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Uwatoko R, Kani N, Makino S, Naka T, Okamoto K, Miyakawa H, Hashimoto N, Iio R, Ueda Y, Hayashi T. Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome with recurrent acute cholecystitis: a case report. CEN Case Rep 2024; 13:215-219. [PMID: 37962818 PMCID: PMC11144172 DOI: 10.1007/s13730-023-00831-5] [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: 04/17/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) can induce life-threatening complications, including acute kidney injury, encephalopathy, and gastrointestinal complications. On the other hand, there have been few reports of cholecystitis associated with STEC-HUS. In this study, we report the case of an 83-year-old Japanese man who developed recurrent acute cholecystitis associated with STEC-HUS. Prior to establishing a definite diagnosis of STEC-HUS, plasma exchange and hemodialysis were initiated, which resulted in a rapid increase in the platelet count and decrease in lactate dehydrogenase levels. The patient presented an enlarged gallbladder detected by computed tomography during the course of treatment. Due to recurrent flare-ups, the patient had to undergo several rounds of endoscopic retrograde biliary drainage and, ultimately, cholecystectomy to prevent relapse of acute cholecystitis. Since cholecystitis was thought to have been caused by complex mechanisms in this case, we discussed those from multiple perspectives. This case report highlights the need for particular care to be given to the management of pre-existing diseases as well as STEC-HUS, especially in older patients.
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Affiliation(s)
- Ryuta Uwatoko
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
| | - Nao Kani
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Shuzo Makino
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Tomoya Naka
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Kazuhiro Okamoto
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Hiromitsu Miyakawa
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Nobuhiro Hashimoto
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Rei Iio
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Yoshiyasu Ueda
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
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Avdonin PP, Blinova MS, Generalova GA, Emirova KM, Avdonin PV. The Role of the Complement System in the Pathogenesis of Infectious Forms of Hemolytic Uremic Syndrome. Biomolecules 2023; 14:39. [PMID: 38254639 PMCID: PMC10813406 DOI: 10.3390/biom14010039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/24/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Hemolytic uremic syndrome (HUS) is an acute disease and the most common cause of childhood acute renal failure. HUS is characterized by a triad of symptoms: microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In most of the cases, HUS occurs as a result of infection caused by Shiga toxin-producing microbes: hemorrhagic Escherichia coli and Shigella dysenteriae type 1. They account for up to 90% of all cases of HUS. The remaining 10% of cases grouped under the general term atypical HUS represent a heterogeneous group of diseases with similar clinical signs. Emerging evidence suggests that in addition to E. coli and S. dysenteriae type 1, a variety of bacterial and viral infections can cause the development of HUS. In particular, infectious diseases act as the main cause of aHUS recurrence. The pathogenesis of most cases of atypical HUS is based on congenital or acquired defects of complement system. This review presents summarized data from recent studies, suggesting that complement dysregulation is a key pathogenetic factor in various types of infection-induced HUS. Separate links in the complement system are considered, the damage of which during bacterial and viral infections can lead to complement hyperactivation following by microvascular endothelial injury and development of acute renal failure.
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Affiliation(s)
- Piotr P. Avdonin
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
| | - Maria S. Blinova
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
| | - Galina A. Generalova
- Saint Vladimir Moscow City Children’s Clinical Hospital, 107014 Moscow, Russia; (G.A.G.); (K.M.E.)
- Department of Pediatrics, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Khadizha M. Emirova
- Saint Vladimir Moscow City Children’s Clinical Hospital, 107014 Moscow, Russia; (G.A.G.); (K.M.E.)
- Department of Pediatrics, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Pavel V. Avdonin
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
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Kellnerová S, Huber S, Massri M, Fleischer V, Losso K, Sarg B, Kremser L, Talasz H, He X, Varrone E, Brigotti M, Ardissino G, Orth-Höller D, Würzner R. Enzymatic Cleavage of Stx2a in the Gut and Identification of Pancreatic Elastase and Trypsin as Possible Main Cleavers. Microorganisms 2023; 11:2487. [PMID: 37894145 PMCID: PMC10609011 DOI: 10.3390/microorganisms11102487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/15/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
Shiga toxins (Stxs), especially the Stx2a subtype, are the major virulence factors involved in enterohemorrhagic Escherichia coli (EHEC)-associated hemolytic uremic syndrome (eHUS), a life-threatening disease causing acute kidney injury, especially in children. After oral transmission and colonization in the gut, EHEC release Stx. Intracellular cleavage of the Stx A subunit, when followed by reduction, boosts the enzymatic activity that causes damage to targeted cells. This cleavage was assumed to be mostly mediated by furin during Stx intracellular trafficking. To investigate whether this cleavage could occur in the intestine, even prior to entering target cells, Stx2a A subunit structure (intact or cleaved) was characterized after its exposure to specific host factors present in human stool. The molecular weight of Stx2a A subunit/fragments was determined by immunoblotting after electrophoretic separation under reducing conditions. In this study, it was demonstrated that Stx2a is cleaved by certain human stool components. Trypsin and chymotrypsin-like elastase 3B (CELA3B), two serine proteases, were identified as potential candidates that can trigger the extracellular cleavage of Stx2a A subunit directly after its secretion by EHEC in the gut. Whether the observed cleavage indeed translates to natural infections and plays a role in eHUS pathogenesis has yet to be determined. If so, it seems likely that a host's protease profile could affect disease development by changing the toxin's biological features.
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Affiliation(s)
- Sára Kellnerová
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.K.); (S.H.); (M.M.); (V.F.)
| | - Silke Huber
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.K.); (S.H.); (M.M.); (V.F.)
| | - Mariam Massri
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.K.); (S.H.); (M.M.); (V.F.)
| | - Verena Fleischer
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.K.); (S.H.); (M.M.); (V.F.)
| | - Klemens Losso
- Institute of Analytical Chemistry and Radiochemistry, University of Innsbruck, 6020 Innsbruck, Austria;
- Department of Food Technology and Nutrition, MCI|The Entrepreneurial School, 6020 Innsbruck, Austria
| | - Bettina Sarg
- Protein Core Facility, Institute of Medical Biochemistry, Center of Chemistry and Biomedicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.S.); (L.K.); (H.T.)
| | - Leopold Kremser
- Protein Core Facility, Institute of Medical Biochemistry, Center of Chemistry and Biomedicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.S.); (L.K.); (H.T.)
| | - Heribert Talasz
- Protein Core Facility, Institute of Medical Biochemistry, Center of Chemistry and Biomedicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.S.); (L.K.); (H.T.)
| | - Xiaohua He
- Western Regional Research Center, U.S. Department of Agriculture, Agricultural Research Service, Albany, CA 74710, USA;
| | - Elisa Varrone
- Department of Medical and Surgical Sciences, School of Medicine, University of Bologna, 40126 Bologna, Italy; (E.V.); (M.B.)
| | - Maurizio Brigotti
- Department of Medical and Surgical Sciences, School of Medicine, University of Bologna, 40126 Bologna, Italy; (E.V.); (M.B.)
| | - Gianluigi Ardissino
- Center for HUS Prevention, Control and Management at Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Dorothea Orth-Höller
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.K.); (S.H.); (M.M.); (V.F.)
- MB-LAB–Clinical Microbiology Laboratory, 6020 Innsbruck, Austria
| | - Reinhard Würzner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, 6020 Innsbruck, Austria; (S.K.); (S.H.); (M.M.); (V.F.)
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4
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Galvez C, Krall P, Rojas A, Oh J, Cano F. HUS with mutations in CFH and STEC infection treated with eculizumab in a 4-year-old girl. Pediatr Nephrol 2023; 38:1195-1203. [PMID: 35969277 DOI: 10.1007/s00467-022-05694-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome secondary to Shiga-toxin-producing Escherichia coli infection (STEC-HUS) generally shows a favorable outcome. Few cases develop extra-renal complications, since neurological involvement is an important cause of morbidity and mortality. The role of complement in STEC-HUS has been recently highlighted, and the use of eculizumab in severe cases has been communicated. HUS results from environmental and genetic factors, but the simultaneous occurrence of STEC and complement mutations remains undetermined. METHODS A pediatric case with severe STEC-HUS carrying CFH mutations, with favorable response to eculizumab is analyzed. RESULTS STEC-HUS was diagnosed in a 4-year-old girl with classic HUS, including low C3. Peritoneal dialysis was started due to hypertension, oligoanuria, and pleural effusion. She evolved with generalized tonic-clonic seizures and required mechanical ventilation. MRI reported multiple supra- and infratentorial ischemic lesions with laminar/striatal cortical necrosis and leukoencephalopathy. After two eculizumab doses, a significative stabilization in diuresis, blood pressure, creatinine, and C3 was achieved. At the third week, episodes of massive digestive bleeding and a life-threatening condition required a colectomy thus preserving the ileocecal valve. Due to atypical evolution, a genetic study was considered, identifying two heterozygous variants (CFH S1191L/V1197A). CONCLUSION STEC-HUS in patients with a genetic predisposition has been previously reported, but the low frequency of occurrence makes it a rare disease. As in the present case, patients with atypical course might benefit from genetic analysis to evaluate early eculizumab initiation and to better understand its phenotype. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Carla Galvez
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile
| | - Paola Krall
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile.,Institute of Medicine, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Alejandro Rojas
- Institute of Medicine, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Jun Oh
- Department of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Cano
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile.
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Cauchois R, Muller R, Lagarde M, Dignat-George F, Tellier E, Kaplanski G. Is Endothelial Activation a Critical Event in Thrombotic Thrombocytopenic Purpura? J Clin Med 2023; 12:jcm12030758. [PMID: 36769407 PMCID: PMC9918301 DOI: 10.3390/jcm12030758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a severe thrombotic microangiopathy. The current pathophysiologic paradigm suggests that the ADAMTS13 deficiency leads to Ultra Large-Von Willebrand Factor multimers accumulation with generation of disseminated microthrombi. Nevertheless, the role of endothelial cells in this pathology remains an issue. In this review, we discuss the various clinical, in vitro and in vivo experimental data that support the important role of the endothelium in this pathology, suggesting that ADAMTS13 deficiency may be a necessary but not sufficient condition to induce TTP. The "second hit" model suggests that in TTP, in addition to ADAMTS13 deficiency, endogenous or exogenous factors induce endothelial activation affecting mainly microvascular cells. This leads to Weibel-Palade bodies degranulation, resulting in UL-VWF accumulation in microcirculation. This endothelial activation seems to be worsened by various amplification loops, such as the complement system, nucleosomes and free heme.
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Affiliation(s)
- Raphael Cauchois
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, INSERM, INRAE, C2VN, CHU Conception, Internal Medicine and Clinical Immunology, 13005 Marseille, France
- French Reference Center for Thrombotic Microangiopathies, 75571 Paris, France
- Correspondence:
| | - Romain Muller
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, INSERM, INRAE, C2VN, CHU Conception, Internal Medicine and Clinical Immunology, 13005 Marseille, France
| | - Marie Lagarde
- French Reference Center for Thrombotic Microangiopathies, 75571 Paris, France
- Aix Marseille University, INSERM, INRAE, C2VN, 13005 Marseille, France
| | - Françoise Dignat-George
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, INSERM, INRAE, C2VN, CHU Conception, Hematology Laboratory, 13005 Marseille, France
| | - Edwige Tellier
- French Reference Center for Thrombotic Microangiopathies, 75571 Paris, France
- Aix Marseille University, INSERM, INRAE, C2VN, 13005 Marseille, France
| | - Gilles Kaplanski
- Aix Marseille University, Assistance Publique Hôpitaux de Marseille, INSERM, INRAE, C2VN, CHU Conception, Internal Medicine and Clinical Immunology, 13005 Marseille, France
- French Reference Center for Thrombotic Microangiopathies, 75571 Paris, France
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6
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Liu Y, Thaker H, Wang C, Xu Z, Dong M. Diagnosis and Treatment for Shiga Toxin-Producing Escherichia coli Associated Hemolytic Uremic Syndrome. Toxins (Basel) 2022; 15:10. [PMID: 36668830 PMCID: PMC9862836 DOI: 10.3390/toxins15010010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Shiga toxin-producing Escherichia coli (STEC)-associated hemolytic uremic syndrome (STEC-HUS) is a clinical syndrome involving hemolytic anemia (with fragmented red blood cells), low levels of platelets in the blood (thrombocytopenia), and acute kidney injury (AKI). It is the major infectious cause of AKI in children. In severe cases, neurological complications and even death may occur. Treating STEC-HUS is challenging, as patients often already have organ injuries when they seek medical treatment. Early diagnosis is of great significance for improving prognosis and reducing mortality and sequelae. In this review, we first briefly summarize the diagnostics for STEC-HUS, including history taking, clinical manifestations, fecal and serological detection methods for STEC, and complement activation monitoring. We also summarize preventive and therapeutic strategies for STEC-HUS, such as vaccines, volume expansion, renal replacement therapy (RRT), antibiotics, plasma exchange, antibodies and inhibitors that interfere with receptor binding, and the intracellular trafficking of the Shiga toxin.
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Affiliation(s)
- Yang Liu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Hatim Thaker
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Chunyan Wang
- Department of Nephrology, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Zhonggao Xu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
| | - Min Dong
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
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7
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Genest DS, Patriquin CJ, Licht C, John R, Reich HN. Renal Thrombotic Microangiopathy: A Review. Am J Kidney Dis 2022; 81:591-605. [PMID: 36509342 DOI: 10.1053/j.ajkd.2022.10.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA), a pathological lesion observed in a wide spectrum of diseases, is triggered by endothelial injury and/or dysfunction. Although TMA lesions are often accompanied by clinical features of microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury, renal-limited forms of TMA are not infrequently encountered in clinical practice. The presence of renal-limited manifestations can be diagnostically challenging, often delaying the initiation of targeted therapy. Prompt investigation and empirical treatment of TMA is warranted to reduce associated morbidity and mortality. Major advances have been made with respect to the pathophysiology of primary TMA entities, with the subsequent development of novel diagnostic tools and lifesaving therapies for diseases like thrombotic thrombocytopenic purpura and complement-mediated TMA. This article will review the clinical presentation and pathologic hallmarks of TMA involving the kidney, and the disease-specific mechanisms that contribute to the endothelial injury that characterizes TMA lesions. Diagnostic approach and both empirical and disease-specific treatment strategies will be discussed, along with the potential role for emerging targeted disease-specific therapies.
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Affiliation(s)
- Dominique Suzanne Genest
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rohan John
- Division of Laboratory Medicine and Pathology, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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8
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Ray R, Singh P. Prevalence and Implications of Shiga Toxin-Producing E. coli in Farm and Wild Ruminants. Pathogens 2022; 11:1332. [PMID: 36422584 PMCID: PMC9694250 DOI: 10.3390/pathogens11111332] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 08/27/2023] Open
Abstract
Shiga-toxin-producing Escherichia coli (STEC) is a food-borne pathogen that causes human gastrointestinal infections across the globe, leading to kidney failure or even death in severe cases. E. coli are commensal members of humans and animals' (cattle, bison, and pigs) guts, however, may acquire Shiga-toxin-encoded phages. This acquisition or colonization by STEC may lead to dysbiosis in the intestinal microbial community of the host. Wildlife and livestock animals can be asymptomatically colonized by STEC, leading to pathogen shedding and transmission. Furthermore, there has been a steady uptick in new STEC variants representing various serotypes. These, along with hybrids of other pathogenic E. coli (UPEC and ExPEC), are of serious concern, especially when they possess enhanced antimicrobial resistance, biofilm formation, etc. Recent studies have reported these in the livestock and food industry with minimal focus on wildlife. Disturbed natural habitats and changing climates are increasingly creating wildlife reservoirs of these pathogens, leading to a rise in zoonotic infections. Therefore, this review comprehensively surveyed studies on STEC prevalence in livestock and wildlife hosts. We further present important microbial and environmental factors contributing to STEC spread as well as infections. Finally, we delve into potential strategies for limiting STEC shedding and transmission.
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Affiliation(s)
| | - Pallavi Singh
- Department of Biological Sciences, Northern Illinois University, Dekalb, IL 60115, USA
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Formeck CL, Manrique-Caballero CL, Gómez H, Kellum JA. Uncommon Causes of Acute Kidney Injury. Crit Care Clin 2022; 38:317-347. [DOI: 10.1016/j.ccc.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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10
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Cortes C, Desler C, Mazzoli A, Chen JY, Ferreira VP. The role of properdin and Factor H in disease. Adv Immunol 2022; 153:1-90. [PMID: 35469595 DOI: 10.1016/bs.ai.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The complement system consists of three pathways (alternative, classical, and lectin) that play a fundamental role in immunity and homeostasis. The multifunctional role of the complement system includes direct lysis of pathogens, tagging pathogens for phagocytosis, promotion of inflammatory responses to control infection, regulation of adaptive cellular immune responses, and removal of apoptotic/dead cells and immune complexes from circulation. A tight regulation of the complement system is essential to avoid unwanted complement-mediated damage to the host. This regulation is ensured by a set of proteins called complement regulatory proteins. Deficiencies or malfunction of these regulatory proteins may lead to pro-thrombotic hematological diseases, renal and ocular diseases, and autoimmune diseases, among others. This review focuses on the importance of two complement regulatory proteins of the alternative pathway, Factor H and properdin, and their role in human diseases with an emphasis on: (a) characterizing the main mechanism of action of Factor H and properdin in regulating the complement system and protecting the host from complement-mediated attack, (b) describing the dysregulation of the alternative pathway as a result of deficiencies, or mutations, in Factor H and properdin, (c) outlining the clinical findings, management and treatment of diseases associated with mutations and deficiencies in Factor H, and (d) defining the unwanted and inadequate functioning of properdin in disease, through a discussion of various experimental research findings utilizing in vitro, mouse and human models.
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Affiliation(s)
- Claudio Cortes
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, United States.
| | - Caroline Desler
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Amanda Mazzoli
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Jin Y Chen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States.
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11
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Costigan C, Raftery T, Carroll AG, Wildes D, Reynolds C, Cunney R, Dolan N, Drew RJ, Lynch BJ, O’Rourke DJ, Stack M, Sweeney C, Shahwan A, Twomey E, Waldron M, Riordan M, Awan A, Gorman KM. Neurological involvement in children with hemolytic uremic syndrome. Eur J Pediatr 2022; 181:501-512. [PMID: 34378062 PMCID: PMC8821508 DOI: 10.1007/s00431-021-04200-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
Our objective was to establish the rate of neurological involvement in Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STEC-HUS) and describe the clinical presentation, management and outcome. A retrospective chart review of children aged ≤ 16 years with STEC-HUS in Children's Health Ireland from 2005 to 2018 was conducted. Laboratory confirmation of STEC infection was required for inclusion. Neurological involvement was defined as encephalopathy, focal neurological deficit, and/or seizure activity. Data on clinical presentation, management, and outcome were collected. We identified 240 children with HUS; 202 had confirmed STEC infection. Neurological involvement occurred in 22 (11%). The most common presentation was seizures (73%). In the neurological group, 19 (86%) were treated with plasma exchange and/or eculizumab. Of the 21 surviving children with neurological involvement, 19 (91%) achieved a complete neurological recovery. A higher proportion of children in the neurological group had renal sequelae (27% vs. 12%, P = .031). One patient died from multi-organ failure.Conclusion: We have identified the rate of neurological involvement in a large cohort of children with STEC-HUS as 11%. Neurological involvement in STEC-HUS is associated with good long-term outcome (complete neurological recovery in 91%) and a low case-fatality rate (4.5%) in our cohort. What is Known: • HUS is associated with neurological involvement in up to 30% of cases. • Neurological involvement has been reported as predictor of poor outcome, with associated increased morbidity and mortality. What is New: • The incidence of neurological involvement in STEC-HUS is 11%. • Neurological involvement is associated with predominantly good long-term outcome (90%) and a reduced case-fatality rate (4.5%) compared to older reports.
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Affiliation(s)
- Caoimhe Costigan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Tara Raftery
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Anne G. Carroll
- Department of Radiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Dermot Wildes
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Claire Reynolds
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Robert Cunney
- Department of Clinical Microbiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niamh Dolan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Richard J. Drew
- Department of Clinical Microbiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland
| | - Bryan J. Lynch
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Declan J. O’Rourke
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Maria Stack
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Clodagh Sweeney
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Amre Shahwan
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Eilish Twomey
- Department of Radiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Mary Waldron
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Michael Riordan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Atif Awan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Kathleen M. Gorman
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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Treatment of Shiga-Toxin Hus with Severe Neurologic Features with Eculizumab. Case Rep Pediatr 2021; 2021:8053246. [PMID: 34812294 PMCID: PMC8605924 DOI: 10.1155/2021/8053246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Hemolytic Uremic Syndrome (HUS) is a constellation of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. Shiga toxin-producing Escherichia coli- (STEC-) mediated HUS is a common cause of acute renal failure in children and can rarely result in severe neurological complications such as encephalopathy, seizures, cerebrovascular accidents, and coma. Current literature supports use of eculizumab, a monoclonal antibody that blocks complement activation, in atypical HUS (aHUS). However, those with neurologic complications from STEC-HUS have complement activation and deposition of aggregates in microvasculature and may be treated with eculizumab. In this case report, we describe a 3-year-old boy with diarrhea-positive STEC-HUS who developed severe neurologic involvement in addition to acute renal failure requiring renal replacement therapy. He was initiated on eculizumab therapy, with clinical improvement and organ recovery. This case highlights systemic complications of STEC-HUS in a pediatric patient. The current literature is limited but has suggested a role for complement mediation in cases with severe complications. We review the importance of early recognition of complications, use of eculizumab, and current data available.
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13
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Freiwald T, Afzali B. Renal diseases and the role of complement: Linking complement to immune effector pathways and therapeutics. Adv Immunol 2021; 152:1-81. [PMID: 34844708 PMCID: PMC8905641 DOI: 10.1016/bs.ai.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complement system is an ancient and phylogenetically conserved key danger sensing system that is critical for host defense against pathogens. Activation of the complement system is a vital component of innate immunity required for the detection and removal of pathogens. It is also a central orchestrator of adaptive immune responses and a constituent of normal tissue homeostasis. Once complement activation occurs, this system deposits indiscriminately on any cell surface in the vicinity and has the potential to cause unwanted and excessive tissue injury. Deposition of complement components is recognized as a hallmark of a variety of kidney diseases, where it is indeed associated with damage to the self. The provenance and the pathophysiological role(s) played by complement in each kidney disease is not fully understood. However, in recent years there has been a renaissance in the study of complement, with greater appreciation of its intracellular roles as a cell-intrinsic system and its interplay with immune effector pathways. This has been paired with a profusion of novel therapeutic agents antagonizing complement components, including approved inhibitors against complement components (C)1, C3, C5 and C5aR1. A number of clinical trials have investigated the use of these more targeted approaches for the management of kidney diseases. In this review we present and summarize the evidence for the roles of complement in kidney diseases and discuss the available clinical evidence for complement inhibition.
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Affiliation(s)
- Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States; Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Behdad Afzali
- Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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14
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Lee KS, Jeong YJ, Lee MS. Escherichia coli Shiga Toxins and Gut Microbiota Interactions. Toxins (Basel) 2021; 13:toxins13060416. [PMID: 34208170 PMCID: PMC8230793 DOI: 10.3390/toxins13060416] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/19/2022] Open
Abstract
Escherichia coli (EHEC) and Shigella dysenteriae serotype 1 are enterohemorrhagic bacteria that induce hemorrhagic colitis. This, in turn, may result in potentially lethal complications, such as hemolytic uremic syndrome (HUS), which is characterized by thrombocytopenia, acute renal failure, and neurological abnormalities. Both species of bacteria produce Shiga toxins (Stxs), a phage-encoded exotoxin inhibiting protein synthesis in host cells that are primarily responsible for bacterial virulence. Although most studies have focused on the pathogenic roles of Stxs as harmful substances capable of inducing cell death and as proinflammatory factors that sensitize the host target organs to damage, less is known about the interface between the commensalism of bacterial communities and the pathogenicity of the toxins. The gut contains more species of bacteria than any other organ, providing pathogenic bacteria that colonize the gut with a greater number of opportunities to encounter other bacterial species. Notably, the presence in the intestines of pathogenic EHEC producing Stxs associated with severe illness may have compounding effects on the diversity of the indigenous bacteria and bacterial communities in the gut. The present review focuses on studies describing the roles of Stxs in the complex interactions between pathogenic Shiga toxin-producing E. coli, the resident microbiome, and host tissues. The determination of these interactions may provide insights into the unresolved issues regarding these pathogens.
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Affiliation(s)
- Kyung-Soo Lee
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, 125 Gwahak-ro, Daejeon 34141, Korea;
- Department of Biomolecular Science, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 127 Gajeong-ro, Yuseong-gu, Daejeon 34113, Korea
| | - Yu-Jin Jeong
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, 125 Gwahak-ro, Daejeon 34141, Korea;
- Correspondence: (Y.-J.J.); (M.-S.L.)
| | - Moo-Seung Lee
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, 125 Gwahak-ro, Daejeon 34141, Korea;
- Department of Biomolecular Science, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 127 Gajeong-ro, Yuseong-gu, Daejeon 34113, Korea
- Correspondence: (Y.-J.J.); (M.-S.L.)
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15
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Luna M, Kamariski M, Principi I, Bocanegra V, Vallés PG. Severely ill pediatric patients with Shiga toxin-associated hemolytic uremic syndrome (STEC-HUS) who suffered from multiple organ involvement in the early stage. Pediatr Nephrol 2021; 36:1499-1509. [PMID: 33205220 DOI: 10.1007/s00467-020-04829-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/24/2020] [Accepted: 10/15/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) is the main cause of pediatric acute kidney injury (AKI) in Argentina. Endothelial injury is the trigger event in the microangiopathic process. The host inflammatory response to toxin and E. coli lipopolysaccharide (LPS) is involved in disease pathophysiology. METHODS This retrospective study describes pediatric STEC-HUS patients with multiorgan involvement at the initial phase of disease. A retrospective study of critically ill HUS patients with evidence of E. coli infection was conducted through a period of 15 years. RESULTS Forty-four patients 35.4 ± 4.1 months were admitted to the intensive care unit for 21 ± 2 days. Mechanical ventilation was required in 41 patients, early inotropic support in 37, and 28 developed septic shock. Forty-one patients required kidney replacement therapy for 12 ± 1 days. Forty-one patients showed neurological dysfunction. Dilated cardiomyopathy was demonstrated in 3 patients, left ventricular systolic dysfunction in 4, and hypertension in 17. Four patients had pulmonary hemorrhage, and acute respiratory distress syndrome in 2. Colectomy for transmural colonic necrosis was performed in 3 patients. Thirty-seven patients were treated with therapeutic plasma exchange, and 28 patients received methylprednisolone (10 mg/kg for 3 days). Of the surviving 32 patients, neurological sequelae were seen in 11 and chronic kidney failure in 5. CONCLUSIONS Severe clinical outcome at onset suggests an amplified inflammatory response after exposure to Shiga toxin and/or E. coli LPS. STEC-HUS associated with severe neurological involvement, hemodynamic instability, and AKI requires intensive care and focused therapy.
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Affiliation(s)
- Mariana Luna
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina
| | - Mariana Kamariski
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina
| | - Iliana Principi
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina
| | - Victoria Bocanegra
- Instituto de Medicina y Biología Experimental de Cuyo (IMBECU), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Mendoza, Argentina
| | - Patricia G Vallés
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina. .,Área de Fisiopatología, Departamento de Patología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Mendoza, Argentina.
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16
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Feitz WJC, van Setten PA, van der Velden TJAM, Licht C, van den Heuvel LPJW, van de Kar NCAJ. Cell Biological Responses after Shiga Toxin-1 Exposure to Primary Human Glomerular Microvascular Endothelial Cells from Pediatric and Adult Origin. Int J Mol Sci 2021; 22:ijms22115615. [PMID: 34070679 PMCID: PMC8199108 DOI: 10.3390/ijms22115615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/17/2021] [Accepted: 05/22/2021] [Indexed: 01/16/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is characterized by a triad of symptoms consisting of hemolytic anemia, thrombocytopenia and acute renal failure. The most common form of HUS is caused by an infection with Shiga toxin (Stx) producing Escherichia coli bacteria (STEC-HUS), and the kidneys are the major organs affected. The development of HUS after an infection with Stx occurs most frequently in children under the age of 5 years. However, the cause for the higher incidence of STEC-HUS in children compared to adults is still not well understood. Human glomerular microvascular endothelial cells (HGMVECs) isolated and cultured from pediatric and adult kidney tissue were investigated with respect to Stx binding and different cellular responses. Shiga toxin-1 (Stx-1) inhibited protein synthesis in both pediatric and adult HGMVECs in a dose-dependent manner at basal conditions. The preincubation of pediatric and adult HGMVECs for 24 hrs with TNFα resulted in increased Stx binding to the cell surface and a 20-40% increase in protein synthesis inhibition in both age groups. A decreased proliferation of cells was found when a bromodeoxyuridine (BrdU) assay was performed. A trend towards a delay in endothelial wound closure was visible when pediatric and adult HGMVECs were incubated with Stx-1. Although minor differences between pediatric HGMVECs and adult HGMVECs were found in the assays applied in this study, no significant differences were observed. In conclusion, we have demonstrated that in vitro primary HGMVECs isolated from pediatric and adult kidneys do not significantly differ in their cell biological responses to Stx-1.
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Affiliation(s)
- Wouter J. C. Feitz
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Department of Pediatrics, Amalia Children’s Hospital, Radboudumc, 6525 GA Nijmegen, The Netherlands;
| | - Petra A. van Setten
- Department of Pediatrics, Amalia Children’s Hospital, Radboudumc, 6525 GA Nijmegen, The Netherlands;
| | - Thea J. A. M. van der Velden
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
| | - Christoph Licht
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Lambert P. J. W. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
- Department of Development and Regeneration, Department of Pediatric Nephrology, KU, 3000 Leuven, Belgium
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
- Department of Pediatrics, Amalia Children’s Hospital, Radboudumc, 6525 GA Nijmegen, The Netherlands;
- Correspondence: ; Tel.: +31-24-36-14430
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17
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Monet-Didailler C, Chevallier A, Godron-Dubrasquet A, Allard L, Delmas Y, Contin-Bordes C, Brissaud O, Llanas B, Harambat J. Outcome of children with Shiga toxin-associated haemolytic uraemic syndrome treated with eculizumab: a matched cohort study. Nephrol Dial Transplant 2021; 35:2147-2153. [PMID: 31411695 DOI: 10.1093/ndt/gfz158] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/27/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment with eculizumab in Shiga toxin-associated haemolytic and uraemic syndrome (STEC-HUS) remains controversial despite its increasing utilization. The aim of our study was to evaluate the outcomes of children treated with eculizumab for STEC-HUS in a single-centre matched cohort study. METHODS Data were retrospectively collected from medical records of children diagnosed with STEC-HUS. The outcomes of patients treated with eculizumab for STEC-HUS were compared with those of a control group of untreated patients matched for age, sex and severity of acute kidney injury with a 1:2 matching scheme. RESULTS Eighteen children (median age 40.6 months) with STEC-HUS treated with eculizumab were compared with 36 matched control patients (median age 36.4 months) who did not receive eculizumab. All patients survived in the two groups. Within 1 month of HUS onset, the evolution of haematological and renal parameters did not differ between the two groups. At 12 months of follow-up, renal outcome was not significantly different between the two groups. At the last follow-up, the prevalence of decreased glomerular filtration rate in the eculizumab group (27%) was not statistically different from that in controls (38%), as was the prevalence of proteinuria and high blood pressure. Children who received eculizumab more often had extrarenal sequelae during follow-up. Eculizumab treatment appeared to be safe in children with STEC-HUS. CONCLUSION The benefit of eculizumab on renal and extrarenal outcomes in STEC-HUS could not be established based on our findings. However, efficacy and safety are not best assessed by the observational design and small sample size of our study. Randomized controlled trials are thus required to determine the efficacy of eculizumab in this indication.
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Affiliation(s)
- Catherine Monet-Didailler
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Audrey Chevallier
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Astrid Godron-Dubrasquet
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Lise Allard
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Yahsou Delmas
- Service de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Cécile Contin-Bordes
- Laboratoire d'Immunologie et Immunogénétique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Olivier Brissaud
- Service de Réanimation Pédiatrique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Brigitte Llanas
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Jérôme Harambat
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
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18
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Varrone E, Carnicelli D, Brigotti M. Extracellular Vesicles and Renal Endothelial Cells: A Fatal Attraction in Hemolytic Uremic Syndrome. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:795-804. [PMID: 33652019 DOI: 10.1016/j.ajpath.2021.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/22/2021] [Accepted: 02/10/2021] [Indexed: 12/14/2022]
Abstract
This review focuses on typical hemolytic uremic syndrome (HUS), a life-threatening sequela of human infections caused, particularly in children, by Shiga toxin-producing Escherichia coli strains. Thrombotic microangiopathy of the brain and the kidney is the end point of toxin action, resulting in the hallmarks of HUS (ie, thrombocytopenia, anemia, and acute renal failure). A growing body of evidence points to the role of extracellular vesicles released in the blood of patients by toxin-challenged circulating cells (monocytes, neutrophils, and erythrocytes) and platelets, as a key factor in the pathogenesis of HUS. This review provides i) an updated description of the pathogenesis of Shiga toxin-producing E. coli infections; ii) an analysis of blood cell-derived extracellular vesicles, and of their parent cells, as triggering factors in HUS; and iii) a model explaining why Shiga toxin-containing vesicles dock preferentially to the endothelia of target organs.
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Affiliation(s)
- Elisa Varrone
- Department of Experimental, Diagnostic and Specialty Medicine, School of Medicine, University of Bologna, Bologna, Italy
| | - Domenica Carnicelli
- Department of Experimental, Diagnostic and Specialty Medicine, School of Medicine, University of Bologna, Bologna, Italy
| | - Maurizio Brigotti
- Department of Experimental, Diagnostic and Specialty Medicine, School of Medicine, University of Bologna, Bologna, Italy.
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Moore SR, Menon SS, Cortes C, Ferreira VP. Hijacking Factor H for Complement Immune Evasion. Front Immunol 2021; 12:602277. [PMID: 33717083 PMCID: PMC7947212 DOI: 10.3389/fimmu.2021.602277] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/15/2021] [Indexed: 12/15/2022] Open
Abstract
The complement system is an essential player in innate and adaptive immunity. It consists of three pathways (alternative, classical, and lectin) that initiate either spontaneously (alternative) or in response to danger (all pathways). Complement leads to numerous outcomes detrimental to invaders, including direct killing by formation of the pore-forming membrane attack complex, recruitment of immune cells to sites of invasion, facilitation of phagocytosis, and enhancement of cellular immune responses. Pathogens must overcome the complement system to survive in the host. A common strategy used by pathogens to evade complement is hijacking host complement regulators. Complement regulators prevent attack of host cells and include a collection of membrane-bound and fluid phase proteins. Factor H (FH), a fluid phase complement regulatory protein, controls the alternative pathway (AP) both in the fluid phase of the human body and on cell surfaces. In order to prevent complement activation and amplification on host cells and tissues, FH recognizes host cell-specific polyanionic markers in combination with complement C3 fragments. FH suppresses AP complement-mediated attack by accelerating decay of convertases and by helping to inactivate C3 fragments on host cells. Pathogens, most of which do not have polyanionic markers, are not recognized by FH. Numerous pathogens, including certain bacteria, viruses, protozoa, helminths, and fungi, can recruit FH to protect themselves against host-mediated complement attack, using either specific receptors and/or molecular mimicry to appear more like a host cell. This review will explore pathogen complement evasion mechanisms involving FH recruitment with an emphasis on: (a) characterizing the structural properties and expression patterns of pathogen FH binding proteins, as well as other strategies used by pathogens to capture FH; (b) classifying domains of FH important in pathogen interaction; and (c) discussing existing and potential treatment strategies that target FH interactions with pathogens. Overall, many pathogens use FH to avoid complement attack and appreciating the commonalities across these diverse microorganisms deepens the understanding of complement in microbiology.
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Affiliation(s)
- Sara R Moore
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Smrithi S Menon
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Claudio Cortes
- Department of Foundational Medical Sciences, Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
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20
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Rocchetti L, Munari B, Varrone E, Porcellini E, Orth-Höller D, Würzner R, Carnicelli D, Brigotti M. Method for the Detection of the Cleaved Form of Shiga Toxin 2a Added to Normal Human Serum. Toxins (Basel) 2021; 13:toxins13020094. [PMID: 33530614 PMCID: PMC7911550 DOI: 10.3390/toxins13020094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/14/2021] [Accepted: 01/21/2021] [Indexed: 11/16/2022] Open
Abstract
The pathogenesis of Escherichia coli-induced hemolytic uremic syndrome (eHUS) caused by infections with pathogenic Shiga toxin (Stx) producing E. coli (STEC) is centered on bacterial (e.g., Stx) and host factors (circulating cells, complement system, serum proteins) whose interaction is crucial for the immediate outcome and for the development of this life-threatening sequela. Stx2a, associated to circulating cells (early toxemia) or extracellular vesicles (late toxemia) in blood, is considered the main pathogenic factor in the development of eHUS. Recently, it was found that the functional properties of Stx2a (binding to circulating cells and complement components) change according to modifications of the structure of the toxin, i.e., after a single cleavage of the A subunit resulting in two fragments, A1 and A2, linked by a disulfide bridge. Herein, we describe a method to be used for the detection of the cleaved form of Stx2a in the serum of STEC-infected or eHUS patients. The method is based on the detection of the boosted inhibitory activity of the cleaved toxin, upon treatment with reducing agents, on a rabbit cell-free translation system reconstituted with human ribosomes. The method overcomes the technical problem caused by the presence of inhibitors of translation in human serum that have been stalled by the addition of RNAase blockers and by treatment with immobilized protein G. This method, allowing the detection of Stx2a at concentrations similar to those found by ELISA in the blood of STEC-infected patients, could be a useful tool to study the contribution of the cleaved form of Stx2a in the pathogenesis of eHUS.
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Affiliation(s)
- Lucrezia Rocchetti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy; (L.R.); (B.M.); (E.V.); (E.P.); (D.C.)
| | - Beatrice Munari
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy; (L.R.); (B.M.); (E.V.); (E.P.); (D.C.)
| | - Elisa Varrone
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy; (L.R.); (B.M.); (E.V.); (E.P.); (D.C.)
| | - Elisa Porcellini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy; (L.R.); (B.M.); (E.V.); (E.P.); (D.C.)
| | - Dorothea Orth-Höller
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, A-6020 Innsbruck, Austria; (D.O.-H.); (R.W.)
| | - Reinhard Würzner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, A-6020 Innsbruck, Austria; (D.O.-H.); (R.W.)
| | - Domenica Carnicelli
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy; (L.R.); (B.M.); (E.V.); (E.P.); (D.C.)
| | - Maurizio Brigotti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy; (L.R.); (B.M.); (E.V.); (E.P.); (D.C.)
- Correspondence: ; Tel.: +39-051-209-4716
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Shiga Toxin 2a Binds to Complement Components C3b and C5 and Upregulates Their Gene Expression in Human Cell Lines. Toxins (Basel) 2020; 13:toxins13010008. [PMID: 33374102 PMCID: PMC7824702 DOI: 10.3390/toxins13010008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/16/2020] [Accepted: 12/22/2020] [Indexed: 01/06/2023] Open
Abstract
Enterohemorrhagic Escherichia coli (EHEC) infections can cause EHEC-associated hemolytic uremic syndrome (eHUS) via its main virulent factor, Shiga toxins (Stxs). Complement has been reported to be involved in the progression of eHUS. The aim of this study was to investigate the interactions of the most effective subtype of the toxin, Stx2a, with pivotal complement proteins C3b and C5. The study further examined the effect of Stx2a stimulation on the transcription and synthesis of these complement proteins in human target cell lines. Binding of Stx2a to C3b and C5 was evaluated by ELISA. Kidney and gut cell lines (HK-2 and HCT-8) were stimulated with varied concentrations of Stx2a. Subsequent evaluation of complement gene transcription was studied by real-time PCR (qPCR), and ELISAs and Western blots were performed to examine protein synthesis of C3 and C5 in supernatants and lysates of stimulated HK-2 cells. Stx2a showed a specific binding to C3b and C5. Gene transcription of C3 and C5 was upregulated with increasing concentrations of Stx2a in both cell lines, but protein synthesis was not. This study demonstrates the binding of Stx2a to complement proteins C3b and C5, which could potentially be involved in regulating complement during eHUS infection, supporting further investigations into elucidating the role of complement in eHUS pathogenesis.
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Wijnsma KL, Veissi ST, de Wijs S, van der Velden T, Volokhina EB, Wagener FADTG, van de Kar NCAJ, van den Heuvel LP. Heme as Possible Contributing Factor in the Evolvement of Shiga-Toxin Escherichia coli Induced Hemolytic-Uremic Syndrome. Front Immunol 2020; 11:547406. [PMID: 33414780 PMCID: PMC7783363 DOI: 10.3389/fimmu.2020.547406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/16/2020] [Indexed: 01/29/2023] Open
Abstract
Shiga-toxin (Stx)-producing Escherichia coli hemolytic-uremic syndrome (STEC-HUS) is one of the most common causes of acute kidney injury in children. Stx-mediated endothelial injury initiates the cascade leading to thrombotic microangiopathy (TMA), still the exact pathogenesis remains elusive. Interestingly, there is wide variability in clinical presentation and outcome. One explanation for this could be the enhancement of TMA through other factors. We hypothesize that heme, as released during extensive hemolysis, contributes to the etiology of TMA. Plasma levels of heme and its scavenger hemopexin and degrading enzyme heme-oxygenase-1 (HO-1) were measured in 48 STEC-HUS patients. Subsequently, the effect of these disease-specific heme concentrations, in combination with Stx, was assessed on primary human glomerular microvascular endothelial cells (HGMVECs). Significantly elevated plasma heme levels up to 21.2 µM were found in STEC-HUS patients compared to controls and were inversely correlated with low or depleted plasma hemopexin levels (R2 −0.74). Plasma levels of HO-1 are significantly elevated compared to controls. Interestingly, especially patients with high heme levels (n = 12, heme levels above 75 quartile range) had high plasma HO-1 levels with median of 332.5 (86–720) ng/ml (p = 0.008). Furthermore, heme is internalized leading to a significant increase in reactive oxygen species production and stimulated both nuclear translocation of NF-κB and increased levels of its target gene (tissue factor). In conclusion, we are the first to show elevated heme levels in patients with STEC-HUS. These increased heme levels mediate endothelial injury by promoting oxidative stress and a pro-inflammatory and pro-thrombotic state. Hence, heme may be a contributing and driving factor in the pathogenesis of STEC-HUS and could potentially amplify the cascade leading to TMA.
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Affiliation(s)
- Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Susan T Veissi
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sem de Wijs
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thea van der Velden
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank A D T G Wagener
- Department of Dentistry-Orthodontics and Craniofacial Biology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - L P van den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
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Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
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Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Direct activation of the alternative complement pathway by SARS-CoV-2 spike proteins is blocked by factor D inhibition. Blood 2020; 136:2080-2089. [PMID: 32877502 PMCID: PMC7596849 DOI: 10.1182/blood.2020008248] [Citation(s) in RCA: 235] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/25/2020] [Indexed: 12/20/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly contagious respiratory virus that can lead to venous/arterial thrombosis, stroke, renal failure, myocardial infarction, thrombocytopenia, and other end-organ damage. Animal models demonstrating end-organ protection in C3-deficient mice and evidence of complement activation in humans have led to the hypothesis that SARS-CoV-2 triggers complement-mediated endothelial damage, but the mechanism is unclear. Here, we demonstrate that the SARS-CoV-2 spike protein (subunit 1 and 2), but not the N protein, directly activates the alternative pathway of complement (APC). Complement-dependent killing using the modified Ham test is blocked by either C5 or factor D inhibition. C3 fragments and C5b-9 are deposited on TF1PIGAnull target cells, and complement factor Bb is increased in the supernatant from spike protein–treated cells. C5 inhibition prevents the accumulation of C5b-9 on cells, but not C3c; however, factor D inhibition prevents both C3c and C5b-9 accumulation. Addition of factor H mitigates the complement attack. In conclusion, SARS-CoV-2 spike proteins convert nonactivator surfaces to activator surfaces by preventing the inactivation of the cell-surface APC convertase. APC activation may explain many of the clinical manifestations (microangiopathy, thrombocytopenia, renal injury, and thrombophilia) of COVID-19 that are also observed in other complement-driven diseases such as atypical hemolytic uremic syndrome and catastrophic antiphospholipid antibody syndrome. C5 inhibition prevents accumulation of C5b-9 in vitro but does not prevent upstream complement activation in response to SARS-CoV-2 spike proteins.
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Yuan X, Yu J, Gerber G, Chaturvedi S, Cole M, Chen H, Metjian A, Sperati CJ, Braunstein EM, Brodsky RA. Ex vivo assays to detect complement activation in complementopathies. Clin Immunol 2020; 221:108616. [PMID: 33148511 DOI: 10.1016/j.clim.2020.108616] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022]
Abstract
In complement-driven thrombotic microangiopathies, failure to regulate complement activation leads to end-organ damage. The modified Ham (mHam) test measures complement-mediated killing of a nucleated cell in vitro but lacks a confirmatory assay and reliable positive controls. We demonstrate that C5b-9 accumulation on the surface of TF1 PIGAnull cells correlates with cell killing in the mHam. We also show that Sialidase treatment of cells or addition of Shiga toxin 1 to human serum serve as a more reliable positive control for the mHam than cobra venom factor or lipopolysaccharide. Simultaneously performing the mHam and measuring C5b-9 accumulation either in GVB++ or GVB0 MgEGTA buffer with the addition of complement pathway specific inhibitors (anti-C5 antibody or a factor D inhibitor, ACH-145951) can be used to localize defects in complement regulation. As more targeted complement inhibitors become available, these assays may aid in the selection of personalized treatments for patients with complement-mediated diseases.
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Affiliation(s)
- Xuan Yuan
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jia Yu
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gloria Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael Cole
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hang Chen
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ara Metjian
- Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA
| | - C John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Volokhina EB, Feitz WJC, Elders LM, van der Velden TJAM, van de Kar NCAJ, van den Heuvel LPWJ. Shiga Toxin Selectively Upregulates Expression of Syndecan-4 and Adhesion Molecule ICAM-1 in Human Glomerular Microvascular Endothelium. Toxins (Basel) 2020; 12:E435. [PMID: 32635212 PMCID: PMC7405002 DOI: 10.3390/toxins12070435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is a severe renal disease that is often preceded by infection with Shiga toxin (Stx)-producing Escherichia coli (STEC). The exact mechanism of Stx-mediated inflammation on human glomerular microvascular endothelial cells (HGMVECs) during HUS is still not well understood. In this study, we investigated the effect of Stx1 on the gene expression of proteins involved in leucocyte-mediated and complement-mediated inflammation. Our results showed that Stx1 enhances the mRNA and protein expression of heparan sulfate proteoglycan (HSPG) syndecan-4 in HGMVECs pre-stimulated with tumor necrosis factor α (TNFα). CD44 was upregulated on mRNA but not on protein level; no effect on the mRNA expression of other tested HSPGs glypican-1 and betaglycan was observed. Furthermore, Stx1 upregulated the mRNA, cell surface expression, and supernatant levels of the intercellular adhesion molecule-1 (ICAM-1) in HGMVECs. Interestingly, no effect on the protein levels of alternative pathway (AP) components was observed, although C3 mRNA was upregulated. All observed effects were much stronger in HGMVECs than in human umbilical endothelial cells (HUVECs), a common model cell type used in endothelial studies. Our results provide new insights into the role of Stx1 in the pathogenesis of HUS. Possibilities to target the overexpression of syndecan-4 and ICAM-1 for STEC-HUS therapy should be investigated in future studies.
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Affiliation(s)
- Elena B. Volokhina
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (L.M.E.); (T.J.A.M.v.d.V.); (N.C.A.J.v.d.K.); (L.P.W.J.v.d.H.)
- Department of Laboratory Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Wouter J. C. Feitz
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (L.M.E.); (T.J.A.M.v.d.V.); (N.C.A.J.v.d.K.); (L.P.W.J.v.d.H.)
| | - Lonneke M. Elders
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (L.M.E.); (T.J.A.M.v.d.V.); (N.C.A.J.v.d.K.); (L.P.W.J.v.d.H.)
| | - Thea J. A. M. van der Velden
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (L.M.E.); (T.J.A.M.v.d.V.); (N.C.A.J.v.d.K.); (L.P.W.J.v.d.H.)
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (L.M.E.); (T.J.A.M.v.d.V.); (N.C.A.J.v.d.K.); (L.P.W.J.v.d.H.)
| | - Lambertus P. W. J. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (L.M.E.); (T.J.A.M.v.d.V.); (N.C.A.J.v.d.K.); (L.P.W.J.v.d.H.)
- Department of Laboratory Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium
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Netti GS, Santangelo L, Paulucci L, Piscopo G, Torres DD, Carbone V, Giordano P, Spadaccino F, Castellano G, Stallone G, Gesualdo L, Chironna M, Ranieri E, Giordano M. Low C3 Serum Levels Predict Severe Forms of STEC-HUS With Neurologic Involvement. Front Med (Lausanne) 2020; 7:357. [PMID: 32671083 PMCID: PMC7332746 DOI: 10.3389/fmed.2020.00357] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The correlation between the severity of hemolytic uremic syndrome related to Shiga toxin–producing Escherichia coli (STEC-HUS) and involvement of the complement system has been examined in a small number of studies, with conflicting results. In the present study, we investigated whether serum C3 levels on admission are associated with neurologic involvement. Methods: To this purpose, 68 consecutive STEC-HUS patients were recruited and main clinical and laboratory variables ad hospital admission were compared between those with or without neurologic involvement. Results: STEC-HUS patients who developed neurologic involvement (NI) showed significant higher leukocyte count, C-reactive protein and hemoglobin, and lower sodium levels as compared with those without. Interestingly, baseline serum levels of C3 were significantly lower in patients with NI as compared with those without (p < 0.001). Moreover, when stratified according to need of Eculizumab rescue therapy due to severe NI, patients treated with this drug showed baseline C3 serum levels significantly lower than those who were not (p < 0.001). Low C3 was independent risk factor for NI in our patients' population when entered as covariate in a multivariate logistic regression analysis including other major variables previously proposed as possible predictors of poor prognosis in STEC-HUS (for instance, leukocyte count, c-reactive protein, sodium levels) (HR 6.401, 95%CI 1.617–25.334, p = 0.008 for C3). To underline the role of complement in the worsening of STEC-HUS patients' clinical conditions and outcomes, all patients were divided into two groups according to the baseline lower vs. normal serum levels of C3 and the main data on care needs were assessed. Interestingly more patients with lower C3 serum levels required renal replacement therapy (p = 0.024), anti-hypertensive therapy (p = 0.011), Intensive Care Unit admission (p = 0.009), and longer hospitalization (p = 0.003), thus displaying significantly more severe disease features as compared with those with normal C3 serum levels. Conclusions: Our data suggests that children with STEC-HUS with decreased C3 concentrations at admission are more likely to develop neurologic involvement and are at increased risk of having severe clinical complications.
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Affiliation(s)
- Giuseppe Stefano Netti
- Unit of Clinical Pathology and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Luisa Santangelo
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Leonardo Paulucci
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Giovanni Piscopo
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Diletta D Torres
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Vincenza Carbone
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
| | - Paolo Giordano
- Post Graduated School in Pediatrics, University of Genoa, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Federica Spadaccino
- Unit of Clinical Pathology and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giuseppe Castellano
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giovanni Stallone
- Nephrology Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Maria Chironna
- Department of Biomedical Sciences and Human Oncology, Hygiene Unit, University of Bari Aldo Moro, Bari, Italy
| | - Elena Ranieri
- Unit of Clinical Pathology and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Mario Giordano
- Unit of Pediatric Nephrology, University Hospital Policlinico Consorziale - Giovanni XXIII, Bari, Italy
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Molecular Biology of Escherichia Coli Shiga Toxins' Effects on Mammalian Cells. Toxins (Basel) 2020; 12:toxins12050345. [PMID: 32456125 PMCID: PMC7290813 DOI: 10.3390/toxins12050345] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022] Open
Abstract
Shiga toxins (Stxs), syn. Vero(cyto)toxins, are potent bacterial exotoxins and the principal virulence factor of enterohemorrhagic Escherichia coli (EHEC), a subset of Shiga toxin-producing E. coli (STEC). EHEC strains, e.g., strains of serovars O157:H7 and O104:H4, may cause individual cases as well as large outbreaks of life-threatening diseases in humans. Stxs primarily exert a ribotoxic activity in the eukaryotic target cells of the mammalian host resulting in rapid protein synthesis inhibition and cell death. Damage of endothelial cells in the kidneys and the central nervous system by Stxs is central in the pathogenesis of hemolytic uremic syndrome (HUS) in humans and edema disease in pigs. Probably even more important, the toxins also are capable of modulating a plethora of essential cellular functions, which eventually disturb intercellular communication. The review aims at providing a comprehensive overview of the current knowledge of the time course and the consecutive steps of Stx/cell interactions at the molecular level. Intervention measures deduced from an in-depth understanding of this molecular interplay may foster our basic understanding of cellular biology and microbial pathogenesis and pave the way to the creation of host-directed active compounds to mitigate the pathological conditions of STEC infections in the mammalian body.
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Mühlen S, Dersch P. Treatment Strategies for Infections With Shiga Toxin-Producing Escherichia coli. Front Cell Infect Microbiol 2020; 10:169. [PMID: 32435624 PMCID: PMC7218068 DOI: 10.3389/fcimb.2020.00169] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 01/07/2023] Open
Abstract
Infections with Shiga toxin-producing Escherichia coli (STEC) cause outbreaks of severe diarrheal disease in children and the elderly around the world. The severe complications associated with toxin production and release range from bloody diarrhea and hemorrhagic colitis to hemolytic-uremic syndrome, kidney failure, and neurological issues. As the use of antibiotics for treatment of the infection has long been controversial due to reports that antibiotics may increase the production of Shiga toxin, the recommended therapy today is mainly supportive. In recent years, a variety of alternative treatment approaches such as monoclonal antibodies or antisera directed against Shiga toxin, toxin receptor analogs, and several vaccination strategies have been developed and evaluated in vitro and in animal models. A few strategies have progressed to the clinical trial phase. Here, we review the current understanding of and the progress made in the development of treatment options against STEC infections and discuss their potential.
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Affiliation(s)
- Sabrina Mühlen
- Institute for Infectiology, University of Münster, Münster, Germany.,German Center for Infection Research (DZIF), Associated Site University of Münster, Münster, Germany
| | - Petra Dersch
- Institute for Infectiology, University of Münster, Münster, Germany.,German Center for Infection Research (DZIF), Associated Site University of Münster, Münster, Germany
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Kumar D, Romero Y, Schuck KN, Smalley H, Subedi B, Fleming SD. Drivers and regulators of humoral innate immune responses to infection and cancer. Mol Immunol 2020; 121:99-110. [PMID: 32199212 DOI: 10.1016/j.molimm.2020.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/21/2022]
Abstract
The complement cascade consists of cell bound and serum proteins acting together to protect the host from pathogens, remove cancerous cells and effectively links innate and adaptive immune responses. Despite its usefulness in microbial neutralization and clearance of cancerous cells, excessive complement activation causes an immune imbalance and tissue damage in the host. Hence, a series of complement regulatory proteins present at a higher concentration in blood plasma and on cell surfaces tightly regulate the cascade. The complement cascade can be initiated by B-1 B cell production of natural antibodies. Natural antibodies arise spontaneously without any known exogenous antigenic or microbial stimulus and protect against invading pathogens, clear apoptotic cells, provide tissue homeostasis, and modulate adaptive immune functions. Natural IgM antibodies recognize microbial and cancer antigens and serve as an activator of complement mediated lysis. This review will discuss advances in complement activation and regulation in bacterial and viral infections, and cancer. We will also explore the crosstalk of natural antibodies with bacterial populations and cancer.
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Affiliation(s)
- Deepak Kumar
- Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Yeni Romero
- Department of Biochemistry and Molecular Biophysics, Kansas State University, Manhattan, KS, USA
| | - Kaitlynn N Schuck
- Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Haley Smalley
- Division of Biology, Kansas State University, Manhattan, KS, USA
| | - Bibek Subedi
- Division of Biology, Kansas State University, Manhattan, KS, USA
| | - Sherry D Fleming
- Division of Biology, Kansas State University, Manhattan, KS, USA.
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Gallan AJ, Chang A. A New Paradigm for Renal Thrombotic Microangiopathy. Semin Diagn Pathol 2020; 37:121-126. [PMID: 32085935 DOI: 10.1053/j.semdp.2020.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 02/06/2023]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia and microangiopathic hemolytic anemia, results from acute and/or chronic endothelial cell injury, and often manifests with kidney dysfunction. TMA can be observed in a wide spectrum of clinical scenarios, which includes but is not limited to thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, severe (malignant) hypertension, preeclampsia/eclampsia, antiphospholipid antibody syndrome, scleroderma renal crisis, drug toxicities, or metabolic disorders. These different conditions are impossible to distinguish based solely on the pathologic findings, necessitating correlation with clinical and laboratory data. For both treating physicians and pathologists, the absence of specific pathologic features for a particular etiology or association with TMA remains a great source of frustration and confusion that currently accompanies this complex topic. In this review, we introduce a new paradigm for TMA that coalesces around the important contribution of the complement system, which has potential implications for therapeutic management, disease recurrence in the kidney allograft, and genetic risks to family members.
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Affiliation(s)
- Alexander J Gallan
- Medical College of Wisconsin, Department of Pathology, Milwaukee, WI 53226.
| | - Anthony Chang
- The University of Chicago, Department of Pathology, Chicago, IL 60637
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Balestracci A, Meni Bataglia L, Toledo I, Beaudoin L, Alvarado C. C3 levels and acute outcomes in Shiga toxin-related hemolytic uremic syndrome. Pediatr Nephrol 2020; 35:331-339. [PMID: 31475299 DOI: 10.1007/s00467-019-04334-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/24/2019] [Accepted: 08/07/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The correlation between complement activation and severity of hemolytic uremic syndrome related to Shiga toxin-producing Escherichia coli (STEC-HUS) has been examined in few studies, with conflicting results. We investigated whether C3 levels on admission are associated with worse acute outcomes. METHODS Demographic, clinical, and laboratory variables were compared between dialyzed and non-dialyzed patients and between those with or without extrarenal complications. Univariate and multivariate analyses were performed; odds ratio (OR) and 95% confidence interval (95%CI) were calculated. C3 concentrations were correlated with dialysis length (Spearman test) and ROC curves with area under the curves (AUC) were calculated to identify C3 concentrations able to discriminate patients with dialysis requirements and complicated course. RESULTS Among 49 children, 33 had normal and 16 had decreased C3 concentrations. Higher hemoglobin, lactic dehydrogenase, urea and creatinine and lower albumin, sodium, and C3 and C4 concentrations at admission were associated with dialysis requirement; only creatinine remained significant (p = 0.03, OR 2.1, 95%CI 1.34-2.7) by multivariate analysis. Patients with a complicated course presented higher leukocyte count, hemoglobin and lactic dehydrogenase and lower albumin, sodium, and C3 and C4. In the multivariate analysis, leukocyte count (p = 0.02, OR 2.6, 95%CI 1.4-4.3) and C3 concentration (p = 0.039, OR 1.7, 95%CI 1.1-2.73) were independently associated with a complicated disease. C3 levels correlated with dialysis length (r = - 0.42, p = 0.002); nevertheless, they were unable to discriminate dialysis requirement (AUC = 0.25, 95%CI 0.11-0.38) and extrarenal complications (AUC = 0.24, 95%CI 0.11-0.4). CONCLUSIONS Our study suggests that decreased C3 levels at admission are associated with a more complicated STEC-HUS episode.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina.
| | - Luciana Meni Bataglia
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| | - Caupolican Alvarado
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
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Manrique-Caballero CL, Peerapornratana S, Formeck C, Del Rio-Pertuz G, Gomez Danies H, Kellum JA. Typical and Atypical Hemolytic Uremic Syndrome in the Critically Ill. Crit Care Clin 2020; 36:333-356. [PMID: 32172817 DOI: 10.1016/j.ccc.2019.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hemolytic uremic syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome have a similar clinical presentation. Diagnostic needs to be prompt to decrease mortality, because identifying the different disorders can help to tailor specific, effective therapies. However, diagnosis is challenging and morbidity and mortality remain high, especially in the critically ill population. Development of clinical prediction scores and rapid diagnostic tests for hemolytic uremic syndrome based on mechanistic knowledge are needed to facilitate early diagnosis and assign timely specific treatments to patients with hemolytic uremic syndrome variants.
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Affiliation(s)
- Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand; Department of Laboratory Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand
| | - Cassandra Formeck
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 3, Pittsburgh, PA 15224, USA
| | - Gaspar Del Rio-Pertuz
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Hernando Gomez Danies
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA.
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Joseph A, Cointe A, Mariani Kurkdjian P, Rafat C, Hertig A. Shiga Toxin-Associated Hemolytic Uremic Syndrome: A Narrative Review. Toxins (Basel) 2020; 12:E67. [PMID: 31973203 PMCID: PMC7076748 DOI: 10.3390/toxins12020067] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 01/28/2023] Open
Abstract
The severity of human infection by one of the many Shiga toxin-producing Escherichia coli (STEC) is determined by a number of factors: the bacterial genome, the capacity of human societies to prevent foodborne epidemics, the medical condition of infected patients (in particular their hydration status, often compromised by severe diarrhea), and by our capacity to devise new therapeutic approaches, most specifically to combat the bacterial virulence factors, as opposed to our current strategies that essentially aim to palliate organ deficiencies. The last major outbreak in 2011 in Germany, which killed more than 50 people in Europe, was evidence that an effective treatment was still lacking. Herein, we review the current knowledge of STEC virulence, how societies organize the prevention of human disease, and how physicians treat (and, hopefully, will treat) its potentially fatal complications. In particular, we focus on STEC-induced hemolytic and uremic syndrome (HUS), where the intrusion of toxins inside endothelial cells results in massive cell death, activation of the coagulation within capillaries, and eventually organ failure.
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Affiliation(s)
- Adrien Joseph
- Department of Nephrology, AP-HP, Hôpital Tenon, F-75020 Paris, France; (A.J.); (C.R.)
| | - Aurélie Cointe
- Department of Microbiology, AP-HP, Hôpital Robert Debré, F-75019 Paris, France; (A.C.); (P.M.K.)
| | | | - Cédric Rafat
- Department of Nephrology, AP-HP, Hôpital Tenon, F-75020 Paris, France; (A.J.); (C.R.)
| | - Alexandre Hertig
- Department of Renal Transplantation, Sorbonne Université, AP-HP, Hôpital Pitié Salpêtrière, F-75013 Paris, France
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Harkins VJ, McAllister DA, Reynolds BC. Shiga-Toxin E. coli Hemolytic Uremic Syndrome: Review of Management and Long-term Outcome. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00208-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Purpose of Review
We review the pathophysiology of Shiga-Toxin Enteropathogenic–Hemolytic Uremic Syndrome (STEC-HUS), strategies to ameliorate or prevent evolution of STEC-HUS, management and the improved recognition of long-term adverse outcomes.
Recent Findings
Following on from the preclinical evidence of a role for the complement system in STEC-HUS, the use of complement blocking agents has been the major focus of most recent clinical research. Novel therapies to prevent or lessen HUS have yet to enter the clinical arena. The long-term outcomes of STEC-HUS, similarly to other causes of AKI, are not as benign as previously thought.
Summary
Optimizing supportive care in STEC-HUS is the only current recommended treatment. The administration of early isotonic fluids may reduce the severity and duration of STEC-HUS. The role of complement blockade in the management of STEC-HUS remains unclear. The long-term sequelae from STEC-HUS are significant and patients with apparent full renal recovery remain at risk.
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Kushak RI, Boyle DC, Rosales IA, Ingelfinger JR, Stahl GL, Ozaki M, Colvin RB, Grabowski EF. Platelet thrombus formation in eHUS is prevented by anti-MBL2. PLoS One 2019; 14:e0220483. [PMID: 31881024 PMCID: PMC6934323 DOI: 10.1371/journal.pone.0220483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022] Open
Abstract
E. coli associated Hemolytic Uremic Syndrome (epidemic hemolytic uremic syndrome, eHUS) caused by Shiga toxin-producing bacteria is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury that cause acute renal failure in up to 65% of affected patients. We hypothesized that the mannose-binding lectin (MBL) pathway of complement activation plays an important role in human eHUS, as we previously demonstrated that injection of Shiga Toxin-2 (Stx-2) led to fibrin deposition in mouse glomeruli that was blocked by co-injection of the anti-MBL-2 antibody 3F8. However, the markers of platelet thrombosis in affected mouse glomeruli were not delineated. To investigate the effect of 3F8 on markers of platelet thrombosis, we used kidney sections from our mouse model (MBL-2+/+ Mbl-A/C-/-; MBL2 KI mouse). Mice in the control group received PBS, while mice in a second group received Stx-2, and those in a third group received 3F8 and Stx-2. Using double immunofluorescence (IF) followed by digital image analysis, kidney sections were stained for fibrin(ogen) and CD41 (marker for platelets), von-Willebrand factor (marker for endothelial cells and platelets), and podocin (marker for podocytes). Electron microscopy (EM) was performed on ultrathin sections from mice and human with HUS. Injection of Stx-2 resulted in an increase of both fibrin and platelets in glomeruli, while administration of 3F8 with Stx-2 reduced both platelet and fibrin to control levels. EM studies confirmed that CD41-positive objects observed by IF were platelets. The increases in platelet number and fibrin levels by injection of Stx-2 are consistent with the generation of platelet-fibrin thrombi that were prevented by 3F8.
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Affiliation(s)
- R. I. Kushak
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - D. C. Boyle
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - I. A. Rosales
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - J. R. Ingelfinger
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - G. L. Stahl
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - M. Ozaki
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - R. B. Colvin
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - E. F. Grabowski
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Mahat U, Matar RB, Rotz SJ. Use of complement monoclonal antibody eculizumab in Shiga toxin producing Escherichia coli associated hemolytic uremic syndrome: A review of current evidence. Pediatr Blood Cancer 2019; 66:e27913. [PMID: 31286658 DOI: 10.1002/pbc.27913] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022]
Abstract
Complement activation plays an important role in the pathogenesis of atypical hemolytic uremic syndrome. Eculizumab is a monoclonal antibody that blocks complement activity and has been approved for use in the treatment of atypical hemolytic uremic syndrome (HUS). Less well appreciated is the role of complement in Shiga toxin-induced HUS (Shiga toxin producing Escherichia coli [STEC]-HUS). To a limited extent, eculizumab has been used off label in patients with severe STEC-HUS with neurological involvement. Through a systematic search of available databases, we identified 16 reports describing the use of eculizumab in STEC-HUS (eight case reports/series, seven retrospective studies, and one prospective cohort study). All studies described its use in severe STEC-HUS with neurological or multiorgan dysfunction; none were randomized or blinded. Four studies used the control groups. Although the overall quality of evidence is low, some published studies showed positive clinical improvement after treatment with eculizumab in severe STEC-HUS with progressive neurological involvement.
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Affiliation(s)
- Upendra Mahat
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children's, Cleveland, Ohio
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Seth J Rotz
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children's, Cleveland, Ohio
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Lee MS, Tesh VL. Roles of Shiga Toxins in Immunopathology. Toxins (Basel) 2019; 11:E212. [PMID: 30970547 PMCID: PMC6521259 DOI: 10.3390/toxins11040212] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 12/20/2022] Open
Abstract
Shigella species and Shiga toxin-producing Escherichia coli (STEC) are agents of bloody diarrhea that may progress to potentially lethal complications such as diarrhea-associated hemolytic uremic syndrome (D+HUS) and neurological disorders. The bacteria share the ability to produce virulence factors called Shiga toxins (Stxs). Research over the past two decades has identified Stxs as multifunctional toxins capable of inducing cell stress responses in addition to their canonical ribotoxic function inhibiting protein synthesis. Notably, Stxs are not only potent inducers of cell death, but also activate innate immune responses that may lead to inflammation, and these effects may increase the severity of organ injury in patients infected with Stx-producing bacteria. In the intestines, kidneys, and central nervous system, excessive or uncontrolled host innate and cellular immune responses triggered by Stxs may result in sensitization of cells to toxin mediated damage, leading to immunopathology and increased morbidity and mortality in animal models (including primates) and human patients. Here, we review studies describing Stx-induced innate immune responses that may be associated with tissue damage, inflammation, and complement activation. We speculate on how these processes may contribute to immunopathological responses to the toxins.
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Affiliation(s)
- Moo-Seung Lee
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, 125 Gwahak-ro, Daejeon 34141, Korea.
- Department of Biomolecular Science, KRIBB School of Bioscience, Korea University of Science and Technology (UST), 127 Gajeong-ro, Yuseong-gu, Daejeon 34113, Korea.
| | - Vernon L Tesh
- Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, Bryan, TX 77807, USA.
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Frémeaux-Bacchi V, Sellier-Leclerc AL, Vieira-Martins P, Limou S, Kwon T, Lahoche A, Novo R, Llanas B, Nobili F, Roussey G, Cailliez M, Ulinski T, Deschênes G, Alberti C, Weill FX, Mariani P, Loirat C. Complement Gene Variants and Shiga Toxin-Producing Escherichia coli-Associated Hemolytic Uremic Syndrome: Retrospective Genetic and Clinical Study. Clin J Am Soc Nephrol 2019; 14:364-377. [PMID: 30674459 PMCID: PMC6419292 DOI: 10.2215/cjn.05830518] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 12/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Inherited complement hyperactivation is critical for the pathogenesis of atypical hemolytic uremic syndrome (HUS) but undetermined in postdiarrheal HUS. Our aim was to investigate complement activation and variants of complement genes, and their association with disease severity in children with Shiga toxin-associated HUS. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Determination of complement biomarkers levels and next-generation sequencing for the six susceptibility genes for atypical HUS were performed in 108 children with a clinical diagnosis of post-diarrheal HUS (75 Shiga toxin-positive, and 33 Shiga toxin-negative) and 80 French controls. As an independent control cohort, we analyzed the genotypes in 503 European individuals from the 1000 Genomes Project. RESULTS During the acute phase of HUS, plasma levels of C3 and sC5b-9 were increased, and half of patients had decreased membrane cofactor protein expression, which normalized after 2 weeks. Variants with minor allele frequency <1% were identified in 12 Shiga toxin-positive patients with HUS (12 out of 75, 16%), including pathogenic variants in four (four out of 75, 5%), with no significant differences compared with Shiga toxin-negative patients with HUS and controls. Pathogenic variants with minor allele frequency <0.1% were found in three Shiga toxin-positive patients with HUS (three out of 75, 4%) versus only four European controls (four out of 503, 0.8%) (odds ratio, 5.2; 95% confidence interval, 1.1 to 24; P=0.03). The genetic background did not significantly affect dialysis requirement, neurologic manifestations, and sC5b-9 level during the acute phase, and incident CKD during follow-up. However, the only patient who progressed to ESKD within 3 years carried a factor H pathogenic variant. CONCLUSIONS Rare variants and complement activation biomarkers were not associated with severity of Shiga toxin-associated HUS. Only pathogenic variants with minor allele frequency <0.1% are more frequent in Shiga toxin-positive patients with HUS than in controls.
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Affiliation(s)
- Véronique Frémeaux-Bacchi
- Service d’Immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- Team “Complement and Disease,” Centre de recherche des Cordeliers, Sorbonne Université, INSERM, Paris, France
| | | | - Paula Vieira-Martins
- Service d’Immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Limou
- Institute for Transplantation in Urology and Nephrology, Centre Hospitalo-Universitaire de Nantes, Centre de Recherche en Transplantation et Immunologie, Institut National de la Santé et de la Recherche Médicale U1064, Université de Nantes, Ecole Centrale de Nantes, Nantes, France
| | | | - Annie Lahoche
- Pediatric Nephrology Department, Hôpital Jeanne de Flandre, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Robert Novo
- Pediatric Nephrology Department, Hôpital Jeanne de Flandre, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Brigitte Llanas
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France
| | - François Nobili
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Besançon, Besançon, France
| | - Gwenaëlle Roussey
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Nantes, Nantes, France
| | - Mathilde Cailliez
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Marseille, Marseille, France
| | - Tim Ulinski
- Pediatric Nephrology Department, Hôpital Trousseau, University Pierre and Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | | | - Corinne Alberti
- Unit of Clinical Epidemiology, Institut National de la Santé et de la Recherche Médicale U1123 and Centre d'Investigation Clinique-Epidémiologie Clinique 1426, and
| | - François-Xavier Weill
- Institut Pasteur, Unité des Bactéries Pathogènes Entériques, Centre National de Référence des Escherichia coli, Shigella et Salmonella, Paris, France
| | - Patricia Mariani
- Laboratory of Microbiology, Escherichia coli Associated National Reference Center, Hôpital Robert Debré, University Paris Diderot, Assistance Publique-Hôpitaux de Paris, Paris, France
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Zoja C, Buelli S, Morigi M. Shiga toxin triggers endothelial and podocyte injury: the role of complement activation. Pediatr Nephrol 2019; 34:379-388. [PMID: 29214442 DOI: 10.1007/s00467-017-3850-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/12/2017] [Accepted: 11/10/2017] [Indexed: 02/07/2023]
Abstract
Shiga toxin (Stx)-producing Escherichia coli (STEC) is the offending agent in post-diarrhea-associated hemolytic uremic syndrome (HUS), a disorder characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney failure, with thrombi occluding the renal microvasculature. Endothelial dysfunction has been recognized as the trigger event in the development of microangiopathic processes. Glomerular endothelial cells are susceptible to the toxic effects of Stxs that, via nuclear factor kappa B (NF-κB) activation, induce the expression of genes encoding for adhesion molecules and chemokines, culminating in leukocyte adhesion and platelet thrombus formation on the activated endothelium. Complement activation via the alternative pathway has been seen in patients during the acute phase of STEC-associated HUS. Experimental evidence has highlighted the role of complement proteins in driving glomerular endothelium toward a thrombogenic phenotype. At the glomerular level, podocytes are also an important target of Stx-induced complement activation. Glomerular injury as a consequence of podocyte dysfunction and loss is thus a mechanism that might affect long-term renal outcomes in the disease. New approaches to targeting the complement system may be useful therapeutic options for patients with STEC-HUS.
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Affiliation(s)
- Carlamaria Zoja
- Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Stezzano, 87, 24126, Bergamo, Italy.
| | - Simona Buelli
- Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Stezzano, 87, 24126, Bergamo, Italy
| | - Marina Morigi
- Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Stezzano, 87, 24126, Bergamo, Italy
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Gavriilaki E, Anagnostopoulos A, Mastellos DC. Complement in Thrombotic Microangiopathies: Unraveling Ariadne's Thread Into the Labyrinth of Complement Therapeutics. Front Immunol 2019; 10:337. [PMID: 30891033 PMCID: PMC6413705 DOI: 10.3389/fimmu.2019.00337] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/08/2019] [Indexed: 12/20/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) are a heterogeneous group of syndromes presenting with a distinct clinical triad: microangiopathic hemolytic anemia, thrombocytopenia, and organ damage. We currently recognize two major entities with distinct pathophysiology: thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Beyond them, differential diagnosis also includes TMAs associated with underlying conditions, such as drugs, malignancy, infections, scleroderma-associated renal crisis, systemic lupus erythematosus (SLE), malignant hypertension, transplantation, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), and disseminated intravascular coagulation (DIC). Since clinical presentation alone is not sufficient to differentiate between these entities, robust pathophysiological features need to be used for early diagnosis and appropriate treatment. Over the last decades, our understanding of the complement system has evolved rapidly leading to the characterization of diseases which are fueled by complement dysregulation. Among TMAs, complement-mediated HUS (CM-HUS) has long served as a disease model, in which mutations of complement-related genes represent the first hit of the disease and complement inhibition is an effective and safe strategy. Based on this knowledge, clinical conditions resembling CM-HUS in terms of phenotype and genotype have been recognized. As a result, the role of complement in TMAs is rapidly expanding in recent years based on genetic and functional studies. Herein we provide an updated overview of key pathophysiological processes underpinning complement activation and dysregulation in TMAs. We also discuss emerging clinical challenges in streamlining diagnostic algorithms and stratifying TMA patients that could benefit more from complement modulation. With the advent of next-generation complement therapeutics and suitable disease models, these translational perspectives could guide a more comprehensive, disease- and target-tailored complement intervention in these disorders.
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Affiliation(s)
- Eleni Gavriilaki
- BMT Unit, Hematology Department, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | - Dimitrios C Mastellos
- Division of Biodiagnostic Sciences and Technologies, INRASTES, National Center for Scientific Research Demokritos, Athens, Greece
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Abstract
Hemolytic uremic syndrome (HUS) is the clinical triad of thrombocytopenia, anemia, and acute kidney injury. Classically associated with enterocolitis from Shiga toxin-producing Escherichia coli, HUS is also associated with Streptococcus pneumoniae infections; genetic dysregulation of the alternative complement pathway or coagulation cascade; and, rarely, a hereditary disorder of cobalamin C metabolism. These share a common final pathway of a prothrombotic and proinflammatory state on the endothelial cell surface, with fibrin and platelet deposition. Much work has been done to distinguish between the different mechanisms of disease, thereby informing the optimal therapeutic interventions for each entity.
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Affiliation(s)
- Ellen M Cody
- Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 158, Aurora, CO 80045, USA
| | - Bradley P Dixon
- Departments of Pediatrics & Medicine, University of Colorado School of Medicine, 12631 E. 17th Avenue, Aurora, CO 80045, USA.
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43
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Brigotti M, Orth-Höller D, Carnicelli D, Porcellini E, Galassi E, Tazzari PL, Ricci F, Manoli F, Manet I, Talasz H, Lindner HH, Speth C, Erbeznik T, Fuchs S, Posch W, Chatterjee S, Würzner R. The structure of the Shiga toxin 2a A-subunit dictates the interactions of the toxin with blood components. Cell Microbiol 2019; 21:e13000. [PMID: 30578712 PMCID: PMC6492301 DOI: 10.1111/cmi.13000] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/06/2018] [Accepted: 12/17/2018] [Indexed: 12/29/2022]
Abstract
Hemolytic uremic syndrome (eHUS) is a severe complication of human infections with Shiga toxins (Stxs)-producing Escherichia coli. A key step in the pathogenesis of eHUS is the interaction of Stxs with blood components before the targeting of renal endothelial cells. Here, we show that a single proteolytic cleavage in the Stx2a A-subunit, resulting into two fragments (A1 and A2) linked by a disulfide bridge (cleaved Stx2a), dictates different binding abilities. Uncleaved Stx2a was confirmed to bind to human neutrophils and to trigger leukocyte/platelet aggregate formation, whereas cleaved Stx2a was ineffective. Conversely, binding of complement factor H was confirmed for cleaved Stx2a and not for uncleaved Stx2a. It is worth noting that uncleaved and cleaved Stx2a showed no differences in cytotoxicity for Vero cells or Raji cells, structural conformation, and contaminating endotoxin. These results have been obtained by comparing two Stx2a batches, purified in different laboratories by using different protocols, termed Stx2a(cl; cleaved toxin, Innsbruck) and Stx2a(uncl; uncleaved toxin, Bologna). Stx2a(uncl) behaved as Stx2a(cl) after mild trypsin treatment. In this light, previous controversial results obtained with purified Stx2a has to be critically re-evaluated; furthermore, characterisation of the structure of circulating Stx2a is mandatory to understand eHUS-pathogenesis and to develop therapeutic approaches.
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Affiliation(s)
- Maurizio Brigotti
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Sede di Patologia Generale, Università di Bologna, Bologna, Italy
| | - Dorothea Orth-Höller
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Domenica Carnicelli
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Sede di Patologia Generale, Università di Bologna, Bologna, Italy
| | - Elisa Porcellini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Sede di Patologia Generale, Università di Bologna, Bologna, Italy
| | - Elisabetta Galassi
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Sede di Patologia Generale, Università di Bologna, Bologna, Italy
| | - Pier Luigi Tazzari
- Servizio di Immunoematologia e Trasfusionale, Ospedale S. Orsola-Malpighi, Bologna, Italy
| | - Francesca Ricci
- Servizio di Immunoematologia e Trasfusionale, Ospedale S. Orsola-Malpighi, Bologna, Italy
| | - Francesco Manoli
- Istituto per la Sintesi Organica e la Fotoreattività, Consiglio Nazionale delle Ricerche, Bologna, Italy
| | - Ilse Manet
- Istituto per la Sintesi Organica e la Fotoreattività, Consiglio Nazionale delle Ricerche, Bologna, Italy
| | - Heribert Talasz
- Division of Clinical Biochemistry, Biocentre, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert H Lindner
- Division of Clinical Biochemistry, Biocentre, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Speth
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Erbeznik
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Fuchs
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Wilfried Posch
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sneha Chatterjee
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Reinhard Würzner
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
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Buelli S, Zoja C, Remuzzi G, Morigi M. Complement Activation Contributes to the Pathophysiology of Shiga Toxin-Associated Hemolytic Uremic Syndrome. Microorganisms 2019; 7:microorganisms7010015. [PMID: 30634669 PMCID: PMC6352217 DOI: 10.3390/microorganisms7010015] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/21/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
Shiga toxin (Stx)-producing Escherichia coli (STEC) infections have become a threat to public health globally because of the severe illnesses that they can trigger, such as hemorrhagic colitis and the post-diarrheal hemolytic uremic syndrome (HUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Glomerular endothelial cells are primary targets of Stx which, after binding to its specific receptor globotriaosylceramide, upregulates proinflammatory proteins involved both in the recruitment and adhesion of leukocytes and thrombus formation at the site of endothelial injury. In this review, we discuss the role of complement activation in promoting glomerular microvascular dysfunction, providing evidence from experimental models and patients with STEC-HUS. Within the glomerulus, an important target for Stx-induced complement activation is the podocyte, a cell type that is in close contact with endothelial cells and participates in maintaining the filtration barrier. Recently, podocyte injury and loss have been indicated as potential risk factors for long-term renal sequelae in patients with STEC-HUS. Therapeutic approaches targeting the complement system, that may be useful options for patients with STEC-HUS, will also be discussed.
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Affiliation(s)
- Simona Buelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy.
| | - Marina Morigi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
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45
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Tsai HM. Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndromes. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00042-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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46
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Eculizumab in the treatment of Shiga toxin haemolytic uraemic syndrome. Pediatr Nephrol 2019; 34:1485-1492. [PMID: 30058046 PMCID: PMC6660499 DOI: 10.1007/s00467-018-4025-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 12/26/2022]
Abstract
Haemolytic uraemic syndrome (HUS) remains a leading cause of paediatric acute kidney injury (AKI). Haemolytic uraemic syndrome is characterised by the triad of microangiopathic haemolytic anaemia, thrombocytopenia and AKI. In ~ 90% of cases, HUS is a consequence of infection with Shiga toxin-producing E. coli (STEC), most commonly serotype O157:H7. Acute mortality from STEC-HUS is now less than 5%; however, there is significant long-term renal morbidity in one third of survivors. Currently, no specific treatment exists for STEC-HUS. There is growing interest in the role of complement in the pathogenesis of STEC-HUS due to the discovery of inherited and acquired dysregulation of the alternative complement system in the closely related disorder, atypical HUS (aHUS). The treatment of aHUS has been revolutionised by the introduction of the anti-C5 monoclonal antibody, eculizumab. However, the role of complement and anti-complement therapy in STEC-HUS remains unclear. Herein, we review the current evidence of the role of complement in STEC-HUS focusing on the use of eculizumab in this disease.
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47
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Ağbaş A, Göknar N, Akıncı N, Yıldırım ZY, Taşdemir M, Benzer M, Gökçe İ, Candan C, Küçük N, Uzuner S, Özçelik G, Demirkol D, Sever L, Çalışkan S. Outbreak of Shiga toxin-producing Escherichia-coli-associated hemolytic uremic syndrome in Istanbul in 2015: outcome and experience with eculizumab. Pediatr Nephrol 2018; 33:2371-2381. [PMID: 30159625 DOI: 10.1007/s00467-018-4033-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study aims to identify epidemiological and clinical characteristics of patients and report our experience with eculizumab treatment during an outbreak of hemolytic uremic syndrome (HUS) caused by Shiga toxin-producing Escherichia coli (STEC) in Istanbul in 2015. METHODS Thirty-two children (21 females, median age 3.25 years) were included in this study. Demographic, clinical and laboratory data, and treatment details were retrospectively collected. Renal outcomes were assessed at last follow-up visit. To assess the effect of eculizumab on prognosis of STEC-HUS, subgroup analysis was performed on patients who required dialysis. RESULTS A high number of cases occurred within a certain region of Istanbul. Stool samples were cultured from 21 patients (65%), and enteroaggregative E. coli (EAEC; n = 7) and enterohemorrhagic E. coli (EHEC; n = 3) strains were detected. Rates of dialysis treatment, neurological manifestations, and death were 59%, 25%, and 3%, respectively. Mean follow-up duration was 8.6 ± 2.6 months (range 3-12 months). None of the patients (n = 25) was on dialysis at the final visit. The complete renal recovery rate was 54%. Nine patients were treated with eculizumab. At final follow-up visit, no differences in estimated glomerular filtration rate, proteinuria level, or hypertension incidence were observed between patients treated with eculizumab and those not treated with eculizumab. CONCLUSIONS An outbreak of EAEC occurred in a specific region of Istanbul. Livestock markets were suspected as the source. Evidence for beneficial effects of eculizumab on renal outcome was not clear in this cohort.
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Affiliation(s)
- Ayşe Ağbaş
- Pediatric Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Nilüfer Göknar
- Pediatric Nephrology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Nurver Akıncı
- Pediatric Nephrology, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Zeynep Yürük Yıldırım
- Pediatric Nephrology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Taşdemir
- Pediatric Nephrology, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - Meryem Benzer
- Pediatric Nephrology, Bakırköy Dr Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - İbrahim Gökçe
- Pediatric Nephrology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Cengiz Candan
- Pediatric Nephrology, Faculty of Medicine, Medeniyet University, Istanbul, Turkey
| | - Nuran Küçük
- Pediatric Nephrology, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Selçuk Uzuner
- Pediatric Intensive Care Unit, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey
| | - Gül Özçelik
- Pediatric Nephrology, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Demet Demirkol
- Pediatric Intensive Care Unit, Faculty of Medicine, Koç University, Istanbul, Turkey.,Pediatric Intensive Care Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Lale Sever
- Pediatric Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Salim Çalışkan
- Pediatric Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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48
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Knabl L, Berktold M, Hamad OA, Fromell K, Chatterjee S, Speth C, Talasz H, Lindner K, Hermann M, Nilsson-Ekdahl K, Nilsson B, Streif W, Martini J, Würzner R, Orth-Höller D. Shiga toxin 2a binds antithrombin and heparin, but does not directly activate platelets. Int J Med Microbiol 2018; 308:969-976. [DOI: 10.1016/j.ijmm.2018.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/13/2018] [Accepted: 07/22/2018] [Indexed: 12/20/2022] Open
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49
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Percheron L, Gramada R, Tellier S, Salomon R, Harambat J, Llanas B, Fila M, Allain-Launay E, Lapeyraque AL, Leroy V, Adra AL, Bérard E, Bourdat-Michel G, Chehade H, Eckart P, Merieau E, Piètrement C, Sellier-Leclerc AL, Frémeaux-Bacchi V, Dimeglio C, Garnier A. Eculizumab treatment in severe pediatric STEC-HUS: a multicenter retrospective study. Pediatr Nephrol 2018; 33:1385-1394. [PMID: 29572749 DOI: 10.1007/s00467-018-3903-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 01/20/2018] [Accepted: 01/24/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome related to Shiga-toxin-secreting Escherichia coli infection (STEC-HUS) remains a common cause of acute kidney injury in young children. No specific treatment has been validated for this severe disease. Recently, experimental studies highlight the potential role of complement in STEC-HUS pathophysiology. Eculizumab (EC), a monoclonal antibody against terminal complement complex, has been used in severe STEC-HUS patients, mostly during the 2011 German outbreak, with conflicting results. METHODS On behalf of the French Society of Pediatric Nephrology, we retrospectively studied 33 children from 15 centers treated with EC for severe STEC-HUS. Indication for EC was neurologic involvement in 20 patients, cardiac and neurologic involvement in 8, cardiac involvement in 2, and digestive involvement in 3. Based on medical status at last follow-up, patients were divided into two groups: favorable (n = 15) and unfavorable outcomes (n = 18). RESULTS Among patients with favorable outcome, 11/14 patients (79%) displayed persistent blockade of complement activity before each EC reinjection. Conversely, in patients with unfavorable outcome, only 9/15 (53%) had persistent blockade (p = n.s.). Among 28 patients presenting neurological symptoms, 19 had favorable neurological outcome including 17 with prompt recovery following first EC injection. Only two adverse effects potentially related to EC treatment were reported. CONCLUSIONS Taken together, these results may support EC use in severe STEC-HUS patients, especially those presenting severe neurological symptoms. The study, however, is limited by absence of a control group and use of multiple therapeutic interventions in treatment groups. Thus, prospective, controlled trials should be undertaken.
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Affiliation(s)
- Lucas Percheron
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France.
| | - Raluca Gramada
- Service de Neuroradiologie Diagnostique et Thérapeutique, CHU Purpan, Toulouse, France
| | - Stéphanie Tellier
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France
| | - Remi Salomon
- Service de Néphrologie Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jérôme Harambat
- Service de Néphrologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France
| | - Brigitte Llanas
- Service de Néphrologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France
| | - Marc Fila
- Service de Néphrologie Pédiatrique, Hôpital Robert Debré-Paris, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emma Allain-Launay
- Service de Néphrologie Pédiatrique, Hôpital Mère-Enfants, CHU Nantes, Nantes, France
| | - Anne-Laure Lapeyraque
- Service de Néphrologie Pédiatrique, CHU de Sainte-Justine à Montréal Canada, Montréal, Canada
| | - Valerie Leroy
- Service de Néphrologie Pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Anne-Laure Adra
- Service de Néphrologie Pédiatrique, Hôpital Arnaud de Villeneuve, CHU Montpellier, Montpellier, France
| | - Etienne Bérard
- Service de Néphrologie Pédiatrique, Hôpital Archet 2, CHU Nice, Nice, France
| | | | - Hassid Chehade
- Service de Néphrologie Pédiatrique, CHU de Lausanne Suisse, Lausanne, Switzerland
| | - Philippe Eckart
- Service de Pédiatrie Médicale, Hôpital côte de nacre, CHU Caen, Caen, France
| | - Elodie Merieau
- Service de Néphrologie, Hôpital Clocheville, CHU Tours, Tours, France
| | | | | | - Véronique Frémeaux-Bacchi
- Laboratoire d'immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Chloe Dimeglio
- Biostatistiques, Informatique Médicale, UMR 1027 Inserm, Université Paul Sabatier, Toulouse, France
| | - Arnaud Garnier
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France.
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Nalluru SS, Sridharan M, Go RS, Said S, Marshall AL. Shiga Toxin as a Potential Trigger of CFHR1 Deletion-Associated Thrombotic Microangiopathy. Am J Med Sci 2018; 356:492-498. [PMID: 30177262 DOI: 10.1016/j.amjms.2018.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/28/2022]
Abstract
Thrombotic microangiopathy (TMA) may result from a variety of clinical conditions, including thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome and complement-mediated hemolytic uremic syndrome. Thrombocytopenic purpura is diagnosed when ADAMTS13 is <10%, while a diagnosis of Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome is made with the evidence of infection by Shiga toxin-producing Escherichia coli. Diagnosis of complement-mediated hemolytic uremic syndrome is not dependent on a specific laboratory test and is a diagnosis of exclusion. TMA is a rare disease and finding individuals that have more than 1 concurrent etiology leading to TMA is even more rare. Here we describe the presentation and management of an individual with CFHR1 deletion-associated TMA also found to have a positive stool Shiga toxin. We discuss the significance of Shiga toxin in serving as a trigger for development of TMA in an individual predisposed to development of TMA due to presence of a homozygous deletion in CFHR1.
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Affiliation(s)
| | | | - Ronald S Go
- Mayo Clinic, Division of Hematology, Rochester, Minnesota.
| | - Samar Said
- Mayo Clinic, Division of Hematology, Rochester, Minnesota.
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