CFHR3/1 deletion-rapid remission following complement blockade. Pediatr Nephrol 2018; 33:1437-1442. [PMID: 29728803 PMCID: PMC6019431 DOI: 10.1007/s00467-018-3957-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/27/2018] [Accepted: 04/02/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is caused by the abundance of uncleaved ultralarge von Willebrand factor multimers (ULvWF) due to acquired (autoantibody-mediated) or congenital vWF protease ADAMTS13 deficiency. Current treatment recommendations include plasma exchange therapy and immunosuppression for the acquired form and (fresh) frozen plasma for congenital TTP. CASE-DIAGNOSIS/TREATMENT A previously healthy, 3-year-old boy presented with acute microangiopathic hemolytic anemia, thrombocytopenia, erythrocyturia and mild proteinuria, but normal renal function, and elevated circulating sC5b-9 levels indicating complement activation. He was diagnosed with atypical hemolytic uremic syndrome and treated with a single dose of eculizumab, followed by prompt resolution of all hematological parameters. However, undetectably low plasma ADAMTS13 activity in the pre-treatment sample, associated with inhibitory ADAMTS13 antibodies, subsequently changed the diagnosis to acquired TTP. vWF protease activity normalized within 15 months without further treatment, and the patient remained in long-term clinical and laboratory remission. Extensive laboratory workup revealed a homozygous deletion of CFHR3/1 negative for anti-CFH antibodies, but no mutations of ADAMTS13, (other) alternative pathway of complement regulators or coagulation factors. CONCLUSIONS This case, together with a previous report of a boy with congenital TTP (Pecoraro et al. Am J Kidney Dis 66:1067, 2015), strengthens evolving in-vitro and ex-vivo evidence that ULvWF interferes with complement regulation and contributes to the TTP phenotype. Comprehensive, prospective complement studies in patients with TTP may lead to a better pathophysiological understanding and novel treatment approaches for acquired or congenital forms.
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Affiliation(s)
- Martin Bitzan
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Room B RC.6651, Montreal, Québec, H4A 3J1, Canada.
| | - Rawan M Hammad
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Room B RC.6651, Montreal, Québec, H4A 3J1, Canada
| | - Arnaud Bonnefoy
- Service d'hématologie-oncologie, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | - Watfa Shahwan Al Dhaheri
- Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Room B RC.6651, Montreal, Québec, H4A 3J1, Canada
- Department of Pediatric, Tawam Hospital, Al Ain, United Arab Emirates
| | - Catherine Vézina
- Division of Hematology/Oncology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Georges-Étienne Rivard
- Service d'hématologie-oncologie, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
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Sánchez-Corral P, Pouw RB, López-Trascasa M, Józsi M. Self-Damage Caused by Dysregulation of the Complement Alternative Pathway: Relevance of the Factor H Protein Family. Front Immunol 2018; 9:1607. [PMID: 30050540 PMCID: PMC6052053 DOI: 10.3389/fimmu.2018.01607] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022] Open
Abstract
The alternative pathway is a continuously active surveillance arm of the complement system, and it can also enhance complement activation initiated by the classical and the lectin pathways. Various membrane-bound and plasma regulatory proteins control the activation of the potentially deleterious complement system. Among the regulators, the plasma glycoprotein factor H (FH) is the main inhibitor of the alternative pathway and its powerful amplification loop. FH belongs to a protein family that also includes FH-like protein 1 and five factor H-related (FHR-1 to FHR-5) proteins. Genetic variants and abnormal rearrangements involving the FH protein family have been linked to numerous systemic and organ-specific diseases, including age-related macular degeneration, and the renal pathologies atypical hemolytic uremic syndrome, C3 glomerulopathies, and IgA nephropathy. This review covers the known and recently emerged ligands and interactions of the human FH family proteins associated with disease and discuss the very recent experimental data that suggest FH-antagonistic and complement-activating functions for the FHR proteins.
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Affiliation(s)
- Pilar Sánchez-Corral
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Richard B Pouw
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Margarita López-Trascasa
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mihály Józsi
- Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary.,MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
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28
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Gastrointestinal pathogens in anti-FH antibody positive and negative Hemolytic Uremic Syndrome. Pediatr Res 2018; 84:118-124. [PMID: 29795200 DOI: 10.1038/s41390-018-0009-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 03/06/2018] [Accepted: 03/17/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prodromal symptoms are frequently reported in the atypical form of Hemolytic uremic syndrome (aHUS) suggesting implication of infectious triggers. Some pathogens may also play a role in the mechanisms of production of autoantibody directed against Factor H (FH), a complement regulator, leading to aHUS. METHODS The presence of 15 gastrointestinal (GI) pathogens was investigated by using xTAG-based multiplex PCR techniques on stools collected at the acute phase in a cohort of Indian HUS children classified according to the presence or absence of anti-FH autoantibodies. RESULTS Prevalence of pathogens in patients with anti-FH antibody (62.5%) was twice that in those without (31.5%). Different pathogens were detected, the most frequent being Clostridium difficile, Giardia intestinalis, Salmonella, Shigella, Rotavirus, Norovirus and Entamoeba histolytica. No stool was positive for Shigatoxin. CONCLUSION This study reveals a higher prevalence of GI pathogens in anti-FH positive than in negative patients. No single pathogen was implicated exclusively in one form of HUS. These pathogens may play a role in the disease initiation by inducing complement activation or an autoimmune response.
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29
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Goicoechea de Jorge E, López Lera A, Bayarri-Olmos R, Yebenes H, Lopez-Trascasa M, Rodríguez de Córdoba S. Common and rare genetic variants of complement components in human disease. Mol Immunol 2018; 102:42-57. [PMID: 29914697 DOI: 10.1016/j.molimm.2018.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 12/21/2022]
Abstract
Genetic variability in the complement system and its association with disease has been known for more than 50 years, but only during the last decade have we begun to understand how this complement genetic variability contributes to the development of diseases. A number of reports have described important genotype-phenotype correlations that associate particular diseases with genetic variants altering specific aspects of the activation and regulation of the complement system. The detailed functional characterization of some of these genetic variants provided key insights into the pathogenic mechanisms underlying these pathologies, which is facilitating the design of specific anti-complement therapies. Importantly, these analyses have sometimes revealed unknown features of the complement proteins. As a whole, these advances have delineated the functional implications of genetic variability in the complement system, which supports the implementation of a precision medicine approach based on the complement genetic makeup of the patients. Here we provide an overview of rare complement variants and common polymorphisms associated with disease and discuss what we have learned from them.
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Affiliation(s)
- Elena Goicoechea de Jorge
- Department of Immunology, Complutense University, Madrid, Spain; Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Alberto López Lera
- Research Institute Hospital Universitario La Paz (IdiPaz), Madrid, Spain; Ciber de Enfermedades Raras, Madrid, Spain
| | - Rafael Bayarri-Olmos
- Department of Clinical Immunology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hugo Yebenes
- Ciber de Enfermedades Raras, Madrid, Spain; Molecular Pathology and Complement Genetics Unit. Centro de Investigaciones Biológicas, CSIC, Madrid, Spain
| | | | - Santiago Rodríguez de Córdoba
- Ciber de Enfermedades Raras, Madrid, Spain; Molecular Pathology and Complement Genetics Unit. Centro de Investigaciones Biológicas, CSIC, Madrid, Spain.
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30
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Pouw RB, Gómez Delgado I, López Lera A, Rodríguez de Córdoba S, Wouters D, Kuijpers TW, Sánchez-Corral P. High Complement Factor H-Related (FHR)-3 Levels Are Associated With the Atypical Hemolytic-Uremic Syndrome-Risk Allele CFHR3*B. Front Immunol 2018; 9:848. [PMID: 29740447 PMCID: PMC5928496 DOI: 10.3389/fimmu.2018.00848] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/05/2018] [Indexed: 02/05/2023] Open
Abstract
Dysregulation of the complement alternative pathway (AP) is a major pathogenic mechanism in atypical hemolytic-uremic syndrome (aHUS). Genetic or acquired defects in factor H (FH), the main AP regulator, are major aHUS drivers that associate with a poor prognosis. FH activity has been suggested to be downregulated by homologous FH-related (FHR) proteins, including FHR-3 and FHR-1. Hence, their relative levels in plasma could be disease-relevant. The genes coding for FH, FHR-3, and FHR-1 (CFH, CFHR3, and CFHR1, respectively) are polymorphic and located adjacent to each other on human chromosome 1q31.3. We have previously shown that haplotype CFH(H3)–CFHR3*B–CFHR1*B associates with aHUS and reduced FH levels. In this study, we used a specific enzyme-linked immunosorbent assay to quantify FHR-3 in plasma samples from controls and patients with aHUS genotyped for the three known CFHR3 alleles (CFHR3*A, CFHR3*B, and CFHR3*Del). In the 218 patients carrying at least one copy of CFHR3, significant differences between CFHR3 genotype groups were found, with CFHR3*A/Del patients having the lowest FHR-3 concentration (0.684–1.032 µg/mL), CFHR3*B/Del and CFHR3*A/A patients presenting intermediate levels (1.437–2.201 µg/mL), and CFHR3*A/B and CFHR3*B/B patients showing the highest concentration (2.330–4.056 µg/mL) (p < 0.001). These data indicate that CFHR3*A is a low-expression allele, whereas CFHR3*B, associated with increased risk of aHUS, is a high-expression allele. Our study reveals that the aHUS-risk haplotype CFH(H3)–CFHR3*B–CFHR1*B generates twofold more FHR-3 than the non-risk CFH(H1)–CFHR3*A–CFHR1*A haplotype. In addition, FHR-3 levels were higher in patients with aHUS than in control individuals with the same CFHR3 genotype. These data suggest that increased plasma levels of FHR-3, altering the balance between FH and FHR-3, likely impact the FH regulatory functions and contribute to the development of aHUS.
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Affiliation(s)
- Richard B Pouw
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Irene Gómez Delgado
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Alberto López Lera
- Immunology Unit, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Biological Research Center (CIB)-CSIC, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands.,Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Pilar Sánchez-Corral
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
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31
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Patterson JM, Bolster L, Larratt L. Case Series of 3 Patients Diagnosed With Atypical Hemolytic Uremic Syndrome Successfully Treated With Steroids, Plasmapheresis, and Rituximab. Can J Kidney Health Dis 2018; 5:2054358117747262. [PMID: 29308213 PMCID: PMC5751898 DOI: 10.1177/2054358117747262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/24/2017] [Indexed: 11/17/2022] Open
Abstract
Rationale Atypical hemolytic uremic syndrome, which has a high probability of chronic kidney disease, morbidity, and mortality, needs to be promptly recognized when patients present with microangiopathic hemolysis. Presenting Concerns of the Patient Three patients present with laboratory parameters consistent with a thrombotic microangiopathy. With a suspected diagnosis of thrombotic thrombocytopenic purpura, steroids with plasmapheresis were initiated. Diagnoses With ADAMTS13 levels reported normal, the suspected diagnoses were reevaluated. Given ongoing renal impairment, atypical hemolytic uremic syndrome was strongly considered. Interventions When local funding issues precluded the prompt use of eculizumab, 4 doses of weekly rituximab were trialed. Outcome Over 2 years later, all 3 patients have sustained durable remissions defined by the absence of kidney impairment or laboratory investigations concerning for microangiopathic hemolytic relapse. Lessons Learned In cases of a suspected autoimmune mechanism leading to atypical hemolytic uremic syndrome, long-term use of eculizumab may not be required.
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Affiliation(s)
| | - Lauren Bolster
- Division of Hematology, University of Alberta, Edmonton, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, Canada
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32
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Cserhalmi M, Uzonyi B, Merle NS, Csuka D, Meusburger E, Lhotta K, Prohászka Z, Józsi M. Functional Characterization of the Disease-Associated N-Terminal Complement Factor H Mutation W198R. Front Immunol 2017; 8:1800. [PMID: 29321782 PMCID: PMC5733548 DOI: 10.3389/fimmu.2017.01800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/30/2017] [Indexed: 12/23/2022] Open
Abstract
Dysregulation of the complement alternative pathway is involved in the pathogenesis of several diseases, including the kidney diseases atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy (C3G). In a patient, initially diagnosed with chronic glomerulonephritis, possibly C3G, and who 6 years later had an episode of aHUS, a heterozygous missense mutation leading to a tryptophan to arginine exchange (W198R) in the factor H (FH) complement control protein (CCP) 3 domain has previously been identified. The aim of this study was to clarify the functional relevance of this mutation. To this end, wild-type (FH1-4WT) and mutant (FH1-4W198R) CCPs 1-4 of FH were expressed as recombinant proteins. The FH1-4W198R mutant showed decreased C3b binding compared with FH1-4WT. FH1-4W198R had reduced cofactor and decay accelerating activity compared with the wild-type protein. Hemolysis assays demonstrated impaired capacity of FH1-4W198R to protect rabbit erythrocytes from human complement-mediated lysis, and also to prevent lysis of sheep erythrocytes in human serum induced by a monoclonal antibody binding in FH CCP5 domain, compared with that of FH1-4WT. Thus, the FH W198R exchange results in impaired complement alternative pathway regulation. The heterozygous nature of this mutation in the index patient may explain the manifestation of two diseases, likely due to different triggers leading to complement dysregulation in plasma or on cell surfaces.
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Affiliation(s)
- Marcell Cserhalmi
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Barbara Uzonyi
- MTA-ELTE Immunology Research Group, Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Nicolas S Merle
- UMRS 1138, Cordeliers Research Center, Complement and Diseases Team, INSERM, Paris, France
| | - Dorottya Csuka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Edgar Meusburger
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Karl Lhotta
- Department of Nephrology and Dialysis, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.,MTA-SE Immunology and Hematology Research Group, Semmelweis University, Budapest, Hungary
| | - Mihály Józsi
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
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33
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Jullien P, Laurent B, Claisse G, Masson I, Dinic M, Thibaudin D, Berthoux F, Alamartine E, Mariat C, Maillard N. Deletion Variants of CFHR1 and CFHR3 Associate with Mesangial Immune Deposits but Not with Progression of IgA Nephropathy. J Am Soc Nephrol 2017; 29:661-669. [PMID: 29114042 DOI: 10.1681/asn.2017010019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 10/08/2017] [Indexed: 11/03/2022] Open
Abstract
Activation of complement through the alternative pathway has a key role in the pathogenesis of IgA nephropathy (IgAN). Large, international, genome-wide association studies have shown that deletion of complement factor H-related genes 1 and 3 (CFHR3,1Δ) is associated with a reduced risk of developing IgAN, although the prognostic value of these deletions in IgAN remains unknown. Here, we compared the renal outcomes of patients with IgAN according to their CFHR3,1Δ genotype. This retrospective, monocentric cohort study included 639 white patients with biopsy-proven IgAN since 1979 (mean age at diagnosis, 40.1 years; median follow-up, 132 months). We determined the number of CFHR3 and CFHR1 gene copies by quantitative PCR and collected clinical and biologic data by reviewing the patients' medical records. In all, 30.5% of the patients were heterozygous and 4% were homozygous for CFHR3,1Δ We did not detect an association between CFHR3,1Δ and age, eGFR, urinary protein excretion rate, or the presence of hypertension or hematuria at the time of diagnosis. The mean intensities of immune IgA, IgG, and C3 deposits were lower in the group with heterozygous or homozygous gene deletions than in those with no deletion. However, CFHR3,1Δ did not associate with progression to stage 3 CKD or renal death. In conclusion, the CFHR3,1Δ genotype did not associate with progression toward CKD stages 3 and 5 in our white population of patients with IgAN, although it did associate with a reduced level of glomerular immune deposits.
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Affiliation(s)
- Perrine Jullien
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and.,Groupe Immunité des Muqueuses et Agents Pathogènes Laboratory, Equipe d'Accueil 3064, Jean Monnet University, Saint-Etienne, Communauté d'Universités et Établissements de Lyon, France
| | - Blandine Laurent
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Guillaume Claisse
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Ingrid Masson
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Miriana Dinic
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Damien Thibaudin
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Francois Berthoux
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Eric Alamartine
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and
| | - Christophe Mariat
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and.,Groupe Immunité des Muqueuses et Agents Pathogènes Laboratory, Equipe d'Accueil 3064, Jean Monnet University, Saint-Etienne, Communauté d'Universités et Établissements de Lyon, France
| | - Nicolas Maillard
- Department of Nephrology, Dialysis and Renal Transplantation, University North Hospital, Saint-Etienne, France; and .,Groupe Immunité des Muqueuses et Agents Pathogènes Laboratory, Equipe d'Accueil 3064, Jean Monnet University, Saint-Etienne, Communauté d'Universités et Établissements de Lyon, France
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34
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Brocklebank V, Johnson S, Sheerin TP, Marks SD, Gilbert RD, Tyerman K, Kinoshita M, Awan A, Kaur A, Webb N, Hegde S, Finlay E, Fitzpatrick M, Walsh PR, Wong EKS, Booth C, Kerecuk L, Salama AD, Almond M, Inward C, Goodship TH, Sheerin NS, Marchbank KJ, Kavanagh D. Factor H autoantibody is associated with atypical hemolytic uremic syndrome in children in the United Kingdom and Ireland. Kidney Int 2017; 92:1261-1271. [PMID: 28750931 PMCID: PMC5652378 DOI: 10.1016/j.kint.2017.04.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/31/2017] [Accepted: 04/28/2017] [Indexed: 01/23/2023]
Abstract
Factor H autoantibodies can impair complement regulation, resulting in atypical hemolytic uremic syndrome, predominantly in childhood. There are no trials investigating treatment, and clinical practice is only informed by retrospective cohort analysis. Here we examined 175 children presenting with atypical hemolytic uremic syndrome in the United Kingdom and Ireland for factor H autoantibodies that included 17 children with titers above the international standard. Of the 17, seven had a concomitant rare genetic variant in a gene encoding a complement pathway component or regulator. Two children received supportive treatment; both developed established renal failure. Plasma exchange was associated with a poor rate of renal recovery in seven of 11 treated. Six patients treated with eculizumab recovered renal function. Contrary to global practice, immunosuppressive therapy to prevent relapse in plasma exchange-treated patients was not adopted due to concerns over treatment-associated complications. Without immunosuppression, the relapse rate was high (five of seven). However, reintroduction of treatment resulted in recovery of renal function. All patients treated with eculizumab achieved sustained remission. Five patients received renal transplants without specific factor H autoantibody-targeted treatment with recurrence in one who also had a functionally significant CFI mutation. Thus, our current practice is to initiate eculizumab therapy for treatment of factor H autoantibody-mediated atypical hemolytic uremic syndrome rather than plasma exchange with or without immunosuppression. Based on this retrospective analysis we see no suggestion of inferior treatment, albeit the strength of our conclusions is limited by the small sample size.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Sally Johnson
- Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, UK
| | - Thomas P Sheerin
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen D Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rodney D Gilbert
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Meredith Kinoshita
- The Department for Paediatric Nephrology & Transplantation, The Children's University Hospital, Dublin, Ireland
| | - Atif Awan
- The Department for Paediatric Nephrology & Transplantation, The Children's University Hospital, Dublin, Ireland
| | - Amrit Kaur
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Nicholas Webb
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Eric Finlay
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Patrick R Walsh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Edwin K S Wong
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | | | - Larissa Kerecuk
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Alan D Salama
- UCL Centre for Nephrology, Royal Free London NHS Foundation Trust, Rowland Hill Street, London, UK
| | - Mike Almond
- Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, UK
| | - Carol Inward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | - Timothy H Goodship
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Kevin J Marchbank
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK.
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35
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A novel CFHR1-CFHR5 hybrid leads to a familial dominant C3 glomerulopathy. Kidney Int 2017; 92:876-887. [PMID: 28729035 DOI: 10.1016/j.kint.2017.04.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 04/14/2017] [Accepted: 04/28/2017] [Indexed: 11/23/2022]
Abstract
The intrinsic similarity shared between the members of the complement factor H family, which comprises complement factor H and five complement factor H-related (CFHR) genes, leads to various recombination events. In turn these events lead to deletions of some genes or abnormal proteins, which are found in patients with atypical hemolytic uremic syndrome or C3 glomerulopathies. Here we describe a novel genetic rearrangement generated from a heterozygous deletion spanning 146 Kbp involving multiple CFHR genes leading to a CFHR1-R5 hybrid protein. This deletion was found in four family members presenting with a familial dominant glomerulopathy histologically classified as an overlap of dense deposit disease and C3 glomerulonephritis. Affected patients exhibited permanently low C3 and factor B levels and high amounts of activation fragments sC5b9 and Bb, indicating a systemic alternative pathway dysregulation. The abnormal protein, characterized by Western blot and immunoprecipitation, was shown to circulate in association with CFHR1 and CFHR2, attributable to its two N-terminal dimerization motifs. The presence of this protein is associated with a perturbation of Factor H activity on the C3 convertase decay. Thus, our study highlights the role of CFHRs in the physiopathology of C3 glomerulopathies and stresses the importance of screening CFHRs in all familial C3 glomerulopathies. Such hybrids described till now were always associated with familial forms.
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36
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Münch J, Bachmann A, Grohmann M, Mayer C, Kirschfink M, Lindner TH, Bergmann C, Halbritter J. Effective immunosuppressive management with belatacept and eculizumab in post-transplant aHUS due to a homozygous deletion of CFHR1/ CFHR3 and the presence of CFH antibodies. Clin Kidney J 2017; 10:742-746. [PMID: 29225802 PMCID: PMC5716210 DOI: 10.1093/ckj/sfx053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/08/2017] [Indexed: 01/29/2023] Open
Abstract
Atypical haemolytic uraemic syndrome (aHUS) may clinically present as acute renal graft failure resulting from excessive activation of the complement cascade. While mutations of complement-encoding genes predispose for aHUS, it is generally thought to require an additional insult (e.g. drugs) to trigger and manifest the full-blown clinical syndrome. Calcineurin inhibitors (CNIs) used for immunosuppression act as potential triggers, especially in the post-transplantation setting. Therefore, CNI-free immunosuppressive regimens may be beneficial. We report on a 58-year-old woman who developed aHUS with acute graft failure within 20 days after renal transplantation. Genetic investigation revealed a homozygous deletion of the CFH-related 1 (CFHR1) and CFHR3 genes in addition to the presence of autoantibodies against complement factor H (CFH). The patient was treated with plasmapheresis and administration of the complement component 5 (C5) antibody eculizumab, and her immunosuppressive regimen was switched from CNI (tacrolimus) to the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor belatacept. Renal graft function recovered and stabilized over an 18-month follow-up period. We describe the successful management of post-transplant aHUS using a CNI-free immunosuppressive regimen based on eculizumab and belatacept. Ideally, adequate molecular diagnostics, performed prior to transplantation, can identify relevant genetic risk factors for graft failure and help to select patients for individualized immunosuppressive regimens.
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Affiliation(s)
- Johannes Münch
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | - Anette Bachmann
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | - Maik Grohmann
- Center for Human Genetics, Bioscientia, Ingelheim, Germany
| | - Christof Mayer
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | | | - Tom H Lindner
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | | | - Jan Halbritter
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
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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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Csincsi ÁI, Szabó Z, Bánlaki Z, Uzonyi B, Cserhalmi M, Kárpáti É, Tortajada A, Caesar JJE, Prohászka Z, Jokiranta TS, Lea SM, Rodríguez de Córdoba S, Józsi M. FHR-1 Binds to C-Reactive Protein and Enhances Rather than Inhibits Complement Activation. THE JOURNAL OF IMMUNOLOGY 2017; 199:292-303. [PMID: 28533443 DOI: 10.4049/jimmunol.1600483] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/21/2017] [Indexed: 01/28/2023]
Abstract
Factor H-related protein (FHR) 1 is one of the five human FHRs that share sequence and structural homology with the alternative pathway complement inhibitor FH. Genetic studies on disease associations and functional analyses indicate that FHR-1 enhances complement activation by competitive inhibition of FH binding to some surfaces and immune proteins. We have recently shown that FHR-1 binds to pentraxin 3. In this study, our aim was to investigate whether FHR-1 binds to another pentraxin, C-reactive protein (CRP), analyze the functional relevance of this interaction, and study the role of FHR-1 in complement activation and regulation. FHR-1 did not bind to native, pentameric CRP, but it bound strongly to monomeric CRP via its C-terminal domains. FHR-1 at high concentration competed with FH for CRP binding, indicating possible complement deregulation also on this ligand. FHR-1 did not inhibit regulation of solid-phase C3 convertase by FH and did not inhibit terminal complement complex formation induced by zymosan. On the contrary, by binding C3b, FHR-1 allowed C3 convertase formation and thereby enhanced complement activation. FHR-1/CRP interactions increased complement activation via the classical and alternative pathways on surfaces such as the extracellular matrix and necrotic cells. Altogether, these results identify CRP as a ligand for FHR-1 and suggest that FHR-1 enhances, rather than inhibits, complement activation, which may explain the protective effect of FHR-1 deficiency in age-related macular degeneration.
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Affiliation(s)
- Ádám I Csincsi
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Lendület Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary
| | - Zsóka Szabó
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Lendület Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary
| | - Zsófia Bánlaki
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Lendület Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary
| | - Barbara Uzonyi
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Immunology Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary
| | - Marcell Cserhalmi
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Lendület Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary
| | - Éva Kárpáti
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Lendület Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary
| | - Agustín Tortajada
- Departamento Medicina Celular y Molecular, Centro de Investigaciones Biológicas, 28040 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras, 28040 Madrid, Spain
| | - Joseph J E Caesar
- Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, United Kingdom
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Internal Medicine, Semmelweis University, H-1125 Budapest, Hungary; and
| | - T Sakari Jokiranta
- Research Programs Unit, Immunobiology, Haartman Institute, University of Helsinki, FI-00014 Helsinki, Finland
| | - Susan M Lea
- Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, United Kingdom
| | - Santiago Rodríguez de Córdoba
- Departamento Medicina Celular y Molecular, Centro de Investigaciones Biológicas, 28040 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras, 28040 Madrid, Spain
| | - Mihály Józsi
- Hungarian Academy of Sciences-Eötvös Loránd University MTA-ELTE Lendület Complement Research Group, Department of Immunology, ELTE Eötvös Loránd University, 1117 Budapest, Hungary;
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Trojnár E, Józsi M, Uray K, Csuka D, Szilágyi Á, Milosevic D, Stojanović VD, Spasojević B, Rusai K, Müller T, Arbeiter K, Kelen K, Szabó AJ, Reusz GS, Hyvärinen S, Jokiranta TS, Prohászka Z. Analysis of Linear Antibody Epitopes on Factor H and CFHR1 Using Sera of Patients with Autoimmune Atypical Hemolytic Uremic Syndrome. Front Immunol 2017; 8:302. [PMID: 28424685 PMCID: PMC5371605 DOI: 10.3389/fimmu.2017.00302] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/03/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction In autoimmune atypical hemolytic uremic syndrome (aHUS), the complement regulator factor H (FH) is blocked by FH autoantibodies, while 90% of the patients carry a homozygous deletion of its homolog complement FH-related protein 1 (CFHR1). The functional consequence of FH-blockade is widely established; however, the molecular basis of autoantibody binding and the role of CFHR1 deficiency in disease pathogenesis are still unknown. We performed epitope mapping of FH to provide structural insight in the autoantibody recruitment on FH and potentially CFHR1. Methods Eight anti-FH positive aHUS patients were enrolled in this study. With overlapping synthetic FH and CFHR1 peptides, we located the amino acids (aa) involved in binding of acute and convalescence stage autoantibodies. We confirmed the location of the mapped epitopes using recombinant FH domains 19–20 that carried single-aa substitutions at the suspected antibody binding sites in three of our patients. Location of the linear epitopes and the introduced point mutations was visualized using crystal structures of the corresponding domains of FH and CFHR1. Results We identified three linear epitopes on FH (aa1157–1171; aa1177–1191; and aa1207–1226) and one on CFHR1 (aa276–290) that are recognized both in the acute and convalescence stages of aHUS. We observed a similar extent of autoantibody binding to the aHUS-specific epitope aa1177–1191 on FH and aa276–290 on CFHR1, despite seven of our patients being deficient for CFHR1. Epitope mapping with the domain constructs validated the location of the linear epitopes on FH with a distinct autoantibody binding motif within aa1183–1198 in line with published observations. Summary According to the results, the linear epitopes we identified are located close to each other on the crystal structure of FH domains 19–20. This tertiary configuration contains the amino acids reported to be involved in C3b and sialic acid binding on the regulator, which may explain the functional deficiency of FH in the presence of autoantibodies. The data we provide identify the exact structures involved in autoantibody recruitment on FH and confirm the presence of an autoantibody binding epitope on CFHR1.
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Affiliation(s)
- Eszter Trojnár
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Mihály Józsi
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, Eötvös Loránd University, Budapest, Hungary
| | - Katalin Uray
- MTA-ELTE Research Group of Peptide Chemistry, Hungarian Academy of Sciences, Eötvös Loránd University, Budapest, Hungary
| | - Dorottya Csuka
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Ágnes Szilágyi
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Danko Milosevic
- Department of Pediatric Nephrology, Dialysis and Transplantation, University of Zagreb, School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Vesna D Stojanović
- Medical Faculty, Institute for Child and Youth Health Care of Vojvodina, University of Novi Sad, Novi Sad, Serbia
| | - Brankica Spasojević
- University Children's Hospital, Nephrology, Dialysis and Transplantation Unit, Belgrade, Serbia
| | - Krisztina Rusai
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Thomas Müller
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Klaus Arbeiter
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Kata Kelen
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabó
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - György S Reusz
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Satu Hyvärinen
- Research Programs Unit, Immunobiology, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - T Sakari Jokiranta
- Research Programs Unit, Immunobiology, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
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Palamuthusingam D, Mantha M, Oliver K, Bavishi K, Dheda S. Mini review: A unique case of crescentic C3 glomerulonephritis. Nephrology (Carlton) 2017; 22:261-264. [PMID: 28205354 DOI: 10.1111/nep.12925] [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] [Received: 08/18/2016] [Accepted: 09/12/2016] [Indexed: 11/29/2022]
Abstract
Kidney involvement is an under-recognized complication of non-Hodgkin lymphomas. They occur in a variety of mechanisms and differ widely in their clinical presentation. We take this opportunity to report a case of a 65 year-old man who developed a rapidly progressive glomerulonephritis within days after completing his first cycle of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone) chemotherapy for newly diagnosed mantle cell lymphoma. He was odematous, hypertensive, oliguric with nephrotic range proteinuria and an active urine sediment. A renal biopsy showed a crescentic C3 glomerulonephritis (C3GN) with no evidence endocapillary or mesangial hypercellularity. He was promptly treated with immunosuppression and dialysis, with resumption of his chemotherapy. Genetic testing on complement proteins revealed a homozygous deletion spanning the CFHR1 and CFHR3 genes. Crescentic C3GN is a rare form of kidney injury, and this is the first known case of lymphoma-associated kidney involvement manifesting as C3GN. This article explores the possible mechanism of disease and reviews the literature of lymphoma-related kidney disease.
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Affiliation(s)
| | - Murty Mantha
- Department of Renal Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Kimberley Oliver
- Department of Anatomical Pathology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ketan Bavishi
- Department of Haematology, Cairns Hospital, Cairns, Queensland, Australia
| | - Shyam Dheda
- Department of Renal Medicine, Cairns Hospital, Cairns, Queensland, Australia
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41
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Association among Complement Factor H Autoantibodies, Deletions of CFHR, and the Risk of Atypical Hemolytic Uremic Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13121209. [PMID: 27929404 PMCID: PMC5201350 DOI: 10.3390/ijerph13121209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 12/02/2022]
Abstract
To evaluate the association among complement factor H-related (CFHRs) gene deficiency, complement factor H (CFH) autoantibodies, and atypical hemolytic uremic syndrome (aHUS) susceptibility. EMBASE, PubMed, and the ISI Web of Science databases were searched for all eligible studies on the relationship among CFHRs deficiency, anti-FH autoantibodies, and aHUS risk. Eight case-control studies with 927 cases and 1182 controls were included in this study. CFHR1 deficiency was significantly associated with an increased risk of aHUS (odds ratio (OR) = 3.61, 95% confidence interval (95% CI), 1.96, 6.63, p < 0.001), while no association was demonstrated in individuals with only CFHR1/R3 deficiency (OR = 1.32, 95% CI, 0.50, 3.50, p = 0.56). Moreover, a more significant correlation was observed in people with both FH-anti autoantibodies and CFHR1 deficiency (OR = 11.75, 95% CI, 4.53, 30.44, p < 0.001) in contrast to those with only CFHR1 deficiency. In addition, the results were essentially consistent among subgroups stratified by study quality, ethnicity, and gene detection methods. The present meta-analysis indicated that CFHR1 deletion was significantly associated with the risk of aHUS, particularly when combined with anti-FH autoantibodies, indicating that potential interactions among CFHR1 deficiency and anti-FH autoantibodies might impact the risk of aHUS.
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42
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Cheong HI, Jo SK, Yoon SS, Cho H, Kim JS, Kim YO, Koo JR, Park Y, Park YS, Shin JI, Yoo KH, Oh D. Clinical Practice Guidelines for the Management of Atypical Hemolytic Uremic Syndrome in Korea. J Korean Med Sci 2016; 31:1516-28. [PMID: 27550478 PMCID: PMC4999392 DOI: 10.3346/jkms.2016.31.10.1516] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/10/2016] [Indexed: 12/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare syndrome characterized by micro-angiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. The major pathogenesis of aHUS involves dysregulation of the complement system. Eculizumab, which blocks complement C5 activation, has recently been proven as an effective agent. Delayed diagnosis and treatment of aHUS can cause death or end-stage renal disease. Therefore, a diagnosis that differentiates aHUS from other forms of thrombotic microangiopathy is very important for appropriate management. These guidelines aim to offer recommendations for the diagnosis and treatment of patients with aHUS in Korea. The guidelines have largely been adopted from the current guidelines due to the lack of evidence concerning the Korean population.
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Affiliation(s)
- Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Sung Soo Yoon
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Young Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Ja Ryong Koo
- Division of Nephrology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong, Korea
| | - Yong Park
- Division of Hematology, Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, School of Medicine, CHA University, Seongnam, Korea.
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43
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Durey MAD, Sinha A, Togarsimalemath SK, Bagga A. Anti-complement-factor H-associated glomerulopathies. Nat Rev Nephrol 2016; 12:563-78. [PMID: 27452363 DOI: 10.1038/nrneph.2016.99] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atypical haemolytic uraemic syndrome (aHUS), an important cause of acute kidney injury, is characterized by dysregulation of the complement pathway, frequent need for dialysis, and progression to end-stage renal disease. Autoantibodies against complement factor H (FH), the main plasma regulatory protein of the alternative pathway of the complement system, account for a considerable proportion of children with aHUS. The autoantibodies are usually associated with the occurrence of a homozygous deletion in the genes encoding the FH-related proteins FHR1 and FHR3. High levels of autoantibodies, noted at the onset of disease and during relapses, induce functional deficiency of FH, whereas their decline, in response to plasma exchanges and/or immunosuppressive therapy, is associated with disease remission. Management with plasma exchange and immunosuppression is remarkably effective in inducing and maintaining remission in aHUS associated with FH autoantibodies, whereas terminal complement blockade with eculizumab is considered the most effective therapy in other forms of aHUS. Anti-FH autoantibodies are also detected in a small proportion of patients with C3 glomerulopathies, which are characterized by chronic glomerular injury mediated by activation of the alternative complement pathway and predominant C3 deposits on renal histology.
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Affiliation(s)
- Marie-Agnes Dragon Durey
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 15 rue de l'ecole de medecine, 75006 Paris, France.,Université Paris Descartes, Paris, France.,Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Shambhuprasad Kotresh Togarsimalemath
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 15 rue de l'ecole de medecine, 75006 Paris, France.,Université Paris Descartes, Paris, France
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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Abstract
C3 glomerulopathy (C3G) describes a spectrum of glomerular diseases defined by shared renal biopsy pathology: a predominance of C3 deposition on immunofluorescence with electron microscopy permitting disease sub-classification. Complement dysregulation underlies the observed pathology, a causal relationship that is supported by well described studies of genetic and acquired drivers of disease. In this article, we provide an overview of the features of C3G, including a discussion of disease definition and a review of the causal role of complement. We discuss molecular markers of disease and how biomarkers are informing our evolving understanding of underlying pathology. Research advances are laying the foundation for complement inhibition as a targeted approach to treatment of C3G.
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45
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Nozal P, López-Trascasa M. Autoantibodies against alternative complement pathway proteins in renal pathologies. Nefrologia 2016; 36:489-495. [PMID: 27267919 DOI: 10.1016/j.nefro.2016.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/04/2015] [Accepted: 01/14/2016] [Indexed: 11/19/2022] Open
Abstract
Complement system activation plays an important role in several renal pathologies, including antibody-mediated glomerulonephritis, ischaemia-reperfusion injury of trasplanted kidneys or renal allograft rejection. Besides these conditions, alternative pathway abnormalities are directly involved in the pathogenesis of C3 glomerulopathies and atypical haemolytic uraemic syndrome. These abnormalities may be inherited or acquired, the latter as autoantibodies directed against the various components and regulators of the alternative complement pathway. The functional consequences of some of these antibodies and their association with these conditions are well known, whereas for other antibodies only isolated cases have been reported. This article describes the autoantibodies that target the alternative complement pathway proteins, their characteristics and their clinical relevance in renal pathologies.
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Affiliation(s)
- Pilar Nozal
- Unidad de Inmunología, Hospital Universitario La Paz. IdiPAZ. CIBERER U-754, Madrid, España
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46
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Åkesson A, Blom AM, Klintman J, Zetterberg E. Indications of underdiagnosis of atypical haemolytic uraemic syndrome in a cohort referred to the Coagulation Unit in Malmo, Sweden, for analysis of ADAMTS13 2007-2012. Nephrology (Carlton) 2016; 22:555-561. [PMID: 27175932 DOI: 10.1111/nep.12818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/07/2016] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Abstract
AIM Complement-mediated atypical haemolytic uraemic syndrome (aHUS) is a rare disease with high mortality and morbidity if left untreated. The diagnostic work-up is complicated and the manifestations overlap with other conditions. Therefore, we hypothesize that complement-mediated aHUS is an under diagnosed disease. METHODS A cohort of 768 referrals referred to the Coagulation Unit in Malmo, Sweden, for analysis of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), 2007-2012, were retrospectively reviewed. Subjects were included on the basis of presence of haemolytic anaemia, thrombocytopaenia, renal failure and ADAMTS13 > 0.05. They were excluded if tested positive for Escherichia coli. Included subjects were categorized as "suspected HUS" with and without potential causes and triggers. Levels of C3 and C4, presence of complement factor H (CFH)-specific antibodies and associated deficiency in complement factor H related protein 1 (CFHR1) were analyzed on frozen samples. RESULTS In total, 134/316 (42%) unique subjects fulfilled inclusion criteria; 103 were categorized as "suspected HUS associated with potential causes/triggers" and 31 subjects categorized as "suspected HUS" without such association. One case of complement-mediated aHUS had been confirmed during the treatment period. Laboratory analyses performed showed that in total 78 cases had findings consistent with complement-mediated aHUS: 24 cases indicated presence of CFH-specific antibodies whereof five cases had isolated low C3 titres and six cases had deficiency of CFHR1. Additionally 54 cases indicated isolated alternative pathway consumption. CONCLUSION The results suggest that the presence of complement-mediated aHUS was under diagnosed in this cohort calling for improvement of diagnostic availability.
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Affiliation(s)
- Alexander Åkesson
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Anna M Blom
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jenny Klintman
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Eva Zetterberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
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47
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Shaw PX, Stiles T, Douglas C, Ho D, Fan W, Du H, Xiao X. Oxidative stress, innate immunity, and age-related macular degeneration. AIMS MOLECULAR SCIENCE 2016; 3:196-221. [PMID: 27239555 PMCID: PMC4882104 DOI: 10.3934/molsci.2016.2.196] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Age-related macular degeneration (AMD) is a leading cause of vision loss affecting tens of millions of elderly worldwide. Early AMD is characterized by the appearance of soft drusen, as well as pigmentary changes in the retinal pigment epithelium (RPE). These soft, confluent drusen can progress into two forms of advanced AMD: geographic atrophy (GA, or dry AMD) or choroidal neovascularization (CNV, or wet AMD). Both forms of AMD result in a similar clinical progression in terms of loss of central vision. The exact mechanism for developing early AMD, as well as triggers responsible for progressing to advanced stage of disease, is still largely unknown. However, significant evidence exists demonstrating a complex interplay of genetic and environmental factors as causes of AMD progression. Multiple genes and/or single nucleotide polymorphisms (SNPs) have been found associated with AMD, including various genes involved in the complement pathway, lipid metabolism and extracellular matrix (ECM) remodeling. Of the known genetic contributors to disease risk, the CFH Y402H and HTRA1/ARMS polymorphisms contribute to more than 50% of the genetic risk for AMD. Environmentally, oxidative stress plays a critical role in many aging diseases including cardiovascular disease, cancer, Alzheimer’s disease and AMD. Due to the exposure to sunlight and high oxygen concentration, the oxidative stress burden is higher in the eye than other tissues, which can be further complicated by additional oxidative stressors such as smoking. Increasingly, evidence is accumulating suggesting that functional abnormalities of the innate immune system incurred via high risk genotypes may be contributing to the pathogenesis of AMD by altering the inflammatory homeostasis in the eye, specifically in the handling of oxidation products. As the eye in non-pathological instances maintains a low level of inflammation despite the presence of a relative abundance of potentially inflammatory molecules, we have previously hypothesized that the tight homeostatic control of inflammation via the innate immune system is likely critical for avoidance of disease progression. However, the presence of a multitude of potential triggers of inflammation results in a sensitive balance in which perturbations thereof would subsequently alter the inflammatory state of the retina, leading to a state of chronic inflammation and pathologic progression. In this review, we will highlight the background literature surrounding the known genetic and environmental contributors to AMD risk, as well as a discussion of the potential mechanistic interplay of these factors that lead to disease pathogenesis with particular emphasis on the delicate control of inflammatory homeostasis and the centrality of the innate immune system in this process.
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Affiliation(s)
- Peter X Shaw
- Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Travis Stiles
- Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Christopher Douglas
- Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Daisy Ho
- Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Wei Fan
- Huaxi Hospital, Sichuan University, China
| | | | - Xu Xiao
- Sichuan People's Hospital, Chengdu, Sichuan, China
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Muff-Luett M, Nester CM. The Genetics of Ultra-Rare Renal Disease. J Pediatr Genet 2016; 5:33-42. [PMID: 27617140 DOI: 10.1055/s-0036-1572515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/02/2015] [Indexed: 12/14/2022]
Abstract
The complement-mediated renal diseases are a group of ultra-rare renal diseases that disproportionately affect children and young adults and frequently lead to irreversible renal failure. Genetic mutations in alternate pathway of complement genes are pathomechanistically involved in a significant number of these unique diseases. Here, we review our current understanding of the role of genetics in the primary complement-mediated renal diseases affecting children, with a focus on atypical hemolytic uremic syndrome and C3 glomerulopathy. Also, included is a brief discussion of the related diseases whose relationship to complement abnormality has been suspected but not yet confirmed. Advances in genetics have transformed both treatment and outcomes in these historically difficult to treat, highly morbid diseases.
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Affiliation(s)
- Melissa Muff-Luett
- Division of Pediatric Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Carla M Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States; Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, United States
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Nozal P, Bernabéu-Herrero ME, Uzonyi B, Szilágyi Á, Hyvärinen S, Prohászka Z, Jokiranta TS, Sánchez-Corral P, López-Trascasa M, Józsi M. Heterogeneity but individual constancy of epitopes, isotypes and avidity of factor H autoantibodies in atypical hemolytic uremic syndrome. Mol Immunol 2016; 70:47-55. [DOI: 10.1016/j.molimm.2015.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/30/2015] [Accepted: 12/02/2015] [Indexed: 01/27/2023]
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