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Burke L, Sethi SK, Boyer O, Licht C, McCulloch M, Shah R, Luyckx VA, Raina R. Voice of a caregiver: call for action for multidisciplinary teams in the care for children with atypical hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:1961-1963. [PMID: 37782345 DOI: 10.1007/s00467-023-06158-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023]
Affiliation(s)
| | - Sidharth Kumar Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Olivia Boyer
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Raghav Shah
- Northeast Ohio Medical University, Rootstown, OH, USA
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Valerie A Luyckx
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rupesh Raina
- Northeast Ohio Medical University, Rootstown, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Nephrology, Cleveland Clinic Akron General and Akron Children's Hospital, Akron, OH, USA.
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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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Zhang P, Yang X, Fu MZ, Gao CL, Fang X, Xia ZK. Risk Factors and Clinical Outcomes of Renal Thrombotic Microangiopathy in Children with Lupus Nephritis in Terms of Pathological and Clinical Features. Nephron Clin Pract 2024:1-9. [PMID: 38852577 DOI: 10.1159/000538240] [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: 05/20/2022] [Accepted: 03/05/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is an important risk factor for the prognosis of lupus nephritis (LN). Patients with LN complicated with TMA tend to be critically ill with high mortality and poor prognosis. In the present study, we retrospectively analyzed the clinical manifestations, laboratory results, renal pathological manifestations, and prognosis of children with LN-TMA and analyzed the risk factors for end-stage renal disease (ESRD) in children with LN-TMA. METHODS Seventy-four patients with LN and renal TMA (rTMA) were selected and compared to 128 LN controls without TMA (1:2 ratio) matched according to demographics, pathological type and treatments. RESULTS The mean values of systolic blood pressure, diastolic blood pressure (DBP), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), urinary protein quantitation (PRO), urine red blood cells, N-acetyl-β-D-glucosidase (NAG), retinol-binding protein, systemic lupus erythematosus disease activity score (SLEDAI), and activity index (AI) scores in the TMA group were all higher than those in the non-TMA group (p < 0.05 and p < 0.01). The mean values of complement C3, hemoglobin, platelets, estimated glomerular filtration rate, and chronic index (CI) score in the TMA group were all lower than those in the non-TMA group (p < 0.05 and p < 0.01). The number of cases of glomerular crescent, fibrous crescent, endocapillary proliferation, tubular atrophy, interstitial fibrosis, C3 and C1q deposition in the TMA group was higher than that in the non-TMA group (p < 0.05 and p < 0.01). The 3-year and 5-year renal survival rates in the TMA group (88.93% vs. 97.00%, p < 0.05) and TMA group (61.41% vs. 82.31%, p < 0.05) were significantly lower than those in the non-TMA group. Multivariate Cox regression analysis showed that serum creatinine before treatment (≥110 μmol/L), TMA and interstitial fibrosis were independent risk factors for the development of ESRD in LN children. CONCLUSION The general condition of children with TMA is critical, and the prognosis is poor. Early detection, early treatment and the development of new treatments are key to improving LN-TMA outcomes in children.
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Affiliation(s)
- Pei Zhang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China,
| | - Xiao Yang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Meng-Zhen Fu
- Department of Pediatric Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Chun-Lin Gao
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Xiang Fang
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zheng-Kun Xia
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
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Hallam TM, Andreadi A, Sharp SJ, Brocklebank V, Gardenal E, Dreismann A, Lotery AJ, Marchbank KJ, Harris CL, Jones AV, Kavanagh D. Comprehensive functional characterization of Complement factor I rare variant genotypes identified in the SCOPE Geographic Atrophy cohort. J Biol Chem 2024:107452. [PMID: 38852887 DOI: 10.1016/j.jbc.2024.107452] [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: 04/10/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/11/2024] Open
Abstract
Rare variants (RVs) in the gene encoding the regulatory enzyme complement factor I (CFI; FI) that reduce protein function or levels increase age-related macular degeneration (AMD) risk. A total of 3357 subjects underwent screening in the SCOPE natural history study for Geographic Atrophy (GA) secondary to AMD, including CFI sequencing followed by serum FI measurement. Eleven CFI RV genotypes that were challenging to categorise as Type I (low serum level) or Type II (normal serum level but reduced enzymatic function) were characterized in the context of pure FI protein in C3b and C4b fluid phase cleavage assays and a novel bead-based functional assay (BBFA) of surface-bound C3b cleavage. A further 4 variants predicted or previously characterized as benign, were analysed using the BBFA to add confidence to their classification. In all, 3 variants [W51S, C67R, I370T] resulted in low expression. A further 4 variants [P64L, R339Q, G527V and P528T] were identified as being highly deleterious with IC50s for C3b breakdown >1 log increased vs the WT protein, while 2 variants [K476E and R474Q] were ∼1 log reduced in function. Meanwhile, 6 variants [P50A, T203I, K441R, E548Q, P553S, S570T] had IC50s similar to wild-type (WT). Odds ratios (ORs) and BBFA IC50s were positively correlated (r=0.76, P<0.01), whilst ORs vs combined annotation dependent depletion (CADD) scores were not (r=0.43, P=0.16). Overall, 15 CFI RVs were functionally characterized which may aid future patient stratification approaches for complement-targeted therapies. Pure protein in vitro analysis remains the gold standard for determining the functional consequence of CFI RVs.
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Affiliation(s)
- Thomas M Hallam
- Gyroscope Therapeutics Limited, A Novartis Company, London, UK.
| | - Anneliza Andreadi
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Scott J Sharp
- Gyroscope Therapeutics Limited, A Novartis Company, London, UK
| | - Vicky Brocklebank
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Anna Dreismann
- Gyroscope Therapeutics Limited, A Novartis Company, London, UK
| | - Andrew J Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University Hospital Southampton, University of Southampton, Southampton, United Kingdom
| | - Kevin J Marchbank
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claire L Harris
- Gyroscope Therapeutics Limited, A Novartis Company, London, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amy V Jones
- Gyroscope Therapeutics Limited, A Novartis Company, London, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK; Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Iba T, Helms J, Maier CL, Levi M, Scarlatescu E, Levy JH. The role of thromboinflammation in acute kidney injury among patients with septic coagulopathy. J Thromb Haemost 2024; 22:1530-1540. [PMID: 38382739 DOI: 10.1016/j.jtha.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Inflammation and coagulation are critical self-defense mechanisms for mitigating infection that can nonetheless induce tissue injury and organ dysfunction. In severe cases, like sepsis, a dysregulated thromboinflammatory response may result in multiorgan dysfunction. Sepsis-associated acute kidney injury (AKI) is a significant contributor to patient morbidity and mortality. The connection between AKI and thromboinflammation is largely due to unique aspects of the renal vasculature. Specifically, the interaction between blood cells with the endothelial, glomerular, and peritubular capillary systems during thromboinflammation reduces oxygen supply to tubular epithelial cells. Previous studies have focused on tubular epithelial cell damage due to hypoxia, oxidative stress, and nephrotoxins. Although these factors are pivotal in acute tubular injury or necrosis, recent studies have demonstrated that AKI in sepsis encompasses a mixture of tubular and glomerular damage subtypes. In cases of sepsis-induced coagulopathy, thromboinflammation within the glomerulus and peritubular capillaries is an important pathogenic mechanism for AKI. Unfortunately, and despite the use of renal replacement therapy, the development of AKI in sepsis continues to be associated with high morbidity, mortality, and clinical challenges requiring alternative approaches. This review introduces the important role of thromboinflammation in AKI pathogenesis and details innovative vascular-targeting therapeutic strategies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- French National Institute of Health and Medical Research, United Medical Resources 1260, Regenerative Nanomedicine, Federation de Medicine Translationnelle de Strasbourg, Strasbourg University Hospital, Medical Intensive Care Unit - NHC, Strasbourg University, Strasbourg, France
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals National Health Service Foundation Trust, Cardio-metabolic Programme-National Institute for Health and Care Research University College London Hospitals/University College London Biomedical Research Centre, London, United Kingdom
| | - Ecaterina Scarlatescu
- University of Medicine and Pharmacy "Carol Davila," Bucharest, Romania; Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Shankar T, Arora P, Jose JR, Kaushik A. Thrombotic microangiopathy following a white-lipped pit viper envenomation. BMJ Case Rep 2024; 17:e258813. [PMID: 38782420 DOI: 10.1136/bcr-2023-258813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Certain snake envenomation patients with consumptive coagulopathy, termed venom-induced consumption coagulopathy, develop thrombotic microangiopathy (TMA). Due to predominant renal involvement, TMA is said to resemble haemolytic uraemic syndrome and is treated with haemodialysis. We present a case of a young male who presented to the emergency department after being bitten by a white-lipped pit viper (Trimeresurus albolabris). He developed heart failure in addition to acute kidney injury secondary to TMA. He was treated with 30 vials of anti-snake venom according to national guidelines and underwent haemodialysis. Despite haemodialysis, the patient's ventilatory parameters continued to worsen, necessitating invasive mechanical ventilation. Thus, he was initiated on plasma exchange therapy, to which the patient responded well. TMA has not been reported in Trimeresurus envenomations yet, to the best of our knowledge. Additionally, plasma exchange therapy can be considered an adjunctive therapy for snakebite patients who develop TMA.
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Affiliation(s)
- Takshak Shankar
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Poonam Arora
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Jewel Rani Jose
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Aseem Kaushik
- Emergency Medicine, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
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Maisons V, Duval A, Mesnard L, Frimat M, Fakhouri F, Grangé S, Servais A, Cartery C, Fauchier L, Coppo P, Titeca-Beauport D, Fage N, Delmas Y, Quérard AH, Seret G, Bobot M, Le Quintrec M, Ville S, von Tokarski F, Chauvet S, Wynckel A, Martins M, Schurder J, Barbet C, Sautenet B, Gatault P, Caillard S, Vuiblet V, Halimi JM. Assessment of epidemiology and outcomes of adult patients with kidney-limited thrombotic microangiopathies. Kidney Int 2024; 105:1100-1112. [PMID: 38431217 DOI: 10.1016/j.kint.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/31/2024] [Accepted: 02/12/2024] [Indexed: 03/05/2024]
Abstract
Thrombotic microangiopathies (TMA) are usually associated with hematological features (RH-TMA). The epidemiology of TMA limited to kidneys (RL-TMA) is unclear Therefore, patients with TMA and native kidney biopsies were identified during 2009-2022 in 20 French hospitals and results evaluated. RL-TMA was present in 341/757 (45%) patients and associated with lower creatinine levels (median 184 vs 346 μmol/L) than RH-TMA. RL-TMA resulted from virtually all identified causes, more frequently from anti-VEGF treatment and hematological malignancies but less frequently from shigatoxin-associated hemolytic uremic syndrome (HUS), systemic sclerosis, gemcitabine and bacterial infection, and even less frequently when three or more causes/triggers were combined (RL-TMA: 5%; RH-TMA: 12%). RL-TMA was associated with significantly lower major cardiovascular events (10% vs 20%), kidney replacement therapy (23% vs 43%) and death (12% vs 20%) than RH-TMA during follow-up (median 28 months). Atypical HUS (aHUS) was found in 326 patients (RL-TMA: 43%, RH-TMA: 44%). Among the 69 patients with proven complement-mediated aHUS, eculizumab (anti-C5 therapy) was used in 43 (62%) (RL-TMA: 35%; RH-TMA: 71%). Among the 257 other patients with aHUS, including 51% with RL-TMA, eculizumab was used in 29 but with unclear effects of this treatment. Thus, RL-TMA represents a very high proportion of patients with TMA and results from virtually all known causes of TMA and includes 25% of patients with complement-mediated aHUS. Adverse outcomes of RL-TMA are lower compared to RH-TMA but remain significant. Anti-C5 therapy was rarely used in RL-TMA, even in proven complement-mediated aHUS, and its effects remain to be assessed.
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Affiliation(s)
- Valentin Maisons
- Service de Néphrologie, CHU de Tours, Tours, France; U1246, INSERM, SPHERE, Université de Tours, Université de Nantes, Tours, Nantes, France
| | - Anna Duval
- Service de Néphrologie, CHU de Strasbourg, Strasbourg, France
| | | | - Marie Frimat
- Service de Néphrologie, CHU de Lille, Lille, France
| | - Fadi Fakhouri
- Service de Néphrologie, CHU Vaudois, Lausanne, Switzerland
| | | | - Aude Servais
- Service de Néphrologie, APHP Hopital Necker, Paris, France
| | - Claire Cartery
- Service de Néphrologie, CH de Valenciennes, Valenciennes, France
| | | | - Paul Coppo
- Service d'Hématologie, Centre de référence pour les microangiopathies thrombotiques (CNR-MAT), APHP Hopital Saint-Antoine, Paris, France
| | | | - Nicolas Fage
- Service de Néphrologie, Département de médecine intensive reanimation-médecine hyperbare, CHU d'Angers, Angers, France
| | - Yahsou Delmas
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | | | - Guillaume Seret
- Service de Néphrologie, Pole Santé Sud Echo Le Mans, Le Mans, France
| | - Mickaël Bobot
- Service de Néphrologie, CHU de Marseille; Aix, Marseille Université, INSERM 1263, INRAE 1260, C2VN, CERIMED, Marseille, France
| | | | - Simon Ville
- Service de Néphrologie, CHU de Nantes, Nantes, France
| | | | - Sophie Chauvet
- Service de Néphrologie, APHP Hopital Européen Georges Pompidou, Paris, France
| | | | - Manon Martins
- Service de Néphrologie, CHU de Rennes, Rennes, France
| | - Juliet Schurder
- Service de Néphrologie, CH de Saint-Malo, Saint-Malo, France
| | | | | | - Philippe Gatault
- Service de Néphrologie, CHU de Tours, U1327, INSERM, ISCHEMIA, Université de Tours, Tours, France
| | - Sophie Caillard
- U1246, INSERM, SPHERE, Université de Tours, Université de Nantes, Tours, Nantes, France
| | - Vincent Vuiblet
- Service de Pathologie, Institut d'Intelligence Artificielle en Santé, CHU de Reims et Université de Reims Champagne Ardenne, Reims, France
| | - Jean-Michel Halimi
- Service de Néphrologie, CHU de Tours, U1327, INSERM, ISCHEMIA, Université de Tours, Tours, France.
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Zhang PL, Metcalf BD, Khan S, Abukhaled J, Zafar K, Li W, Kanaan HD. Hydralazine use can be associated with IgM-dominated immune complex-mediated glomerulonephritis. Ultrastruct Pathol 2024:1-6. [PMID: 38685716 DOI: 10.1080/01913123.2024.2346660] [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: 01/27/2024] [Accepted: 04/19/2024] [Indexed: 05/02/2024]
Abstract
CONTEXT IgM-dominant immune complex-mediated glomerulonephritis (IgM-dominant ICMGN) is a rare renal entity, characterized by a membranoproliferative pattern by light microscopy, dominant IgM staining by immunofluorescent staining, and subendothelial deposits by electron microscopy. This study was to investigate if some of IgM-ICMGN were associated with autoimmune disorders induced by hydralazine. DESIGN Seven IgM-dominant ICMGN cases were identified over 8 years. Their pathologic phenotypes and clinical scenarios were analyzed in detail. RESULTS Patients' ages ranged from 47 to 87 years old with 5 women and two men. Six of seven patients had drug-induced autoimmune phenomenon (hydralazine-induced positive ANCA and ANA). All of them had renal dysfunction and some proteinuria. Most pathologic features showed a membranoproliferative pattern of glomerulonephritis with dominant IgM deposits at subendothelial spaces. IgM nephropathy (a variant of focal segmental glomerulosclerosis), chronic thrombotic microangiopathy, and cryoglobulinemic glomerulopathy were ruled out in the cases. CONCLUSION The hydralazine-induced autoimmune phenomenon can be seen in IgM-dominant ICMGN, which should be classified as a subtype of membranoproliferative glomerulonephritis.
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Affiliation(s)
- Ping L Zhang
- Department of Pathology, Corewell Health (East), Royal Oak, MI, USA
| | | | - Sarang Khan
- Department of Pathology, Corewell Health (East), Royal Oak, MI, USA
| | - Jamal Abukhaled
- Division of Nephrology, Corewell Health (East), Royal Oak, MI, USA
| | - Khalid Zafar
- Division of Nephrology, Corewell Health (East), Royal Oak, MI, USA
| | - Wei Li
- Department of Pathology, Corewell Health (East), Royal Oak, MI, USA
| | - Hassan D Kanaan
- Department of Pathology, Corewell Health (East), Royal Oak, MI, USA
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9
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Boen JRA, Gevaert AB, Dendooven A, Krüger D, Tubeeckx M, Van Fraeyenhove J, Bruyns T, Segers VFM, Van Craenenbroeck EM. Divergent cardiac and renal effects of miR-181c-5p inhibition in a rodent heart failure model. Front Cardiovasc Med 2024; 11:1383046. [PMID: 38725830 PMCID: PMC11079209 DOI: 10.3389/fcvm.2024.1383046] [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: 02/06/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
Aims MiR-181c-5p overexpression associates with heart failure (HF) and cardiac damage, but the underlying pathophysiology remains unclear. This study investigated the effect of miR-181c-5p inhibition on cardiac function and fibrosis in a rodent model of diastolic dysfunction, and evaluated additional effects on kidney as relevant comorbid organ. Methods and results Diastolic dysfunction was induced in male C57/BL6J mice (n = 20) by combining high-fat diet, L-NG-nitroarginine methyl ester, and angiotensin II administration, and was compared to sham controls (n = 18). Mice were randomized to subcutaneous miR-181c-5p antagomiR (INH) or scrambled antagomiR injections (40 mg/kg/week). HF mice demonstrated diastolic dysfunction and increased fibrosis, which was attenuated by INH treatment. Remarkably, HF + INH animals had a threefold higher mortality rate (60%) compared to HF controls (20%). Histological examination revealed increased glomerular damage in all INH treated mice, and signs of thrombotic microangiopathy (TMA) in mice who died prematurely. Quantitative polymerase chain reaction demonstrated a miR-181c-5p-related downregulation of cardiac but not renal Tgfbr1 in HF + INH mice, while INH treatment reduced renal but not cardiac Vegfa expression in all mice. Conclusion This study demonstrates cardiac anti-fibrotic effects of miR-181c-5p inhibition in a rodent HF model through targeting of Tgfbr1 in the heart. Despite improved diastolic function, HF + INH mice had higher mortality due to increased predisposition for TMA, increased renal fibrosis and glomerular damage, associated with Vegfa downregulation in kidneys.
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Affiliation(s)
- Jente R. A. Boen
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Wilrijk, Belgium
- Laboratory of Physiopharmacology, GENCOR Department, University of Antwerp, Wilrijk, Belgium
| | - Andreas B. Gevaert
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Wilrijk, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Amélie Dendooven
- Department of Pathology, Ghent University Hospital, Gent, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
| | - Dustin Krüger
- Laboratory of Physiopharmacology, GENCOR Department, University of Antwerp, Wilrijk, Belgium
| | - Michiel Tubeeckx
- Laboratory of Physiopharmacology, GENCOR Department, University of Antwerp, Wilrijk, Belgium
| | - Jens Van Fraeyenhove
- Laboratory of Physiopharmacology, GENCOR Department, University of Antwerp, Wilrijk, Belgium
| | - Tine Bruyns
- Laboratory of Physiopharmacology, GENCOR Department, University of Antwerp, Wilrijk, Belgium
| | - Vincent F. M. Segers
- Laboratory of Physiopharmacology, GENCOR Department, University of Antwerp, Wilrijk, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Emeline M. Van Craenenbroeck
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Wilrijk, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
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Andeen NK, Hou J. Diagnostic Challenges and Emerging Pathogeneses of Selected Glomerulopathies. Pediatr Dev Pathol 2024:10935266241237656. [PMID: 38576387 DOI: 10.1177/10935266241237656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Recent progress in glomerular immune complex and complement-mediated diseases have refined diagnostic categories and informed mechanistic understanding of disease development in pediatric patients. Herein, we discuss selected advances in 3 categories. First, membranous nephropathy antigens are increasingly utilized to characterize disease in pediatric patients and include phospholipase A2 receptor (PLA2R), Semaphorin 3B (Sema3B), neural epidermal growth factor-like 1 (NELL1), and protocadherin FAT1, as well as the lupus membranous-associated antigens exostosin 1/2 (EXT1/2), neural cell adhesion molecule 1 (NCAM1), and transforming growth factor beta receptor 3 (TGFBR3). Second, we examine advances in techniques for paraffin and light chain immunofluorescence (IF), including the former's function as a salvage technique and their necessity for diagnosis in adolescent cases of membranous-like glomerulopathy with masked IgG kappa deposits (MGMID) and proliferative glomerulonephritis with monotypic Ig deposits (PGNMID), respectively. Finally, progress in understanding the roles of complement in pediatric glomerular disease is reviewed, with specific attention to overlapping clinical, histologic, and genetic or functional alternative complement pathway (AP) abnormalities among C3 glomerulopathy (C3G), infection-related and post-infectious GN, "atypical" post-infectious GN, immune complex mediated membranoproliferative glomerulonephritis (IC-MPGN), and atypical hemolytic uremic syndrome (aHUS).
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Affiliation(s)
- Nicole K Andeen
- Oregon Health & Science University, Department of Pathology and Laboratory Medicine, Portland, OR, USA
| | - Jean Hou
- Cedars-Sinai Medical Center, Department of Pathology, Los Angeles, CA, USA
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11
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Mubarak M, Raza A, Rashid R, Sapna F, Shakeel S. Thrombotic microangiopathy after kidney transplantation: Expanding etiologic and pathogenetic spectra. World J Transplant 2024; 14:90277. [PMID: 38576763 PMCID: PMC10989473 DOI: 10.5500/wjt.v14.i1.90277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/28/2024] [Accepted: 03/04/2024] [Indexed: 03/15/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is an uncommon but serious complication that not only affects native kidneys but also transplanted kidneys. This review is specifically focused on post-transplant TMA (PT-TMA) involving kidney transplant recipients. Its reported prevalence in the latter population varies from 0.8% to 14% with adverse impacts on both graft and patient survival. It has many causes and associations, and the list of etiologic agents and associations is growing constantly. The pathogenesis is equally varied and a variety of patho genetic pathways lead to the development of microvascular injury as the final common pathway. PT-TMA is categorized in many ways in order to facilitate its management. Ironically, more than one causes are contributory in PT-TMA and it is often difficult to pinpoint one particular cause in an individual case. Pathologically, the hallmark lesions are endothelial cell injury and intravascular thrombi affecting the microvasculature. Early diagnosis and classification of PT-TMA are imperative for optimal outcomes but are challenging for both clinicians and pathologists. The Banff classification has addressed this issue and has developed minimum diagnostic criteria for pathologic diagnosis of PT-TMA in the first phase. Management of the condition is also challenging and still largely empirical. It varies from simple maneuvers, such as plasmapheresis, drug withdrawal or modification, or dose reduction, to lifelong complement blockade, which is very expensive. A thorough understanding of the condition is imperative for an early diagnosis and quick treatment when the treatment is potentially effective. This review aims to increase the awareness of relevant stakeholders regarding this important, potentially treatable but under-recognized cause of kidney allograft dysfunction.
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Affiliation(s)
- Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Amber Raza
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Rahma Rashid
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
| | - Fnu Sapna
- Department of Pathology, Montefiore Medical Center, The University Hospital for Albert Einstein School of Medicine, Bronx, NY 10461, United States
| | - Shaheera Shakeel
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
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Sweeney CA, Quader M, Kim C. Thrombotic Microangiopathic Anemia After Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:784-787. [PMID: 38172028 DOI: 10.1053/j.jvca.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Craig A Sweeney
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA.
| | - Mohammed Quader
- Department of Surgery, Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Christin Kim
- Department of Anesthesia, Division of Anesthesia Critical Care, Virginia Commonwealth University, Richmond, VA
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Frimat M, Gnemmi V, Stichelbout M, Provôt F, Fakhouri F. Pregnancy as a susceptible state for thrombotic microangiopathies. Front Med (Lausanne) 2024; 11:1343060. [PMID: 38476448 PMCID: PMC10927739 DOI: 10.3389/fmed.2024.1343060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
Pregnancy and the postpartum period represent phases of heightened vulnerability to thrombotic microangiopathies (TMAs), as evidenced by distinct patterns of pregnancy-specific TMAs (e.g., preeclampsia, HELLP syndrome), as well as a higher incidence of nonspecific TMAs, such as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, during pregnancy. Significant strides have been taken in understanding the underlying mechanisms of these disorders in the past 40 years. This progress has involved the identification of pivotal factors contributing to TMAs, such as the complement system, ADAMTS13, and the soluble VEGF receptor Flt1. Regardless of the specific causal factor (which is not generally unique in relation to the usual multifactorial origin of TMAs), the endothelial cell stands as a central player in the pathophysiology of TMAs. Pregnancy has a major impact on the physiology of the endothelium. Besides to the development of placenta and its vascular consequences, pregnancy modifies the characteristics of the women's microvascular endothelium and tends to render it more prone to thrombosis. This review aims to delineate the distinct features of pregnancy-related TMAs and explore the contributing mechanisms that lead to this increased susceptibility, particularly influenced by the "gravid endothelium." Furthermore, we will discuss the potential contribution of histopathological studies in facilitating the etiological diagnosis of pregnancy-related TMAs.
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Affiliation(s)
- Marie Frimat
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
- Inserm, Institut Pasteur de Lille, Univ. Lille, Lille, France
| | | | | | - François Provôt
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, CHUV and University of Lausanne, Lausanne, Switzerland
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Dessaix K, Bontoux C, Aubert O, Grünenwald A, Sberro Soussan R, Zuber J, Duong Van Huyen JP, Anglicheau D, Legendre C, Fremeaux Bacchi V, Rabant M. De novo thrombotic microangiopathy after kidney transplantation in adults: Interplay between complement genetics and multiple endothelial injury. Am J Transplant 2024:S1600-6135(24)00097-2. [PMID: 38320731 DOI: 10.1016/j.ajt.2024.01.029] [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: 09/08/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024]
Abstract
De novo thrombotic microangiopathy (dnTMA), after renal transplantation may significantly alter graft outcomes. However, its pathogenesis and the role of complement alternative pathway dysregulation remain elusive. We studied all consecutive adult patients with a kidney allograft biopsy performed between January 2004 and March 2016 displaying dnTMA. Ninety-two patients were included. The median time of occurrence was 166 (IQR 25-811) days. The majority (82.6 %) had TMA localized only in the graft. Calcineurin inhibitor toxicity and antibody-mediated rejection (ABMR) were the 2 most frequent causes (54.3% and 37.0%, respectively). However, etiological factors were multiple in 37% patients. Interestingly, pathogenic variants in the genes of complement alternative pathway were significantly more frequent in the 42 tested patients than in healthy controls (16.7% vs 3.7% respectively, P < .008). The overall graft survival after biopsy was 66.0% at 5 years and 23.4% at 10 years, significantly worse than a matched cohort without TMA. Moreover, graft survival of patients with TMA and ABMR was worse than a matched cohort with ABMR without TMA. The 2 main prognostic factors were a positive C4d staining and a lower estimated glomerular filtration rate at diagnosis. DnTMA is a severe and multifactorial disease, induced by 1 or several endothelium-insulting conditions, mostly calcineurin inhibitor toxicity and ABMR.
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Affiliation(s)
- Kathleen Dessaix
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Christophe Bontoux
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Laboratory of Clinical and Experimental Pathology, Hospital-Integrated Biobank (BB-0033-00025), Team 4, Institute of Research on Cancer and Aging of Nice, InsermU1081, CNRS UMR7284, FHU OncoAge, Institut Hospitalo-Universitaire RespirERA, Université Côte d'Azur, Hôpital Pasteur, CHU de Nice, CEDEX 1, Nice, France
| | - Olivier Aubert
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; INSERM, PARCC, Paris Translational Reseach for Organ Transplantation, Université Paris Cité, Paris, France
| | - Anne Grünenwald
- INSERM, UMRS 1138, Inflammation, Complement and Cancer Team, Centre de recherche des Cordeliers, Sorbonne Universités, Université Paris Cité, Paris, France
| | - Rebecca Sberro Soussan
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Julien Zuber
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Jean-Paul Duong Van Huyen
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; INSERM, PARCC, Paris Translational Reseach for Organ Transplantation, Université Paris Cité, Paris, France
| | - Dany Anglicheau
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France
| | - Christophe Legendre
- Service des Maladies du Rein et du Métabolisme, Transplantation et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France
| | - Veronique Fremeaux Bacchi
- INSERM, UMRS 1138, Inflammation, Complement and Cancer Team, Centre de recherche des Cordeliers, Sorbonne Universités, Université Paris Cité, Paris, France; Service d'Immunologie, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Université Paris Cité, Paris, France
| | - Marion Rabant
- Laboratoire d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants maladies, Université Paris Cité, Paris, France; Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France.
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15
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Leisring J, Brodsky SV, Parikh SV. Clinical Evaluation and Management of Thrombotic Microangiopathy. Arthritis Rheumatol 2024; 76:153-165. [PMID: 37610060 DOI: 10.1002/art.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
Thrombotic microangiopathy (TMA) refers to a diverse group of diseases that share clinical and histopathologic features. TMA is clinically characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and organ injury that stems from endothelial damage and vascular occlusion. There are several disease states with distinct pathophysiological mechanisms that manifest as TMA. These conditions are associated with significant morbidity and mortality and require urgent recognition and treatment. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are traditionally considered to be primary forms of TMA, but TMA more commonly occurs in association with a coexisting condition such as infection, pregnancy, autoimmune disease, or malignant hypertension, among others. Determining the cause of TMA is a diagnostic challenge because of limited availability of disease-specific testing. However, identifying the underlying etiology is imperative as treatment strategies differ. Our understanding of the conditions that cause TMA is evolving. Recent advances have led to improved comprehension of the varying pathogenic mechanisms that drive TMA. Development of targeted therapeutics has resulted in significant improvements in patient outcomes. In this article, we review the pathogenesis and clinical features of the different TMA-causing conditions. We outline a practical approach to diagnosis and management and discuss empiric and disease-specific treatment strategies.
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Affiliation(s)
- Joshua Leisring
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Samir V Parikh
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Sun I, Lee ST, Chen YG, Mao YC, Chen FC, Chen YH, Tsai SH, Ho CH. Thromboembolic events following a pit viper bite from Protobothrops mucrosquamatus (Taiwan Habu): A report of two cases. Toxicon 2024; 238:107572. [PMID: 38145881 DOI: 10.1016/j.toxicon.2023.107572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/01/2023] [Accepted: 12/17/2023] [Indexed: 12/27/2023]
Abstract
Protobothrops mucrosquamatus, also known as the Taiwan Habu, is a venomous snake prevalent in Taiwan. It is accountable for most snakebites in the region. The toxin of the Taiwan Habu has significant hemorrhagic potential. However, patients bitten by this snake often suffer more local injuries than systemic ones. This report presents two cases of individuals bitten by the Taiwan Habu who subsequently experienced thromboembolism. In the first case, an 88-year-old male, bitten on his fourth toe, suffered a cerebral infarction 32 hours post-bite. In the second case, an 82-year-old female, bitten on her ankle, experienced cardiac arrest 19 hours later. Both patients promptly received antivenom and showed no signs of coagulopathy either before or after the snakebite. However, elevated coagulation factor VIII levels were observed in the first case. Our aim is to understand the mechanism behind these thromboembolic events. This report emphasizes the unusually high level of coagulation factor VIIIa and highlights the need for further investigation into the mechanisms involved. Consequently, physicians should assess the risk of thromboembolic events in snakebite patients by evaluating coagulation factors during treatment.
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Affiliation(s)
- I Sun
- Department of Emergency Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung City, 80284, Taiwan; Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Siou-Ting Lee
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan; Department of Obstetrics and Gynecology, Taoyuan Armed Forces General Hospital, Taoyuan City, 32551, Taiwan
| | - Yu-Guang Chen
- The Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Yan-Chiao Mao
- Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung City, 40705, Taiwan
| | - Feng-Chen Chen
- Department of Emergency Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung City, 80284, Taiwan; Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Yen-Hsiu Chen
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan
| | - Cheng-Hsuan Ho
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, 114202, Taiwan; Institute of Toxicology, College of Medicine, National Taiwan University, Taipei City, 100233, Taiwan.
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17
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Nakamura Y, Kato N, Tatematsu Y, Arai Y, Mori N, Shibata K, Yamazaki M, Yasui H, Fujiwara S, Yamakawa T, Maruyama S. Clinical characteristics of anti-GBM disease with thrombotic microangiopathy: a case report and literature review. CEN Case Rep 2024; 13:37-44. [PMID: 37213063 PMCID: PMC10201029 DOI: 10.1007/s13730-023-00797-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/12/2023] [Indexed: 05/23/2023] Open
Abstract
The coexistence of anti-glomerular basement membrane (anti-GBM) disease with thrombotic microangiopathy (TMA) is rarely encountered, and the clinical characteristics of this phenomenon are not well known.A 76-year-old Japanese woman with a history of idiopathic pulmonary disease was diagnosed with anti-GBM disease due to rapidly progressive glomerulonephritis and a positive anti-GBM antibody test result. We treated the patient with hemodialysis, glucocorticoids, and plasmapheresis. During treatment, the patient suddenly became comatose. TMA was then diagnosed because of thrombocytopenia and microangiopathic hemolytic anemia. The activity of a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS-13) was retained at 48%. Although we continued the treatment, the patient died of respiratory failure. An autopsy revealed the cause of respiratory failure to be an acute exacerbation of interstitial pneumonia. The clinical findings of the renal specimen indicated anti-GBM disease; however, there were no lesions suggestive of TMA. A genetic test did not reveal an apparent genetic mutation of the atypical hemolytic uremic syndrome.We conducted a literature review of past case reports of anti-GBM disease with TMA. The following clinical characteristics were obtained. First, 75% of the cases were reported in Asia. Second, TMA tended to appear during the treatment course for anti-GBM disease and usually resolved within 12 weeks. Third, ADAMTS-13 activity was retained above 10% in 90% of the cases. Fourth, central nervous system manifestations occurred in more than half of the patients. Fifth, the renal outcome was very poor. Further studies are required to understand the pathophysiology of this phenomenon.
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Affiliation(s)
- Yoshihiro Nakamura
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan.
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshitaka Tatematsu
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshifumi Arai
- Department of Pathology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Nozomi Mori
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Katsuaki Shibata
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Michiko Yamazaki
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Hirotoshi Yasui
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shinji Fujiwara
- Department of Hematology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Taishi Yamakawa
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
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Whelan R, Lih D, Xue J, Himmelfarb J, Zheng Y. Modeling Shiga toxin-induced human renal-specific microvascular injury. Integr Biol (Camb) 2024; 16:zyae001. [PMID: 38266067 DOI: 10.1093/intbio/zyae001] [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: 09/11/2023] [Revised: 12/14/2023] [Accepted: 12/27/2023] [Indexed: 01/26/2024]
Abstract
Shiga toxin (Stx) causes significant renal microvascular injury and kidney failure in the pediatric population, and an effective targeted therapy has yet to be demonstrated. Here we established a human kidney microvascular endothelial cell line for the study of Stx mediated injuries with respect to their morphologic, phenotypic, and transcriptional changes, and modeled Stx induced thrombotic microangiopathy (TMA) in flow-mediated 3D microvessels. Distinct from other endothelial cell lines, both isolated primary and immortalized human kidney microvascular endothelial cells demonstrate robust cell-surface expression of the Stx receptor Gb3, and concomitant dose-dependent toxicity to Stx, with significant contributions from caspase-dependent cell death. Use of a glucosylceramide synthase inhibitor (GCSi) to target disruption of the synthetic pathway of Gb3 resulted in remarkable protection of kidney microvascular cells from Stx injury, shown in both cellular morphologies, caspase activation and transcriptional analysis from RNA sequencing. Importantly, these findings are recapitulated in 3D engineered kidney microvessels under flow. Moreover, whole blood perfusion through Stx-treated microvessels led to marked platelet binding on the vessel wall, which was significantly reduced with the treatment of GCSi. These results validate the feasibility and utility of a bioengineered ex vivo human microvascular model under flow to recapitulate relevant blood-endothelial interactions in STEC-HUS. The profound protection afforded by GCSi demonstrates a preclinical opportunity for investigation in human tissue approximating physiologic conditions. Moreover, this work provides a broad foundation for novel investigation into TMA injury pathogenesis and treatment. Insight Box: Shiga toxin (Stx) causes endothelial injury that results in significant morbidity and mortality in the pediatric population, with no effective targeted therapy. This paper utilizes human kidney microvascular cells to examine Stx mediated cell death in both 2D culture and flow-mediated 3D microvessels, with injured microvessels also developing marked platelet binding and thrombi formation when perfused with blood, consistent with the clinical picture of HUS. This injury is abrogated with a small molecule inhibitor targeting the synthetic pathway of the Shiga toxin receptor. Our findings shed light onto Stx-induced vascular injuries and pave a way for broad investigation into thrombotic microangiopathies.
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Affiliation(s)
- Russell Whelan
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Daniel Lih
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
- Institute of Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
| | - Jun Xue
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
- Institute of Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
| | - Jonathan Himmelfarb
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
- Institute of Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
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19
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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20
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Abughanimeh OK, Baljevic M, Nester A. Novel Heterozygous Missense Variants in Diacylglycerol Kinase Epsilon and Complement Factor I: Potential Pathogenic Association With Atypical Hemolytic Uremic Syndrome. Cureus 2024; 16:e52633. [PMID: 38374836 PMCID: PMC10876284 DOI: 10.7759/cureus.52633] [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] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy (TMA), which copresents with microangiopathic hemolytic anemia, thrombocytopenia, and kidney injury. While typical HUS is normally preceded by infections such as Shiga-toxin-producing Escherichia coli, atypical HUS (aHUS) has a genetic component that leads to dysregulation of the alternative complement pathway. We report a case of a 69-year-old female who developed aHUS after undergoing an elective knee surgery. Genetic testing revealed novel mutations affecting diacylglycerol kinase epsilon (DGKE) protein and complement factor I (CFI) that were not reported before as pathogenic. The patient was treated with eculizumab, leading to the complete resolution of TMA with no lasting organ damage.
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Affiliation(s)
- Omar K Abughanimeh
- Division of Hematology-Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, USA
| | - Muhamed Baljevic
- Division of Hematology-Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Vanderbilt-Ingram Cancer Center, Nashville, USA
| | - Alex Nester
- Division of Hematology-Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, USA
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Aluf O, Parente S, Radin M, Campa L, Gazzola V, Olugbogi A, Tesio N, Ugo H, Zanetti E, Zevallos C, Versino E, Lembo D, Roccatello D, Sciascia S. The estimated prevalence of antiphospholipid antibodies and criteria-antiphospholipid syndrome in subjects with renal thrombotic microangiopathy. Lupus 2024; 33:75-82. [PMID: 38116607 DOI: 10.1177/09612033231217351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND While the prevalence of antiphospholipid antibodies (aPL) in venous and arterial thrombotic events had already been estimated by previous studies, the prevalence of aPL in subjects with Thrombotic Microangiopathy (TMA) is still not fully elucidated. Thus, we conducted a systematic review to estimate the frequency of aPL in subjects with biopsy-proven renal TMA. METHODS We conducted in the PubMed database a search for English-language studies investigating the presence of aPL in subjects with biopsy-proven renal TMA from January 1985 to December 2022. Keywords used in the search included: 'antiphospholipid syndrome', 'antiphospholipid antibodies' and 'thrombotic microangiopathy'. Cohorts of HUS patients were excluded due to the risk of over-estimating the prevalence of aPL in these populations. The median frequency for positive aPL including anticardiolipin antibodies (aCL), antibodies against β2-glycoprotein-I (anti-β2GPI) and lupus anticoagulant (LA) was then calculated. RESULTS 522 articles were identified through the literature search. Six studies, assessing the prevalence of aPL in 211 subjects with renal TMA, were retrieved. The overall aPL prevalence was estimated as 24.4% (range 22-56). The estimated prevalence of aCL (IgG/IgM), anti-β2GPI, (IgG/IgM) and LA was 4.0% (range 3-27), 4.0% (range 3-16) and 18.9% (range 13-25), respectively. APS was diagnosed in 16.3% (range 11-29) of the patients. Of note, a high level of heterogeneity was observed when comparing the reported aPL profiles for each study. CONCLUSIONS This comprehensive systematic analysis of studies investigating the prevalence of aPL in renal TMA showed that, despite the high heterogeneity of the included studies, aPL are present in about one case out of four renal-TMA cases.
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Affiliation(s)
- Ofir Aluf
- MedInTO, University of Torino, Torino, Italy
| | - Silvia Parente
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Massimo Radin
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | | | | | | | | | | | | | | | - Elisabetta Versino
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - David Lembo
- Department of Clinical and Biological Sciences, Laboratory of Molecular Virology and Antiviral Research, University of Turin, Orbassano, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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22
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Gheiasi B, Taghinezhad F, Patel DK, Salimi E, Babashahi M, Mozafari A. Thrombocytopenia Secondary to COVID-19: Outcomes Analysis in Terms of Thrombotic Microangiopathy, Acute Kidney Injury, and Mortality. Int J Hematol Oncol Stem Cell Res 2024; 18:7-13. [PMID: 38680710 PMCID: PMC11055419 DOI: 10.18502/ijhoscr.v18i1.14740] [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] [Received: 10/17/2022] [Accepted: 12/16/2023] [Indexed: 05/01/2024] Open
Abstract
Background: COVID-19 usually complicates respiratory failure; microvascular, macrovascular, and renal complications are common. Both micro and macrovascular complications are associated with multi-organ dysfunction and in-hospital mortality. Thrombotic microangiopathy (TMA) causes microvascular thromboses associated with organ failure, including acute kidney injury (AKI). Materials and Methods: This Retrospective Cohort study included 100 COVID-19 patients with thrombocytopenia, followed up in a university hospital's intensive care unit (ICU). The primary endpoints were in-hospital mortality or discharge from the hospital and assessing the occurrence of TMA and AKI during the hospitalization. The effect of thrombotic microangiopathy and acute kidney injury on mortality was investigated using logistic regression models in Stata software version 12.1. Results: The TMA and AKI were associated with in-hospital mortality in COVID-19 patients presenting with thrombocytopenia in multivariate regression analysis, adjusted for other variables. The effect of AKI on mortality was obtained (adjusted OR 4.09, 95% CI: 1.33-12.53, p = 0.01). Moreover, the odds of mortality due to TMA were ten-fold higher in the patients who had TMA than those who did not (adjusted OR 10.26, 95% CI: 1.26-83.76, p = 0.03). Conclusion: We outlined TMA in COVID-19 patients, which could be responsible for kidney injury and mortality in critically COVID-19 patients.
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Affiliation(s)
- Bahareh Gheiasi
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | | | - Darshik Kumar Patel
- Department of Intensive Care Medicine, Loyola Medicine - Macneal Hospital, Berwyn, IL, USA
| | - Ebrahim Salimi
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Mashallah Babashahi
- Department of Laboratory Sciences, School of Allied Medical Sciences, University of Medical Sciences, Ilam, Iran
| | - Aliashraf Mozafari
- Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
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23
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Avdonin PP, Blinova MS, Generalova GA, Emirova KM, Avdonin PV. The Role of the Complement System in the Pathogenesis of Infectious Forms of Hemolytic Uremic Syndrome. Biomolecules 2023; 14:39. [PMID: 38254639 PMCID: PMC10813406 DOI: 10.3390/biom14010039] [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: 09/30/2023] [Revised: 11/24/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Hemolytic uremic syndrome (HUS) is an acute disease and the most common cause of childhood acute renal failure. HUS is characterized by a triad of symptoms: microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In most of the cases, HUS occurs as a result of infection caused by Shiga toxin-producing microbes: hemorrhagic Escherichia coli and Shigella dysenteriae type 1. They account for up to 90% of all cases of HUS. The remaining 10% of cases grouped under the general term atypical HUS represent a heterogeneous group of diseases with similar clinical signs. Emerging evidence suggests that in addition to E. coli and S. dysenteriae type 1, a variety of bacterial and viral infections can cause the development of HUS. In particular, infectious diseases act as the main cause of aHUS recurrence. The pathogenesis of most cases of atypical HUS is based on congenital or acquired defects of complement system. This review presents summarized data from recent studies, suggesting that complement dysregulation is a key pathogenetic factor in various types of infection-induced HUS. Separate links in the complement system are considered, the damage of which during bacterial and viral infections can lead to complement hyperactivation following by microvascular endothelial injury and development of acute renal failure.
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Affiliation(s)
- Piotr P. Avdonin
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
| | - Maria S. Blinova
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
| | - Galina A. Generalova
- Saint Vladimir Moscow City Children’s Clinical Hospital, 107014 Moscow, Russia; (G.A.G.); (K.M.E.)
- Department of Pediatrics, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Khadizha M. Emirova
- Saint Vladimir Moscow City Children’s Clinical Hospital, 107014 Moscow, Russia; (G.A.G.); (K.M.E.)
- Department of Pediatrics, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Pavel V. Avdonin
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
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24
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Chen HY, Shih JC, Tsai MH, Chung CH. Long-term survival and renal outcomes of thrombotic microangiopathy in pregnancy: A retrospective cohort study. Int J Gynaecol Obstet 2023; 163:940-947. [PMID: 37317480 DOI: 10.1002/ijgo.14918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Thrombotic microangiopathy (TMA) in pregnancy can rapidly progress, leading to severe morbidities. This study aimed to compare baseline demographics and clinical outcomes between pregnant women with and without TMA. METHODS Using the National Health Insurance Research Database, 207 patients with pregnancy-related TMA from January 1, 2006 to December 31, 2015 were enrolled. Their data were compared with a 1:4 propensity score-matched cohort of 828 pregnant women without TMA to evaluate mortality and end-stage renal disease (ESRD) risks. Cox proportional hazards models were used to estimate the adjusted hazard ratio and 95% confidence intervals. RESULTS A total of 1035 participants were included. The risks of mortality and ESRD were 4.46 and 5.97 times higher for the TMA cohort, respectively. Subgroup analysis revealed higher mortality and ESRD risks in patients with TMA aged >40 years with a history of hypertension, stroke, cancer, concomitant stroke, malignant hypertension, or gastroenterocolitis than in the matched cohort. CONCLUSION Pregnant patients with TMA, especially those older and with comorbidities and organ involvement, faced increased mortality and ESRD risks. Physicians should collaborate with obstetricians throughout the prenatal and postpartum periods for these patients.
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Affiliation(s)
- Hsin-Yu Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Jin-Chung Shih
- Departments of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Meng-Han Tsai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ching-Hu Chung
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
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25
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Costigan C, Balgobin S, Zappitelli M. Drugs in treating paediatric acute kidney injury. Pediatr Nephrol 2023; 38:3923-3936. [PMID: 37052689 DOI: 10.1007/s00467-023-05956-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/03/2023] [Accepted: 03/17/2023] [Indexed: 04/14/2023]
Abstract
Acute kidney injury (AKI) is a complex syndrome which affects a significant proportion of hospitalized children. The breadth and impact of AKI on health outcomes in both adults and children have come to the fore in recent years with increasing awareness encouraging research advancement. Despite this, management strategies for most types of AKI remain heavily reliant on fluid and electrolyte management, hemodynamic optimization, nephrotoxin avoidance and appropriate initiation of kidney replacement therapy. Specific drugs targeting the mechanisms involved in AKI remain elusive. Recent improvement in appreciation of the complexity of AKI pathophysiology has allowed for greater opportunity to consider novel therapeutic agents. A number of drugs specifically targeting AKI are in various stages of development. This review will consider some novel and repurposed agents; interrogate the plausibility of the proposed mechanisms of action, as they relate to what we know about the pathophysiology of AKI; and review the level of existing literature supporting their efficacy. The evidence base, particularly in children, is limited.
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Affiliation(s)
- Caoimhe Costigan
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Steve Balgobin
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Rm 11.9722, Toronto, ON, M5G 0A4, Canada.
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26
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Shankar T, Kaeley N, Rajta M, Pundir A, Kaushik A. Management of Snakebite-Induced Thrombotic Microangiopathy (TMA) With Plasmapheresis. Cureus 2023; 15:e50104. [PMID: 38186452 PMCID: PMC10771023 DOI: 10.7759/cureus.50104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Snakebites affect a lot of people in India. Of these, the hemotoxic snakebites may induce a consumptive coagulopathy, which has been termed now as "Venom-Induced Consumptive Coagulopathy" (VICC). Some patients with VICC develop Thrombotic Microangiopathy (TMA). The primary end-organ damage in TMA is renal, for which hemodialysis is the mainstay of treatment. Recently there has been some focus on plasma exchange as an adjunctive treatment for TMA. Here we present a case of a young male who developed snakebite-induced TMA and who was successfully managed with plasma exchange.
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Affiliation(s)
- Takshak Shankar
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Nidhi Kaeley
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Mukund Rajta
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ashwani Pundir
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Aseem Kaushik
- Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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27
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Chen FF, Yu XJ, Wang H, Zhang X, Tan Y, Qu Z, Wang SX, Yu F, Chen M, Zhao MH. Clinical value of the renal pathologic scoring system in complement-mediated thrombotic microangiopathy. Ren Fail 2023; 45:2161396. [PMID: 36648027 PMCID: PMC9848373 DOI: 10.1080/0886022x.2022.2161396] [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] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES This study was initiated to establish a renal thrombotic microangiopathy (TMA) scoring system based on clinical needs and investigate its predictive value for patients' long-term outcomes. METHODS Kidney biopsy-proven Complement-mediated TMA (C-TMA) patients from January 2000 to December 2017 in Peking University First Hospital were retrospectively studied. Both acute and chronic TMA-related lesions, including 15 pathologic indices, were semiquantitatively scored. The interobserver and intraobserver reproducibility and correlation between the pathologic indices and clinical parameters were analyzed. Furthermore, the patients were divided into 2 groups by dialysis use at baseline, and the association of these pathologic indices with their prognostic outcomes was assessed between the two groups. RESULTS Ninety-two patients with renal biopsy-proven C-TMA were enrolled. All fifteen included pathology indices showed good or moderate interobserver and intraobserver reproducibility and correlated well with several clinical parameters. Several clinicopathological indices were worse in the dialysis group than in the nondialysis group, such as serum creatinine, hemoglobin, platelet count, and estimated glomerular filtration rate. Moreover, morphologic features in the dialysis group presented with more severe vascular lesions. Interstitial fibrosis and chronic tubulointerstitial lesions were related to a trend of high risk of continuous dialysis in the dialysis group. Based on univariate and multivariable Cox regression analysis, more severe glomerular lesions, including glomerular mesangiolysis, glomerular basement membrane double contours and glomerular mesangial proliferation, were identified as risk factors predicting worse prognosis. CONCLUSIONS Our renal C-TMA semiquantitative scoring system is reliable with good reproducibility and prognostic value in clinical practice, which needs further validation.
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Affiliation(s)
- Fei-Fei Chen
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Hui Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, PR China
| | - Xu Zhang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, PR China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Zhen Qu
- Department of Nephrology, Peking University International Hospital, Beijing, PR China,CO-CONTACT Zhen Qu Renal Division, Peking University International Hospital, Beijing, PR China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, PR China,CO-CONTACT Su-Xia Wang Department of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing100034, PR China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Department of Nephrology, Peking University International Hospital, Beijing, PR China,CONTACT Feng Yu Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Department of Nephrology, Peking University International Hospital, Beijing102206, PR China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Renal Pathology Center, Institute of Nephrology, Peking University First Hospital; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR China,Peking-Tsinghua Center for Life Sciences, PR China
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28
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Vasuri F, Lisi AP, Ciavarella C, Degiovanni A, Fabbrizio B, Valente S, Vischini G, La Manna G, D'Errico A, Pasquinelli G. Caveolin-1 in situ expression in glomerular and peritubular capillaries as a marker of ultrastructural progression and severity of renal thrombotic microangiopathy. J Nephrol 2023; 36:2327-2333. [PMID: 37480399 DOI: 10.1007/s40620-023-01645-5] [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: 11/12/2022] [Accepted: 04/06/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Thrombotic microangiopathy is a severe and potentially life-threatening condition inducing severe endothelial injury in many organs, particularly native and transplanted kidneys. Current pathological studies by our group have identified the use of Caveolin-1 immunohistochemistry as a potential marker of endothelial damage and progression degree of thrombotic microangiopathy. The aim of the present work was to evaluate Caveolin-1 as a marker of severity in thrombotic microangiopathy kidney disease, according to the ultrastructural progression of the disease evaluated by transmission electron microscopy. MATERIALS AND METHODS Twenty-nine patients (17 non-transplanted and 12 transplanted) were retrospectively selected, biopsied for suspected or histologically-confirmed thrombotic microangiopathy. Transmission electron microscopy was performed in all cases, and an ultrastructural score of thrombotic microangiopathy-related glomerular disease was assessed (from 0 to 3+). Immunohistochemistry for Caveolin-1 was automatically performed. RESULTS The mean percentage of Caveolin-1-positive glomerular capillaries was 53.2 ± 40.6% and 28.0 ± 42.8% in the active thrombotic microangiopathy versus previous thrombotic microangiopathy cases (p = 0.085), considering both native and transplanted kidneys. The presence of progressive disease correlated with diffuse Caveolin-1 immunoreactivity (p = 0.031), and ultrastructural score correlated with glomerular Caveolin-1 positivity, progressively increasing from 22.5% of the Score 0 group to 95.5% of the Score 3 group (p = 0.036). DISCUSSION Caveolin-1 proved to be a very useful marker of early endothelial damage in the course of thrombotic microangiopathy for both native and transplanted kidneys, therefore worth considering in routine practice. Diffuse glomerular Caveolin-1 immunoreactivity correlates with the severity of the thrombotic disease and it can appear very early, even before ultrastructurally evident endothelial damage.
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Affiliation(s)
- Francesco Vasuri
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.
| | - Anthony P Lisi
- Department of Pharmacology and Physiology, Drexel University College of Medicine, 245 N. 15th Street, Philadelphia, PA, 19102, USA
| | - Carmen Ciavarella
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Alessio Degiovanni
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Benedetta Fabbrizio
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Sabrina Valente
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Gisella Vischini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonia D'Errico
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Gianandrea Pasquinelli
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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29
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Brocklebank V, Walsh PR, Smith-Jackson K, Hallam TM, Marchbank KJ, Wilson V, Bigirumurame T, Dutt T, Montgomery EK, Malina M, Wong EKS, Johnson S, Sheerin NS, Kavanagh D. Atypical hemolytic uremic syndrome in the era of terminal complement inhibition: an observational cohort study. Blood 2023; 142:1371-1386. [PMID: 37369098 PMCID: PMC10651868 DOI: 10.1182/blood.2022018833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 05/11/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
Historically, the majority of patients with complement-mediated atypical hemolytic uremic syndrome (CaHUS) progress to end-stage kidney disease (ESKD). Single-arm trials of eculizumab with a short follow-up suggested efficacy. We prove, for the first time to our knowledge, in a genotype matched CaHUS cohort that the 5-year cumulative estimate of ESKD-free survival improved from 39.5% in a control cohort to 85.5% in the eculizumab-treated cohort (hazard ratio, 4.95; 95% confidence interval [CI], 2.75-8.90; P = .000; number needed to treat, 2.17 [95% CI, 1.81-2.73]). The outcome of eculizumab treatment is associated with the underlying genotype. Lower serum creatinine, lower platelet count, lower blood pressure, and younger age at presentation as well as shorter time between presentation and the first dose of eculizumab were associated with estimated glomerular filtration rate >60 ml/min at 6 months in multivariate analysis. The rate of meningococcal infection in the treated cohort was 550 times greater than the background rate in the general population. The relapse rate upon eculizumab withdrawal was 1 per 9.5 person years for patients with a pathogenic mutation and 1 per 10.8 person years for those with a variant of uncertain significance. No relapses were recorded in 67.3 person years off eculizumab in those with no rare genetic variants. Eculizumab was restarted in 6 individuals with functioning kidneys in whom it had been stopped, with no individual progressing to ESKD. We demonstrated that biallelic pathogenic mutations in RNA-processing genes, including EXOSC3, encoding an essential part of the RNA exosome, cause eculizumab nonresponsive aHUS. Recessive HSD11B2 mutations causing apparent mineralocorticoid excess may also present with thrombotic microangiopathy.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Patrick R. Walsh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kate Smith-Jackson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas M. Hallam
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kevin J. Marchbank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Theophile Bigirumurame
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tina Dutt
- Department of Haematology, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Emma K. Montgomery
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Edwin K. S. Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Neil S. Sheerin
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health and Care Research Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
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Freedman SB, van de Kar NCAJ, Tarr PI. Shiga Toxin-Producing Escherichia coli and the Hemolytic-Uremic Syndrome. N Engl J Med 2023; 389:1402-1414. [PMID: 37819955 DOI: 10.1056/nejmra2108739] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Affiliation(s)
- Stephen B Freedman
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
| | - Nicole C A J van de Kar
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
| | - Phillip I Tarr
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
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31
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Song ZR, Jiang L, Li Y, Xiang CG, Liu ZY, Li MS, Zhang H, Zhou XJ. Kidney-Predominant Thrombotic Microangiopathy Associated With TREX1 Frameshift Mutation. Kidney Int Rep 2023; 8:2172-2176. [PMID: 37850007 PMCID: PMC10577363 DOI: 10.1016/j.ekir.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Zhuo-ran Song
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Lei Jiang
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Yang Li
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Chen-gang Xiang
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Zhi-ying Liu
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Meng-shi Li
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
| | - Xu-jie Zhou
- Renal Division, Peking University First Hospital, Beijing, People’s Republic of China
- Kidney Genetics Center, Peking University Institute of Nephrology, Beijing, People’s Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People’s Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, People’s Republic of China
- State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing, People’s Republic of China
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32
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Li B, Zhang X, Lv H, Yang X, Gao Y, Hu Z, Ma C. Case report: A case of new mutation in SERPINC1 leading to thrombotic microangiopathy. Front Genet 2023; 14:1278511. [PMID: 37829283 PMCID: PMC10565210 DOI: 10.3389/fgene.2023.1278511] [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: 08/16/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction: Hereditary antithrombin-III deficiency can significantly increase the risk for thrombosis, which is common in limb deep vein and pulmonary cases. However, thrombotic microangiopathy (TMA) caused by hereditary antithrombin deficiency is rare. Case Presentation: We reported the case of a 32-year-old Chinese female patient with TMA with renal injury caused by decreased antithrombin-III activity due to a new mutation (chr1-173884049 c.50A>G) in SERPINC1, which encodes antithrombin-III. In this case, the patient had no history of relevant drug use, diabetes, or monoclonal plasma cells in the bone marrow puncture. Consequently, TMA of the kidney was considered secondary to hereditary antithrombin-III deficiency. Gene detection was the only clue that led us to suspect that TMA was caused by hereditary antithrombin deficiency. Conclusion: Our findings indicated that for patients with repeated findings of antithrombin-III activity less than 50%, the possibility of antithrombin-III deficiency and complete gene detection must be considered immediately after excluding the use of anticoagulants and lack of availability to facilitate early detection, diagnosis, and intervention.
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Affiliation(s)
- Bing Li
- Department of Nephrology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Qingdao, China
| | - Xiaohui Zhang
- Department of Nephrology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Qingdao, China
| | - Hailin Lv
- Department of Nephrology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Qingdao, China
| | - Xiaoqing Yang
- Department of Pathology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yanxia Gao
- Department of Nephrology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Qingdao, China
| | - Zhao Hu
- Department of Nephrology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, China
| | - Chengjun Ma
- Department of Nephrology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Qingdao, China
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Zhou Z, Zhang D, Wang Y, Liu C, Wang L, Yuan Y, Xu X, Jiang Y. Urinary exosomes: a promising biomarker of drug-induced nephrotoxicity. Front Med (Lausanne) 2023; 10:1251839. [PMID: 37809338 PMCID: PMC10556478 DOI: 10.3389/fmed.2023.1251839] [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: 07/02/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Drug-induced nephrotoxicity (DIN) is a big concern for clinical medication, but the clinical use of certain nephrotoxic drugs is still inevitable. Current testing methods make it hard to detect early renal injury accurately. In addition to understanding the pathogenesis and risk factors of drug-induced nephrotoxicity, it is crucial to identify specific renal injury biomarkers for early detection of DIN. Urine is an ideal sample source for biomarkers related to kidney disease, and urinary exosomes have great potential as biomarkers for predicting DIN, which has attracted the attention of many scholars. In the present paper, we will first introduce the mechanism of DIN and the biogenesis of urinary exosomes. Finally, we will discuss the changes in urinary exosomes in DIN and compare them with other predictive indicators to enrich and boost the development of biomarkers of DIN.
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Affiliation(s)
- Zunzhen Zhou
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Dailiang Zhang
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Yongjing Wang
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Chongzhi Liu
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Limei Wang
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Yi Yuan
- Orthopedic Department, Dazhou Integrated TCM and Western Medicine Hospital, Dazhou Second People’s Hospital, Dazhou, China
| | - Xiaodan Xu
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Yuan Jiang
- Clinical Medical College, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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Nava Gutiérrez W, Garza-Escobar JD, Sandoval-González AC, Alonso-Tellez CA. Treatment Challenges of Acquired Thrombotic Thrombocytopenic Purpura in Pediatric Patients From a Low-Income Country. Cureus 2023; 15:e45540. [PMID: 37868518 PMCID: PMC10586228 DOI: 10.7759/cureus.45540] [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] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
This study presents a comprehensive analysis of two cases of acquired thrombotic thrombocytopenic purpura (aTTP) observed in pediatric patients from a low-income country. In the instances described, both patients underwent a treatment regimen involving plasma exchange and immunosuppressive therapy conducted without the use of caplacizumab. Caplacizumab, an approved drug for adults known for its limited availability and high cost, has exhibited efficacy in reducing response time and recurrence frequency in aTTP cases. This approach resulted in significant clinical improvement and eventual remission of symptoms in one of the cases. These cases underscore the urgent necessity for a more inclusive approach in national health programs and international treatment guidelines. Specifically, there is a call to expand the existing comprehensive treatment algorithms to accommodate countries lacking access to caplacizumab. This adaptation aims to ensure the availability of suitable and effective treatment options for aTTP patients in regions facing limited pharmaceutical accessibility.
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Affiliation(s)
- Willy Nava Gutiérrez
- Hematology and Oncology, Universidad de Monterrey, Monterrey, MEX
- Hematology and Oncology, Instituto Mexicano Del Seguro Social, Monterrey, MEX
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Hallam TM, Sharp SJ, Andreadi A, Kavanagh D. Complement factor I: Regulatory nexus, driver of immunopathology, and therapeutic. Immunobiology 2023; 228:152410. [PMID: 37478687 DOI: 10.1016/j.imbio.2023.152410] [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: 04/14/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 07/23/2023]
Abstract
Complement factor I (FI) is the nexus for classical, lectin and alternative pathway complement regulation. FI is an 88 kDa plasma protein that circulates in an inactive configuration until it forms a trimolecular complex with its cofactor and substrate whereupon a structural reorganization allows the catalytic triad to cleave its substrates, C3b and C4b. In keeping with its role as the master complement regulatory enzyme, deficiency has been linked to immunopathology. In the setting of complete FI deficiency, a consumptive C3 deficiency results in recurrent infections with encapsulated microorganisms. Aseptic cerebral inflammation and vasculitic presentations are also less commonly observed. Heterozygous mutations in the factor I gene (CFI) have been demonstrated to be enriched in atypical haemolytic uraemic syndrome, albeit with a very low penetrance. Haploinsufficiency of CFI has also been associated with decreased retinal thickness and is a strong risk factor for the development of age-related macular degeneration. Supplementation of FI using plasma purified or recombinant protein has long been postulated, however, technical difficulties prevented progression into clinical trials. It is only using gene therapy that CFI supplementation has reached the clinic with GT005 in phase I/II clinical trials for geographic atrophy.
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Affiliation(s)
- T M Hallam
- Gyroscope Therapeutics Limited, A Novartis Company, Rolling Stock Yard, London N7 9AS, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK
| | - S J Sharp
- Gyroscope Therapeutics Limited, A Novartis Company, Rolling Stock Yard, London N7 9AS, UK
| | - A Andreadi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK
| | - D Kavanagh
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK; NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne NE4 5PL, UK.
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36
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Lupuşoru G, Andronesi AG, Lupuşoru M, Ailincăi I, Sfeatcu R, Văcăroiu I, Banu M, Achim C, Ismail G. Hantavirus infections in the South‑Eastern European countries: A study of two cases and literature review. Exp Ther Med 2023; 26:430. [PMID: 37602312 PMCID: PMC10433441 DOI: 10.3892/etm.2023.12129] [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: 01/25/2023] [Accepted: 06/09/2023] [Indexed: 08/22/2023] Open
Abstract
Hantavirus infection is a rare zoonosis in South-Eastern Europe. Depending on the serotype involved, the virus can cause hemorrhagic fever with renal syndrome which is also known as endemic nephropathy, and cardiopulmonary syndrome. Prompt diagnosis of the disease is essential for reducing the risk of severe manifestations and complications like chronic kidney disease, secondary hypertension or even death because there is no specific treatment or vaccine approved. The present study reported two cases of hemorrhagic fever with renal syndrome diagnosed in the Department of Nephrology of The Fundeni Clinical Institute (Romania). In both patients, kidney needle biopsy played a major role in establishing the diagnosis. The difficulties encountered in diagnosing this disease were also emphasized, taking into consideration the rarity of this infection in South-Eastern Europe. The key literature data on the epidemiology, pathogenesis and management of this infection were further reviewed.
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Affiliation(s)
- Gabriela Lupuşoru
- Department of Nephrology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Nephrology, The Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Andreea Gabriella Andronesi
- Department of Nephrology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Nephrology, The Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mircea Lupuşoru
- Department of Physiology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioana Ailincăi
- Department of Nephrology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Nephrology, The Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Ruxandra Sfeatcu
- Department of Oral Health and Community Dentistry, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ileana Văcăroiu
- Department of Nephrology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Nephrology, The St John Emergency Clinical Hospital, 042122 Bucharest, Romania
| | - Mihaela Banu
- Department of Anatomy, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Camelia Achim
- Department of Nephrology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Nephrology, The Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, The ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Nephrology, The Fundeni Clinical Institute, 022328 Bucharest, Romania
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Birlutiu V, Neamtu B, Birlutiu RM, Ghibu AM, Dobritoiu ES. Our Experience with SARS-CoV-2 Infection and Acute Kidney Injury: Results from a Single-Center Retrospective Observational Study. Healthcare (Basel) 2023; 11:2402. [PMID: 37685436 PMCID: PMC10487568 DOI: 10.3390/healthcare11172402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Renal failure in COVID-19 patients is reportedly related to multiple factors such as a direct SARS-CoV-2 cytopathic effect, cytokine storm, the association of pulmonary and/or cardiovascular lesions, the presence of thrombotic microangiopathy, endothelial damage, or the use of potentially nephrotoxic medications. METHODS We retrospectively analyzed 466 cases of SARS-CoV-2 infection, comparing 233 patients with acute kidney injury (AKI) with 233 patients without AKI in terms of their demographic characteristics, comorbidities, clinical background, laboratory investigations, time of AKI onset, therapy, and outcomes after using univariate analysis and a CART decision-tree approach. The latter was constructed in a reverse manner, starting from the top with the root and branching out until the splitting ceased, interconnecting all the predictors to predict the overall outcome (AKI vs. non-AKI). RESULTS There was a statistically significant difference between the clinical form distribution in the two groups, with fewer mild (2 vs. 5) and moderate (54 vs. 133) cases in the AKI group than in the non-AKI group and more severe and critical patients in the AKI cohort (116 vs. 92 and 60 vs. 3). There were four deaths (1.71%) in the non-AKI group and 120 deaths in the AKI group (51.5%) (p-value < 0.001). We noted statistically significant differences between the two study groups in relation to different tissue lesions (LDH), particularly at the pulmonary (CT severity score), hepatic (AST, ALT), and muscular levels (Creatine kinase). In addition, an exacerbated procoagulant and inflammatory profile in the study group was observed. The CART algorithm approach yielded decision paths that helped sort the risk of AKI progression into three categories: the low-risk category (0-40%), the medium-risk category (40-80%), and the high-risk category (>80%). It recognized specific inflammatory and renal biomarker profiles with particular cut-off points for procalcitonin, ferritin, LDH, creatinine, initial urea, and creatinine levels as important predictive factors of AKI outcomes (93.3% overall performance). CONCLUSIONS Our study revealed the association between particular risk factors and AKI progression in COVID-19 patients. Diabetes, dyspnea on admission, the need for supplemental oxygen, and admission to the intensive care unit all had a crucial role in producing unfavorable outcomes, with a death rate of more than 50%. Necessary imaging studies (CT scan severity score) and changes in specific biomarker levels (ferritin and C-reactive protein levels) were also noted. These factors should be further investigated in conjunction with the pathophysiological mechanisms of AKI progression in COVID-19 patients.
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Affiliation(s)
- Victoria Birlutiu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Romania, Str. Lucian Blaga, Nr. 2A, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, Bvd Corneliu Coposu, Nr. 2-4, 550245 Sibiu, Romania
| | - Bogdan Neamtu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Romania, Str. Lucian Blaga, Nr. 2A, 550169 Sibiu, Romania
- Pediatric Research Department, Pediatric Clinical Hospital Sibiu, Str. Pompeiu Onofreiu, Nr. 2-4, 550166 Sibiu, Romania
| | - Rares-Mircea Birlutiu
- Clinical Hospital of Orthopedics, Traumatology, and Osteoarticular TB Bucharest, B-dul Ferdinand 35–37, Sector 2, 021382 Bucharest, Romania
| | - Andreea Magdalena Ghibu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Romania, Str. Lucian Blaga, Nr. 2A, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, Bvd Corneliu Coposu, Nr. 2-4, 550245 Sibiu, Romania
| | - Elena Simona Dobritoiu
- Faculty of Medicine, Lucian Blaga University of Sibiu, Romania, Str. Lucian Blaga, Nr. 2A, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, Bvd Corneliu Coposu, Nr. 2-4, 550245 Sibiu, Romania
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38
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Dirim AB, Safak S, Balci MC, Ozyavuz P, Garayeva N, Tiryaki TO, Oto OA, Ozluk Y, Kilicaslan I, Solakoglu S, Artan AS, Yazici H, Turkmen A, Ozturk S. Concurrent Cobalamin C and Plasminogen Deficiencies in a Patient with Chronic Thrombotic Microangiopathy. Nephron Clin Pract 2023; 148:54-62. [PMID: 37611544 DOI: 10.1159/000533417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 07/07/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Although most patients with atypical hemolytic uremic syndrome (aHUS) have variants in genes participating in alternative complement pathways, rare variants in non-complement pathway-related genes, including DGKE, INF2, MMACHC, PLG, and THBD, have also been described. CASE PRESENTATION We report an 18-year-old male patient with renal biopsy-proven chronic thrombotic microangiopathy that raised suspicion of aHUS. Whole-exome sequencing revealed a novel pathogenic homozygous MMACHC c.484G>T (p.Gly162Trp) variant. Subsequently, clinical and laboratory findings confirmed cobalamin C (Cbl C) deficiency. Also, homozygous missense c.1112C>T PLG (p.Thr371Ile) variant was detected (it had been reported as a variant of unknown significance). However, the low serum plasminogen (PLG) activity proved the pathogenicity of c.1112C>T. Hence, the patient was diagnosed with concurrent Cbl C and PLG deficiencies. Segregation analysis revealed that the mother and father had the same heterozygous PLG and MMACHC variants. PLG variants have generally been described in aHUS patients concomitant with complement gene variants in the literature; therefore, the association between aHUS and PLG variants is controversial. The possible contribution of PLG deficiency to thrombotic microangiopathy was also discussed in this case. CONCLUSION Non-complement-mediated aHUS is an exceptional disorder. A limited number of genes are involved in this entity. To our knowledge, this is the first aHUS patient diagnosed with both Cbl C and PLG deficiencies in the literature.
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Affiliation(s)
- Ahmet Burak Dirim
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Department of Genetics, Istanbul University Aziz Sancar Institute of Experimental Medicine, Graduate School of Health Sciences, Istanbul University, Istanbul, Turkey
| | - Seda Safak
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Cihan Balci
- Division of Pediatric Metabolic Disorders, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Pelin Ozyavuz
- Department of Genetics, Haseki Teaching and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Nurane Garayeva
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tarik Onur Tiryaki
- Division of Hematology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Isin Kilicaslan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Seyhun Solakoglu
- Department of Histology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayse Serra Artan
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Savas Ozturk
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Afrouzian M, Kozakowski N, Liapis H, Broecker V, Truong L, Avila-Casado C, Regele H, Seshan S, Ambruzs JM, Farris AB, Buob D, Chander PN, Cheraghvandi L, Clahsen-van Groningen MC, de Almeida Araujo S, Ertoy Baydar D, Formby M, Galesic Ljubanovic D, Herrera Hernandez L, Honsova E, Mohamed N, Ozluk Y, Rabant M, Royal V, Stevenson HL, Toniolo MF, Taheri D. Thrombotic Microangiopathy in the Renal Allograft: Results of the TMA Banff Working Group Consensus on Pathologic Diagnostic Criteria. Transpl Int 2023; 36:11590. [PMID: 37680648 PMCID: PMC10481335 DOI: 10.3389/ti.2023.11590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023]
Abstract
The Banff community summoned the TMA Banff Working Group to develop minimum diagnostic criteria (MDC) and recommendations for renal transplant TMA (Tx-TMA) diagnosis, which currently lacks standardized criteria. Using the Delphi method for consensus generation, 23 nephropathologists (panelists) with >3 years of diagnostic experience with Tx-TMA were asked to list light, immunofluorescence, and electron microscopic, clinical and laboratory criteria and differential diagnoses for Tx-TMA. Delphi was modified to include 2 validations rounds with histological evaluation of whole slide images of 37 transplant biopsies (28 TMA and 9 non-TMA). Starting with 338 criteria in R1, MDC were narrowed down to 24 in R8 generating 18 pathological, 2 clinical, 4 laboratory criteria, and 8 differential diagnoses. The panelists reached a good level of agreement (70%) on 76% of the validated cases. For the first time in Banff classification, Delphi was used to reach consensus on MDC for Tx-TMA. Phase I of the study (pathology phase) will be used as a model for Phase II (nephrology phase) for consensus regarding clinical and laboratory criteria. Eventually in Phase III (consensus of the consensus groups) and the final MDC for Tx-TMA will be reported to the transplantation community.
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Affiliation(s)
- Marjan Afrouzian
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | | | - Helen Liapis
- Department of Pathology and Immunology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Nephrology, Ludwig Maximilian University, Munich, Germany
| | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Luon Truong
- Department of Pathology, The Houston Methodist Hospital, Houston, TX, United States
| | - Carmen Avila-Casado
- Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Surya Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States
| | | | - Alton Brad Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - David Buob
- Department of Pathology, Université de Sorbonne, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | | | - Lukman Cheraghvandi
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Marian C Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Aachen, Germany
| | - Stanley de Almeida Araujo
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Dilek Ertoy Baydar
- Department of Pathology, School of Medicine, Koç University, Sarıyer, Türkiye
| | - Mark Formby
- Department of Anatomical Pathology, NSW Health Pathology, Callaghan, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | | | | | - Eva Honsova
- AeskuLab Pathology and Department of Pathology, Charles University, Prague, Czechia
| | - Nasreen Mohamed
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Virginie Royal
- Department of Pathology, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QC, Canada
| | - Heather L Stevenson
- Department of Pathology, John Sealy School of Medicine, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Maria Fernanda Toniolo
- Kidney Pancreas Transplantation, Instituto de Nefrología-Nephrology, Buenos Aires, Argentina
| | - Diana Taheri
- Department of Pathology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Xu C, Wong V, Kurniawan A, Wilson S, Gopal B, Lawton PD. Eculizumab was safe and effective in the management of transplant-associated thrombotic microangiopathy in a heart transplant recipient with concurrent COVID-19 infection. Intern Med J 2023; 53:1506-1508. [PMID: 37599228 DOI: 10.1111/imj.16178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/27/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Chi Xu
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Renal Services, Western Health, Melbourne, Victoria, Australia
| | - Vincent Wong
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Renal Services, Western Health, Melbourne, Victoria, Australia
| | | | - Scott Wilson
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Basu Gopal
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Paul D Lawton
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
- Menzies School of Health Research, Darwin, Northwest Territories, Australia
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Aterini L, Gallo M, Vadalà B, Aterini S. Thrombotic Microangiopathy and Multiple Organ Failure in Scleroderma Renal Crisis: A Case Report. Cureus 2023; 15:e44322. [PMID: 37779794 PMCID: PMC10538352 DOI: 10.7759/cureus.44322] [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] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
This case report can be considered a rare occurrence of scleroderma renal crisis (SRC) presenting with a severe clinical course and multiple organ failure. A patient diagnosed with systemic sclerosis four years earlier was admitted to the hospital because of severe malignant systolic-diastolic arterial hypertension and acute kidney injury (AKI). Exacerbating disease suggested thrombotic microangiopathy (TMA) and the PLASMIC (Platelet count; combined hemoLysis variable; absence of Active cancer; absence of Stem-cell or solid-organ transplant; MCV; INR; Creatinine) score was used in the differential diagnosis. Despite the timely initiation of therapy with ACE inhibitors (ACE-I), the progressive renal failure required hemodialysis treatment, but renal function never recovered. Disease duration, skin involvement, and previous specific pharmacological therapy represented multiple risk factors that determined a clinical course complicated by pericardial tamponade with acute heart failure, acute pancreatitis, and ischemic stroke, with fatal evolution. These complications presented a challenging clinical sequence of events requiring an interdisciplinary course of action. Timely ascertainment of the SRC is important given the possible severe organ involvement as well as mortality. A diagnosis of scleroderma renal crisis should be considered in cases of acute kidney injury associated with known risk factors. Early treatment and collaboration between rheumatology and renal physicians can improve patient outcomes.
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Affiliation(s)
- Lorenzo Aterini
- Nephrology, AOU (Azienda Ospedaliera Universitaria) Meyer Children Hospital, School of Human Health Sciences at University of Firenze, Firenze, ITA
| | - Marco Gallo
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Firenze, ITA
| | - Barbara Vadalà
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Firenze, ITA
| | - Stefano Aterini
- Hemodialysis Centre, Istituto Fiorentino di Cura e Assistenza (IFCA), Firenze, ITA
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Gallant TL, Zheng E, Hobbs AM, Becka AJ, Bertsch RA. Complement-Mediated Thrombotic Microangiopathy in a Patient With Antiphospholipid Syndrome and Anti-glomerular Basement Membrane Antibodies. Cureus 2023; 15:e42410. [PMID: 37637585 PMCID: PMC10448002 DOI: 10.7759/cureus.42410] [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] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a range of diseases characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury. Complement-mediated TMA is a rare, life-threatening subtype of TMA that occurs due to the uncontrolled activation of the alternative complement pathway in the absence of normal regulation, often resulting from deficiencies of various regulatory proteins. Anti-glomerular basement membrane (anti-GBM) disease, previously known as Goodpasture syndrome, is a life-threatening form of vasculitis in which immunoglobulin G autoantibodies bind to the alpha-3 chain of type IV collagen in alveolar and glomerular basement membranes. We present the case of a patient with a history of antiphospholipid syndrome who was diagnosed with complement-mediated TMA during hospital admission for elevated anti-GBM antibody titers discovered during an outpatient evaluation for elevated creatinine levels. Upon admission, treatment was started for presumed anti-GBM disease, including high-dose intravenous methylprednisolone injections and multiple plasmapheresis sessions. However, renal biopsy results showed no evidence of anti-GBM disease, but rather evidence of TMA. Subsequent laboratory studies revealed decreased complement levels, suggestive of a diagnosis of complement-mediated TMA. The patient was started on rituximab and eculizumab infusions, and she was discharged in stable condition after a 15-day hospitalization with outpatient appointments scheduled for genetic testing and further infusions. This case illustrates the importance of recognizing the key clinical and diagnostic features of complement-mediated TMA to promptly initiate appropriate therapy.
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Affiliation(s)
- Tara L Gallant
- College of Medicine, California Northstate University College of Medicine, Elk Grove, USA
| | - Emily Zheng
- College of Medicine, California Northstate University College of Medicine, Elk Grove, USA
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Gaspert A, Büttner-Herold M, Amann K. [Basic nephropathology for pathologists-part 2 : Non-inflammatory lesions]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00292-023-01204-6. [PMID: 37368052 DOI: 10.1007/s00292-023-01204-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 06/28/2023]
Abstract
The evaluation of kidney biopsies for specific renal diseases or kidney transplant biopsies is mainly restricted to specialized centers. Lesions in nonneoplastic renal tissue in partial nephrectomies or nephrectomies due to renal tumors, especially noninflammatory, ischemic, vascular changes or diabetic nephropathy can be of greater prognostic significance than the tumor itself in patients with a localized tumor and good tumor-associated survival. In this part of basic nephropathology for pathologists, the most common noninflammatory lesions of the vascular, glomerular and tubulo-interstitial compartment are discussed.
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Affiliation(s)
- Ariana Gaspert
- Abteilung für Nephropathologie, Institut für Pathologie und Molekularpathologie, Universitätsspital Zürich, Schmelzbergstr. 12, 8091, Zürich, Schweiz.
| | - Maike Büttner-Herold
- Abteilung für Nephropathologie, Institut für Pathologie, Friedrich-Alexander Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Kerstin Amann
- Abteilung für Nephropathologie, Institut für Pathologie, Friedrich-Alexander Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, Erlangen, Deutschland
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44
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Mahmoudjafari Z, Alencar MC, Alexander MD, Johnson DJ, Yeh J, Evans MD. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy and the role of advanced practice providers and pharmacists. Bone Marrow Transplant 2023:10.1038/s41409-023-01951-3. [PMID: 37059738 DOI: 10.1038/s41409-023-01951-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a severe and potentially life-threatening complication. HSCT-TMA is often underdiagnosed due to multifactorial pathophysiology and a historic lack of standard diagnostic criteria. Identification of the multi-hit hypothesis and the key role of the complement system, particularly the lectin pathway of complement, has led to development of treatments targeting the underlying pathogenesis of HSCT-TMA. Additional research is ongoing to investigate the efficacy and safety of these targeted therapies in patients with HSCT-TMA. Advanced practice providers (APPs; nurse practitioners and physician assistants) and pharmacists are critical members of the multidisciplinary HSCT team and ensure management of patients throughout the continuum of care. Additionally, pharmacists and APPs can improve patient care through medication management of complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives to improve outcomes. Understanding the presentation, prognosis, pathophysiology, and treatment options for HSCT-TMA can improve each of these efforts. Collaborative practice model for monitoring and care of HSCT-TMA. Advanced practice providers and pharmacists contribute to many aspects of patient care in transplant centers, including medication management for complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives. HSCT-TMA is a severe and potentially life-threatening complication that is often underdiagnosed. The collaboration of a multidisciplinary team of advanced practice providers, pharmacists, and physicians can optimize recognition, diagnosis, management, and monitoring of patients with HSCT-TMA, thereby improving outcomes for these patients.
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Affiliation(s)
- Zahra Mahmoudjafari
- Department of Pharmacy, University of Kansas Cancer Center, Kansas City, KS, USA.
| | - Maritza C Alencar
- Oncology Service Line, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Darren J Johnson
- Pediatric Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jason Yeh
- Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | - Misty D Evans
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- Sarah Cannon Pediatric Hematology/Oncology & Cellular Therapy at TriStar Centennial, Nashville, TN, USA
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45
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Galvez C, Krall P, Rojas A, Oh J, Cano F. HUS with mutations in CFH and STEC infection treated with eculizumab in a 4-year-old girl. Pediatr Nephrol 2023; 38:1195-1203. [PMID: 35969277 DOI: 10.1007/s00467-022-05694-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome secondary to Shiga-toxin-producing Escherichia coli infection (STEC-HUS) generally shows a favorable outcome. Few cases develop extra-renal complications, since neurological involvement is an important cause of morbidity and mortality. The role of complement in STEC-HUS has been recently highlighted, and the use of eculizumab in severe cases has been communicated. HUS results from environmental and genetic factors, but the simultaneous occurrence of STEC and complement mutations remains undetermined. METHODS A pediatric case with severe STEC-HUS carrying CFH mutations, with favorable response to eculizumab is analyzed. RESULTS STEC-HUS was diagnosed in a 4-year-old girl with classic HUS, including low C3. Peritoneal dialysis was started due to hypertension, oligoanuria, and pleural effusion. She evolved with generalized tonic-clonic seizures and required mechanical ventilation. MRI reported multiple supra- and infratentorial ischemic lesions with laminar/striatal cortical necrosis and leukoencephalopathy. After two eculizumab doses, a significative stabilization in diuresis, blood pressure, creatinine, and C3 was achieved. At the third week, episodes of massive digestive bleeding and a life-threatening condition required a colectomy thus preserving the ileocecal valve. Due to atypical evolution, a genetic study was considered, identifying two heterozygous variants (CFH S1191L/V1197A). CONCLUSION STEC-HUS in patients with a genetic predisposition has been previously reported, but the low frequency of occurrence makes it a rare disease. As in the present case, patients with atypical course might benefit from genetic analysis to evaluate early eculizumab initiation and to better understand its phenotype. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Carla Galvez
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile
| | - Paola Krall
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile.,Institute of Medicine, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Alejandro Rojas
- Institute of Medicine, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Jun Oh
- Department of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Cano
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile.
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Glover EK, Smith-Jackson K, Brocklebank V, Wilson V, Walsh PR, Montgomery EK, Wong EKS, Johnson S, Malina M, Kavanagh D, Sheerin NS. Assessing the Impact of Prophylactic Eculizumab on Renal Graft Survival in Atypical Hemolytic Uremic Syndrome. Transplantation 2023; 107:994-1003. [PMID: 36413152 PMCID: PMC10065821 DOI: 10.1097/tp.0000000000004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/22/2022] [Accepted: 08/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare cause of end-stage kidney disease and associated with poor outcomes after kidney transplantation from early disease recurrence. Prophylactic eculizumab treatment at the time of transplantation is used in selected patients with aHUS. We report a retrospective case note review describing transplant outcomes in patients with aHUS transplanted between 1978 and 2017, including those patients treated with eculizumab. METHODS The National Renal Complement Therapeutics Centre database identified 118 kidney transplants in 86 recipients who had a confirmed diagnosis of aHUS. Thirty-eight kidney transplants were performed in 38 recipients who received prophylactic eculizumab. The cohort not treated with eculizumab comprised 80 transplants in 60 recipients and was refined to produce a comparable cohort of 33 transplants in 32 medium and high-risk recipients implanted since 2002. Complement pathway genetic screening was performed. Graft survival was censored for graft function at last follow-up or patient death. Graft survival without eculizumab treatment is described by complement defect status and by Kidney Disease: Improving Global Outcomes risk stratification. RESULTS Prophylactic eculizumab treatment improved renal allograft survival ( P = 0.006) in medium and high-risk recipients with 1-y survival of 97% versus 64% in untreated patients. Our data supports the risk stratification advised by Kidney Disease: Improving Global Outcomes. CONCLUSIONS Prophylactic eculizumab treatment dramatically improves graft survival making transplantation a viable therapeutic option in aHUS.
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Affiliation(s)
- Emily K Glover
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Kate Smith-Jackson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Patrick R Walsh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Emma K Montgomery
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Edwin K S Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
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Abstract
COVID (Coronavirus disease)-19 is a systemic disease and the kidney is one of the target organs of infection. Kidney injury is common and can occur in up to 40% of patients. Several glomerular diseases have been reported in association with COVID-19. Some are likely related to COVID-19 whereas many are likely coincidental. Glomerular diseases that are frequently reported in COVID-19 and have a plausible mechanistic explanation, are likely to be related to COVID-19. On the other hand, glomerular diseases that are seldom reported and have no known plausible mechanism, are likely to be unrelated. Collapsing glomerulopathy (CG) is by far the most prevalent. Its association with COVID-19, resembling human immunodeficiency virus (HIV) and CG, led to the newly proposed term “COVID-19 associated nephropathy” or “COVAN”. High-risk APOL1 genotypes are the major risk factor in COVAN patients. Podocytopathy, membranous nephropathy, pauci-immune crescentic glomerulonephritis, and thrombotic microangiopathy are also reported. In kidney allografts, CG remains the most common glomerular pathology. Patients typically present with acute kidney injury (AKI) or abnormal urinary findings at the time of or shortly after COVID-19 diagnosis. Treatment of glomerular disease in COVID-19 patients is challenging. Providers should cautiously consider balancing risks and benefit of immunosuppression, particularly in patients with active diseases. Short-term outcomes vary but generally remain poor with high morbidity and mortality. Future study of long-term outcomes is needed to improve our understanding of glomerular disease associated with COVID-19.
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Moore M, Afolayan-Oloye O, Kroneman O, Li W, Kanaan HD, Zhang PL. Proteinuria in thrombotic microangiopathy is associated with partial podocytopathy. Ultrastruct Pathol 2023; 47:219-226. [PMID: 36906888 DOI: 10.1080/01913123.2023.2189341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) results in acute kidney injury, but the cause of heavy proteinuria in this disorder is puzzling. The goal of this study was to determine if there were significant effacement of foot processes and CD133-positive hyperplastic podocytes in TMA to explain the proteinuria. METHODS The study included 12 negative controls (renal parenchyma removed from renal cell carcinoma) and 28 thrombotic microangiopathy due to different etiologies. The percent of foot process effacement was estimated, and proteinuria level was obtained for each TMA case. Both groups of cases were stained for CD133 by immunohistochemical method, and the number of positive CD133 in hyperplastic podocytes was counted and analyzed. RESULTS Nineteen (19) of 28 (68%) TMA cases had nephrotic range proteinuria (urine protein/creatinine >3). Twenty-one (21) of 28 (75%) TMA cases showed positive CD133 staining in scattered hyperplastic podocytes within Bowman's space but was absent in control cases. The percent of foot process effacement (56 ± 4%) correlated with proteinuria (protein/creatinine ratio 4.4 ± 0.6) (r = 0.46, p = .0237) in TMA group. CONCLUSION Our data indicate that the proteinuria in TMA can be associated with significant effacement of foot processes. CD133-positive hyperplastic podocytes can be seen in the majority of TMA cases of this cohort, indicating a partial podocytopathy.
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Affiliation(s)
- Megan Moore
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | | | - Olaf Kroneman
- Division of Nephrology, Beaumont Health, Royal Oak, MI, USA
| | - Wei Li
- Department of Pathology, Beaumont Labs, Royal Oak, MI, USA
| | | | - Ping L Zhang
- Department of Pathology, Beaumont Labs, Royal Oak, MI, USA
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49
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Ravindran A, Pereira Palma LM, Fervenza FC, Sethi S. Overlap of C3 Glomerulopathy and Thrombotic Microangiopathy: A Case Series. Kidney Int Rep 2023; 8:619-627. [PMID: 36938079 PMCID: PMC10014380 DOI: 10.1016/j.ekir.2022.12.009] [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: 08/23/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Dysregulation of alternative complement pathway underlies the pathogenesis of both C3 glomerulopathy (C3G) and thrombotic microangiopathy (TMA). In this study, we describe both disease entities occurring in 5 patients. Methods We identified 114 patients at our institution from 2007 to 2016 with C3G in native kidney biopsies and those with concurrent TMA were included. Results The median age at diagnosis was 58 years (range: 28-69); all were male. Median serum creatinine and proteinuria at presentation were 2.3 mg/dl and 2089 mg/d, respectively. Three cases presented with TMA-predominant phenotype and 2 with C3G-predominant phenotype. Immunofluorescence (IF) showed bright C3 staining in mesangium and/or capillary walls. Electron microscopy showed marked subendothelial expansion by fluffy material in the capillary loops without associated deposits. However, capillary wall deposits were present in other loops in 4 cases. Mesangial deposits were present in all cases. Four cases showed low C3, of which 2 showed low C4. Complement evaluation in 3 cases showed pathogenic CFH mutation in 1 case, and multiple variant of unknown significance along with factor B autoantibody and C4 nephritic factor in 1 case. One patient negative for complement abnormalities had a monoclonal gammopathy. Three cases were treated with steroids and/or immunosuppressants. One case progressed to end-stage renal disease (ESRD) at 38.3 months; the remaining showed median serum creatinine and proteinuria of 2.5 mg/dl and 1169 mg/d, respectively at median follow-up of 17.5 months. Conclusion Overlap of C3G and TMA is rare and can clinically present as C3G-predominant or TMA-predominant phenotype. The significance of concurrent C3G/TMA findings on long-term renal survival remains to be explored.
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Affiliation(s)
- Aishwarya Ravindran
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Sanjeev Sethi, Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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[Electron microscopy in nephropathology]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:84-94. [PMID: 36480038 DOI: 10.1007/s00292-022-01164-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/13/2022]
Abstract
Non-neoplastic kidney diseases represent a broad spectrum of diseases. Although their pathogenesis differs, the histological findings may be similar in terms of conventional morphology. A precise classification of these diseases is a prerequisite for correct therapy and prognostic assessment. In the diagnostic process, the magnification achieved by electron microscopy is essential and cannot be replaced by any other technique. The most frequent diagnostic questions addressed by ultrastructural studies represent (1) alterations of podocytes (e.g., minimal-change disease), (2) changes of the thickness and structure of the glomerular basement membrane (e.g., diabetic glomerulosclerosis or Alport disease), (3) the presence, characteristics and exact localisation of immune complexes (e.g., membranous glomerulonephritis or lupus nephritis), (4) alterations of endothelial cells and capillaries (e.g., thrombotic microangiopathy) and (5) diseases of the tubular cells (e.g., light-chain nephropathy or toxic effects). Therefore, ultrastructural investigations are-together with conventional microscopy and immunohistochemistry (or immunofluorescence)-an integral part of the so-called triple-diagnostics in routine nephropathology.
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