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Sethi SK, S S, Nair A, Soni K, Bihari Bansal S, Rana AS, Raina R. What came first, atypical hemolytic uremic syndrome or malignant hypertension: a clinical dilemma. Ren Fail 2024; 46:2327484. [PMID: 38466192 DOI: 10.1080/0886022x.2024.2327484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Affiliation(s)
- Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Savita S
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Aishwarya Nair
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Kritika Soni
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | | | - Abhyuday S Rana
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Akron, Ohio, USA
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2
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Thangaraju S, Khandelwal P, Mishra K, Kumar M, Puraswani M, Saini R, Hari P, Coshic P, Sinha A, Bagga A. Abbreviated protocol of plasma exchanges for patients with anti-factor H associated hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:2091-2097. [PMID: 38270601 DOI: 10.1007/s00467-024-06279-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Plasma exchanges (PEX) and immunosuppression are the cornerstone of management of anti-factor H (FH) antibody-associated atypical hemolytic uremic syndrome (aHUS), particularly if access to eculizumab is limited. The duration of therapy with PEX for anti-FH aHUS is empirical. METHODS We compared the efficacy of abbreviated PEX protocol (10-12 sessions) in a prospective cohort of patients diagnosed with anti-FH aHUS (2020-2022), to standard PEX protocol (20-22 sessions) in a historical cohort (2016-2019; n = 65). Efficacy was defined as 70% decline in anti-FH titers or fall to ≤ 1300 AU/ml at 4 weeks. Patients in both cohorts received similar immunosuppression with oral prednisolone, IV cyclophosphamide (5 doses) and mycophenolate mofetil. Outcomes included efficacy, rates of hematological remission and adverse kidney outcomes at 1, 3 and 6 months. RESULTS Of 23 patients, 8.2 ± 2.1 years old enrolled prospectively, two were excluded for significant protocol deviation. PEX was abbreviated in 18/21 (86%) patients to 11.5 ± 3.3 sessions. Abbreviation failed for lack of hematological remission by day 14 (n = 2) and persistent neurological manifestations (n = 1). All patients in whom PEX was abbreviated achieved > 70% reduction in anti-FH titers at day 28. The percentage fall in anti-FH titers was similar for the abbreviated vs. standard PEX protocols at 1, 3 and 6 months. At last follow-up, at median 50 months and 25 months for standard and abbreviated cohorts, the estimated GFR was similar at 104.8 ± 29.1 vs. 93.7 ± 53.4, respectively (P = 0.42). CONCLUSION Abbreviation of the duration of PEX is feasible and efficacious in reducing anti-FH titers. Short-term outcomes were comparable in patients managed by abbreviated and standard PEX protocols.
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Affiliation(s)
- Sharan Thangaraju
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Rahul Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Poonam Coshic
- Department of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Savige J. Tips for Testing Adults With Suspected Genetic Kidney Disease. Am J Kidney Dis 2024; 83:816-824. [PMID: 38147894 DOI: 10.1053/j.ajkd.2023.10.011] [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: 04/10/2023] [Revised: 10/08/2023] [Accepted: 10/14/2023] [Indexed: 12/28/2023]
Abstract
Genetic kidney disease is common but often unrecognized. It accounts for most cystic kidney diseases and tubulopathies, many forms of congenital abnormalities of the kidney and urinary tract (CAKUT), and some glomerulopathies. Genetic kidney disease is typically suspected where the disease usually has a genetic basis or there is another affected family member, a young age at onset, or extrarenal involvement, but there are also many exceptions to these "rules". Genetic testing requires the patient's written informed consent. When a patient declines testing, another later conversation may be worthwhile. Genetic testing not only indicates the diagnosis but also the inheritance pattern, likely at-risk family members, disease in other organs, clinical course, and possibly effective treatments. Sometimes genetic testing does not identify a pathogenic variant even where other evidence is strong. A variant of uncertain significance (VUS) may be reported but should not be used for clinical decision making. It may be reclassified after more information becomes available without necessarily retesting the patient. Patients should be provided with a copy of their genetic test report, the results explained, and at-risk family members offered "cascade" testing. A referral to a clinical geneticist or genetic counselor helps identify affected family members and in providing advice to assist with reproductive decisions.
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Affiliation(s)
- Judy Savige
- University of Melbourne Department of Medicine (Melbourne Health and Northern health), Royal Melbourne Hospital, Parkville, Australia.
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4
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Maruyama S, Ikeda Y, Kaname S, Kato N, Matsumoto M, Ishikawa Y, Shimono A, Miyakawa Y, Nangaku M, Shibagaki Y, Okada H. Eculizumab for adult patients with atypical haemolytic-uraemic syndrome: full dataset analysis of Japanese post-marketing surveillance. J Nephrol 2024:10.1007/s40620-024-01921-y. [PMID: 38809358 DOI: 10.1007/s40620-024-01921-y] [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: 08/27/2023] [Accepted: 02/10/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Eculizumab has been approved for atypical haemolytic-uraemic syndrome (aHUS) in Japan since 2013. Post-marketing surveillance enrolled patients with aHUS who received ≥ 1 dose of eculizumab to assess eculizumab safety and effectiveness. METHODS We evaluated serious adverse events and effectiveness endpoints, i.e., haematologic normalization, a decrease of ≥ 25% in serum creatinine (sCr) levels, and complete thrombotic microangiopathy (TMA) response in adult patients with aHUS without other underlying diseases. In addition, the difference of baseline characteristics between patients who did and did not meet effectiveness endpoints was examined. RESULTS In this safety and effectiveness analysis, 79 adult patients were included; median age was 54.0 years, median treatment duration was 30 weeks. Total exposure time of eculizumab was 75.51 patient-years, and 94 serious adverse events were reported in 39 patients. No unexpected safety signals were identified in this population. Mean platelet count, lactate dehydrogenase and estimated glomerular filtration rate significantly improved after 7 days of treatment. Complete TMA response, haematologic normalization and the improvement of sCr levels were met by 35.3%, 40.4% and 51.3% of patients, respectively. Median treatment duration was shorter in patients who did not achieve complete TMA response (6 weeks) than in patients who did (114 weeks). Multivariate analysis suggested that the time from the most recent TMA episode to start of eculizumab treatment was negatively associated with kidney function improvement. CONCLUSIONS No unexpected safety signals of eculizumab were identified in Japanese patients with aHUS in a real-world setting. Renal outcomes were negatively associated with the time from the most recent TMA episode to the initiation of eculizumab treatment.
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Affiliation(s)
- Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-City, Tokyo, 181-8611, Japan
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, 840 Shijyo-cho, Kashihara City, Nara, 634-8522, Japan
| | - Yumiko Ishikawa
- Alexion Pharma GK, 3-1-1 Shibaura, Minato-Ku, Tokyo, 108-0023, Japan
| | - Akihiko Shimono
- Alexion Pharma GK, 3-1-1 Shibaura, Minato-Ku, Tokyo, 108-0023, Japan
| | - Yoshitaka Miyakawa
- Department of Haematology, Saitama Medical University, 38 Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, 38 Moroyama, Iruma-Gun, Saitama, 350-0495, Japan
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5
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Tschongov T, Konwar S, Busch A, Sievert C, Hartmann A, Noris M, Gastoldi S, Aiello S, Schaaf A, Panse J, Zipfel PF, Dabrowska-Schlepp P, Häffner K. Moss-produced human complement factor H with modified glycans has an extended half-life and improved biological activity. Front Immunol 2024; 15:1383123. [PMID: 38799460 PMCID: PMC11117068 DOI: 10.3389/fimmu.2024.1383123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Most drugs that target the complement system are designed to inhibit the complement pathway at either the proximal or terminal levels. The use of a natural complement regulator such as factor H (FH) could provide a superior treatment option by restoring the balance of an overactive complement system while preserving its normal physiological functions. Until now, the systemic treatment of complement-associated disorders with FH has been deemed unfeasible, primarily due to high production costs, risks related to FH purified from donors' blood, and the challenging expression of recombinant FH in different host systems. We recently demonstrated that a moss-based expression system can produce high yields of properly folded, fully functional, recombinant FH. However, the half-life of the initial variant (CPV-101) was relatively short. Here we show that the same polypeptide with modified glycosylation (CPV-104) achieves a pharmacokinetic profile comparable to that of native FH derived from human serum. The treatment of FH-deficient mice with CPV-104 significantly improved important efficacy parameters such as the normalization of serum C3 levels and the rapid degradation of C3 deposits in the kidney compared to treatment with CPV-101. Furthermore, CPV-104 showed comparable functionality to serum-derived FH in vitro, as well as similar performance in ex vivo assays involving samples from patients with atypical hemolytic uremic syndrome, C3 glomerulopathy and paroxysomal nocturnal hematuria. CPV-104 - the human FH analog expressed in moss - will therefore allow the treatment of complement-associated human diseases by rebalancing instead of inhibiting the complement cascade.
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Affiliation(s)
- Todor Tschongov
- Department of Internal Medicine IV (Nephrology), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Swagata Konwar
- Department of Internal Medicine IV (Nephrology), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | - Andrea Hartmann
- Department of Infection Biology, Leibniz Insitute for Natural Product Research and Infection Biology, Jena, Germany
| | - Marina Noris
- Centro di Ricerche Cliniche per le Malattie Rare “Aldo e Cele Dacco”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Sara Gastoldi
- Centro di Ricerche Cliniche per le Malattie Rare “Aldo e Cele Dacco”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Sistiana Aiello
- Centro di Ricerche Cliniche per le Malattie Rare “Aldo e Cele Dacco”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD) Germany Pauwelsstrasse 30, Aachen, Germany
| | - Peter F. Zipfel
- Department of Infection Biology, Leibniz Insitute for Natural Product Research and Infection Biology, Jena, Germany
- Institute of Microbiology, Friedrich-Schiller-University, Jena, Germany
| | | | - Karsten Häffner
- Department of Internal Medicine IV (Nephrology), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Celegen K, Gulhan B, Fidan K, Yuksel S, Yilmaz N, Yılmaz AC, Demircioğlu Kılıç B, Gokce I, Kavaz Tufan A, Kalyoncu M, Nalcacıoglu H, Ozlu SG, Kurt Sukur ED, Canpolat N, K Bayazit A, Çomak E, Tabel Y, Tulpar S, Celakil M, Bek K, Zeybek C, Duzova A, Ozcakar B, Topaloglu R, Soylemezoglu O, Ozaltin F. Adolescence-onset atypical hemolytic uremic syndrome: is it different from infant-onset? Clin Exp Nephrol 2024:10.1007/s10157-024-02505-7. [PMID: 38704765 DOI: 10.1007/s10157-024-02505-7] [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: 10/11/2023] [Accepted: 04/08/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare, mostly complement-mediated thrombotic microangiopathy. The majority of patients are infants. In contrast to infantile-onset aHUS, the clinical and genetic characteristics of adolescence-onset aHUS have not been sufficiently addressed to date. METHODS A total of 28 patients (21 girls, 7 boys) who were diagnosed as aHUS between the ages of ≥10 years and <18 years were included in this study. All available data in the Turkish Pediatric aHUS registry were collected and analyzed. RESULTS The mean age at diagnosis was 12.8±2.3 years. Extra-renal involvement was noted in 13 patients (46.4%); neurological involvement was the most common (32%). A total of 21 patients (75%) required kidney replacement therapy. Five patients (17.8%) received only plasma therapy and 23 (82%) of the patients received eculizumab. Hematologic remission and renal remission were achieved in 25 (89.3%) and 17 (60.7%) of the patients, respectively. Compared with the infantile-onset aHUS patients, adolescent patients had a lower complete remission rate during the first episode (p = 0.002). Genetic analyses were performed in all and a genetic variant was detected in 39.3% of the patients. The mean follow-up duration was 4.9±2.6 years. At the last visit, adolescent patients had lower eGFR levels (p = 0.03) and higher rates of chronic kidney disease stage 5 when compared to infantile-onset aHUS patients (p = 0.04). CONCLUSIONS Adolescence-onset aHUS is a rare disease but tends to cause more permanent renal dysfunction than infantile-onset aHUS. These results may modify the management approaches in these patients.
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Affiliation(s)
- Kubra Celegen
- Department of Pediatric Nephrology, Kayseri Education and Research Hospital, Kayseri, Türkiye
| | - Bora Gulhan
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey.
| | - Kibriya Fidan
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Türkiye
| | - Selcuk Yuksel
- Department of Pediatric Nephrology, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Türkiye
| | - Neslihan Yilmaz
- Department of Pediatric Nephrology, Necip Fazil City Hospital, Kahramanmaras, Türkiye
| | - Aysun Caltik Yılmaz
- Department of Pediatric Nephrology, Faculty of Medicine, Baskent University, Ankara, Türkiye
| | | | - Ibrahim Gokce
- Department of Pediatric Nephrology, Faculty of Medicine, Marmara University, Istanbul, Türkiye
| | - Aslı Kavaz Tufan
- Department of Pediatric Nephrology, Faculty of Medicine, Osmangazi University, Eskisehir, Türkiye
| | - Mukaddes Kalyoncu
- Department of Pediatric Nephrology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Türkiye
| | - Hulya Nalcacıoglu
- Department of Pediatric Nephrology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Türkiye
| | - Sare Gulfem Ozlu
- Department of Pediatric Nephrology, Ankara City Training and Research Hospital, Ankara, Türkiye
| | - Eda Didem Kurt Sukur
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, İstanbul, Türkiye
| | - Aysun K Bayazit
- Department of Pediatric Nephrology, Faculty of Medicine, Cukurova University, Adana, Türkiye
| | - Elif Çomak
- Department of Pediatric Nephrology, Faculty of Medicine, Akdeniz University, Antalya, Türkiye
| | - Yılmaz Tabel
- Department of Pediatric Nephrology, Faculty of Medicine, Inonu University, Malatya, Türkiye
| | - Sebahat Tulpar
- Department of Pediatric Nephrology, Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
| | - Mehtap Celakil
- Department of Pediatric Nephrology, Sakarya University Training and Research Hospital, Sakarya, Türkiye
| | - Kenan Bek
- Department of Pediatric Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Türkiye
| | - Cengiz Zeybek
- Department of Pediatric Nephrology, Gulhane Training and Research Hospital, Ankara, Türkiye
| | - Ali Duzova
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey
| | - Birsin Ozcakar
- Department of Pediatric Nephrology, Faculty of Medicine, Ankara University, Ankara, Türkiye
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey
| | - Oguz Soylemezoglu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Türkiye
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey
- Nephrogenetics Laboratory, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
- Center for Genomics and Rare Diseases, Hacettepe University, Ankara, Türkiye
- Department of Bioinformatics, Hacettepe University Institute of Health Sciences, Ankara, Türkiye
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7
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Okawa A, Yoshihara M, Osafune A, Umezu T, Kajiyama H. Plasma Exchange in Postpartum Hemorrhage (PPH)-Associated Thrombotic Microangiopathy (TMA): A Case Report. Cureus 2024; 16:e59623. [PMID: 38832165 PMCID: PMC11146476 DOI: 10.7759/cureus.59623] [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: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare yet potentially life-threatening condition. The diagnosis is difficult as there are other conditions presenting with features akin to TMA during the peripartum period such as eclampsia, preeclampsia, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, and antiphospholipid syndrome. A 28-year-old woman with no significant past medical history developed TMA following a massive hemorrhage after an emergency cesarean section at 41 weeks of gestation. This case was finally diagnosed as postpartum hemorrhage (PPH)-associated TMA. The patient fully recovered after plasma exchange therapy. We posit the value of accumulating case reports, given that the documentation on the efficacy of plasma exchange in PPH-associated TMA is limited.
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Affiliation(s)
- Asuka Okawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, JPN
- Department of Obstetrics and Gynecology, Kariya Toyota General Hospital, Kariya, JPN
| | - Masato Yoshihara
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, JPN
| | - Ayako Osafune
- Department of Obstetrics and Gynecology, Kariya Toyota General Hospital, Kariya, JPN
| | - Tomokazu Umezu
- Department of Obstetrics and Gynecology, Kariya Toyota General Hospital, Kariya, JPN
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, JPN
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8
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [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: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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9
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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10
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Bleathman F, Kausman JY, Hosking LM, Forbes TA. Ravulizumab facilitates reduced burden of vascular access, a major benefit in paediatric atypical haemolytic uraemic syndrome. J Paediatr Child Health 2024. [PMID: 38661088 DOI: 10.1111/jpc.16552] [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] [Received: 01/31/2024] [Revised: 03/04/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Atypical haemolytic uraemic syndrome (aHUS) is a rare thrombotic microangiopathy resulting from dysregulation of the alternative complement pathway, leading to multi-organ dysfunction and chronic kidney disease. Eculizumab is an anti-C5 monoclonal antibody therapy that has significantly improved aHUS disease control and patient outcomes, however it requires fortnightly intravenous dosing. This often necessitates long term central access and a high hospital attendance burden. Ravulizumab is a novel, next-generation anti-C5 monoclonal antibody engineered from eculizumab to reduce endosomal degradation of the antibody, increasing the dosing interval up to 8 weeks. CASE SERIES In this retrospective case series we present the transition of three children with aHUS from eculizumab to ravulizumab from a single tertiary paediatric nephrology service. All patients underwent genomic and immunological work up for aHUS, with no cause found. After stabilisation with eculizumab, two patients developed macrovascular thrombotic complications associated with indwelling central vascular catheters, ultimately leading to central access failure. All patients were transitioned from eculizumab to ravulizumab without relapse of aHUS. One patient successfully underwent deceased donor kidney transplantation with ravulizumab for complement inhibition. All patients have transitioned to peripheral access for infusions given the reduced frequency of dosing, maintaining good control of aHUS for 2-4 years. CONCLUSION Ravulizumab permits sufficiently reduced frequency of infusion to allow for administration by peripheral cannulation - removing the risks of long term central vascular access often required to deliver eculizumab to paediatric patients.
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Affiliation(s)
- Freya Bleathman
- Department of Nephrology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Joshua Y Kausman
- Department of Nephrology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Kidney Flagship, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Laine M Hosking
- Immunology Laboratory, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Thomas A Forbes
- Department of Nephrology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Kidney Flagship, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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11
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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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12
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Tan YC, Teo ECY, Ng HJ. A Rare Case of Atypical Hemolytic Uremic Syndrome (aHUS) Precipitated by Dengue and the Treatment Landscape in Singapore. Cureus 2024; 16:e58731. [PMID: 38779250 PMCID: PMC11110694 DOI: 10.7759/cureus.58731] [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: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease caused by uncontrolled complement activation due to complement dysregulation. It is often triggered by precipitating events such as infections, inflammation, pregnancy, or medications. Dengue, an endemic viral infection in Southeast Asia, can activate the complement pathway, thereby triggering aHUS in genetically susceptible individuals. Here, we present the case of a 33-year-old male who presented with Dengue fever and subsequently developed aHUS. Plasma exchange (PLEX) successfully normalized his neurological status and hematological parameters. Although his renal function improved, it failed to normalize. Eculizumab, a monoclonal antibody that inhibits C5, was administered for a total of six months. The treatment was successfully discontinued without evidence of relapse after six months of follow-up. This case report demonstrates the safety of discontinuing eculizumab in patients who do not possess pathogenic mutations or variants in complement factors.
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Affiliation(s)
- Yan Chin Tan
- Haematology, Sengkang General Hospital, Sengkang, SGP
| | | | - Heng Joo Ng
- Haematology, Singapore General Hospital, Bukit Merah, SGP
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13
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Jefferis J, Mallett AJ. Exploring the impact and utility of genomic sequencing in established CKD. Clin Kidney J 2024; 17:sfae043. [PMID: 38464959 PMCID: PMC10921391 DOI: 10.1093/ckj/sfae043] [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: 10/09/2023] [Indexed: 03/12/2024] Open
Abstract
Clinical genetics is increasingly recognized as an important area within nephrology care. Clinicians require awareness of genetic kidney disease to recognize clinical phenotypes, consider use of genomics to aid diagnosis, and inform treatment decisions. Understanding the broad spectrum of clinical phenotypes and principles of genomic sequencing is becoming increasingly required in clinical nephrology, with nephrologists requiring education and support to achieve meaningful patient outcomes. Establishment of effective clinical resources, multi-disciplinary teams and education is important to increase application of genomics in clinical care, for the benefit of patients and their families. Novel applications of genomics in chronic kidney disease include pharmacogenomics and clinical translation of polygenic risk scores. This review explores established and emerging impacts and utility of genomics in kidney disease.
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Affiliation(s)
- Julia Jefferis
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew J Mallett
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
- Department of Renal Medicine, Townsville University Hospital, Douglas, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, Australia
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14
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Crawford B, Strebeck P, Saccente S. Constipation and hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:603-607. [PMID: 37474629 DOI: 10.1007/s00467-023-06093-8] [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: 05/09/2023] [Revised: 06/20/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Shiga toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) classically presents with diarrhea. Absence of diarrheal prodrome increases suspicion for atypical HUS (aHUS). Inability to obtain a fecal specimen for culture or culture-independent testing limits the ability to differentiate STEC-HUS and aHUS. CASE-DIAGNOSIS/TREATMENT Our patient presented with abdominal pain and constipation, and evaluation of pallor led to a diagnosis of HUS. There was a complete absence of diarrhea during the disease course. Lack of fecal specimen for several days delayed testing for STEC. Treatment for atypical HUS was initiated with complement-blockade therapy. PCR-testing for Shiga toxin from fecal specimen later returned positive. Alternative complement-pathway testing did not identify a causative genetic variant or anti-Factor H antibody. A diagnosis of STEC-HUS was assigned, and complement-blockade therapy was stopped. CONCLUSION Diagnosis of aHUS remains a diagnosis of exclusion, whereby other causes of HUS are eliminated with reasonable certainty. Exclusion of STEC is necessary and relies on testing availability and recognition of testing limitations. Diarrhea-negative STEC-HUS remains a minority of cases, and future research is needed to explore the clinical characteristics of these patients.
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Affiliation(s)
- Brendan Crawford
- Division of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Paige Strebeck
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Suzanne Saccente
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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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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16
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Miyazaki Y, Fukuda M, Hirayu N, Nabeta M, Takasu O. Pregnancy-Associated Atypical Hemolytic Uremic Syndrome Successfully Treated with Ravulizumab: A Case Report. Cureus 2024; 16:e54207. [PMID: 38496102 PMCID: PMC10942846 DOI: 10.7759/cureus.54207] [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: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Pregnancy-associated atypical hemolytic-uremic syndrome (p-aHUS) refers to a pregnancy that leads to thrombotic microangiopathy (TMA). This disease is associated with adverse maternal outcomes. We encountered a case of p-aHUS, in which treatment with ravulizumab, a long-acting C5 inhibitor, resulted in a favorable clinical course and recovery of renal function. The patient was a 31-year-old woman with no apparent medical history. She developed TMA on the third postpartum day and was initially treated with steroids, plasma exchange, and hemodialysis (HD). On the seventh day of treatment initiation, she was diagnosed with p-aHUS, and treatment with ravulizumab was started. Following administration, her platelet count increased, and her acute kidney injury improved. Consequently, HD was discontinued after six sessions, and the patient was discharged on the 28th day of treatment initiation and continued her recovery at home. Similar to eculizumab, ravulizumab is an effective treatment for p-aHUS. Early administration of ravulizumab after diagnosis of p-aHUS may contribute to favorable clinical outcomes and recovery of renal function, as observed in the present case.
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Affiliation(s)
- Yoshihiro Miyazaki
- Advanced Emergency and Critical Care Center, Kurume University Hospital, Kurume, JPN
| | - Masafumi Fukuda
- Advanced Emergency and Critical Care Center, Kurume University Hospital, Kurume, JPN
| | - Nobuhisa Hirayu
- Advanced Emergency and Critical Care Center, Kurume University Hospital, Kurume, JPN
| | - Masakazu Nabeta
- Advanced Emergency and Critical Care Center, Kurume University Hospital, Kurume, JPN
| | - Osamu Takasu
- Advanced Emergency and Critical Care Center, Kurume University Hospital, Kurume, JPN
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17
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Ardissino G, Cresseri D, Mancuso MC, Capone V, Porcaro L, Amico V, Tangredi M, Grovetti E, Griffini S, Castellano G, Montini G, Consonni D, Cugno M. Outcome of atypical hemolytic uremic syndrome: role of triggers and complement abnormalities in the response to C5 inhibition. J Nephrol 2024:10.1007/s40620-023-01873-9. [PMID: 38280096 DOI: 10.1007/s40620-023-01873-9] [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: 08/10/2023] [Accepted: 12/26/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Atypical-hemolytic uremic syndrome (aHUS) is a rare thrombotic microangiopathy often due to uncontrolled complement activation, characterized by high risk of end-stage kidney disease (ESKD). Eculizumab has improved the outcome, however, its efficacy varies among patients and its discontinuation is debated. METHODS To identify characteristics associated with treatment response, we analyzed 244 aHUS patients referred to our center. Patients were classified according to the presence/absence of complement abnormalities and/or triggers at onset in 4 categories: (1) primary (complement abnormality without trigger), (2) secondary (trigger without complement abnormality), (3) combined (trigger and complement abnormality), (4) idiopathic (no trigger, no complement abnormality). Response to treatment was evaluated by comparing the response to eculizumab with that of conventional therapy. Short- and long-term outcomes were evaluated with the relapse rate after discontinuation of C5-inhibition. RESULTS Patients had a better outcome with eculizumab compared to conventional treatment, with a response rate of 81.9% vs 56.9%, p < 0.001 and a long-term cumulative incidence of ESKD of 5.8% vs 22.5% (hazard ratio 0.25, 95% confidence interval: 0.10-0.80). The excellent global response was driven by the primary and combined groups (89.8% vs 54.0% and 89.3% vs 54.2%, respectively). The relapse rate following discontinuation of the C5-inhibitor was as high as 66.7% in the primary group, 18.7% in the combined, and 0% in the secondary and idiopathic groups. CONCLUSIONS Our data show a better outcome in aHUS patients treated with C5-inhibition, particularly in the primary and combined forms, which have a high risk of relapse after discontinuation that is not observed in the secondary and idiopathic forms.
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Affiliation(s)
- Gianluigi Ardissino
- Center for HUS Prevention, Control and Management at the Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy.
| | - Donata Cresseri
- Center for HUS Prevention, Control and Management at the Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Cristina Mancuso
- Center for HUS Prevention, Control and Management at the Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Valentina Capone
- Center for HUS Prevention, Control and Management at the Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Luigi Porcaro
- Medical Genetics Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Amico
- Medical Genetics Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marianna Tangredi
- Center for HUS Prevention, Control and Management at the Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Grovetti
- Medicina Interna Dipartimento di Fisiopatologia Medico‑Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Samantha Griffini
- Medicina Interna Dipartimento di Fisiopatologia Medico‑Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giuseppe Castellano
- Center for HUS Prevention, Control and Management at the Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Medicina Interna Dipartimento di Fisiopatologia Medico‑Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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18
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Cordero L, Cavero T, Gutiérrez E, Trujillo H, Sandino J, Auñón P, Rivero M, Morales E. Rational use of eculizumab in secondary atypical hemolytic uremic syndrome. Front Immunol 2024; 14:1310469. [PMID: 38274833 PMCID: PMC10808527 DOI: 10.3389/fimmu.2023.1310469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background Secondary atypical hemolytic uremic syndrome (secondary aHUS) is a heterogeneous group of thrombotic microangiopathies (TMA) associated with various underlying conditions. Unlike primary aHUS, there is still no hard evidence on the efficacy of complement blockade in secondary aHUS, since the two main series that investigated this subject showed discrepant results. Our work aims to reassess the efficacy of eculizumab in treating secondary aHUS. Methods Observational, retrospective, single-center study, in which we analyzed the hematological and renal evolution of 23 patients diagnosed with secondary aHUS who received treatment with eculizumab and compared them with a control cohort of 14 patients. Complete renal response was defined as the recovery of renal function before the event, partial renal response as a recovery of 50% of lost glomerular filtration rate, and hematological response as normalization of hemoglobin and platelets. Results We found no statistically significant differences in baseline characteristics or disease severity between both groups. After a median of 5 doses of eculizumab, the group of patients who received complement blockade presented a significant difference in renal response (complete in 52.3% of patients and partial in 23.8%) compared to the control cohort (complete response 14.3% and partial of 14.3%). Rates of hematological remission were similar in both groups (90.9% in the eculizumab cohort and 85.7% in the control cohort). Conclusion Early and short-term use of eculizumab in patients with secondary aHUS could be an effective and safe therapeutic option, assuring better renal recovery compared to patients who do not receive complement blockade.
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Affiliation(s)
- Lucía Cordero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Cavero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Eduardo Gutiérrez
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Hernando Trujillo
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Justo Sandino
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Auñón
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Rivero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Enrique Morales
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
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19
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Kunwor B, Sharma B, Chhetri ST, Joshi P, Pradhan D. Atypical hemolytic uremic syndrome in a child: A rare case report. Clin Case Rep 2024; 12:e8356. [PMID: 38161638 PMCID: PMC10753129 DOI: 10.1002/ccr3.8356] [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: 07/24/2023] [Revised: 11/07/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Atypical hemolytic uremic syndrome, a rare thrombotic microangiopathy, necessitates early diagnosis and comprehensive care due to its potential severity, emphasizing the importance of a multidisciplinary approach to improve outcomes.
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Affiliation(s)
- Bishal Kunwor
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | - Bishal Sharma
- Nepalese Army Institute of Health SciencesKathmanduNepal
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20
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Gençay AG, Işık S, Yürük Yıldırım Z, Demirkol D. A Renal Disease Triggered by COVID-19. Clin Pediatr (Phila) 2024; 63:114-118. [PMID: 37964416 DOI: 10.1177/00099228231210718] [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] [Indexed: 11/16/2023]
Affiliation(s)
- Ali Genco Gençay
- Pediatric Intensive Care Unit, Istanbul University Faculty of Medicine, Turkey
| | - Sinan Işık
- Department of Pediatrics, Istanbul University Faculty of Medicine, Turkey
| | | | - Demet Demirkol
- Pediatric Intensive Care Unit, Istanbul University Faculty of Medicine, Turkey
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21
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Moronti V, Carubbi F, Sollima L, Piscitani L, Ferri C. End stage renal disease in patient with microscopic polyangiitis and atypical hemolytic-uremic syndrome arose 3 weeks after the third dose of anti-SARS-CoV2 vaccine mRNA-1273: A case report with literature revision. Medicine (Baltimore) 2023; 102:e36560. [PMID: 38115241 PMCID: PMC10727565 DOI: 10.1097/md.0000000000036560] [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: 08/16/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
RATIONALE Immune system deregulation, including AAV, is a key event that may potentially evolve into ESRD. Abnormal activation of the cAP is also a cardinal feature of TMA, particularly aHUS. The kidney is the most frequently involved organ, and renal-limited forms of TMA are often encountered in clinical practice. Isolated case reports described the occurrence of renal TMA in AAV patients. Some cases of both de novo and relapses of AAV and/or TMAs after anti-SARS-CoV2 vaccination have been reported. We reported, for the 1st time, a case of patients with new-onset MPA and aHUS occurring 3 weeks after the third dose of mRNA-1273 vaccine anti-SARS-CoV2. PATIENT CONCERNS We present a 67-year-old man, affected by arterial hypertension, reported, after mRNA-1273 vaccine anti-SARS-CoV2, anuria, fatigue, anorexia and nausea. Laboratory data revealed acute renal failure. DIAGNOSIS Positivity of MPO-ANCA was observed. 7 days after admission, we observed a worsening of anemia and thrombocytopenia with haptoglobin reduction, LDH increase and presence of schistocytes. Plasma levels of ADAMTS-13 were normal. A renal biopsy was performed, and findings were consistent with microscopic polyangiitis, with features of micro-thrombotic glomerulopathy. Genetic tests revealed absence of hybrid genes associated with the increased risk of aHUS. INTERVENTIONS AND OUTCOMES We started renal replacement treatment, including hemodialysis, and pulsed methylprednisolone, with no improvement of laboratory parameters. Then, plasma exchange was performed leading to partial haematological response. Only with Eculizumab, a human C5 inhibitor, we observed a normalization of haptoglobin levels and platelets' count. However, three months after discharge, the patient still required hemodialysis. LESSONS To our knowledge we observed the first case aHUS, without genetic predisposition, associated with MPA occurring after the third dose of anti-SARS-CoV2 vaccine. This case report highlights the potential link between anti-SARS-CoV2 vaccine as a trigger of MPA and aHUS. This systematic review offers additional perspectives. It is plausible to hypothesize that the vaccine was the trigger for the development of these 2 diseases.Solid evidence on the mechanisms of interaction between vaccine and immune system, the role of genetic predisposition, and other variables, will shed additional light on the controversial link between anti-SARS-CoV2 vaccine and autoimmunity.
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Affiliation(s)
- Veronica Moronti
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Francesco Carubbi
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Laura Sollima
- Anatomy and Pathological Histology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Luca Piscitani
- Nephrology and Dialysis Division, Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Claudio Ferri
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
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22
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Wang C, Fang W, Sun W, Zhao S, Peng L. Clinical characteristics, treatments, and outcomes of interferon-beta-induced thrombotic microangiopathy: a literature-based retrospective analysis. Ther Adv Neurol Disord 2023; 16:17562864231216634. [PMID: 38107441 PMCID: PMC10725149 DOI: 10.1177/17562864231216634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/08/2023] [Indexed: 12/19/2023] Open
Abstract
Background Thrombotic microangiopathy (TMA) is a rare side effect of interferon-beta (IFN-β) therapy. The clinical characteristics of IFN-β-induced TMA are unknown. Objectives To explore the clinical characteristics of IFN-β-induced TMA and provide reference for the prevention of TMA. Design Articles on IFN-β-induced TMA were collected by searching the literature in relevant Chinese and English databases from inception to 31 July 2023. Methods Data in the articles were extracted and analyzed retrospectively. Results Forty-seven patients, with a median age of 41 years (range 22, 66), were included in the analysis. The median time to the diagnosis of IFN-β-induced TMA was 8 years (range 0.1-30) after administration. The main clinical symptoms were neurological symptoms (51.1%), hypertension (78.7%), dyspnea (19.1%), edema (19.1%), asthenia/fatigue (19.1%), and digestive symptoms (17.0%). Most patients presented with hemolytic anemia (76.6%), thrombocytopenia (63.8%), and acute kidney injury (70.2%). All patients stopped IFN-β and received plasma exchange therapy (53.2%), systemic steroids (46.8%), antihypertensive therapy (46.8%), eculizumab (12.8%), and rituximab (12.8%). Kidney damage was not completely reversible; 40.4% of patients achieved renal function and hematology remission, 27.7% developed chronic kidney disease, 25.5% developed end-stage renal disease, and 2.1% died. Conclusion IFN-β-induced TMA is a rare but serious complication that can be life-threatening. It may occur after many years of IFN-β therapy, and patients taking IFN-β should be monitored for symptoms such as headache and hypertension.
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Affiliation(s)
- Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Chunjiang Wang is also affiliated to College of pharmacy, Changsha Medical University, Changsha, Hunan, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Chunjiang Wang is also affiliated to College of pharmacy, Changsha Medical University, Changsha, Hunan, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Chunjiang Wang is also affiliated to College of pharmacy, Changsha Medical University, Changsha, Hunan, China
| | - Shaoli Zhao
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China
| | - Liping Peng
- Department of Cardiology, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, Yuelu District, Changsha, Hunan 410013, China
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Story CM, Gerber GF, Chaturvedi S. Medical consult: aHUS, TTP? How to distinguish and what to do. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:745-753. [PMID: 38066937 PMCID: PMC10727109 DOI: 10.1182/hematology.2023000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) caused by an autoantibody-mediated deficiency of ADAMTS13 and atypical hemolytic syndrome (aHUS) caused by alternative complement dysregulation are the most common primary thrombotic microangiopathies (TMAs). The evaluation of a patient with TMA is a medical emergency since it is critical to quickly distinguish iTTP and aHUS from other causes of TMA. Untreated iTTP is rapidly fatal, and delays in initiating complement inhibition in aHUS increase the risk of irreversible renal failure. An ADAMTS13 activity level of less than 10% is diagnostic of iTTP in the appropriate clinical setting. In settings where rapid-turnaround ADAMTS13 testing is not available, clinical features and clinical prediction tools are useful to identify patients who should receive emergent plasma exchange. We present an evidence-based approach to the initial (first 24 hours) diagnosis and management of iTTP and review the clinical and laboratory features that can be used to identify patients with aHUS who will benefit from early C5 blockade. We also discuss the potential use of complement blockade to improve outcomes in selected patients with secondary TMA.
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Affiliation(s)
- Charlotte M Story
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gloria F Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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24
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Tang ZC, Hui H, Shi C, Chen X. New findings in preventing recurrence and improving renal function in AHUS patients after renal transplantation treated with eculizumab: a systemic review and meta-analyses. Ren Fail 2023; 45:2231264. [PMID: 37563792 PMCID: PMC10424606 DOI: 10.1080/0886022x.2023.2231264] [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: 10/13/2022] [Revised: 04/24/2023] [Accepted: 04/22/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The long-term mortality of kidney transplantation patients with atypical hemolytic uremic syndrome remains high, and the efficacy of the main treatment eculizumab is still controversial. OBJECTIVE A comprehensive systematic review and meta-analysis of clinical trials using eculizumab in renal transplant patients with atypical hemolytic uremic syndrome was conducted to evaluate the efficacy of this therapy and its impact on renal function. METHODS A comprehensive systematic search was conducted across multiple reputable databases, including Ovid (MEDLINE, EMBASE), PubMed, and the Cochrane Library (since database inception), to identify relevant studies exploring the use of eculizumab in patients with atypical hemolytic uremic kidney transplantation. Various renal function parameters, such as dialysis, rejection, glomerular filtration rate, serum creatinine, lactate dehydrogenase, and platelet count, along with patient relapse rates, were extracted and summarized using a combination of robust statistical methods, including fixed effects, random effects, and general inverse variance methods. RESULT Eighteen trials with 618 subjects were analyzed. Our analysis suggests that the use of eculizumab is associated with a reduced likelihood of AHUS recurrence (odds ratio (OR) = 0.05, 95% CI: 0.00-0.13), as well as a significant reduction in the need for dialysis (odds ratio (OR) = 0.13, 95% CI: 0.01-0.32). Additionally, eculizumab treatment led to lower serum creatinine levels (mean differences (MD) = 126.931μmoI/L, 95% CI: 115.572μmoI/L-138.290μmoI/L) and an improved glomerular filtration rate (mean differences (MD) = 59.571 ml/min, 95% CI: 57.876 ml/min-61.266 mL/min). Our results also indicate that the use of eculizumab reduces the likelihood of rejection (odds ratio (OR) = 0.09, 95% CI: 0.01-0.22). Furthermore, the drug was effective in improving platelet counts (×10∧9/L) (mean differences (MD) = 163.421, 95% CI: 46.998-279.844) and lactate dehydrogenase levels (mean differences (MD) = 336.608 U/L, 95% CI: 164.816 U/L-508.399 U/L). CONCLUSIONS Based on the meta-analysis, treatment with eculizumab can reduce dialysis rates and improve patients' quality of life by enhancing renal function.
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Affiliation(s)
| | - Huang Hui
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Chunru Shi
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Xiangmei Chen
- Renal Medicine Department, Chinese PLA General Hospital, Beijing, China
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25
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Ávila A, Cao M, Espinosa M, Manrique J, Morales E. Recommendations for the individualised management of atypical hemolytic uremic syndrome in adults. Front Med (Lausanne) 2023; 10:1264310. [PMID: 38105887 PMCID: PMC10722909 DOI: 10.3389/fmed.2023.1264310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Background Despite significant advances in therapeutic management of atypical hemolytic uremic syndrome (aHUS), guidelines are not timely updated and achieving a consensus on management recommendations remains a topic of ongoing discussion. Methods A Scientific Committee with five experts was set up. A literature review was conducted and publications addressing the classification of aHUS, patient profiles and therapeutic approach were selected. Recommendations were proposed at an initial meeting, evaluated through an online questionnaire and validated during a second meeting. Results Patients with confirmed or clear suspicion of aHUS should be treated with C5 inhibitors within 24 h of the diagnosis or suspicion of aHUS. Treatment monitoring and the decision to interrupt treatment should be individualised according to the risk of relapse and each patient's evolution. aHUS with a genetic variant or associated with pregnancy should be treated for at least 6-12 months; de novo aHUS associated with kidney transplant until renal function is recovered and genetic variants are ruled out; aHUS associated with malignant hypertension until genetic variants are ruled out; aHUS associated with non-kidney transplant, autoimmune diseases, infection-or drug-induced until the thrombotic microangiopathy is resolved. Patients with a high risk of relapse should be treated for longer than 6-12 months. Conclusion These recommendations provides physicians who are not familiar with the disease with recommendations for the management of aHUS in adults. The experts who participated advocate early treatment, maintenance for at least 6-12 months and treatment interruption guided by genetic background, trigger factors, risk of relapse and evolution.
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Affiliation(s)
- Ana Ávila
- Department of Nephrology, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Mercedes Cao
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Joaquín Manrique
- Department of Nephrology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
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26
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Chen X, Zhang X, Wang Y, Wang S, Zhao M. Genetic, clinical, and pathological study of patients with severe hypertension-associated renal microangiopathy. J Nephrol 2023; 36:2477-2490. [PMID: 37103770 DOI: 10.1007/s40620-023-01644-6] [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: 04/08/2022] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Severe hypertension may be a prominent manifestation of complement-mediated thrombotic microangiopathy. Furthermore, patients with severe hypertension-associated thrombotic microangiopathy may present with concurrent hematologic abnormalities that mimic complement-mediated thrombotic microangiopathy. Whether or not severe hypertension-associated thrombotic microangiopathy is associated with genetic susceptibility in complement- and/or coagulation-pathway genes remains unclear, and there is thus a need to identify clinicopathological clues to distinguish between these entities. METHODS Forty-five patients with concomitant severe hypertension and thrombotic microangiopathy on kidney biopsy were identified retrospectively. Whole-exome sequencing was performed to identify rare variants in 29 complement- and coagulation-cascade genes. Clinicopathological features were compared between patients with severe hypertension-associated thrombotic microangiopathy and complement-mediated thrombotic microangiopathy with severe hypertension. RESULTS Three patients with pathogenic variants diagnostic of complement-mediated thrombotic microangiopathy and two with anti-factor H antibody positivity were diagnosed with complement-mediated thrombotic microangiopathy with severe hypertension. Among the 40 patients with severe hypertension-associated thrombotic microangiopathy, 53 rare variants of uncertain significance were found in the analyzed genes in 34 (34/40, 85%) patients, of whom 12 patients harbored two or more variants. Compared with complement-mediated thrombotic microangiopathy patients with severe hypertension, patients with severe hypertension-associated thrombotic microangiopathy were more likely to have left ventricular wall thickening (p < 0.001), less-severe acute glomerular thrombotic microangiopathy lesions including mesangiolysis and subendothelial space widening (both p < 0.001), and less arteriolar thrombosis formation (p < 0.001). CONCLUSIONS Rare genetic variants involving complement and coagulation pathways can be found in patients with severe hypertension-associated thrombotic microangiopathy; their role needs further investigation. Cardiac remodeling and acute glomerular TMA lesions may help to differentiate between severe hypertension-associated thrombotic microangiopathy and complement-mediated thrombotic microangiopathy with severe hypertension.
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Affiliation(s)
- Xuejing Chen
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China
| | - Xu Zhang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China.
- Institute of Nephrology, Peking University, Beijing, China.
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China.
| | - Suxia Wang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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27
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Petr V, Thurman JM. The role of complement in kidney disease. Nat Rev Nephrol 2023; 19:771-787. [PMID: 37735215 DOI: 10.1038/s41581-023-00766-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
The complement cascade comprises soluble and cell surface proteins and is an important arm of the innate immune system. Once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammatory, vasoactive and metabolic responses. Although complement is crucial to host defence and homeostasis, its inappropriate or uncontrolled activation can also drive tissue injury. For example, the complement system has been known for more than 50 years to be activated by glomerular immune complexes and to contribute to autoimmune kidney disease. Notably, the latest research shows that complement is also activated in kidney diseases that are not traditionally thought of as immune-mediated, including haemolytic-uraemic syndrome, diabetic kidney disease and focal segmental glomerulosclerosis. Several complement-targeted drugs have been approved for the treatment of kidney disease, and additional anti-complement agents are being investigated in clinical trials. These drugs are categorically different from other immunosuppressive agents and target pathological processes that are not effectively inhibited by other classes of immunosuppressants. The development of these new drugs might therefore have considerable benefits in the treatment of kidney disease.
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Affiliation(s)
- Vojtech Petr
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua M Thurman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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28
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Imanifard Z, Liguori L, Remuzzi G. TMA in Kidney Transplantation. Transplantation 2023; 107:2329-2340. [PMID: 36944606 DOI: 10.1097/tp.0000000000004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Thrombotic microangiopathy (TMA) is a rare and devastating complication of kidney transplantation, which often leads to graft failure. Posttransplant TMA (PT-TMA) may occur either de novo or as a recurrence of the disease. De novo TMA can be triggered by immunosuppressant drugs, antibody-mediated rejection, viral infections, and ischemia/reperfusion injury in patients with no evidence of the disease before transplantation. Recurrent TMA may occur in the kidney grafts of patients with a history of atypical hemolytic uremic syndrome (aHUS) in the native kidneys. Studies have shown that some patients with aHUS carry genetic abnormalities that affect genes that code for complement regulators (CFH, MCP, CFI) and components (C3 and CFB), whereas in 10% of patients (mostly children), anti-FH autoantibodies have been reported. The incidence of aHUS recurrence is determined by the underlying genetic or acquired complement abnormality. Although treatment of the causative agents is usually the first line of treatment for de novo PT-TMA, this approach might be insufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve kidney function. Targeted complement inhibition is an effective treatment for recurrent TMA and may be effective in de novo PT-TMA as well, but it is necessary to establish which patients can benefit from different therapeutic options and when and how these can be applied.
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Affiliation(s)
- Zahra Imanifard
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
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29
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Al Riyami D, Mohammed S, Al Salmi I, Metry A, Al Kalbani N, Almurshadi F, Al Rasbi S, Al Ismaili F, Hola A, Hannawi S. Epidemiology, Management, and Outcome of Atypical Hemolytic Uremic Syndrome in an Omani Cohort. Oman Med J 2023; 38:e569. [PMID: 38317858 PMCID: PMC10839635 DOI: 10.5001/omj.2023.117] [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: 06/09/2022] [Accepted: 06/13/2023] [Indexed: 02/07/2024] Open
Abstract
Objectives Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening disease of chronic uncontrolled complement pathway activation that leads to thrombotic-microangiopathy, along with severe organ damage, including end-stage kidney disease. This study aimed to evaluate the epidemiology, management, and outcome of aHUS in an Omani population. Methods This retrospective descriptive cohort study assessed all cases of aHUS diagnosed and followed up at two tertiary care centers in Oman from January 2008 to December 2019, based on clinical features, complement pathway assays, histopathological, and genetic testing. Results The study accrued 19 patients who fulfilled the inclusion criteria, of whom 11 (57.9%) were male. The participants' median age was 25.0 years (range = 0.1-69.0). Most (15; 78.9%) patients presented in the acute phase of the disease. The triad of hemolytic anemia, acute kidney injury, and thrombocytopenia was present in all patients. A trigger factor (e.g., infection) was identified in 68.4% of cases. Of the 14 (73.7%) patients who underwent kidney biopsy, 10 (71.4%) were found to have aHUS in native kidneys and three in grafted kidneys. Of the 11 (57.9%) patients who underwent genetic analysis, five (45.5%) were found to have a known pathogenic variant in their aHUS susceptibility genes. Plasma exchange followed by eculizumab was the treatment method in 11 (57.9%) cases. Complete renal recovery was achieved in seven (36.8%) patients, while four (21.1%) passed away during the study period. Conclusions The wide spectrum and multiple expressions of aHUS make it a challenge to diagnose and consequently may delay the commencement of the targeted treatment. Eculizumab is considered the first-line therapy and should be commenced as early as possible.
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Affiliation(s)
| | - Saja Mohammed
- Department of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Issa Al Salmi
- Department of Renal Medicine, Royal Hospital, Muscat, Oman
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
| | | | - Naifain Al Kalbani
- Pediatric Nephrology, Child Health Department, Royal Hospital, Muscat, Oman
| | | | - Samira Al Rasbi
- Nursing Directorate, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Alan Hola
- Department of Renal Medicine, Royal Hospital, Muscat, Oman
| | - Suad Hannawi
- Department of Rheumatology, Ministry of Health and Prevention, Dubai, UAE
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30
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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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31
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Durak C, Sahin EG, Yusuf Can Y, Varol F, Cam H. Why has plasma exchange failed in TRACK syndrome? Lessons from a new variant of the atypical hemolytic uremic syndrome. J Clin Apher 2023; 38:647-650. [PMID: 37338178 DOI: 10.1002/jca.22070] [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: 04/11/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare and life-threatening form of thrombotic microangiopathy, associated with high mortality and morbidity. Most cases present with hemolytic anemia, thrombocytopenia, and renal insufficiency. However, it can have unusual multiple end-organ injuries including extrarenal organ and system involvements such as neurologic, cardiac, gastrointestinal, and respiratory systems. We describe a 4-year-old girl who developed aHUS due to the TSEN2 mutation and had cardiac involvement. She did not benefit from plasma exchange, as stated in previous cases. It should be kept in mind that therapeutic plasma exchange may not be beneficial in some cases of aHUS, especially due to genetic mutations.
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Affiliation(s)
- Cansu Durak
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Ebru Guney Sahin
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Yasar Yusuf Can
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Fatih Varol
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
| | - Halit Cam
- Department of Pediatrics, Division of Pediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, University of Health Science, Istanbul, Turkey
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Spasiano A, Palazzetti D, Dimartino L, Bruno F, Baccaro R, Pesce F, Grandaliano G. Underlying Genetics of aHUS: Which Connection with Outcome and Treatment Discontinuation? Int J Mol Sci 2023; 24:14496. [PMID: 37833944 PMCID: PMC10572301 DOI: 10.3390/ijms241914496] [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: 07/31/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease caused by a genetic dysregulation of the alternative complement pathway, characterized by thrombocytopenia, hemolytic anemia, and acute kidney injury, and included in the group of thrombotic microangiopathies. With the introduction of humanized monoclonal antibodies that inhibit C5 activation, the natural history of aHUS completely changed, with a better prognosis, a quick recovery of renal function, and a significant reduction of end-stage renal disease incidence. Nowadays, there is an increasing interest in the molecular and genetic bases of this severe disease. The aim of this narrative review is to provide readers with a practical guide about different possible involved genes, elucidating the specific role of each transcribed protein in the pathogenesis of aHUS. Moreover, we analyzed the main current evidence about the relationship among genetic mutations, outcomes, and the risk of recurrence of this manifold disease.
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Affiliation(s)
- Andrea Spasiano
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.S.); (G.G.)
- Nephrology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Daniela Palazzetti
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.S.); (G.G.)
- Nephrology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Lucrezia Dimartino
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.S.); (G.G.)
- Nephrology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Francesca Bruno
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.S.); (G.G.)
- Nephrology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Rocco Baccaro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.S.); (G.G.)
- Nephrology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Francesco Pesce
- Division of Renal Medicine, Fatebenefratelli Isola Tiberina—Gemelli Isola, 00186 Rome, Italy
| | - Giuseppe Grandaliano
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.S.); (G.G.)
- Nephrology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
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Kelen K, Horváth O, Kis É, Mikes B, Sallay P, Prohászka Z, Szabó AJ, Reusz GS. Immunosuppressive Therapy of Antibody-Mediated aHUS and TTP. Int J Mol Sci 2023; 24:14389. [PMID: 37762692 PMCID: PMC10531618 DOI: 10.3390/ijms241814389] [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: 08/17/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The recent classification of pediatric thrombotic microangiopathies (TMA) takes into consideration mechanisms of disease for guidance to targeted therapies. We present our experience with seven patients with antibody mediated atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP). Five children had aHUS with antibodies against complement factor H (CFH-ab) and two with TTP with antibodies against metalloproteinase ADAMTS13. In the aHUS cases diagnosed and treated before the eculizumab era, CFH-ab was detected using the ELISA assay. Mutational analysis of selected complement genes was performed. TTP was diagnosed if, in addition to microangiopathic hemolytic anemia and thrombocytopenia, ischemic organ involvement and severe deficiency in ADAMTS13 activity were present. Treatment protocol consisted of plasma exchanges (PE) and steroid pulses, followed by the combination of cyclophosphamide and rituximab to achieve long-term immunosuppression. Four patients with CFH-ab and the TTP patients with ADAMTS13 antibodies came into sustained remission. After a median follow-up of 11.7 (range 7.7-12.9) years without maintenance therapy, no disease recurrence was observed; nevertheless, six patients, two had hypertension and two had proteinuria as a late consequence. One patient, with late diagnosis of CFH-ab and additional genetic risk factors who was treated only with PE and plasma substitution, reached end-stage renal disease and was later successfully transplanted using eculizumab prophylaxis. In the cases of antibody-mediated TMAs, PE and early immunosuppressive treatment may result in sustained remission with preserved kidney function. Further data are needed to establish optimal treatment of anti-FH antibody-associated HUS.
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Affiliation(s)
- Kata Kelen
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Orsolya Horváth
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Éva Kis
- Department of Pediatric Cardiology, Gottsegen György Hungarian Institute of Cardiology, 1096 Budapest, Hungary;
| | - Bálint Mikes
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Péter Sallay
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Zoltán Prohászka
- Research Laboratory, Department of Medicine and Hematology, Semmelweis University, 1083 Budapest, Hungary;
| | - Attila József Szabó
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
- Pediatric Center, MTA Center of Excellence, Semmelweis University, 1083 Budapest, Hungary
- ELKH-SE Pediatrics and Nephrology Research Group, 1052 Budapest, Hungary
| | - György S. Reusz
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
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Peddi NC, Vuppalapati S, Sreenivasulu H, Muppalla SK, Reddy Pulliahgaru A. Guardians of Immunity: Advances in Primary Immunodeficiency Disorders and Management. Cureus 2023; 15:e44865. [PMID: 37809154 PMCID: PMC10560124 DOI: 10.7759/cureus.44865] [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: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Primary immunodeficiency disorders (PIDs) are a heterogeneous group of genetic conditions profoundly impacting immune function. The investigation spans various PID categories, offering insights into their distinct pathogenic mechanisms and clinical manifestations. Within the adaptive immune system, B-cell, T-cell, and combined immunodeficiencies are dissected, emphasizing their critical roles in orchestrating effective immune responses. In the realm of the innate immune system, focus is directed toward phagocytes and complement deficiencies, underscoring the pivotal roles of these components in initial defense against infections. Furthermore, the review delves into disorders of immune dysregulation, encompassing hemophagocytic lymphohistiocytosis (HLH), autoimmune lymphoproliferative syndrome (ALPS), immune dysregulation, polyendocrinopathy, enteropathy, and X-linked(IPEX), and autoimmunity polyendocrinopathy candidiasis-ectodermal dystrophy(APECED), elucidating the intricate interplay between immune tolerance and autoimmunity prevention. Diagnostic strategies for PIDs are explored, highlighting advancements in genetic and molecular techniques that enable precise identification of underlying genetic mutations and alterations in immune function. We have also outlined treatment modalities for PIDs, which often entail a multidisciplinary approach involving immunoglobulin replacement, antimicrobial prophylaxis, and, in select cases, hematopoietic stem cell transplantation. Emerging therapies, including gene therapy, hold promise for targeted interventions. In essence, this review encapsulates the complexity of PIDs, emphasizing the critical importance of early diagnosis and tailored therapeutic interventions. As research advances, a clearer understanding of these disorders emerges, fostering optimism for enhanced patient care and management in the future.
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Affiliation(s)
| | - Sravya Vuppalapati
- General Physician, People's Education Society (PES) Institute of Medical Sciences and Research, Kuppam, IND
| | - Himabindu Sreenivasulu
- General Physician, People's Education Society (PES) Institute of Medical Sciences and Research, Kuppam, IND
| | - Sudheer Kumar Muppalla
- Pediatrics, People's Education Society (PES) Institute of Medical Sciences and Research, kuppam, IND
| | - Apeksha Reddy Pulliahgaru
- Pediatrics, People's Education Society (PES) Institute of Medical Sciences and Research, Kuppam, IND
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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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Kirsanova TV, Balakireva AI, Fedorova TA, Pyregov AV, Rogachevskiy OV. [Various phenotypes of postpartum atypical hemolytic uremic syndrome: the role of genetic testing in determining prognosis. Case report]. TERAPEVT ARKH 2023; 95:511-515. [PMID: 38158972 DOI: 10.26442/00403660.2023.06.202233] [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: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
We report a case of atypical hemolytic uremic syndrome (aHUS) that occurred after childbirth in a patient with a history of numerous recurrent episodes of TMA with nephrotic proteinuria and impaired renal function. At 33 weeks of the first spontaneous pregnancy, proteinuria up to 0.8 g/l was first registered, at 38 weeks she was hospitalized with proteinuria, reaching a maximum of 13 g/l, she was delivered promptly, after which progressive thrombocytopenia was noted over the next few days (up to 44×109/l) and anemia and severe arterial hypertension, which could not be corrected by several groups of antihypertensive drugs. Initiated plasma therapy had no effect. After exclusion of all other causes of TMA, therapy with eculizumab was initiated, which made it possible to quickly and completely stop the phenomena of TMA. The presented observation demonstrates the successful treatment of recurrent course of aHUS with eculizumab with the achievement of complete recovery of kidney function in a patient with a homozygous mutation in the MCP gene. It is worth noting the importance of genetic research even in those situations where clinically aHUS is beyond doubt.
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Affiliation(s)
- T V Kirsanova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | | | - T A Fedorova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - A V Pyregov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - O V Rogachevskiy
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
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Connaughton DM, Bhai P, Isenring P, Mahdi M, Sadikovic B, Schenkel LC. Genotypic analysis of a large cohort of patients with suspected atypical hemolytic uremic syndrome. J Mol Med (Berl) 2023; 101:1029-1040. [PMID: 37466676 PMCID: PMC10400659 DOI: 10.1007/s00109-023-02341-4] [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: 11/03/2022] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/20/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. Complement and coagulation gene variants have been associated with aHUS susceptibility. We assessed the diagnostic yield of a next-generation sequencing (NGS) panel in a large cohort of Canadian patients with suspected aHUS. Molecular testing was performed on peripheral blood DNA samples from 167 patients, collected between May 2019 and December 2021, using a clinically validated NGS pipeline. Coding exons with 20 base pairs of flanking intronic regions for 21 aHUS-associated or candidate genes were enriched using a custom hybridization protocol. All sequence and copy number variants were assessed and classified following American College of Medical Genetics guidelines. Molecular diagnostic results were reported for four variants in three individuals (1.8%). Twenty-seven variants of unknown significance were identified in 25 (15%) patients, and 34 unique variants in candidate genes were identified in 28 individuals. An illustrative patient case describing two genetic alterations in complement genes is presented, highlighting that variable expressivity and incomplete penetrance must be considered when interpreting genetic data in patients with complement-mediated disease, alongside the potential additive effects of genetic variants on aHUS pathophysiology. In this cohort of patients with suspected aHUS, using clinical pipelines for genetic testing and variant classification, pathogenic/likely pathogenic variants occurred in a very small percentage of patients. Our results highlight the ongoing challenges in variant classification following NGS panel testing in patients with suspected aHUS, alongside the need for clear testing guidance in the clinical setting. KEY MESSAGES: • Clinical molecular testing for disease associated genes in aHUS is challenging. • Challenges include patient selection criteria, test validation, and interpretation. • Most variants were of uncertain significance (31.7% of patients; VUS + candidates). • Their clinical significance may be elucidated as more evidence becomes available. • Low molecular diagnostic rate (1.8%), perhaps due to strict classification criteria. • Case study identified two likely pathogenic variants; one each in MCP/CD46 and CFI.
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Affiliation(s)
- Dervla M Connaughton
- Schulich School of Medicine & Dentistry, University of Western, London, ON, Canada
- Department of Medicine, Division of Nephrology, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada
| | - Pratibha Bhai
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre (LHSC), London, ON, Canada
| | - Paul Isenring
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | | | - Bekim Sadikovic
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre (LHSC), London, ON, Canada
- Pathology and Laboratory Medicine, Western University, London, ON, Canada
| | - Laila C Schenkel
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre (LHSC), London, ON, Canada.
- Pathology and Laboratory Medicine, Western University, London, ON, Canada.
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Khandelwal P, Joshi A, Mathur A, Puraswani M, Gurjar BS, Sinha A, Hari P, Faruq M, Bagga A. Variants in complement genes are uncommon in patients with anti-factor H autoantibody-associated atypical hemolytic uremic syndrome. Pediatr Nephrol 2023; 38:2659-2668. [PMID: 36622444 DOI: 10.1007/s00467-022-05862-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coexisting genetic variants in patients with anti-factor H (FH)-associated atypical hemolytic uremic syndrome (aHUS) have implications for therapy. We estimated the prevalence of complement genetic variants in children with anti-FH aHUS from a prospective nationwide cohort and determined if significant genetic variants impact long-term kidney outcomes. METHODS Of 436 patients in the database, 77 consecutive patients, 21 with a relapse and 9 with kidney failure and/or death were included. Targeted sequencing, using a 27-gene panel including CFH, CFI, CFB, C3, CD46, PLG, DGKE, and THBD and multiplex ligation-dependent probe amplification of CFH-CFHR region, was performed. The adverse outcome was eGFR < 30 ml/min/1.73 m2 or death. RESULTS Patients had high anti-FH titers 5670 (2177-13,545) AU/ml, relapsing course (42.1%), and adverse outcomes (19.6%). Variants, chiefly of unknown significance, were found in 7 (6.5%; 95% CI 3.1-13.2%); a pathogenic variant was found in one patient. Homozygous deletion of CFHR1 was present in 91.6% compared to 9.8% in 184 healthy controls. Plasma exchanges and immunosuppression showed a trend of improving outcomes, independent of genetic defects (HR 0.32; P = 0.070). Meta-analysis of 18 studies (384 patients) showed that the pooled prevalence of pathogenic and likely pathogenic variants was 3% (95% CI 0-8%). Of 37 total variants in the meta-analysis, 7 (18.9%) each were pathogenic and likely pathogenic; others were variants of unknown significance. CONCLUSIONS Significant variants in complement regulatory genes are rare in patients with anti-FH-associated aHUS. Irrespective of genetic defects, plasma exchanges and immunosuppression showed a statistical trend to improved outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aditi Joshi
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Aradhana Mathur
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Bahadur Singh Gurjar
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Mohammed Faruq
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Holers VM. Complement therapeutics are coming of age in rheumatology. Nat Rev Rheumatol 2023; 19:470-485. [PMID: 37337038 DOI: 10.1038/s41584-023-00981-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/21/2023]
Abstract
The complement system was described over 100 years ago, and it is well established that activation of this pathway accompanies the great majority of autoimmune and inflammatory diseases. In addition, over three decades of work in murine models of human disease have nearly universally demonstrated that complement activation is upstream of tissue injury and the engagement of pro-inflammatory mechanisms such as the elaboration of cytokines and chemokines, as well as myeloid cell recruitment and activation. With that background, and taking advantage of advances in the development of biologic and small-molecule therapeutics, the creation and clinical evaluation of complement therapeutics is now rapidly expanding. This article reviews the current state of the complement therapeutics field, with a focus on their use in diseases cared for or consulted upon by rheumatologists. Included is an overview of the activation mechanisms and components of the system, in addition to the mechanisms by which the complement system interacts with other immune system constituents. The various therapeutic approaches to modulating the system in rheumatic and autoimmune diseases are reviewed. To understand how best to clinically assess the complement system, methods of its evaluation are described. Finally, next-generation therapeutic and diagnostic advances that can be envisioned for the future are discussed.
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Affiliation(s)
- V Michael Holers
- Medicine/Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA.
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Donadelli R, Sinha A, Bagga A, Noris M, Remuzzi G. HUS and TTP: traversing the disease and the age spectrum. Semin Nephrol 2023; 43:151436. [PMID: 37949684 DOI: 10.1016/j.semnephrol.2023.151436] [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: 11/12/2023]
Abstract
Hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenia purpura (TTP) are rare diseases sharing a common pathological feature, thrombotic microangiopathy (TMA). TMA is characterized by microvascular thrombosis with consequent thrombocytopenia, microangiopathic hemolytic anemia and/or multiorgan dysfunction. In the past, the distinction between HUS and TTP was predominantly based on clinical grounds. However, clinical presentation of the two syndromes often overlaps and, the differential diagnosis is broad. Identification of underlying pathogenic mechanisms has enabled the classification of these syndromes on a molecular basis: typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS); atypical HUS or complement-mediated TMA (aHUS/CM-TMA) associated with genetic or acquired defects leading to dysregulation of the alternative pathway (AP) of complement; and TTP that results from a severe deficiency of the von Willebrand Factor (VWF)-cleaving protease, ADAMTS13. The etiology of TMA differs between pediatric and adult patients. Childhood TMA is chiefly caused by STEC-HUS, followed by CM-TMA and pneumococcal HUS (Sp-HUS). Rare conditions such as congenital TTP (cTTP), vitamin B12 metabolism defects, and coagulation disorders (diacylglycerol epsilon mutation) present as TMA chiefly in children under 2 years of age. In contrast secondary causes and acquired ADAMT13 deficiency are more common in adults. In adults, compared to children, diagnostic delays are more frequent due to the wide range of differential diagnoses. In this review we focus on the three major forms of TMA, STEC-HUS, aHUS and TTP, outlining the clinical presentation, diagnosis and management of the affected patients, to help highlight the salient features and the differences between adult and pediatric patients which are relevant for management.
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Affiliation(s)
- Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Aditi Sinha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy.
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Kavanagh D, Greenbaum LA, Bagga A, Karki RG, Chen CW, Vasudevan S, Charney A, Dahlke M, Fakhouri F. Design and Rationale of the APPELHUS Phase 3 Open-Label Study of Factor B Inhibitor Iptacopan for Atypical Hemolytic Uremic Syndrome. Kidney Int Rep 2023; 8:1332-1341. [PMID: 37441479 PMCID: PMC10334406 DOI: 10.1016/j.ekir.2023.04.029] [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: 02/15/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a rare, progressive, and life-threatening form of thrombotic microangiopathy (TMA) which is caused by dysregulation of the alternative complement pathway (AP). Complement inhibition is an effective therapeutic strategy in aHUS, though current therapies require intravenous administration and increase the risk of infection by encapsulated organisms, including meningococcal infection. Further studies are required to define the optimal duration of existing therapies, and to identify new agents that are convenient for long-term administration. Iptacopan (LNP023) is an oral, first-in-class, highly potent, proximal AP inhibitor that specifically binds factor B (FB). In phase 2 studies of IgA nephropathy, paroxysmal nocturnal hemoglobinuria, and C3 glomerulopathy, iptacopan inhibited the AP, showed clinically relevant benefits, and was well tolerated. Iptacopan thus has the potential to become an effective and safe treatment for aHUS, with the convenience of oral administration. Methods Alternative Pathway Phase III to Evaluate LNP023 in aHUS (APPELHUS; NCT04889430) is a multicenter, single-arm, open-label, phase 3 study to evaluate the efficacy and safety of iptacopan in patients (N = 50) with primary complement-mediated aHUS naïve to complement inhibitor therapy (including anti-C5). Eligible patients must have evidence of TMA (platelet count <150 × 109/l, lactate dehydrogenase ≥1.5 × upper limit of normal, hemoglobin ≤ lower limit of normal, serum creatinine ≥ upper limit of normal) and will receive iptacopan 200 mg twice daily. The primary objective is to assess the proportion of patients achieving complete TMA response without the use of plasma exchange or infusion or anti-C5 antibody during 26 weeks of iptacopan treatment. Conclusion APPELHUS will determine if iptacopan is safe and efficacious in patients with aHUS.
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Affiliation(s)
- David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK, and Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Emory School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshri G. Karki
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, East Hanover, New Jersey, USA
| | - Chien-Wei Chen
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, East Hanover, New Jersey, USA
| | - Sajita Vasudevan
- Chief Medical Office and Patient Safety, Novartis Healthcare, Hyderabad, India
| | - Alan Charney
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, East Hanover, New Jersey, USA
| | - Marion Dahlke
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, Basel, Switzerland
| | - Fadi Fakhouri
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Bortolotti M, Barcellini W, Fattizzo B. Molecular pharmacology in complement-mediated hemolytic disorders. Eur J Haematol 2023. [PMID: 37308291 DOI: 10.1111/ejh.14026] [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: 04/10/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
In the last decade, a deeper understanding of the pathogenesis of complement mediated hemolytic disorders, such as paroxysmal nocturnal hemoglobinuria (PNH), cold agglutinin disease (CAD), warm type autoimmune hemolytic anemia (AIHA) with complement activation (wAIHA), and atypical hemolytic uremic syndrome (aHUS), paved the way to the therapeutic shift from purely supportive approaches to complement-targeted therapies. This resulted in a significant improvement in disease management, survival, and quality of life. In this review, we will provide a snapshot of novel therapies for complement-mediated hemolytic anemias with a focus on those ready to use in clinical practice. C5 inhibitors eculizumab and the long-acting ravulizumab, are the established gold standard for untreated PNH patients, whilst the C3 inhibitor pegcetacoplan should be considered for suboptimal responders to anti-C5 drugs. Several additional compounds targeting the complement cascade at different levels (other C5 inhibitors, factor B and D inhibitors) are under active investigation with promising results. In CAD, immunosuppression with rituximab remains the first-line. However, recently FDA and EMA approved the anti-C1s monoclonal antibody, sutimlimab, that showed dramatic responses and whose regulatory approval is soon awaited in many countries. Other drugs under investigation in AIHA include the C3 inhibitor pegcetacoplan, and the anti-C1q ANX005 for warm AIHA with complement activation. Finally, aHUS is an indication for complement inhibitors. Eculizumab and ravulizumab have been approved, whilst other C5 inhibitors, and novel lectin pathway inhibitors are under active investigation in this disease.
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Affiliation(s)
- Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
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Duran MN, Beyazit F, Erbaş M, Özkavak O, Acar C, Bakirdogen S. Successful treatment with eculizumab in a patient with pregnancy-associated atypical hemolytic uremic syndrome. Obstet Med 2023; 16:130-133. [PMID: 37441667 PMCID: PMC10334036 DOI: 10.1177/1753495x211019902] [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: 10/18/2020] [Revised: 05/01/2021] [Accepted: 05/01/2021] [Indexed: 06/04/2024] Open
Abstract
Pregnancy-associated atypical haemolytic uraemic syndrome is a rare and potentially lethal complement-mediated disorder. It can mimic preeclampsia, gestational hypertension, thrombotic thrombocytopenic purpura and hemolysis, elevated liver enzymes and low platelets syndrome. Thus, it can be hard to distinguish pregnancy-associated atypical haemolytic uraemic syndrome from other causes in peri/post-partum women presenting with features of microangiopathic haemolytic anemia, thrombocytopenia and acute kidney injury. We present a case of a 35-year-old woman in her third pregnancy at 32 weeks' gestation who underwent caesarean section due to fetal distress. She developed severe renal impairment, thrombocytopenia and neurologic symptoms within 24 hours after delivery. A diagnosis of pregnancy-associated atypical haemolytic uraemic syndrome was provided, and treatment with plasma therapy followed by eculizumab was initiated. A rapid improvement of both clinical and laboratory parameters was observed. This case demonstrates the significance of early initiation of anti-complement therapy to prevent irreversible renal damage and possible death in women with pregnancy-associated atypical haemolytic uraemic syndrome.
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Affiliation(s)
- Mehmet Nuri Duran
- Department of Obstetrics and Gynecology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fatma Beyazit
- Department of Obstetrics and Gynecology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Mesut Erbaş
- Department of Anesthesiology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Onur Özkavak
- Department of Obstetrics and Gynecology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Celal Acar
- Department of Hematology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Serkan Bakirdogen
- Department of Nephrology, Canakkale Onsekiz Mart University, Canakkale, Turkey
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Diep J, Potter D, Mai J, Hsu D. Atypical haemolytic uremic syndrome with refractory multiorgan involvement and heterozygous CFHR1/CFHR3 gene deletion. BMC Nephrol 2023; 24:127. [PMID: 37147581 PMCID: PMC10161558 DOI: 10.1186/s12882-023-03153-x] [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: 04/06/2022] [Accepted: 03/28/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND We present this challenging case report of Atypical Haemolytic Uremic Syndrome (aHUS) presenting with multi-organ involvement in a patient and heterozygous CFHR1/CFHR3 gene variant, which was refractory to initial eculizumab therapy. CASE PRESENTATION A forty-three year old female presented with aHUS and had heterozygous disease-associated deletions in the complement genes CFHR1/CFHR3. She had progressive kidney failure and severe extra-renal manifestations including cardiomyopathy and haemorrhagic cystitis; as well as pulmonary, gastrointestinal and neurological involvement. The initial kidney biopsy revealed thrombotic microangiopathy (TMA) changes involving all glomeruli. Clinical improvement was initially seen during eculizumab initiation with suppressed CH50 level, but a new rhinovirus/enterovirus upper respiratory tract infection triggered further severe multi-organ disease activity. The extra-renal manifestations stabilised, then ultimately improved after a period of eculizumab dose intensification. However, the impact on dose intensification on this improvement is unclear. Despite the extra-renal clinical improvement, she ultimately progressed to end-stage kidney disease (ESKD), commencing peritoneal dialysis for three years before undergoing a successful uncomplicated cadaveric kidney transplant without prophylactic eculizumab. Two years after transplant, she has excellent transplant graft function without any further disease recurrence. CONCLUSIONS This case highlights the concept of extra-renal manifestations in aHUS initially resistant to eculizumab, which potentially responded to dose intensification. Whilst organ injuries are potentially reversible with timely targeted treatment, it appears that the kidneys are most vulnerable to injury.
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Affiliation(s)
- Jason Diep
- Department of Renal Medicine, Liverpool Hospital, Locked Bag 7103, Liverpool, BC NSW 1871, Australia.
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - Daniela Potter
- Department of Renal Medicine, Liverpool Hospital, Locked Bag 7103, Liverpool, BC NSW 1871, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Jun Mai
- Department of Renal Medicine, Liverpool Hospital, Locked Bag 7103, Liverpool, BC NSW 1871, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Danny Hsu
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Haematology, Liverpool Hospital, Liverpool, NSW, Australia
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Ariceta G. Pharmacological and clinical profile of ravulizumab 100 mg/mL formulation for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Expert Rev Clin Pharmacol 2023; 16:401-410. [PMID: 37128905 DOI: 10.1080/17512433.2023.2209317] [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: 05/03/2023]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are two rare and severe conditions caused by chronic complement (C') system dysregulation. Treatment with eculizumab, a recombinant, humanized monoclonal antibody against complement C5, changed the natural history of both diseases inducing remission and improving patient outcome. Ravulizumab, a new long-acting next-generation C5 inhibitor has been recently approved for treatment of PNH and aHUS. AREAS COVERED Main characteristics of ravulizumab are described: composition, dosing, efficacy and safety profile. Further, an overview of seminal studies and clinical trials using ravulizumab to treat PNH and aHUS in children and adults is detailed. Literature review was performed using the following key words: paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and ravulizumab. EXPERT OPINION Ravulizumab profile to treat PNH and aHUS is equivalent to eculizumab in efficacy and safety but allows extended dosing interval to every 4-8 weeks based on patient weight, and requires reduced infusion time. Less travels to infusion centers and medical visits and decreasing job and school absences, significantly increases patient and families' QoL, while reducing cost. Further infusion time is reduced Ravulizumab will possibly become the treatment of choice for patients with PNH and aHUS on chronic C5 inhibition.
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Affiliation(s)
- Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autonoma Barcelona, Spain
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Tseng MH, Lin SH, Tsai JD, Wu MS, Tsai IJ, Chen YC, Chang MC, Chou WC, Chiou YH, Huang CC. Atypical hemolytic uremic syndrome: Consensus of diagnosis and treatment in Taiwan. J Formos Med Assoc 2023; 122:366-375. [PMID: 36323601 DOI: 10.1016/j.jfma.2022.10.006] [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: 07/05/2022] [Revised: 09/03/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, is a rare but life-threatening systemic disorder caused by the dysregulation of the complement pathway. Current advances in molecular analysis and pathogenesis have facilitated the establishment of diagnosis and development of effective complement blockade. Based on this recent consensus, we provide suggestions regarding the diagnosis and management of aHUS in Taiwan. The diagnosis of aHUS is made by the presence of TMA with normal ADAMTS13 activity without known secondary causes. Although only 60% of patients with aHUS have mutations in genes involving the compliment and coagulation systems, molecular analysis is suggestive for helping establish diagnosis, clarifying the underlying pathophysiology, guiding the treatment decision-making, predicting the prognosis, and deciding renal transplantation. Complement blockade, anti-C5 monoclonal antibody, is the first-line therapy for patients with aHUS. Plasma therapy should be considered for removing autoantibody in patients with atypical HUS caused by anti-CFH or complement inhibitor is unavailable.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taipei, Taiwan
| | - Yeu-Chin Chen
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Chih Chang
- Division of Hematology/Oncology, Department of Internal Medicine, MacKay Children's Hospital, Taipei, Taiwan
| | - Wen-Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
| | - Chiu-Ching Huang
- Division of Nephrology and the Kidney Institute, Department of Internal Medicine, China Medical University and Hospital, Taichung, Taiwan.
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Wada H, Teranishi H, Shimono A, Kato N, Maruyama S, Matsumoto M. Application of a scoring system in Japanese patients diagnosed with atypical hemolytic uremic syndrome to assess the relationship between the score and clinical responses to eculizumab. Thromb J 2023; 21:43. [PMID: 37072821 PMCID: PMC10114489 DOI: 10.1186/s12959-023-00489-0] [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: 01/25/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is caused by complement dysregulation and is generally diagnosed by exclusion from other disorders of thrombotic microangiopathy (TMA). Eculizumab, a terminal complement inhibitor, has been approved for aHUS treatment since 2013 in Japan. Recently, a scoring system was published to support diagnosis of aHUS. Herein we modified this scoring system to apply it to patients diagnosed with aHUS and treated with eculizumab, and assessed the association between the score and clinical responses to eculizumab. METHODS One hundred eighty-eight Japanese patients who were clinically diagnosed with aHUS, treated with eculizumab, and enrolled in post-marketing surveillance (PMS) were included in this analysis. Some of parameters in the original scoring system were replaced with clinically similar parameters collected in the PMS to modify the system, hereafter referred to as the TMA/aHUS score, which ranges from -15 to 20 points. Treatment responses within 90 days after eculizumab initiation were also assessed, and the relationship between treatment response and TMA/aHUS scores calculated at TMA onset was explored. RESULTS The median (range) TMA/aHUS score was 10 (3-16). Receiver operating characteristic curve analysis showed that the cutoff value of TMA/aHUS score to predict treatment response to eculizumab was estimated as 10, and negative predictive value indicated that ≥ 5 points was appropriate to consider assessing the treatment response to eculizumab; 185 (98%) patients had ≥ 5 points and 3 (2%) had < 5 points. Among the patients with ≥ 5 points, 96.1% showed partial response and 31.1% showed complete response. One of the three patients with < 5 points met partial response criteria. No significant difference in the TMA/aHUS scores was observed between survivors and non-survivors, suggesting that the score was not appropriate to predict the outcome (i.e., survival/death) in patients treated with eculizumab. CONCLUSION Almost all patients clinically diagnosed with aHUS scored ≥ 5 points and responded to eculizumab. The TMA/aHUS score system could become a supporting tool for the clinical diagnosis of aHUS and probability of response to treatment with a C5 inhibitor. TRIAL REGISTRATION This study was conducted as per good PMS practice guidelines for drugs (MHLW Ministerial Ordinance No. 171 of 2004).
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Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Hinaga, Yokkaichi, Mie, 5450-132, Japan.
| | | | | | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Tsurumai-Cho 65, Showa-ku, Nagoya, Aichi, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Tsurumai-Cho 65, Showa-ku, Nagoya, Aichi, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyo-Cho 840, Kashihara, Nara, Japan
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48
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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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Mocanu A, Bogos RA, Lazaruc TI, Cianga AL, Lupu VV, Ioniuc I, Alecsa M, Lupu A, Ivanov AV, Miron IC, Starcea IM. Pitfalls of Thrombotic Microangiopathies in Children: Two Case Reports and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13071228. [PMID: 37046448 PMCID: PMC10093431 DOI: 10.3390/diagnostics13071228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
Thrombotic microangiopathy can present itself in the form of several clinical entities, representing a real challenge for diagnosis and treatment in pediatric practice. Our article aims to explore the evolution of two rare cases of pediatric thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) with extremely similar clinical pictures, which, coincidentally, presented at approximately the same time in our hospital. These cases and our literature review demonstrate the multiple facets of thrombotic microangiopathy, which can produce various determinations and salient manifestations even among the pediatric population. TTP and aHUS may represent genuine diagnostic pitfalls through the overlap of their clinical and biological findings, although they develop through fundamentally different mechanisms that require different therapeutic approaches. As a novelty, we underline that COVID-19 infection cannot be excluded as potential trigger for TTP and aHUS in our patients and we predict that other reports of such an association will follow, raising a complex question of COVID-19's implication in the occurrence and evolution of thrombotic microangiopathies. On this matter, we conducted literature research that resulted in 15 cases of COVID-19 pediatric infections associated with either TTP or aHUS. Taking into consideration the morbidity associated with TTP and aHUS, an elaborate differential diagnosis and prompt intervention are of the essence.
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Affiliation(s)
- Adriana Mocanu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Roxana Alexandra Bogos
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Tudor Ilie Lazaruc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Lavinia Cianga
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ileana Ioniuc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Mirabela Alecsa
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ancuta Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Viorica Ivanov
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ingrith Crenguta Miron
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
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50
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Fakhouri F, Schwotzer N, Frémeaux-Bacchi V. How I diagnose and treat atypical hemolytic uremic syndrome. Blood 2023; 141:984-995. [PMID: 36322940 DOI: 10.1182/blood.2022017860] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Our understanding and management of atypical hemolytic uremic syndrome (aHUS) have dramatically improved in the last decade. aHUS has been established as a prototypic disease resulting from a dysregulation of the complement alternative C3 convertase. Subsequently, prospective nonrandomized studies and retrospective series have shown the efficacy of C5 blockade in the treatment of this devastating disease. C5 blockade has become the cornerstone of the treatment of aHUS. This therapeutic breakthrough has been dulled by persistent difficulties in the positive diagnosis of aHUS, and the latter remains, to date, a diagnosis by exclusion. Furthermore, the precise spectrum of complement-mediated renal thrombotic microangiopathy is still a matter of debate. Nevertheless, long-term management of aHUS is increasingly individualized and lifelong C5 blockade is no longer a paradigm that applies to all patients with this disease. The potential benefit of complement blockade in other forms of HUS, notably secondary HUS, remains uncertain.
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Affiliation(s)
- Fadi Fakhouri
- Department of Medicine, Service of Nephrology and Hypertension, Lausanne University Hospital and Université de Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Department of Medicine, Service of Nephrology and Hypertension, Lausanne University Hospital and Université de Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Laboratory of Immunology, Paris University, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Paris, France
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