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Sepúlveda Palamara RA, Modelli de Andrade LG, Fortunato RM, Gómez B, Nieto-Ríos JF. Clinical presentation and management of atypical hemolytic uremic syndrome in Latin America: a narrative review of the literature. Expert Rev Hematol 2024:1-14. [PMID: 38841813 DOI: 10.1080/17474086.2024.2365169] [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: 11/30/2023] [Accepted: 06/04/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Comprehensive information about atypical hemolytic uremic syndrome (aHUS) is relatively scarce outside of Europe and North America. This narrative review assembles available published data about the clinical presentation and management of aHUS in Latin America. AREAS COVERED A search conducted in February 2023 of the MEDLINE (from inception), Embase (from inception), and LILACS/IBECS (1950 to 2023) databases using search terms 'atypical hemolytic uremic syndrome' and 'Latin America' and their variations retrieved 51 records (full papers and conference abstracts) published in English, Spanish, or Portuguese. After de-duplication, manual screening of titles/abstracts and addition of author-known articles, 25 articles were included of which 17 (68%) are full papers. All articles were published during the years 2013-2022. Articles include cohort studies, a registry analysis, and case reports from Argentina, Brazil, Chile and Columbia. Overall, Latin American patients with aHUS present the classic epidemiological, clinical, and genetic characteristics associated with this condition as described in other world regions. Depending on the country and time of reporting, aHUS in Latin America was treated mainly with plasma therapy and/or eculizumab. Where reported, eculizumab substantially improved aHUS-related outcomes in almost all adult and pediatric patients. EXPERT OPINION Eculizumab has dramatically altered the natural course of aHUS, improving prognosis and patient outcomes. Addressing economic challenges and investing in healthcare infrastructure will be essential to implement strategies for timely detection and early treatment of aHUS in Latin America.
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Affiliation(s)
- R A Sepúlveda Palamara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - L G Modelli de Andrade
- Departamento de Clínica Médica, Universidade Estadual Paulista Júlio de Mesquita Filho, Faculdade de Medicina de Botucatu, Botucatu, Brazil
| | - R M Fortunato
- Renal Unit, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
- Department of Nephrology, German Hospital, Buenos Aires, Argentina
- Transplantation Department, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina
| | - B Gómez
- Departamento de Nefrología y Unidad de Trasplante del Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, México
| | - J F Nieto-Ríos
- Departamento de Nefrología y Trasplante Renal, Hospital Pablo Tobón Uribe y Universidad de Antioquia, Medellín, Colombia
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Le Tilly O, Gatault P, Semlali S, Sberro-Soussan R, Passot C, Bertrand D, Desvignes C, Caillard S, Paintaud G, Halimi JM, Ternant D. Eculizumab dose tapering should take into account the nonlinearity of its pharmacokinetics. Br J Clin Pharmacol 2024; 90:1312-1321. [PMID: 38373846 DOI: 10.1111/bcp.16019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/21/2024] Open
Abstract
AIMS Eculizumab is a monoclonal antibody targeting complement protein C5 used in renal diseases. As recommended dosing regimen leads to unnecessarily high concentrations in some patients, tailored dosing therapeutic drug monitoring was proposed to reduce treatment cost. The objectives of the present work were (i) to investigate the target-mediated elimination of eculizumab and (ii) whether a pharmacokinetic model integrating a nonlinear elimination allows a better prediction of eculizumab concentrations than a linear model. METHODS We analysed 377 eculizumab serum concentrations from 44 patients treated for atypical haemolytic uraemic syndrome and C3 glomerulopathy with a population pharmacokinetic approach. Critical concentrations (below which a non-log-linear decline of concentration over time is evidenced) were computed to estimate the relevance of the target-mediated elimination. Simulations of dosing regimens were then performed to predict probabilities of target attainment (i.e. trough >100 mg/L). RESULTS Pharmacokinetics of eculizumab was nonlinear and followed a mixture of first-order (CL = 1.318 mL/day/kg) and Michaelis-Menten elimination (Vmax = 26.07 mg/day, Km = 24.06 mg/L). Volume of distribution (72.39 mL/kg) and clearance were weight-dependent. Critical concentrations (Vmax/CL) ranged from 144.7 to 759.7 mg/L and were inversely related to body weight (P = .013). Nonlinearity was thus noticeable at therapeutic concentrations. Simulations predicted that 1200 mg of eculizumab every 21 days would allow 85% and 76% of patients to maintain a therapeutic exposure, for 50 or 90 kg body weight, respectively. CONCLUSIONS Our study investigates the nonlinear elimination of eculizumab and discusses the importance of accounting for eculizumab target-mediated elimination in therapeutic drug monitoring.
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Affiliation(s)
- Olivier Le Tilly
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
| | - Philippe Gatault
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Nephrology, Arterial Hypertension, Dialysis and Transplant Department, CHRU Tours, Tours, France
| | | | - Rebecca Sberro-Soussan
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research, Paris, France
| | | | - Dominique Bertrand
- Nephrology Department and Transplantation Center, Rouen University Hospital, Rouen, France
| | - Céline Desvignes
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, Strasbourg University Hospital, Strasbourg, France
| | - Gilles Paintaud
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| | - Jean-Michel Halimi
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Nephrology, Arterial Hypertension, Dialysis and Transplant Department, CHRU Tours, Tours, France
| | - David Ternant
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
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Ávila A, Cao M, Espinosa M, Manrique J, Morales E. Recommendations for the individualised management of atypical hemolytic uremic syndrome in adults. Front Med (Lausanne) 2023; 10:1264310. [PMID: 38105887 PMCID: PMC10722909 DOI: 10.3389/fmed.2023.1264310] [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: 07/28/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Background Despite significant advances in therapeutic management of atypical hemolytic uremic syndrome (aHUS), guidelines are not timely updated and achieving a consensus on management recommendations remains a topic of ongoing discussion. Methods A Scientific Committee with five experts was set up. A literature review was conducted and publications addressing the classification of aHUS, patient profiles and therapeutic approach were selected. Recommendations were proposed at an initial meeting, evaluated through an online questionnaire and validated during a second meeting. Results Patients with confirmed or clear suspicion of aHUS should be treated with C5 inhibitors within 24 h of the diagnosis or suspicion of aHUS. Treatment monitoring and the decision to interrupt treatment should be individualised according to the risk of relapse and each patient's evolution. aHUS with a genetic variant or associated with pregnancy should be treated for at least 6-12 months; de novo aHUS associated with kidney transplant until renal function is recovered and genetic variants are ruled out; aHUS associated with malignant hypertension until genetic variants are ruled out; aHUS associated with non-kidney transplant, autoimmune diseases, infection-or drug-induced until the thrombotic microangiopathy is resolved. Patients with a high risk of relapse should be treated for longer than 6-12 months. Conclusion These recommendations provides physicians who are not familiar with the disease with recommendations for the management of aHUS in adults. The experts who participated advocate early treatment, maintenance for at least 6-12 months and treatment interruption guided by genetic background, trigger factors, risk of relapse and evolution.
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Affiliation(s)
- Ana Ávila
- Department of Nephrology, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Mercedes Cao
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Joaquín Manrique
- Department of Nephrology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
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Meyer BJ, Kunz N, Seki S, Higgins R, Ghosh A, Hupfer R, Baldrich A, Hirsiger JR, Jauch AJ, Burgener AV, Lötscher J, Aschwanden M, Dickenmann M, Stegert M, Berger CT, Daikeler T, Heijnen I, Navarini AA, Rudin C, Yamamoto H, Kemper C, Hess C, Recher M. Immunologic and Genetic Contributors to CD46-Dependent Immune Dysregulation. J Clin Immunol 2023; 43:1840-1856. [PMID: 37477760 PMCID: PMC10661731 DOI: 10.1007/s10875-023-01547-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 06/30/2023] [Indexed: 07/22/2023]
Abstract
Mutations in CD46 predispose to atypical hemolytic uremic syndrome (aHUS) with low penetrance. Factors driving immune-dysregulatory disease in individual mutation carriers have remained ill-understood. In addition to its role as a negative regulator of the complement system, CD46 modifies T cell-intrinsic metabolic adaptation and cytokine production. Comparative immunologic analysis of diseased vs. healthy CD46 mutation carriers has not been performed in detail yet. In this study, we comprehensively analyzed clinical, molecular, immune-phenotypic, cytokine secretion, immune-metabolic, and genetic profiles in healthy vs. diseased individuals carrying a rare, heterozygous CD46 mutation identified within a large single family. Five out of six studied individuals carried a CD46 gene splice-site mutation causing an in-frame deletion of 21 base pairs. One child suffered from aHUS and his paternal uncle manifested with adult-onset systemic lupus erythematosus (SLE). Three mutation carriers had no clinical evidence of CD46-related disease to date. CD4+ T cell-intrinsic CD46 expression was uniformly 50%-reduced but was comparable in diseased vs. healthy mutation carriers. Reconstitution experiments defined the 21-base pair-deleted CD46 variant as intracellularly-but not surface-expressed and haploinsufficient. Both healthy and diseased mutation carriers displayed reduced CD46-dependent T cell mitochondrial adaptation. Diseased mutation carriers had lower peripheral regulatory T cell (Treg) frequencies and carried potentially epistatic, private rare variants in other inborn errors of immunity (IEI)-associated proinflammatory genes, not found in healthy mutation carriers. In conclusion, low Treg and rare non-CD46 immune-gene variants may contribute to clinically manifest CD46 haploinsufficiency-associated immune-dysregulation.
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Affiliation(s)
- Benedikt J Meyer
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Natalia Kunz
- Immunobiology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
- Complement and Inflammation Research Section, CIRS, DIR, NHLBI, NIH, Bethesda, USA
| | - Sayuri Seki
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | | | - Adhideb Ghosh
- Dermatology, University Hospital Basel, Basel, Switzerland
- Competence Center for Personalized Medicine, University of Zürich/Eidgenössische Technische Hochschule (ETH), Zürich, Switzerland
| | - Robin Hupfer
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Adrian Baldrich
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Julia R Hirsiger
- Translational Immunology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Annaïse J Jauch
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Anne-Valérie Burgener
- Immunobiology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Jonas Lötscher
- Immunobiology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Markus Aschwanden
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Mihaela Stegert
- Rheumatology Clinic, University Hospital Basel, Basel, Switzerland
| | - Christoph T Berger
- Translational Immunology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
- University Center for Immunology, University Hospital Basel, Basel, Switzerland
| | - Thomas Daikeler
- Rheumatology Clinic, University Hospital Basel, Basel, Switzerland
- University Center for Immunology, University Hospital Basel, Basel, Switzerland
| | - Ingmar Heijnen
- Division Medical Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | | | - Christoph Rudin
- University Children's Hospital, University of Basel, Basel, Switzerland
| | - Hiroyuki Yamamoto
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Claudia Kemper
- Complement and Inflammation Research Section, CIRS, DIR, NHLBI, NIH, Bethesda, USA
| | - Christoph Hess
- Immunobiology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mike Recher
- Immunodeficiency Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland.
- University Center for Immunology, University Hospital Basel, Basel, Switzerland.
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A Multicenter Study Evaluating the Discontinuation of Eculizumab Therapy in Children with Atypical Hemolytic Uremic Syndrome. CHILDREN 2022; 9:children9111734. [DOI: 10.3390/children9111734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Background: Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening thrombotic microangiopathy (TMA), which has been treated successfully with eculizumab. The optimal duration of eculizumab in treating patients with aHUS remains poorly defined. Methods: We conducted a multicenter retrospective study in the Arabian Gulf region for children of less than 18 years of age who were diagnosed with aHUS and who discontinued eculizumab between June 2013 and June 2021 to assess the rate and risk factors of aHUS recurrence. Results: We analyzed 28 patients with a clinical diagnosis of aHUS who had discontinued eculizumab. The most common reason for the discontinuation of eculizumab was renal and hematological remission (71.4%), followed by negative genetic testing (28.6%). During a median follow-up period of 24 months after discontinuation, 8 patients (28.5%) experienced HUS relapse. The risk factors of recurrence were positive genetic mutations (p = 0.020). On the other hand, there was no significant relationship between the relapse and age of presentation, the need for acute dialysis, the duration of eculizumab therapy before discontinuation, or the timing of eculizumab after the presentation. Regarding the renal outcomes after discontinuation, 23 patients were in remission with normal renal function, while 4 patients had chronic kidney disease (CKD) (three of them had pre-existing chronic kidney disease (CKD) before discontinuation, and one case developed a new CKD after discontinuation) and one patient underwent transplantation. Conclusions: The discontinuation of eculizumab in patients with aHUS is not without risk; it can result in HUS recurrence. Eculizumab discontinuation can be performed with close monitoring of the patients. It is essential to assess risk the factors for relapse before eculizumab discontinuation, in particular in children with a positive complement variant and any degree of residual CKD, as HUS relapse may lead to additional loss of kidney function. Resuming eculizumab promptly after relapse is effective in most patients.
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Hanna RM, Henriksen K, Kalantar-Zadeh K, Ferrey A, Burwick R, Jhaveri KD. Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers. Adv Chronic Kidney Dis 2022; 29:149-160.e1. [PMID: 35817522 DOI: 10.1053/j.ackd.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/11/2022]
Abstract
Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.
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Affiliation(s)
- Ramy M Hanna
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA.
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Kamyar Kalantar-Zadeh
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Antoney Ferrey
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenar D Jhaveri
- Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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Tammam SN, El Safy S, Ramadan S, Arjune S, Krakor E, Mathur S. Repurpose but also (nano)-reformulate! The potential role of nanomedicine in the battle against SARS-CoV2. J Control Release 2021; 337:258-284. [PMID: 34293319 PMCID: PMC8289726 DOI: 10.1016/j.jconrel.2021.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023]
Abstract
The coronavirus disease-19 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has taken the world by surprise. To date, a worldwide approved treatment remains lacking and hence in the context of rapid viral spread and the growing need for rapid action, drug repurposing has emerged as one of the frontline strategies in the battle against SARS-CoV2. Repurposed drugs currently being evaluated against COVID-19 either tackle the replication and spread of SARS-CoV2 or they aim at controlling hyper-inflammation and the rampaged immune response in severe disease. In both cases, the target for such drugs resides in the lungs, at least during the period where treatment could still provide substantial clinical benefit to the patient. Yet, most of these drugs are administered systemically, questioning the percentage of administered drug that actually reaches the lung and as a consequence, the distribution of the remainder of the dose to off target sites. Inhalation therapy should allow higher concentrations of the drug in the lungs and lower concentrations systemically, hence providing a stronger, more localized action, with reduced adverse effects. Therefore, the nano-reformulation of the repurposed drugs for inhalation is a promising approach for targeted drug delivery to lungs. In this review, we critically analyze, what nanomedicine could and ought to do in the battle against SARS-CoV2. We start by a brief description of SARS-CoV2 structure and pathogenicity and move on to discuss the current limitations of repurposed antiviral and immune-modulating drugs that are being clinically investigated against COVID-19. This account focuses on how nanomedicine could address limitations of current therapeutics, enhancing the efficacy, specificity and safety of such drugs. With the appearance of new variants of SARS-CoV2 and the potential implication on the efficacy of vaccines and diagnostics, the presence of an effective therapeutic solution is inevitable and could be potentially achieved via nano-reformulation. The presence of an inhaled nano-platform capable of delivering antiviral or immunomodulatory drugs should be available as part of the repertoire in the fight against current and future outbreaks.
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Affiliation(s)
- Salma N. Tammam
- Department of Pharmaceutical Technology, Faculty of Pharmacy & Biotechnology, The German University in Cairo (GUC), 11835 Cairo, Egypt,Corresponding author
| | - Sara El Safy
- Department of Pharmaceutical Technology, Faculty of Pharmacy & Biotechnology, The German University in Cairo (GUC), 11835 Cairo, Egypt
| | - Shahenda Ramadan
- Department of Pharmaceutical Technology, Faculty of Pharmacy & Biotechnology, The German University in Cairo (GUC), 11835 Cairo, Egypt
| | - Sita Arjune
- Institute of Biochemistry, Department of Chemistry, Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Eva Krakor
- Institute of Inorganic Chemistry, Department of Chemistry, , University of Cologne, Greinstraße 6, 50939 Cologne, Germany
| | - Sanjay Mathur
- Institute of Inorganic Chemistry, Department of Chemistry, , University of Cologne, Greinstraße 6, 50939 Cologne, Germany
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Discontinuation of Eculizumab treatment after hematological remission in patients with atypical and drug-induced hemolytic uremic syndrome. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MÉDECINE INTERNE 2021; 60:56-65. [PMID: 34449174 DOI: 10.2478/rjim-2021-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Indexed: 11/20/2022]
Abstract
Introduction: To evaluate the effect of therapeutic plasma exchange(TPE) and eculizumab on hematological and renal survival in atypical hemolytic uremic syndrome(aHUS). Additionally, to examine the reliability of discontinuation of eculizumab treatment.Methods: This was an observational and retrospective study of 18 patients diagnosed with aHUS.Results: The median age of the study population was 30(22-66) years. Four of 18 patients achieved hematological remission with the TPE alone. However, one patient in the died after three sessions of TPE. Eculizumab was used in 13 patients and no death was observed. One year after treatment, improved kidney function was observed in 2 of 3(66%) patients for TPE and 5 of 9(56%) patients for Eculizumab. We discontinued eculizumab treatment in 9 patients. One of the patients who had a C3 gene mutation experienced disease relapse after Eculizumab discontinuation. None of the patients who had drug associated aHUS, developed disease relapse after Eculizumab discontinuation.Conclusion: Eculizumab treatment is a life-saving therapy in aHUS. Treatment discontinuation may be considered at least six months after hematologic remission in patients who had stable renal function or no expectancy for renal survival. Moreover, drug-associated cases seem to tend not to develop disease relapse in the long term.
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9
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Disease-drug and drug-drug interaction in COVID-19: Risk and assessment. Biomed Pharmacother 2021; 139:111642. [PMID: 33940506 PMCID: PMC8078916 DOI: 10.1016/j.biopha.2021.111642] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 12/15/2022] Open
Abstract
COVID-19 is announced as a global pandemic in 2020. Its mortality and morbidity rate are rapidly increasing, with limited medications. The emergent outbreak of COVID-19 prompted by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) keeps spreading. In this infection, a patient's immune response plays pivotal role in the pathogenesis. This inflammatory factor was shown by its mediators that, in severe cases, reach the cytokine at peaks. Hyperinflammatory state may sparks significant imbalances in transporters and drug metabolic machinery, and subsequent alteration of drug pharmacokinetics may result in unexpected therapeutic response. The present scenario has accounted for the requirement for therapeutic opportunities to relive and overcome this pandemic. Despite the diminishing developments of COVID-19, there is no drug still approved to have significant effects with no side effect on the treatment for COVID-19 patients. Based on the evidence, many antiviral and anti-inflammatory drugs have been authorized by the Food and Drug Administration (FDA) to treat the COVID-19 patients even though not knowing the possible drug-drug interactions (DDI). Remdesivir, favipiravir, and molnupiravir are deemed the most hopeful antiviral agents by improving infected patient’s health. Dexamethasone is the first known steroid medicine that saved the lives of seriously ill patients. Some oligopeptides and proteins have also been using. The current review summarizes medication updates to treat COVID-19 patients in an inflammatory state and their interaction with drug transporters and drug-metabolizing enzymes. It gives an opinion on the potential DDI that may permit the individualization of these drugs, thereby enhancing the safety and efficacy.
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Tsai HHC, Moyers JT, Moore CJ, Thinn M. Activated Prothrombin Complex Concentrate-Induced Atypical Hemolytic Uremic Syndrome Treated with Eculizumab. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929616. [PMID: 33678802 PMCID: PMC7959102 DOI: 10.12659/ajcr.929616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 58-year-old Final Diagnosis: Atypical hemolytic uremic syndrome • FEIBA induced aHUS Symptoms: Anemia • renal failure • thrombocytopenia Medication: — Clinical Procedure: — Specialty: Hematology • General and Internal Medicine
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Affiliation(s)
| | - Justin Tyler Moyers
- Division of Hematology and Oncology, Department of Internal Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Christie J Moore
- Department of Hematology and Oncology, Providence Cancer Institute, Portland, OR, USA
| | - MieMie Thinn
- Department of Hematology and Oncology, Veterans Affairs Loma Linda Healthcare System, Loma Linda, CA, USA
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Darwin A, Malpica L, Dhanoa J, Hashmi H. Carfilzomib-induced atypical haemolytic uraemic syndrome: a diagnostic challenge and therapeutic success. BMJ Case Rep 2021; 14:14/2/e239091. [PMID: 33637496 PMCID: PMC7919563 DOI: 10.1136/bcr-2020-239091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a thrombotic microangiopathy (TMA) that presents with renal insufficiency, thrombocytopaenia and microangiopathic haemolytic anaemia. Typical HUS is associated with Shiga toxin while atypical HUS (aHUS) is due to overactivation of the alternative complement pathway. aHUS has numerous causes, including drugs, with rare reports of carfilzomib, a proteasome inhibitor used in multiple myeloma, as causative agent. Cases vary in presentation, presenting a diagnostic challenge. Historically, TMAs were treated with plasma exchange. aHUS, however, is considered refractory to plasma exchange and best treated with eculizumab, a monoclonal antibody targeting C5, a terminal complement protein. We report a patient with history of multiple myeloma who presented with headaches, elevated blood pressure, petechiae, ecchymosis and haemolytic anaemia. His condition was determined to be carfilzomib-induced aHUS and he was successfully treated with eculizumab. Early detection and treatment of drug-induced aHUS is vital in reducing morbidity and mortality related to the condition.
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Affiliation(s)
- Alicia Darwin
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Leonger Malpica
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jugraj Dhanoa
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Hamza Hashmi
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA .,Department of Hematology Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
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12
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Thrombotische Mikroangiopathie. DER NEPHROLOGE 2021; 16:113-123. [PMID: 33552303 PMCID: PMC7856846 DOI: 10.1007/s11560-021-00487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 11/24/2022]
Abstract
Die thrombotische Mikroangiopathie (TMA) zeichnet sich durch eine endothelschadenassoziierte Bildung von Plättchenthromben in arteriellen und venösen Mikrogefäßen aus. Die damit einhergehende Ischämie führt zu schwerwiegenden Organdysfunktionen und kann akut lebensbedrohlich sein. Ätiologisch verbirgt sich hinter der TMA ein sehr heterogenes Erkrankungsspektrum. Neben der thrombotisch-thrombozytopenischen Purpura, die durch eine stark reduzierte ADAMTS13(„a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13“)-Aktivität gekennzeichnet ist, dem infektassoziierten klassischen hämolytisch-urämischen Syndrom (HUS) sowie dem komplementvermittelten atypischen HUS (aHUS) können weitere sehr seltene Erkrankungen oder sekundäre Formen vorliegen. Die differenzialdiagnostische Einteilung ist aufgrund unterschiedlicher therapeutischer Ansätze erforderlich. Der Einsatz neuer spezifischer medikamentöser Behandlungsmethoden hat die Prognose der TMA deutlich verbessert.
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13
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Ariceta G, Fakhouri F, Sartz L, Miller B, Nikolaou V, Cohen D, Siedlecki AM, Ardissino G. Eculizumab discontinuation in atypical haemolytic uraemic syndrome: TMA recurrence risk and renal outcomes. Clin Kidney J 2021; 14:2075-2084. [PMID: 35261761 PMCID: PMC8894930 DOI: 10.1093/ckj/sfab005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background Eculizumab modifies the course of disease in patients with atypical haemolytic uraemic syndrome (aHUS), but data evaluating whether eculizumab discontinuation is safe are limited. Methods Patients enrolled in the Global aHUS Registry who received ≥1 month of eculizumab before discontinuing, demonstrated haematologic or renal response prior to discontinuation and had ≥6 months of follow-up were analysed. The primary endpoint was the proportion of patients suffering from thrombotic microangiopathy (TMA) recurrence after eculizumab discontinuation. Additional endpoints included: estimated glomerular filtration rate changes following eculizumab discontinuation to last available follow-up; number of TMA recurrences; time to TMA recurrence; proportion of patients restarting eculizumab; and changes in renal function. Results We analysed 151 patients with clinically diagnosed aHUS who had evidence of haematologic or renal response to eculizumab, before discontinuing. Thirty-three (22%) experienced a TMA recurrence. Univariate analysis revealed that patients with an increased risk of TMA recurrence after discontinuing eculizumab were those with a history of extrarenal manifestations prior to initiating eculizumab, pathogenic variants or a family history of aHUS. Multivariate analysis showed an increased risk of TMA recurrence in patients with pathogenic variants and a family history of aHUS. Twelve (8%) patients progressed to end-stage renal disease after eculizumab discontinuation; seven (5%) patients eventually received a kidney transplant. Forty (27%) patients experienced an extrarenal manifestation of aHUS after eculizumab discontinuation. Conclusions Eculizumab discontinuation in patients with aHUS is not without risk, potentially leading to TMA recurrence and renal failure. A thorough assessment of risk factors prior to the decision to discontinue eculizumab is essential.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Vall d'Hebron Hospital, and the Autonomous University of Barcelona, Barcelona, Spain
| | - Fadi Fakhouri
- Department of Nephrology and Immunology, CHU de Nantes, Nantes, France
| | - Lisa Sartz
- Department of Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
| | | | | | - David Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Andrew M Siedlecki
- Department of Internal Medicine, Renal Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Gianluigi Ardissino
- Centro per la Cura e lo Studio della Sindrome Emolitico-Uremica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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14
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Neto ME, de Moraes Soler L, Vasconcelos HVG, Nga HS, Bravin AM, Borges JCA, Gonçalves RC, Von Kriiger RB, Quinino RM, de Mello Santana VBB, de Holanda MI, Vaisbich MH, Naseri AP, Kirsztajn GM, Palma LMP, Andrade LGM. Eculizumab interruption in atypical hemolytic uremic syndrome due to shortage: analysis of a Brazilian cohort. J Nephrol 2021; 34:1373-1380. [PMID: 33387344 DOI: 10.1007/s40620-020-00920-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/15/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The risk of eculizumab therapy discontinuation in patients with atypical hemolytic uremic syndrome (aHUS) is unclear. The main objective of this study was to analyze the risk of aHUS relapse after eculizumab interruption due to drug shortage in Brazil. METHODS We screened all the registered dialysis centers in Brazil (n = 800), willing to participate in the aHUS Brazilian shortage cohort, through electronic mail and formal invitation by the Brazilian Society of Nephrology. We included patients with aHUS whose eculizumab therapy underwent unplanned discontinuation for at least 30 days between January 1st, 2016 and December 31st, 2019 during the maintenance phase of treatment. Relapse was defined by the development of thrombocytopenia, hemolytic anemia, acute kidney injury or thrombotic microangiopathy (TMA) in a kidney biopsy. RESULTS We analyzed 25 episodes of exposure to risk of relapse, from 24 patients. Median age was 33 (6-53) years, 18 (72%) were female, 9 (36%) had a functioning renal graft, 5 (20%) were undergoing dialysis. CFH variant was found in 8 (32%) episodes. There were 11 relapses. The risk of relapse was 34%, 44.5% and 58% at 114, 150 and 397 days, respectively. No baseline variable was related to relapse in Cox multivariate analysis, including CFH variant. CONCLUSIONS In this study, the cumulative incidence of aHUS relapse at 397 days was 58% after eculizumab interruption. The presence of complement variant does not seem to be associated with a higher relapse rate. The eculizumab interruption was deemed not safe, considering that the rate of relapse was high.
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Affiliation(s)
- Miguel Ernandes Neto
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil. .,Hospital BP-a Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil.
| | - Lucas de Moraes Soler
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil
| | | | - Hong Si Nga
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil
| | - Ariane Moyses Bravin
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil
| | | | | | | | - Raquel Martins Quinino
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | - Maria Izabel de Holanda
- Hospital Federal de Bonsucesso-Serviço de Nefrologia e Transplante, Rio de Janeiro, RJ, Brazil
| | | | - Alice Pignaton Naseri
- Setor de Nefrologia da Unidade de Gestão de Transplantes da Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | | | - Lilian Monteiro Pereira Palma
- Nefrologia Pediátrica-Departamento de Pediatria da Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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15
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Gomez-Ganda L, Benitez-Carabante MI, Fernandez-Polo A, Muñoz-Lopez M, Renedo-Miro B, Ariceta G, Diaz De Heredia C. Use of Eculizumab in Pediatric Patients With Transplant Associated Thrombotic Microangiopathy. Front Pediatr 2021; 9:761726. [PMID: 34858907 PMCID: PMC8632356 DOI: 10.3389/fped.2021.761726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/06/2021] [Indexed: 01/27/2023] Open
Abstract
Background: Transplant-associated thrombotic microangiopathy (TA-TMA) is a serious complication of hematopoietic stem cell transplantation (HSCT) associated with high morbidity and mortality. High-risk TA-TMA (hrTA-TMA) is characterized by multifactorial endothelial damage caused by environmental stressors, dysregulation of the complement system, and genetic predisposition. Complement inhibitors have significantly decreased mortality and are the current treatment of choice. In this article, we describe our experience with the use of eculizumab in pediatric patients diagnosed with hrT-TMA after HSCT. Method: Retrospective study of pediatric patients with hrTA-TMA treated with eculizumab between January 2016 and December 2020. Results: Four pediatric patients aged 1, 12, 14, and 17 years at the time of HSCT were diagnosed with hrTA-TMA and treated with eculizumab during the study. At diagnosis, they all had renal impairment with proteinuria, and hypertension under treatment with at least two antihypertensive drugs. The patient who presented multisystemic involvement died instead of treatment. The three patients with exclusive renal involvement achieved TA-TMA resolution after treatment with eculizumab for 65, 52, and 40.6 weeks and were able to stop treatment. The two patients with follow-up data one year after eculizumab withdrawal sustained a favorable response. Eculizumab was well tolerated, and with adequate vaccination and antibiotic prophylaxis, did not increase the risk of infection. Conclusions: Eculizumab appears to be both safe and effective for the treatment of hrTA-TMA in patients with renal impairment. Early diagnosis and initiation of treatment may improve response. Eculizumab withdrawal can be contemplated in patients who achieve laboratory and clinical resolution of TA-TMA.
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Affiliation(s)
- Laura Gomez-Ganda
- Pharmacy Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Isabel Benitez-Carabante
- Pediatric Oncology and Hematology Service, Hematopoietic Stem Cell Transplantation Section, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Marina Muñoz-Lopez
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Berta Renedo-Miro
- Pharmacy Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Gema Ariceta
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cristina Diaz De Heredia
- Pediatric Oncology and Hematology Service, Hematopoietic Stem Cell Transplantation Section, Vall d'Hebron University Hospital, Barcelona, Spain
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16
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Complement blockade for TA-TMA: lessons learned from a large pediatric cohort treated with eculizumab. Blood 2020; 135:1049-1057. [PMID: 31932840 DOI: 10.1182/blood.2019004218] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/04/2020] [Indexed: 01/03/2023] Open
Abstract
Overactivated complement is a high-risk feature in hematopoietic stem cell transplant (HSCT) recipients with transplant-associated thrombotic microangiopathy (TA-TMA), and untreated patients have dismal outcomes. We present our experience with 64 pediatric HSCT recipients who had high-risk TA-TMA (hrTA-TMA) and multiorgan injury treated with the complement blocker eculizumab. We demonstrate significant improvement to 66% in 1-year post-HSCT survival in treated patients from our previously reported untreated cohort with same hrTA-TMA features that had 1-year post-HSCT survival of 16.7%. Responding patients benefited from a brief but intensive course of eculizumab using pharmacokinetic/pharmacodynamic-guided dosing, requiring a median of 11 doses of eculizumab (interquartile range [IQR] 7-20). Treatment was discontinued because TA-TMA resolved at a median of 66 days (IQR 41-110). Subjects with higher complement activation measured by elevated blood sC5b-9 at the start of treatment were less likely to respond (odds ratio, 0.15; P = .0014) and required more doses of eculizumab (r = 0.43; P = .0004). Patients with intestinal bleeding had the fastest eculizumab clearance, required the highest number of eculizumab doses (20 vs 9; P = .0015), and had lower 1-year survival (44% vs 78%; P = .01). Over 70% of survivors had proteinuria on long-term follow-up. The best glomerular filtration rate (GFR) recovery in survivors was a median 20% lower (IQR, 7.3%-40.3%) than their pre-HSCT GFR. In summary, complement blockade with eculizumab is an effective therapeutic strategy for hrTA-TMA, but some patients with severe disease lacked a complete response, prompting us to propose early intervention and search for additional targetable endothelial injury pathways.
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17
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Abstract
In December 2019, the world observed an unexpected outbreak of an emerging disease named coronavirus (COVID-19) that was first reported in Wuhan city of Hubei province of China. Recent literature has shown the association between COVID-19 infection and derangement in the coagulation profile. In this paper, we are discussing thrombo-genesis, especially the role of the complement system in the immune response against COVID-19 and the pathogenesis associated with tissue inflammation and thrombosis. This role can stipulate a groundwork for further investigation of the pathophysiologic importance of complement in COVID-19, and could propose targets for specific intervention. In addition, we delineated current treatments for thrombosis and the potential therapies by using agents to block the terminal complement pathway. Low molecular weight heparin for all (unless contraindicated) hospitalized COVID-19 patients can be lifesaving. Agents that inhibit the terminal events of the complement cascade might be crucial for ensuring an efficient treatment, decrease clots and permit early discharge in relation to COVID-19.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Sidra Medicine and Research Center, Doha, Qatar.,Weill Cornell Medicine, Ar-Rayyan, Qatar
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18
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Shah S, Sweis L. A Case Report of Atypical Hemolytic Uremic Syndrome in a Two-Month-Old Infant With a Negative Reported Genetic Profile and Five-Year Follow-Up on Eculizumab. Cureus 2020; 12:e10392. [PMID: 32944483 PMCID: PMC7489445 DOI: 10.7759/cureus.10392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare but life-threatening pediatric disease caused by uncontrolled activation of the alternative complement pathway related to genetic mutations and carries a worse prognosis. In the last decade, a monoclonal antibody against complement C5, eculizumab, has dramatically improved the disease outcomes. The complement mutations in aHUS are detected only in 60%-70% of cases in previous studies. We report a severe presentation of aHUS diagnosed in a two-month-old child who presented with seizures, renal failure with anuria, and microangiopathic hemolytic anemia and required peritoneal dialysis soon after admission. The patient was clinically diagnosed having aHUS and was started on eculizumab on day 4 of hospital admission. The genetic study for major known complement mutations causing aHUS was reported negative. He had a major episode of disease relapse associated with seizures four weeks after eculizumab therapy and required prolonged peritoneal dialysis over more than two months at the time of initial admission. He developed dilated cardiomyopathy and oro-motor dysfunction as complications of aHUS. At five-year follow-up, the patient has stage 3 chronic kidney disease (CKD), proteinuria, hypertension, and required G-tube for feeds. This report discussed the long-term outcome of an infant diagnosed with aHUS and tested negative for common complement mutations on eculizumab therapy. More research is needed to identify novel genes and antibodies contributing to aHUS. While the eculizumab is expensive, and the duration of treatment is not definite, the clinical severity of the disease, relapses, and presence of long-term renal complications are essential factors to decide treatment continuation.
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Affiliation(s)
- Siddharth Shah
- Pediatric Nephrology, Norton Children's and University of Louisville, Louisville, USA
| | - Laith Sweis
- Pediatrics, Norton Children's and University of Louisville, Louisville, USA
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19
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Hanna RM, Abdelnour L, Zuckerman JE, Ferrey AJ, Pai A, Vahabzadeh K, Wilson J, Torres EA, Kalantar-Zadeh K, Kurtz IB. Refractory scleroderma renal crisis precipitated after high-dose oral corticosteroids and concurrent intravitreal injection of bevacizumab. SAGE Open Med Case Rep 2020; 8:2050313X20952650. [PMID: 32913652 PMCID: PMC7443985 DOI: 10.1177/2050313x20952650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022] Open
Abstract
Scleroderma renal crisis is a serious complication that can develop in certain patients with systemic sclerosis. Some risks have been identified as potential triggers of scleroderma renal crisis, including the high-dose oral corticosteroids. Here, we present a patient who developed clinically severe systemic sclerosis and scleroderma renal crisis after exposure to oral corticosteroids and intravitreal vascular endothelial growth factor blockade with bevacizumab for cotton wool spots. The patient's scleroderma renal crisis was severe, progressive, and refractory to the standard of care therapy: oral captopril. Biopsy showed a diffuse thrombotic microangiopathy and findings consistent with scleroderma renal crisis. We hypothesize that depletion of systemic vascular endothelial growth factor with intravitreal anti-vascular endothelial growth factor injections likely contributed to the particularly severe presentation seen in this case. Though the finding of a monoclonal gammopathy of undetermined significance is another complicating factor, this case suggests that vascular endothelial growth factor inhibition may be a newly recognized trigger of scleroderma renal crisis.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
- UC Irvine School of Medicine, Orange,
CA, USA
| | - Lama Abdelnour
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Antoney J Ferrey
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Alex Pai
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | | | - James Wilson
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Everado A Torres
- Department of Medicine, University of
California Irvine, Irvine, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Ira B Kurtz
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Brain Research Institute, Westwood, CA,
USA
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20
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Abstract
The recent COVID-19 pandemic has had a significant impact on our lives and has rapidly expanded to reach more than 4 million cases worldwide by May 2020. These cases are characterized by extreme variability, from a mild or asymptomatic form lasting for a few days up to severe forms of interstitial pneumonia that may require ventilatory therapy and can lead to patient death. Several hypotheses have been drawn up to understand the role of the interaction between the infectious agent and the immune system in the development of the disease and the most severe forms; the role of the cytokine storm seems important. Innate immunity, as one of the first elements of guest interaction with different infectious agents, could play an important role in the development of the cytokine storm and be responsible for boosting more severe forms. Therefore, it seems important to study also this important arm of the immune system to adequately understand the pathogenesis of the disease. Research on this topic is also needed to develop therapeutic strategies for treatment of this disease.
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21
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Lavrishcheva YV, Yakovenko AA, Kudlai DA. [The experience of using the Russian biosimilar of the original drug eculizumab for the treatment of patients with atypical hemolytic-uremic syndrome]. TERAPEVT ARKH 2020; 92:76-80. [PMID: 33346497 DOI: 10.26442/00403660.2020.06.000649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 02/08/2023]
Abstract
Atypical hemolytic-uremic syndrome (aHUS) is a chronic systemic disease of a genetic nature, which is based on uncontrolled activation of the alternative complement pathway, leading to generalized thrombosis in the vessels of the microvasculature (complement-mediated thrombotic microangiopathy). To date, therapy with eculizumab is the most effective and pathogenetically substantiated method of treating patients with ASH. Using the example of three clinical cases of patients with a verified diagnosis of aHUS, the high efficiency and safety of the worlds first bioanalogue of eculizumab in the treatment of adult patients with aHUS (complement-mediated thrombotic microangiopathy) was demonstrated.
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Affiliation(s)
| | - A A Yakovenko
- Pavlov First Saint Petersburg State Medical University
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22
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Hanna RM, Hou J, Hasnain H, Arman F, Selamet U, Wilson J, Olanrewaju S, Zuckerman JE, Barsoum M, Yabu JM, Kurtz I. Diverse Clinical Presentations of C3 Dominant Glomerulonephritis. Front Med (Lausanne) 2020; 7:293. [PMID: 32695788 PMCID: PMC7338606 DOI: 10.3389/fmed.2020.00293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Abstract
C3 dominant immunofluorescence staining is present in a subset of patients with idiopathic immune complex membranoproliferative glomerulonephritis (iMPGN). It is increasingly recognized that iMPGN may be complement driven, as are cases of "typical" C3 glomerulopathy (C3G). In both iMPGN and C3G, a frequent membranoproliferative pattern of glomerular injury may indicate common pathogenic mechanisms via complement activation and endothelial cell damage. Dysregulation of the alternative complement pathway and mutations in certain regulatory factors are highly implicated in C3 glomerulopathy (which encompasses C3 glomerulonephritis, dense deposit disease, and cases of C3 dominant MPGN). We report three cases that demonstrate that an initial biopsy diagnosis of iMPGN does not exclude complement alterations similar to the ones observed in patients with a diagnosis of C3G. The first patient is a 39-year-old woman with iMPGN and C3 dominant staining, with persistently low C3 levels throughout her course. The second case is a 22-year-old woman with elevated anti-factor H antibodies and C3 dominant iMPGN findings on biopsy. The third case is a 25-year-old woman with C3 dominant iMPGN, dense deposit disease, and a crescentic glomerulonephritis on biopsy. We present the varied phenotypic variations of C3 dominant MPGN and review clinical course, complement profiles, genetic testing, treatment course, and peri-transplantation plans. Testing for complement involvement in iMPGN is important given emerging treatment options and transplant planning.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of Medicine, UCI School of Medicine, Irvine, CA, United States.,Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Jean Hou
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Huma Hasnain
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Farid Arman
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Umut Selamet
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States.,Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - James Wilson
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Samuel Olanrewaju
- David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory Medicine, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Marina Barsoum
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Julie M Yabu
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States
| | - Ira Kurtz
- Department of Medicine, Division of Nephrology, David Geffen UCLA School of Medicine, Los Angeles, CA, United States.,UCLA Brain Research Institute, Los Angeles, CA, United States
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23
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Pons S, Fodil S, Azoulay E, Zafrani L. The vascular endothelium: the cornerstone of organ dysfunction in severe SARS-CoV-2 infection. Crit Care 2020; 24:353. [PMID: 32546188 PMCID: PMC7296907 DOI: 10.1186/s13054-020-03062-7] [Citation(s) in RCA: 323] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/04/2020] [Indexed: 12/18/2022] Open
Abstract
In severe SARS-CoV-2 infections, emerging data including recent histopathological studies have emphasized the crucial role of endothelial cells (ECs) in vascular dysfunction, immunothrombosis, and inflammation.Histopathological studies have evidenced direct viral infection of ECs, endotheliitis with diffuse endothelial inflammation, and micro- and macrovascular thrombosis both in the venous and arterial circulations. Venous thrombotic events, particularly pulmonary embolism, with elevated D-dimer and coagulation activation are highly prevalent in COVID-19 patients. The pro-inflammatory cytokine storm, with elevated levels of interleukin-6 (IL-6), IL-2 receptor, and tumor necrosis factor-α, could also participate in endothelial dysfunction and leukocyte recruitment in the microvasculature. COVID-19-induced endotheliitis may explain the systemic impaired microcirculatory function in different organs in COVID-19 patients. Ongoing trials directly and indirectly target COVID-19-related endothelial dysfunctions: i.e., a virus-cell entry using recombinant angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS-2) blockade, coagulation activation, and immunomodulatory therapies, such as anti-IL-6 strategies. Studies focusing on endothelial dysfunction in COVID-19 patients are warranted as to decipher their precise role in severe SARS-CoV-2 infection and organ dysfunction and to identify targets for further interventions.
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Affiliation(s)
- Stéphanie Pons
- INSERM U976, Human Immunology, Pathophysiology and Immunotherapy, Saint-Louis Teaching Hospital, Paris University, Paris, France
- Anesthesia and Critical Care Department, Avicenne Teaching Hospital, Assistance Publique des Hôpitaux de Paris, Bobigny, France
| | - Sofiane Fodil
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique des Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Elie Azoulay
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique des Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Lara Zafrani
- INSERM U976, Human Immunology, Pathophysiology and Immunotherapy, Saint-Louis Teaching Hospital, Paris University, Paris, France.
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique des Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75010, Paris, France.
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24
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Nasonov EL, Reshetnyak TM, Alekberova ZS. [Thrombotic microangiopathy in rheumatology: a link between thrombosis and autoimmunity]. TERAPEVT ARKH 2020; 92:4-14. [PMID: 32598770 DOI: 10.26442/00403660.2020.05.000697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Indexed: 12/16/2022]
Abstract
Uncontrolled hypercoagulation and inflammation (thromboinflammation), which are both independent and closely related and amplifying each other pathological processes, form the basis for pathogenesis of a wide range of diseases and complications, including immuno-inflammatory (autoimmune) rheumatic diseases, with the development of potentially fatal injuries of internal organs. Thrombotic microangiopathy is one of the most prominent prototypes of thromboinflammatory pathological conditions. The close link between environmental factors, hemostasis genetic defects and the complement system, inflammation and autoimmunity as pathogenetic mechanisms of microthrombosis draws particular attention to studying thrombotic microangiopathy in immuno-inflammatory rheumatic diseases, primarily systemic lupus erythematosus, antiphospholipid syndrome and scleroderma renal crisis. In future, these studies may be important for expanding the idea of the role of autoimmune mechanisms in pathogenesis of critical hemostasis disorders in human diseases, and for developing new approaches to therapy. Recently, special attention has been paid to the treatment of systemic lupus erythematosus and antiphospholipid syndrome with eculizumab, which is humanized monoclonal IgG2/4k antibody that blocks the complement component C5a and the membrane attack complex (C5b-9) formation, and which is registered for the treatment of atypical hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, as well as severe forms of myasthenia gravis and neuromyelitis optica. Further studies in this direction will create prerequisites for improving the prognosis not only in patients with orphan disorders, but also for widespread human diseases.
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Atypical hemolytic uremic syndrome and complement blockade: established and emerging uses of complement inhibition. Curr Opin Nephrol Hypertens 2020; 28:278-287. [PMID: 30865166 DOI: 10.1097/mnh.0000000000000499] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Atypical hemolytic uremic syndrome (aHUS) is a diagnosis that has captured the interest of specialists across multiple fields. The hallmark features of aHUS are microangiopathic hemolysis and thrombocytopenia, which creates a diagnostic dilemma because of the occurrence of these findings in a wide variety of clinical disorders. RECENT FINDINGS In most of the instances, aHUS is a diagnosis of exclusion after ruling out causes such as Shigella toxin, acquired or genetic a disintegrin and metalloproteinase thrombospondin motif 13 deficiency (thrombotic thrombocytopenic purpura), and vitamin B12 deficiency. In the purest sense, aHUS is a genetic condition that is activated (or unmasked) by an environmental exposure. However, it is now evident that complement activation is a feature of many diseases. Variants in complement regulatory genes predispose to microangiopathic hemolysis in many rheumatologic, oncologic, and drug-induced vascular, obstetric, peritransplant, and infectious syndromes. SUMMARY Many 'hemolysis syndromes' overlap clinically with aHUS, and we review the literature on the treatment of these conditions with complement inhibition. New reports on the treatment of C3 glomerulopathy, Shiga toxin-related classic hemolytic uremic syndrome, and medication-related thrombotic microangiopathy will be reviewed as well.
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Abstract
Antibody-mediated rejection is a major clinical challenge that limits graft survival. Various modalities of treatment have been reported in small studies in paediatric heart recipients. A novel approach is to use complement-inhibiting agents, such as eculizumab, which inhibits cleavage of C5 to C5a thereby limiting the formation of membrane attack complex and terminal complement-mediated injury of tissue-bound antibodies. This medical modality of treatment has theoretical advantages but the collective experience in its use in the solid organ transplant community remains small. We add to this experience by combining 14 cases from 6 paediatric heart centres in this descriptive study.
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Agana MG, Greydanus DE, Indyk JA, Calles JL, Kushner J, Leibowitz S, Chelvakumar G, Cabral MD. Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century. Dis Mon 2019; 65:303-356. [DOI: 10.1016/j.disamonth.2019.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Deterioration in Clinical Status Is Not Enough to Suspend Eculizumab: A Genetic Complement-Mediated Atypical Hemolytic Uremic Syndrome Case Report. Case Rep Nephrol 2019; 2019:9264824. [PMID: 31360562 PMCID: PMC6652041 DOI: 10.1155/2019/9264824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 11/17/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Mutations in CFI gene coding for complement regulation factors and in THBD gene coding for endothelial cell receptor thrombomodulin could predispose to the disease and hypertension can trigger the onset. Case Presentation A 51-year-old female patient who had received kidney transplant eighteen years ago presented with hypertensive peak and hemolysis pattern. Normal ADAMTS13 levels as well as negative culture and serology for Shiga-toxin excluded, respectively, thrombotic thrombocytopenic purpura (TTP) and typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS). In suspicion of aHUS, we administered eculizumab and hemodialysis sessions were started as the patient showed severe renal failure. After an initial response, the patient developed cerebral hemorrhage. After last eculizumab administration, according to hematological parameters, an unsatisfactory response was observed: given the worsening clinical scenario, we withdrew eculizumab. Pathogenic mutations in CFI and THBD genes were found. After eculizumab reinitiation, looking at hemolysis indexes, we observed a suboptimal response as well as an otherwise adequate renal one: renal graft function was recovered despite persistence of hemolysis signs, after 6 months on regular dialysis. Conclusion For the first time, we report an aHUS case in which a peculiar combination of mutations in CFI and THBD is found. We describe the importance of continuing eculizumab despite deterioration of patient's clinical conditions.
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Hanna RM, Hasnain H, Abdelnour L, Yanny B, Burwick RM. Atypical hemolytic uremic syndrome in a patient with protein-losing enteropathy. J Int Med Res 2019; 47:4027-4032. [PMID: 31364428 PMCID: PMC6726804 DOI: 10.1177/0300060519864808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare disease induced by many triggers, all of which produce a common end phenotype of microangiopathic hemolysis and thrombotic microangiopathy. We herein describe a 63-year-old woman with ongoing protein-losing enteropathy and frequent transudates caused by hypoalbuminemia. The patient was treated with eculizumab with a full hematologic and partial renal response. Protein-losing enteropathy is an inflammatory condition that has been linked with increased complement activation, which can trigger aHUS in patients with loss of CD55 expression. The patient in the present case had an increased estimated glomerular filtration rate but stage IV to V chronic kidney disease. One year later, she remains off dialysis with a stable estimated glomerular filtration rate. We herein report an unusual trigger of complement activation that in turn triggered aHUS in this patient.
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Affiliation(s)
- Ramy M Hanna
- 1 Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Huma Hasnain
- 1 Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Lama Abdelnour
- 1 Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Beshoy Yanny
- 2 Department of Medicine, Division of Digestive Diseases, Hepatology UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Richard M Burwick
- 3 Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
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Eculizumab en el síndrome hemolítico urémico atípico. ¿Hasta cuándo mantenerlo? Nefrologia 2019; 39:440-442. [DOI: 10.1016/j.nefro.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/13/2019] [Indexed: 01/06/2023] Open
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Eculizumab in refractory catastrophic antiphospholipid syndrome: a case report and systematic review of the literature. Clin Exp Med 2019; 19:281-288. [PMID: 31214910 DOI: 10.1007/s10238-019-00565-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare disorder, characterized by the development of multiple vascular thrombosis over a short period of time, in patients with persistently detectable antiphospholipid antibodies (aPLs). The vascular occlusions predominantly affect small vessels. The overall mortality is 36.9%, despite the recent progress in the therapeutic approach. It has been shown that aPLs are able to induce a hypercoagulability state through different mechanisms of action, including complement activation, which in turn plays a key role in the pathogenesis of some thrombotic microangiopathies. Consequently, complement inhibition may be proposed as a targeted intervention to effectively prevent the progression of the microthrombotic storm. The employment of the complement inhibitor eculizumab has been proposed in CAPS on the basis of occasional reports and expert opinion. We report the case of a 54-year-old woman with a CAPS refractory to conventional therapies, who was successfully treated with eculizumab. The administration of this anti-C5 monoclonal antibody aborted the acute progressive thrombotic events and prevented further clinical episodes of thrombosis in the following year. We also faced our case to a systematic literature review, by analyzing all reported cases of CAPS in which eculizumab was added to conventional therapy. Even if further investigation is needed, our results suggest that the inhibition of one mechanism of aPL-induced organ damage may be an add-on treatment for this condition.
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Eculizumab hypersensitivity and desensitization in a toddler with atypical hemolytic uremic syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2409-2410. [PMID: 30946976 DOI: 10.1016/j.jaip.2019.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/13/2019] [Accepted: 03/18/2019] [Indexed: 11/23/2022]
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Madden I, Roumenina LT, Langlois-Meurinne H, Guichoux J, Llanas B, Frémeaux-Bacchi V, Harambat J, Godron-Dubrasquet A. Hemolytic uremic syndrome associated with Bordetella pertussis infection in a 2-month-old infant carrying a pathogenic variant in complement factor H. Pediatr Nephrol 2019; 34:533-537. [PMID: 30560448 DOI: 10.1007/s00467-018-4174-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 12/01/2018] [Accepted: 12/10/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) has been associated with a number of infectious agents. We report here the case of an infant with severe Bordetella pertussis infection who developed HUS. CASE DIAGNOSIS/TREATMENT A 2-month-old preterm male was admitted for severe Bordetella pertussis infection. Symptoms leading to a diagnosis of hemolytic uremic syndrome (HUS) rapidly appeared: hemolytic anemia, thrombocytopenia, and acute kidney injury. He was treated with 25 days of peritoneal dialysis and received complement-targeting therapy with eculizumab (five injections over 2 months), in addition to blood transfusions, antibiotics, and respiratory support. The outcome was favorable. The genetic workup found a complement factor H gene variant which has been associated with atypical HUS. This variant was located in the C3b-binding site and functional tests revealed that it perturbed the regulatory activity of factor H. CONCLUSION This case suggests that pertussis is a strong trigger of HUS and that complement investigations are necessary to guide treatment and understand the pathophysiology.
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Affiliation(s)
- Iona Madden
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France.,Department of Pediatrics, Bayonne Medical Centre, Bayonne, France
| | - Lubka T Roumenina
- INSERM, UMR_S 1138, Team "Complement and diseases", Cordeliers Research Center, Paris, France.,Sorbonne Paris Cite, UMR_S 1138, Centre de Recherche des Cordeliers, University Paris Descartes Paris 5, Paris, France
| | | | - Julie Guichoux
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Brigitte Llanas
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Véronique Frémeaux-Bacchi
- INSERM, UMR_S 1138, Team "Complement and diseases", Cordeliers Research Center, Paris, France.,Laboratory of Immunology, Georges Pompidou Hospital, AP-HP, Paris, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France.
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Abstract
Autoimmunity is a leading cause of chronic kidney disease and loss of native and transplanted kidneys. Conventional immunosuppressive therapies can be effective but are non-specific, noncurative, and risk serious side effects such as life-threatening infection and cancer. Novel therapies and targeted interventions are urgently needed. In this brief review we explore diverse strategies currently in development and under consideration to interrupt underlying disease mechanisms in immune-mediated renal injury. Because autoantibodies are prominent in diagnosis and pathogenesis in multiple human glomerulopathies, we highlight several promising therapies that interfere with functions of early mediators (IgG and complement) of the effector arm and with an epicenter (the germinal center) for induction of humoral immunity.
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Affiliation(s)
- Mary Helen Foster
- a Department of Medicine , Duke University Medical Center , Durham , NC , USA.,b Medical and Research Services , Durham VA Medical Center , Durham , NC , USA
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Kello N, Khoury LE, Marder G, Furie R, Zapantis E, Horowitz DL. Secondary thrombotic microangiopathy in systemic lupus erythematosus and antiphospholipid syndrome, the role of complement and use of eculizumab: Case series and review of literature. Semin Arthritis Rheum 2018; 49:74-83. [PMID: 30598332 DOI: 10.1016/j.semarthrit.2018.11.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/25/2018] [Accepted: 11/26/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Thrombotic microangiopathy (TMA) is a life-threatening, albeit infrequent, complication of systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APS). Recommendations for the treatment of SLE- and APS-related secondary TMA are currently based solely on case reports and expert opinion. Unfortunately, interventions may not yield timely results or effectively halt the progression of TMA. Since complement activation plays a key role in the pathogenesis of secondary TMA due to SLE, APS, a therapy that targets the complement pathway is an attractive intervention. Eculizumab, a recombinant, fully humanized IgG2/IgG4 monoclonal antibody inhibits C5 activation and is FDA-approved for PNH and atypical HUS (aHUS). However, limited case reports are available on its use in treatment of secondary TMA. CASE PRESENTATION AND RESULTS We present the largest case series to date that includes 9 patients with SLE and/or APS who were successfully treated with eculizumab for refractory secondary TMA. In this case series, we report significant responses in hematology values, renal function and other organs following treatment with eculizumab. At 4 weeks, 75% improvement in platelet counts was observed in 78% of patients. Two-thirds of patients demonstrated >75% improvement of haptoglobin and LDH at four weeks. At 4 weeks, eGFR improved by 25% in half of the patients, and 43% had reductions in proteinuria. Two of 3 patients that required hemodialysis were able to be taken off hemodialysis. CONCLUSION Based on these observations, we suggest that eculizumab may be a potential treatment option for acutely ill patients with secondary TMA due to SLE and/or APS who have failed standard of care. A collective approach is needed to better elucidate the role and optimal timing of eculizumab use in the management of TMA complicating SLE and/or APS.
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Affiliation(s)
- Nina Kello
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA.
| | - Lara El Khoury
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Galina Marder
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Richard Furie
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Ekaterini Zapantis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Diane Lewis Horowitz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
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