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Anantharajah A, Goormaghtigh F, Nguvuyla Mantu E, Güler B, Bearzatto B, Momal A, Werion A, Hantson P, Kabamba-Mukadi B, Van Bambeke F, Rodriguez-Villalobos H, Verroken A. Long-term intensive care unit outbreak of carbapenemase-producing organisms associated with contaminated sink drains. J Hosp Infect 2024; 143:38-47. [PMID: 38295006 DOI: 10.1016/j.jhin.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Between 2018 and 2022, a Belgian tertiary care hospital faced a growing issue with acquiring carbapenemase-producing organisms (CPO), mainly VIM-producing P. aeruginosa (PA-VIM) and NDM-producing Enterobacterales (CPE-NDM) among hospitalized patients in the adult intensive care unit (ICU). AIM To investigate this ICU long-term CPO outbreak involving multiple species and a persistent environmental reservoir. METHODS Active case finding, environmental sampling, whole-genome sequencing (WGS) analysis of patient and environmental strains, and implemented control strategies were described in this study. FINDINGS From 2018 to 2022, 37 patients became colonized or infected with PA-VIM and/or CPE-NDM during their ICU stay. WGS confirmed the epidemiological link between clinical and environmental strains collected from the sink drains with clonal strain dissemination and horizontal gene transfer mediated by plasmid conjugation and/or transposon jumps. Environmental disinfection by quaternary ammonium-based disinfectant and replacement of contaminated equipment failed to eradicate environmental sources. Interestingly, efflux pump genes conferring resistance to quaternary ammonium compounds were widespread in the isolates. As removing sinks was not feasible, a combination of a foaming product degrading the biofilm and foaming disinfectant based on peracetic acid and hydrogen peroxide has been evaluated and has so far prevented recolonization of the proximal sink drain by CPO. CONCLUSION The persistence in the hospital environment of antibiotic- and disinfectant-resistant bacteria with the ability to transfer mobile genetic elements poses a serious threat to ICU patients with a risk of shifting towards an endemicity scenario. Innovative strategies are needed to address persistent environmental reservoirs and prevent CPO transmission.
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Affiliation(s)
- A Anantharajah
- Department of Clinical Microbiology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Medical Microbiology Unit, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium.
| | - F Goormaghtigh
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - E Nguvuyla Mantu
- Medical Microbiology Unit, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - B Güler
- Medical Microbiology Unit, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - B Bearzatto
- Center for Applied Molecular Technologies, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - A Momal
- Department of Clinical Microbiology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - A Werion
- Department of Intensive Care, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - P Hantson
- Department of Intensive Care, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - B Kabamba-Mukadi
- Department of Clinical Microbiology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Medical Microbiology Unit, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - F Van Bambeke
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - H Rodriguez-Villalobos
- Department of Clinical Microbiology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Medical Microbiology Unit, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - A Verroken
- Department of Clinical Microbiology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Medical Microbiology Unit, Institute of Experimental and Clinical Research, Université catholique de Louvain (UCLouvain), Brussels, Belgium; Department of Prevention and Control Infection, Cliniques universitaires Saint-Luc, Brussels, Belgium
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2
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Rafat C, Doreille A, Dancer M, Werion A, Benoist JF, Raymond L, Mesnard L. Genetic screening in thrombotic microangiopathy: a plea for methylmalonic aciduria with cobalamine C deficiency detection. Clin Kidney J 2023; 16:2299-2301. [PMID: 37915912 PMCID: PMC10616482 DOI: 10.1093/ckj/sfad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Cédric Rafat
- Service des soins intensifs, Cliniques universitaires Saint Luc, Brussels, Belgium
- French Intensive Renal Network, France
- Centre national de Référence des Microangiopathies Thrombotiques
| | - Alice Doreille
- Service des soins intensifs, Cliniques universitaires Saint Luc, Brussels, Belgium
- Faculté de médecine, Sorbonne Université, Paris, France
- French Intensive Renal Network, France
| | - Marine Dancer
- Faculté de Pharmacie, Université Paris Saclay, France
| | - Alexis Werion
- Service des soins intensifs, Cliniques universitaires Saint Luc, Brussels, Belgium
- Faculté de médecine, Université Catholique de Louvain, Belgium
| | - Jean-François Benoist
- Service des explorations fonctionnelles, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique – Hôpitaux de Paris, France
- Faculté de Pharmacie, Université Paris Saclay, France
| | - Laure Raymond
- Département de génétique, Eurofins Biomnis, Lyon, France
| | - Laurent Mesnard
- Service des soins intensifs, Cliniques universitaires Saint Luc, Brussels, Belgium
- Faculté de médecine, Sorbonne Université, Paris, France
- French Intensive Renal Network, France
- Centre national de Référence des Microangiopathies Thrombotiques
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3
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Werion A, Storms P, Zizi Y, Beguin C, Bernards J, Cambier JF, Dahan K, Dierickx D, Godefroid N, Hilbert P, Lambert C, Levtchenko E, Meyskens T, Poiré X, van den Heuvel L, Claes KJ, Morelle J. Epidemiology, Outcomes, and Complement Gene Variants in Secondary Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00134. [PMID: 37094330 PMCID: PMC10356144 DOI: 10.2215/cjn.0000000000000182] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The identification of complement defects as major drivers of primary atypical hemolytic uremic syndrome (HUS) has transformed the landscape of thrombotic microangiopathies (TMAs), leading to the development of targeted therapies and better patient outcomes. By contrast, little is known about the presentation, genetics, and outcomes of TMA associated with specific diseases or conditions, also referred to as secondary TMA. METHODS In this study, we assessed the relative incidence, clinical and genetic spectra, and long-term outcomes of secondary TMA versus other TMAs in consecutive patients hospitalized with a first episode of TMA from 2009 to 2019 at two European reference centers. RESULTS During the study period, 336 patients were hospitalized with a first episode of TMA. Etiologies included atypical HUS in 49 patients (15%), thrombotic thrombocytopenic purpura (TTP) in 29 (9%), shigatoxin-associated HUS in 70 (21%), and secondary TMA in 188 (56%). The main causes of secondary TMA were hematopoietic stem-cell transplantation ( n =56, 30%), solid-organ transplantation ( n =44, 23%), and malignant hypertension ( n =25, 13%). Rare variants in complement genes were identified in 32 of 49 patients (65%) with atypical HUS and eight of 64 patients (13%) with secondary TMA; pathogenic or likely pathogenic variants were found in 24 of 49 (49%) and two of 64 (3%) of them, respectively ( P < 0.001). After a median follow-up of 1157 days, death or kidney failure occurred in 14 (29%), eight (28%), five (7%), and 121 (64%) patients with atypical HUS, TTP, shigatoxin-associated HUS, and secondary TMA, respectively. Unadjusted and adjusted Cox regressions showed that patients with secondary TMA had the highest risk of death or kidney failure (unadjusted hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.85 to 6.07; P < 0.001; adjusted HR, 4.11; 95% CI, 2.00 to 8.46; P < 0.001; considering atypical HUS as reference). CONCLUSIONS Secondary TMAs represent the main cause of TMA and are independently associated with a high risk of death and progression to kidney failure.
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Affiliation(s)
- Alexis Werion
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pauline Storms
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Ysaline Zizi
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Claire Beguin
- Department of Medical Informatics and Statistics, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Jelle Bernards
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Nephrology, ZNA Middelheim, Antwerpen, Belgium
| | | | - Karin Dahan
- Institut de Pathologie et de Génétique, Gosselies, Belgium
| | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Nathalie Godefroid
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Pediatric Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | - Catherine Lambert
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Elena Levtchenko
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | - Xavier Poiré
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Lambert van den Heuvel
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kathleen J. Claes
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
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4
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Van Hove S, Werion A, Anantharajah A, Belkhir L, van Dievoet MA, Hantson P. Streptococcus Pneumoniae Bacteremia with Acute Kidney Injury and Transient ADAMTS13 Deficiency. Case Rep Infect Dis 2023; 2023:3283606. [PMID: 37159753 PMCID: PMC10163968 DOI: 10.1155/2023/3283606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/30/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023] Open
Abstract
A 43-year-old woman with a medical history of splenectomy for immune thrombocytopenic purpura was diagnosed with Streptococcus pneumoniae bacteremia. Her initial complaints were fever and more importantly painful extremities that appeared cyanotic. During her hospitalisation, she never developed cardiocirculatory failure but presented acute kidney injury (AKI) with oliguria. Laboratory investigations confirmed AKI with serum creatinine 2.55 mg/dL which peaked at 6.49 mg/dL. There was also evidence for disseminated intravascular coagulation (DIC) with decreased platelet count, low fibrinogen levels, and high D-dimer levels. There were no signs of haemolytic anaemia. The initial ADAMTS13 activity was low (17%) but slowly recovered. Renal function progressively improved with supportive therapy, as opposed to the progressing skin necrosis. The association of DIC and low ADAMTS13 activity may have contributed to the severity of microthrombotic complications, even in the absence of thrombotic microangiopathy as thrombotic thrombocytopenic purpura (TTP) or pneumococcal-associated haemolytic uremic syndrome (pa-HUS).
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Affiliation(s)
- Sam Van Hove
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Alexis Werion
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Neuve, Belgium
| | | | - Leila Belkhir
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Neuve, Belgium
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | | | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain, 1200 Brussels, Belgium
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5
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Serre J, Rafat C, Raymond L, Dancer M, Werion A, Nobile G, Bobot M, Rondeau E, Mesnard L, Doreille A. FC030: Diagnostic Yield of Exome Sequencing in Hypertensive Nephropathy. Nephrol Dial Transplant 2022. [DOI: 10.1093/ndt/gfac101.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND AND AIMS
Hypertensive nephrosclerosis ranks as one of the most frequent causes of chronic kidney disease (CKD) worldwide and is deemed to be especially prevalent among patients of African ancestry [1]. The very existence of hypertensive nephropathy has been called into question, especially in young adults. Its diagnostic framework is based on non-specific clinical criteria, and its histopathological features are in fact unspecific.
Genetic testing with exome sequencing (ES) has emerged as a comprehensive tool to detect Mendelian diseases in nephrology with a significant number of post-hoc re-established diagnoses [2]. Nevertheless, ES has yet to be incorporated into the diagnostic workup of patients with hypertensive nephropathy consistently.
This study aimed to investigate the diagnostic yield of ES in patients with a clinical diagnosis of hypertensive nephropathy.
METHOD
Since September 2018, ES is readily available as part of the routine diagnostic workup in our institution. The indication of ES includes hypertensive nephropathy of early onset (i.e. <45 years old). We retrospectively collected the ES performed in the context of hypertensive nephropathy [3] in our institution between September 2018 and February 2021.
RESULTS
A total of 128 patients were sequenced in the context of hypertensive nephropathy with early-onset. Women were 29 (22.7%), the mean age was 43 (35; 51) years and 60% of them were patients of African ancestry. The main indications of ES was an early onset of CKD (47%), a family history of kidney disease (8%) or both (18%). We detected diagnostic variants (ACM class 4/5) in 22 of the 128 patients (17.2%) encompassing a total of 16 different monogenic disorders. Two diseases accounted for more than half of the genetic diagnoses: nephronophthisis (n = 7, 32%) and Alport syndrome (n = 5, 23%). Complement variation did not account for a significant part of the diagnosis.
The diagnostic yield of ES was lower in patients of African ancestry (diagnostic yield of 10.4% versus 27.4% in the non-African ancestry patients; P = 0.01). Co-segregation data was lacking in patients of African ancestry, with significantly more ES performed in singleton (96% compared with 76% in non-African ancestry patients; P < 0.001).
In addition to disease reclassification, genetic diagnosis enabled guidance for family counseling (n = 11, 50% of positive patients) and thus helped for potential related donor selection for transplantation. In the whole cohort, ES results modified the therapeutic in 6 patients (5%) and ruled out potential recurrence in the graft in 10 patients (8%).
CONCLUSION
Physicians should be wary of tentative diagnosis of nephrosclerosis, especially in patients of non-African ethnic background. Instead, it should prompt genetic investigations, which overturned the initial diagnosis in 17% of the cases. The lower diagnostic yield of ES in patients of African ancestry in our cohort might partly be due to the lack of available co-segregation data, as well as the underrepresentation of subjects of African ancestry in the reference genome.
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Affiliation(s)
- Justine Serre
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
| | - Cédric Rafat
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
- French Intensive care Renal Network, Paris, France
| | | | | | - Alexis Werion
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
| | - Giulio Nobile
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
| | - Mickaël Bobot
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
| | - Eric Rondeau
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
- French Intensive care Renal Network, Paris, France
- Faculté de médecine, Sorbonne Université, Paris, France
| | - Laurent Mesnard
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
- French Intensive care Renal Network, Paris, France
- Faculté de médecine, Sorbonne Université, Paris, France
| | - Alice Doreille
- Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Service de Soins Intensifs Néphrologique et Rein Aigu, Paris, France
- French Intensive care Renal Network, Paris, France
- Faculté de médecine, Sorbonne Université, Paris, France
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Abstract
The complement pathway is an essential mechanism in innate immunity, but it is also involved in multiple pathologies. For kidney diseases, strong evidence of a dysregulation in the alternative pathway in atypical hemolytic uremic syndrome (aHUS) led to the use of eculizumab, the first anti-C5 inhibitor available in clinical practice. Intensive fundamental research resulted in the development of subsequent new drugs, such as long-acting C5 inhibitors, oral medications, or antagonists of C5aR, the receptor for C5a. New data in the domain of C5-inhibition in glomerular diseases are still limited and mainly focus on 1) the efficacy of ravulizumab, a long-acting C5 inhibitor in aHUS, and 2) the use of avacopan, a C5aR antagonist, in antineutrophil cytoplasmic antibody vasculitis. Several new studies ongoing or planned for the next few years will evaluate the efficacy of C5 inhibition in secondary thrombotic microangiopathy, C3 glomerulopathy, membranous nephropathy, or immunoglobulin A nephropathy.
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Affiliation(s)
- Alexis Werion
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
- Correspondence: Eric Rondeau Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Rue de la Chine 4, 75020 Paris, France. E-mail:
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7
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Dufour I, Werion A, Belkhir L, Wisniewska A, Perrot M, De Greef J, Schmit G, Yombi JC, Wittebole X, Laterre PF, Jadoul M, Gérard L, Morelle J. Serum uric acid, disease severity and outcomes in COVID-19. Crit Care 2021; 25:212. [PMID: 34127048 PMCID: PMC8201458 DOI: 10.1186/s13054-021-03616-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/24/2021] [Indexed: 12/15/2022]
Abstract
Background The severity of coronavirus disease 2019 (COVID-19) is highly variable between individuals, ranging from asymptomatic infection to critical disease with acute respiratory distress syndrome requiring mechanical ventilation. Such variability stresses the need for novel biomarkers associated with disease outcome. As SARS-CoV-2 infection causes a kidney proximal tubule dysfunction with urinary loss of uric acid, we hypothesized that low serum levels of uric acid (hypouricemia) may be associated with severity and outcome of COVID-19. Methods In a retrospective study using two independent cohorts, we investigated and validated the prevalence, kinetics and clinical correlates of hypouricemia among patients hospitalized with COVID-19 to a large academic hospital in Brussels, Belgium. Survival analyses using Cox regression and a competing risk approach assessed the time to mechanical ventilation and/or death. Confocal microscopy assessed the expression of urate transporter URAT1 in kidney proximal tubule cells from patients who died from COVID-19. Results The discovery and validation cohorts included 192 and 325 patients hospitalized with COVID-19, respectively. Out of the 517 patients, 274 (53%) had severe and 92 (18%) critical COVID-19. In both cohorts, the prevalence of hypouricemia increased from 6% upon admission to 20% within the first days of hospitalization for COVID-19, contrasting with a very rare occurrence (< 1%) before hospitalization for COVID-19. During a median (interquartile range) follow-up of 148 days (50–168), 61 (12%) patients required mechanical ventilation and 93 (18%) died. In both cohorts considered separately and in pooled analyses, low serum levels of uric acid were strongly associated with disease severity (linear trend, P < 0.001) and with progression to death and respiratory failure requiring mechanical ventilation in Cox (adjusted hazard ratio 5.3, 95% confidence interval 3.6–7.8, P < 0.001) or competing risks (adjusted hazard ratio 20.8, 95% confidence interval 10.4–41.4, P < 0.001) models. At the structural level, kidneys from patients with COVID-19 showed a major reduction in urate transporter URAT1 expression in the brush border of proximal tubules. Conclusions Among patients with COVID-19 requiring hospitalization, low serum levels of uric acid are common and associate with disease severity and with progression to respiratory failure requiring invasive mechanical ventilation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03616-3.
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Affiliation(s)
- Inès Dufour
- Division of Nephrology, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Alexis Werion
- Division of Nephrology, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Leila Belkhir
- Division of Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Anastazja Wisniewska
- Division of Nephrology, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Marie Perrot
- Division of Nephrology, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Julien De Greef
- Division of Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Gregory Schmit
- Department of Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Jean Cyr Yombi
- Division of Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Xavier Wittebole
- Department of Intensive Care Medicine, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pierre-François Laterre
- Department of Intensive Care Medicine, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Ludovic Gérard
- Department of Intensive Care Medicine, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium. .,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, 1200, Brussels, Belgium. .,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
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8
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Werion A, Rondeau E. C5 Inhibition in Secondary Thrombotic Microangiopathies: A Yet Unresolved Question. Kidney Int Rep 2021; 6:878-880. [PMID: 33939775 PMCID: PMC8071650 DOI: 10.1016/j.ekir.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Alexis Werion
- Intensive Care Nephrology and Transplantation Department, SINRA, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, SINRA, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
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9
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Timmermans SAMEG, Damoiseaux JGMC, Werion A, Reutelingsperger CP, Morelle J, van Paassen P. Functional and Genetic Landscape of Complement Dysregulation Along the Spectrum of Thrombotic Microangiopathy and its Potential Implications on Clinical Outcomes. Kidney Int Rep 2021; 6:1099-1109. [PMID: 33912760 PMCID: PMC8071658 DOI: 10.1016/j.ekir.2021.01.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 01/30/2023] Open
Abstract
Introduction The syndromes of thrombotic microangiopathy (TMA) are diverse and represent severe endothelial damage caused by various mechanisms. The complement system plays a major role in a subset of patients with TMA, and its recognition is of clinical importance because it guides choice and duration of treatment. Methods We studied a well-defined cohort of patients with TMA and hypothesized that assessment of serum-induced ex vivo C5b9 formation on the endothelium and screening for rare variants in complement genes can better categorize TMA. Results Massive ex vivo C5b9 formation was found in all patients with primary atypical hemolytic uremic syndrome (n/N = 11/11) and in 59% of patients with TMA and coexisting conditions (n/N = 30/51). Massive ex vivo C5b9 formation was associated with rare genetic variants (45% [n/N = 20/44] vs. 0% [n/N = 0/21] patients with normal ex vivo C5b9 formation; P < 0.001). Massive ex vivo C5b9 formation was associated with favorable renal response to therapeutic complement inhibition in patients with TMA and coexisting conditions (86% [n/N = 12/14] vs. 31% [n/N = 5/16] of untreated patients; P < 0.001), indicating complement-mediated TMA rather than secondary disease. Among treated patients, the odds ratio for 1-year kidney survival was 12.0 (95% confidence interval 1.2-115.4). TMA recurrence was linked to rare genetic variants in all cases. Patients with normal ex vivo C5b9 formation had an acute, nonrelapsing form of TMA. Conclusions Ex vivo C5b9 formation and genetic testing appears to categorize TMAs into different groups because it identifies complement as a driving factor of disease, with potential therapeutic and prognostic implications.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology.,Department of Biochemistry, Cardiovascular Research Institute, Maastricht, The Netherlands
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alexis Werion
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Johann Morelle
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Experimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology.,Department of Biochemistry, Cardiovascular Research Institute, Maastricht, The Netherlands
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10
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Werion A, Ponlot E, Lhommel R, Komuta M, Coubeau L, Goffin E. An unusual cause of hypercalcaemia in a home haemodialysis patient: Peritoneal tuberculosis. Int J Infect Dis 2020; 104:222-223. [PMID: 33359441 DOI: 10.1016/j.ijid.2020.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Alexis Werion
- Division of Nephrology, Cliniques Universitaires St Luc, Brussels, Belgium.
| | - Eleonore Ponlot
- Division of Nephrology, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Renaud Lhommel
- Division of Nuclear Medicine, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Mina Komuta
- Division of Pathology, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Laurent Coubeau
- Division of Surgery and Abdominal Transplantation, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Eric Goffin
- Division of Nephrology, Cliniques Universitaires St Luc, Brussels, Belgium
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11
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Werion A, Belkhir L, Perrot M, Schmit G, Aydin S, Chen Z, Penaloza A, De Greef J, Yildiz H, Pothen L, Yombi JC, Dewulf J, Scohy A, Gérard L, Wittebole X, Laterre PF, Miller SE, Devuyst O, Jadoul M, Morelle J. SARS-CoV-2 causes a specific dysfunction of the kidney proximal tubule. Kidney Int 2020; 98:1296-1307. [PMID: 32791255 PMCID: PMC7416689 DOI: 10.1016/j.kint.2020.07.019] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is commonly associated with kidney damage, and the angiotensin converting enzyme 2 (ACE2) receptor for SARS-CoV-2 is highly expressed in the proximal tubule cells. Whether patients with COVID-19 present specific manifestations of proximal tubule dysfunction remains unknown. To test this, we examined a cohort of 49 patients requiring hospitalization in a large academic hospital in Brussels, Belgium. There was evidence of proximal tubule dysfunction in a subset of patients with COVID-19, as attested by low-molecular-weight proteinuria (70-80%), neutral aminoaciduria (46%), and defective handling of uric acid (46%) or phosphate (19%). None of the patients had normoglycemic glucosuria. Proximal tubule dysfunction was independent of pre-existing comorbidities, glomerular proteinuria, nephrotoxic medications or viral load. At the structural level, kidneys from patients with COVID-19 showed prominent tubular injury, including in the initial part of the proximal tubule, with brush border loss, acute tubular necrosis, intraluminal debris, and a marked decrease in the expression of megalin in the brush border. Transmission electron microscopy identified particles resembling coronaviruses in vacuoles or cisternae of the endoplasmic reticulum in proximal tubule cells. Among features of proximal tubule dysfunction, hypouricemia with inappropriate uricosuria was independently associated with disease severity and with a significant increase in the risk of respiratory failure requiring invasive mechanical ventilation using Cox (adjusted hazard ratio 6.2, 95% CI 1.9-20.1) or competing risks (adjusted sub-distribution hazard ratio 12.1, 95% CI 2.7-55.4) survival models. Thus, our data establish that SARS-CoV-2 causes specific manifestations of proximal tubule dysfunction and provide novel insights into COVID-19 severity and outcome.
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Affiliation(s)
- Alexis Werion
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Leila Belkhir
- Division of Internal Medicine and Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Marie Perrot
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Gregory Schmit
- Department of Laboratory Medicine, Microbiology and Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Centre of Forensic Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Selda Aydin
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Laboratory Medicine, Microbiology and Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Zhiyong Chen
- Department of Physiology, Mechanisms of Inherited Kidney Disorders Group, University of Zurich, Zurich, Switzerland
| | - Andrea Penaloza
- Department of Emergency Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Julien De Greef
- Division of Internal Medicine and Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Halil Yildiz
- Division of Internal Medicine and Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Lucie Pothen
- Division of Internal Medicine and Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Jean Cyr Yombi
- Division of Internal Medicine and Infectious Diseases, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Joseph Dewulf
- Department of Laboratory Medicine, Microbiology and Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Anais Scohy
- Department of Laboratory Medicine, Microbiology and Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Ludovic Gérard
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Intensive Care Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Xavier Wittebole
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Intensive Care Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Pierre-François Laterre
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Intensive Care Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Sara E Miller
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Olivier Devuyst
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Physiology, Mechanisms of Inherited Kidney Disorders Group, University of Zurich, Zurich, Switzerland
| | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Department of Emergency Medicine, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
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12
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Timmermans SAMEG, Werion A, Spaanderman MEA, Reutelingsperger CP, Damoiseaux JGMC, Morelle J, van Paassen P. The natural course of pregnancies in women with primary atypical haemolytic uraemic syndrome and asymptomatic relatives. Br J Haematol 2020; 190:442-449. [PMID: 32342491 PMCID: PMC7496636 DOI: 10.1111/bjh.16626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/28/2022]
Abstract
Pregnancy has been linked to various microangiopathies, including primary atypical haemolytic uraemic syndrome (aHUS). Complement dysregulation, often linked to rare variants in complement genes, is key for primary aHUS to manifest and may play a role in pregnancy complications of the mother and fetus. The burden of such complications is unknown, making counselling of women with primary aHUS and asymptomatic relatives difficult. We analyzed the maternal and fetal outcomes of 39 pregnancies from 17 women with primary aHUS and two asymptomatic relatives. Seven out of 39 pregnancies were complicated by pregnancy‐associated aHUS. Five out of 32 pregnancies not linked to pregnancy‐associated aHUS were complicated by pre‐eclampsia or HELLP. Rare genetic variants were identified in 10 women (asymptomatic relatives, n = 2) who had a total of 14 pregnancies, including 10 uncomplicated pregnancies. Thirty‐five out of 39 pregnancies resulted in live birth. Eight out of 19 women had progressed to end‐stage kidney disease, with an incidence of 2·95 (95% confidence interval, 1·37–5·61) per 100 person‐years after the first pregnancy. Thus, we emphasized the frequency of successful pregnancies in women with primary aHUS and asymptomatic relatives. Pregnancies should be monitored closely. Rare genetic variants cannot predict the risk of a given pregnancy.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Alexis Werion
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Chris P Reutelingsperger
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Jan G M C Damoiseaux
- Department of Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Johann Morelle
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
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13
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Timmermans SA, Werion A, Morelle J, van Paassen P. Defects in complement and “secondary” hemolytic uremic syndrome. Kidney Int 2019; 96:517. [DOI: 10.1016/j.kint.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022]
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14
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Werion A, Lengelé JP. Fanconi Syndrome in Alcoholic Patients: Old Concept, New Idea. Nephron Clin Pract 2019; 141:201-202. [PMID: 30602151 DOI: 10.1159/000496035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 12/05/2018] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alexis Werion
- Department of Nephrology, Grand Hôpital de Charleroi, Charleroi, Belgium,
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15
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Werion A, Komuta M, Descamps OS, Henrion J. Statins and Clarithromycin : a dangerous combination. Case report and review of the literature. Acta Gastroenterol Belg 2019; 82:87-92. [PMID: 30888760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- A Werion
- Hepato-gastroenterology unit, Centres Hospitaliers de Jolimont, Haine-Saint-Paul, Belgium
| | - M Komuta
- Anatomo-pathology unit, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - O S Descamps
- Internal medicine department, Centres Hospitaliers de Jolimont, Haine-Saint-Paul, Belgium
| | - J Henrion
- Hepato-gastroenterology unit, Centres Hospitaliers de Jolimont, Haine-Saint-Paul, Belgium
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16
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Werion A, Joris V, Hepp M, Papasokrati L, Marique L, de Ville de Goyet C, Van Regemorter V, Mourad M, Lengelé B, Daumerie C, Marbaix E, Brichard S, Many MC, Craps J. Pioglitazone, a PPARγ Agonist, Upregulates the Expression of Caveolin-1 and Catalase, Essential for Thyroid Cell Homeostasis: A Clue to the Pathogenesis of Hashimoto's Thyroiditis. Thyroid 2016; 26:1320-31. [PMID: 27324467 DOI: 10.1089/thy.2015.0625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peroxisome proliferator-activated receptor γ (PPARγ) is a transcription factor that regulates the expression of multiple target genes involved in several metabolic pathways as well as in inflammation. The expression and cell localization of caveolin-1 (Cav-1), thyroperoxidase (TPO), and dual oxidase (DUOX), involved in extracellular iodination, is modulated by Th1 cytokines in human normal thyroid cells and in Hashimoto's thyroiditis (HT). OBJECTIVES The objectives of this study were (i) to analyze the PPARγ protein and mRNA expression at the follicular level in HT versus controls in correlation with the one of Cav-1; (ii) to study the effects of Th1 cytokines on PPARγ and catalase expression in human thyrocyte primary cultures; and (iii) to study the effects of pioglitazone, a PPARγ agonist, on thyroxisome components (Cav-1, TPO, DUOX) and on catalase, involved in antioxidant defense. RESULTS Although the global expression of PPARγ in the whole gland of patients with HT was not modified compared with controls, there was great heterogeneity among glands and among follicles within the same thyroid. Besides normal (type 1) follicles, there were around inflammatory zones, hyperactive (type 2) follicles with high PPARγ and Cav-1 expression, and inactive (type 3) follicles which were unable to form thyroxine and did not express PPARγ or Cav-1. In human thyrocytes in primary culture, Th1 cytokines decreased PPARγ and catalase expression; pioglitazone increased Cav-1, TPO, and catalase expression. CONCLUSION PPARγ may play a central role in normal thyroid physiology by upregulating Cav-1, essential for the organization of the thyroxisome and extracellular iodination. By upregulating catalase, PPARγ may also contribute to cell homeostasis. The inhibitory effect of Th1 cytokines on PPARγ expression may be considered as a new pathogenetic mechanism for HT, and the use of PPARγ agonists could open a new therapeutic approach.
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Affiliation(s)
- Alexis Werion
- 1 Pôles de Morphologie, Université Catholique de Louvain , Brussels, Belgium
| | - Virginie Joris
- 2 de Pharmacologie et Thérapeutique, et, Université Catholique de Louvain , Brussels, Belgium
| | - Michael Hepp
- 1 Pôles de Morphologie, Université Catholique de Louvain , Brussels, Belgium
| | - Lida Papasokrati
- 1 Pôles de Morphologie, Université Catholique de Louvain , Brussels, Belgium
| | - Lancelot Marique
- 1 Pôles de Morphologie, Université Catholique de Louvain , Brussels, Belgium
| | | | | | - Michel Mourad
- 3 de Chirurgie, et, Université Catholique de Louvain , Brussels, Belgium
| | - Benoit Lengelé
- 1 Pôles de Morphologie, Université Catholique de Louvain , Brussels, Belgium
| | - Chantal Daumerie
- 4 Départements d'Endocrinologie, Université Catholique de Louvain , Brussels, Belgium
| | - Etienne Marbaix
- 5 d'Anatomo-pathologie, Secteur des Sciences de la Santé, Faculté de Médecine, Université Catholique de Louvain , Brussels, Belgium
| | - Sonia Brichard
- 4 Départements d'Endocrinologie, Université Catholique de Louvain , Brussels, Belgium
- 6 d'Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain , Brussels, Belgium
| | | | - Julie Craps
- 1 Pôles de Morphologie, Université Catholique de Louvain , Brussels, Belgium
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