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Thangaraju S, Khandelwal P, Mishra K, Kumar M, Puraswani M, Saini R, Hari P, Coshic P, Sinha A, Bagga A. Abbreviated protocol of plasma exchanges for patients with anti-factor H associated hemolytic uremic syndrome. Pediatr Nephrol 2024:10.1007/s00467-024-06279-8. [PMID: 38270601 DOI: 10.1007/s00467-024-06279-8] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Plasma exchanges (PEX) and immunosuppression are the cornerstone of management of anti-factor H (FH) antibody-associated atypical hemolytic uremic syndrome (aHUS), particularly if access to eculizumab is limited. The duration of therapy with PEX for anti-FH aHUS is empirical. METHODS We compared the efficacy of abbreviated PEX protocol (10-12 sessions) in a prospective cohort of patients diagnosed with anti-FH aHUS (2020-2022), to standard PEX protocol (20-22 sessions) in a historical cohort (2016-2019; n = 65). Efficacy was defined as 70% decline in anti-FH titers or fall to ≤ 1300 AU/ml at 4 weeks. Patients in both cohorts received similar immunosuppression with oral prednisolone, IV cyclophosphamide (5 doses) and mycophenolate mofetil. Outcomes included efficacy, rates of hematological remission and adverse kidney outcomes at 1, 3 and 6 months. RESULTS Of 23 patients, 8.2 ± 2.1 years old enrolled prospectively, two were excluded for significant protocol deviation. PEX was abbreviated in 18/21 (86%) patients to 11.5 ± 3.3 sessions. Abbreviation failed for lack of hematological remission by day 14 (n = 2) and persistent neurological manifestations (n = 1). All patients in whom PEX was abbreviated achieved > 70% reduction in anti-FH titers at day 28. The percentage fall in anti-FH titers was similar for the abbreviated vs. standard PEX protocols at 1, 3 and 6 months. At last follow-up, at median 50 months and 25 months for standard and abbreviated cohorts, the estimated GFR was similar at 104.8 ± 29.1 vs. 93.7 ± 53.4, respectively (P = 0.42). CONCLUSION Abbreviation of the duration of PEX is feasible and efficacious in reducing anti-FH titers. Short-term outcomes were comparable in patients managed by abbreviated and standard PEX protocols.
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Affiliation(s)
- Sharan Thangaraju
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Rahul Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Poonam Coshic
- Department of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Khurana S, Katiyar A, Puraswani M, Sharma D, Walia K, Malhotra R, Mathur P. Molecular mechanisms of colistin- and multidrug-resistance in bacteria among patients with hospital-acquired infections. Future Sci OA 2023; 9:FSO896. [PMID: 37753358 PMCID: PMC10518808 DOI: 10.2144/fsoa-2022-0055] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/08/2023] [Indexed: 09/28/2023] Open
Abstract
Aim The increasing burden of resistance in Gram-negative bacteria (GNB) is becoming a major issue for hospital-acquired infections. Therefore, understanding the molecular mechanisms is important. Methodology Resistance genes of phenotypically colistin-resistant GNB (n = 60) were determined using whole genome sequencing. Antimicrobial susceptibility patterns were detected by Vitek®2 & broth microdilution. Results Of these phenotypically colistin-resistant isolates, 78% were also genetically resistant to colistin. Activation of efflux pumps, and point-mutations in pmrB, and MgrB genes conferred colistin resistance among GNB. Eight different strains of K. pneumoniae were identified and ST43 was the most prominent strain with capsular type-specific (cps) gene KL30. Discussion These results, in combination with rapid diagnostic methods, will help us better advice appropriate antimicrobial regimens.
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Affiliation(s)
- Surbhi Khurana
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
| | - Amit Katiyar
- Centralized Core Research Facility, Bioinformatics Facility, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Puraswani
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
| | - Divya Sharma
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
| | - Kamini Walia
- Epidemiology & Communicable Diseases, Indian Council of Medical Research
| | - Rajesh Malhotra
- Department of Orthopedics, Chief, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi
| | - Purva Mathur
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi
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Khandelwal P, Joshi A, Mathur A, Puraswani M, Gurjar BS, Sinha A, Hari P, Faruq M, Bagga A. Variants in complement genes are uncommon in patients with anti-factor H autoantibody-associated atypical hemolytic uremic syndrome. Pediatr Nephrol 2023; 38:2659-2668. [PMID: 36622444 DOI: 10.1007/s00467-022-05862-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Coexisting genetic variants in patients with anti-factor H (FH)-associated atypical hemolytic uremic syndrome (aHUS) have implications for therapy. We estimated the prevalence of complement genetic variants in children with anti-FH aHUS from a prospective nationwide cohort and determined if significant genetic variants impact long-term kidney outcomes. METHODS Of 436 patients in the database, 77 consecutive patients, 21 with a relapse and 9 with kidney failure and/or death were included. Targeted sequencing, using a 27-gene panel including CFH, CFI, CFB, C3, CD46, PLG, DGKE, and THBD and multiplex ligation-dependent probe amplification of CFH-CFHR region, was performed. The adverse outcome was eGFR < 30 ml/min/1.73 m2 or death. RESULTS Patients had high anti-FH titers 5670 (2177-13,545) AU/ml, relapsing course (42.1%), and adverse outcomes (19.6%). Variants, chiefly of unknown significance, were found in 7 (6.5%; 95% CI 3.1-13.2%); a pathogenic variant was found in one patient. Homozygous deletion of CFHR1 was present in 91.6% compared to 9.8% in 184 healthy controls. Plasma exchanges and immunosuppression showed a trend of improving outcomes, independent of genetic defects (HR 0.32; P = 0.070). Meta-analysis of 18 studies (384 patients) showed that the pooled prevalence of pathogenic and likely pathogenic variants was 3% (95% CI 0-8%). Of 37 total variants in the meta-analysis, 7 (18.9%) each were pathogenic and likely pathogenic; others were variants of unknown significance. CONCLUSIONS Significant variants in complement regulatory genes are rare in patients with anti-FH-associated aHUS. Irrespective of genetic defects, plasma exchanges and immunosuppression showed a statistical trend to improved outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aditi Joshi
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Aradhana Mathur
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Bahadur Singh Gurjar
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Mohammed Faruq
- Genomics and Molecular Medicine, CSIR Institute of Genomics and Integrative Biology, Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Puraswani M, Srivastav S, Aggrawal R, Soni KD, Malhotra R, Kumar S, Sagar S, Gupta A, Mathur P. Eight year study on evolution of antimicrobial resistance in an antimicrobial-naïve trauma population. Indian J Med Microbiol 2023; 44:100355. [PMID: 37356848 DOI: 10.1016/j.ijmmb.2023.01.013] [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: 06/24/2022] [Revised: 12/26/2022] [Accepted: 01/23/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Moreover, the burden of HAIs is higher in ICU admitted patients. Long term studies are beneficial to evolution pattern of AMR. Therefore, this study aimed to evaluate the evolution of AMR pattern over the years in one of the ICUs of a level 1 Trauma Center. This will enable us to modify the prescribing practices according to emerging resistance patterns. METHODS This study was conducted at one of the ICU of level-1 trauma center of tertiary care hospital. The study reports the findings of the AMR surveillance from January 2012 to December 2019. Standard definitions were used to define HAI (www.hais.com). The clinical records of the patients were maintained using ASHAIN indigenous software. Outbreak analysis was done by WHONET. RESULTS From 1st January 2012-31st December 2019, 4305 isolates were obtained from 1969 patients. Most frequent occurring organism were gram negatives among which A. baumannii was common followed by K. pneumoniae, and P. aeruginosa. Retrospective analysis showed 7 outbreaks/clusters during the study period and all the outbreaks occurred from October to December in each year. The increasing trend of AMR pattern emphasizes to strengthen infection control practices and sustained AMR surveillance.
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Affiliation(s)
- Mamta Puraswani
- Department of Laboratory Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Sharad Srivastav
- Department of Laboratory Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Richa Aggrawal
- Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Rajesh Malhotra
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Subodh Kumar
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Sushma Sagar
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Amit Gupta
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Purva Mathur
- Department of Laboratory Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
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Sharad N, Srivastava S, Singh P, Puraswani M, Srivastav S, Malhotra R, Trikha A, Mathur P. Secondary Bacterial Infections in Mucormycosis-COVID-19 Cases: Experience during the Second COVID-19 Wave in India. Microbiol Spectr 2022; 10:e0091922. [PMID: 36301096 PMCID: PMC9769615 DOI: 10.1128/spectrum.00919-22] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/09/2022] [Indexed: 01/05/2023] Open
Abstract
In the second wave of COVID-19 in India, there was a new challenge in the form of mucormycosis. Coinfection with mucormycosis was perilous as both conditions required a prolonged hospital stay, thus serving as an ideal platform for secondary infections. Using a retrospective observational study, we studied secondary infections and their impact on the outcome in COVID-19 patients with mucormycosis. The outcome in these patients was evaluated and compared with COVID-19 patients with mucormycosis but without any secondary infection. SPSS V-20 was used for data analysis. Fifty-five patients tested positive for mucormycosis (55/140; 39.28). Twelve out of these 55 (21.8%) developed secondary infections during their hospital stay. Bloodstream infection was the most common (42.86%) secondary infection. The Gram-negative (GN) organisms were more common (11/16; 68.75%) compared with the Gram-positives (GP) (5/16; 31.25%). But the most common isolate was Enterococcus faecium (5/16; 31.25%). A high percentage of microorganisms isolated were multidrug-resistant (15/16; 93.75%). Two out of five (40%) isolates of Enterococcus faecium were vancomycin-resistant (VRE). High resistance to carbapenems was noted in the GN isolates (9/11; 81.81%). The comparison of length of stay in both subgroups was statistically significant (P value <0.001). When compared, the length of stay in people with adverse outcomes was also statistically significant (P value <0.001). Procalcitonin (PCT) had a positive predictive value for the development of secondary bacterial infections (P value <0.001). Antimicrobial stewardship and strict infection control practices are the need of the hour. IMPORTANCE Although our knowledge about COVID-19 and secondary infections in patients is increasing daily, little is known about the secondary infections in COVID-19-mucormycosis patients. Thus, we have intended to share our experience regarding this subgroup. The importance of this study is that it brings to light the type of secondary infections seen in COVID-19-mucormycosis patients. These secondary infections were partially responsible for the mortality and morbidity of the unfortunate ones. We, as health care workers, can learn the lesson and disseminate the knowledge so that in similar situations, health care workers, even in other parts of the world, know what to expect.
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Affiliation(s)
- Neha Sharad
- Department of Microbiology, AIIMS, New Delhi, India
| | | | - Parul Singh
- Department of Microbiology, AIIMS, New Delhi, India
| | - Mamta Puraswani
- Department of Laboratory Medicine, JPNATC, AIIMS, New Delhi, India
| | - Sharad Srivastav
- Department of Laboratory Medicine, JPNATC, AIIMS, New Delhi, India
| | | | - Anjan Trikha
- Department of Anaesthesia, AIIMS, New Delhi, India
| | - Purva Mathur
- Department of Laboratory Medicine, JPNATC, AIIMS, New Delhi, India
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Srivastav S, Puraswani M, Tewari P, Mathur P. P150 Profile of Candidemia in a national level HAI Surveillance Network of India. Med Mycol 2022. [PMCID: PMC9494488 DOI: 10.1093/mmy/myac072.p150] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Background Candida is responsible for roughly 96% of all opportunistic mycoses and is a major cause of bloodstream infections (BSIs). The potential for nosocomial spread of Candidemia infections is a new concern concurrent with the rapid expansion of intensive care facilities for COVID-19 patients. With the pandemic of COVID-19 now moving into 2022, it is understood that critically ill COVID-infected patients in the ICUs are commonly infected with highly resistant bacterial and fungal infections. Objective To estimate the incidence rates and compare the epidemiology of candidemia in COVID infected and non-infected patients requiring ICU care. Methodology In this 2-year retrospective multicentric study, we present the findings on candidemia from the Healthcare-Associated Infections (HAI) surveillance network which includes 40 hospitals across India and with special emphasis on differences in the epidemiology of Candidemia in COVID infected and non-infected patients in the pre-COVID (April 2019 to April 2020) and COVID times (April 2020 to April 2021) across this network. We compared the incidence of candidemia between COVID infected and non-infected patients using Poisson regression analysis. Chi-squared (χ2) test was used to test for differences in variables such as gender and 14-day mortality between the patients and Wilcoxon rank-sum (Mann-Whitney) test was used to compare median between the patients. Results A total of 628 patients with candidemia were screened from HAI Surveillance Database where 68 patients are COVID infected and 560 non-infected patients from both pre-COVID and COVID periods. Incidence of Candida-associated BSI increased significantly from 1.47 (95% CI, 1.35-1.60) to 3.08 (95% CI, 2.38-3.92) in non-infected and COVID-infected patients respectively, while in CLABSI the rates increased from 2.62 (95% CI, 2.34-2.92) in non-infected to 5.99 (95% CI, 4.30-8.12) in COVID-infected patients. COVID infected patients in the age group (>60 years) were significantly more prone to candidemia compared to non-infected patients. During the COVID period, the maximum time for candidemia to develop (from the time of ICU admission) in COVID-infected patients was shorter (<65 days) than in non-infected patients (>90 days). Conclusion We observed an increased incidence of candidemia in hospitalized patients during the COVID period compared with the same during the pre-COVID period.
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Affiliation(s)
- Sharad Srivastav
- AIIMS Jai Prakash Narayan Apex Trauma Center , New Delhi, New Delhi , India
| | - Mamta Puraswani
- AIIMS Jai Prakash Narayan Apex Trauma Center , New Delhi, New Delhi , India
| | - Prachi Tewari
- AIIMS Jai Prakash Narayan Apex Trauma Center , New Delhi, New Delhi , India
| | - Purva Mathur
- AIIMS Jai Prakash Narayan Apex Trauma Center , New Delhi, New Delhi , India
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Bakthavatchalam YD, Puraswani M, Livingston A, Priya M, Venkatesan D, Sharma D, Iyadurai R, Pichamuthu K, Veeraraghavan B, Mathur P. Novel linear plasmids carrying vanA cluster drives the spread of vancomycin resistance in Enterococcus faecium in India. J Glob Antimicrob Resist 2022; 29:168-172. [PMID: 35339734 DOI: 10.1016/j.jgar.2022.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/23/2021] [Revised: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The genetic basis for the spread of vancomycin resistance in E. faecium is largely unexplored in India. The present study aimed to investigate the plasmid diversity and variation of Tn1546 associated with vanA harbouring VREfm isolates. METHODS A total of 122 VREfm isolates collected from blood cultures were included in this study. MLST analysis was performed on all isolates and they were also screened for the presence of vanA and vanB genes. Whole genome sequencing was performed for a subset of fifteen VREfm isolates belonging to ST1643. RESULTS All of the 122 VREfm isolates carried the vanA gene. Twenty four different sequence types were seen, of these ST1643, ST80 and ST17 were predominant. Whole genome sequencing was performed on fifteen VREfm isolates belonging to ST1643. For eight isolates the vanA gene was found on pRUM like circular plasmids, and for the remaining seven isolates, the vanA gene was found in linear plasmids. Novel Tn1546 variants carrying vanA were found on both circular and linear plasmids. Interestingly, co-presence of vanA and optrA were seen in the backbone of three linear plasmids. CONCLUSION Multiple vanA carrying plasmids and Tn1546 like elements were involved in the dissemination of vancomycin resistance in VREfm. The co-occurrence of Tn1546 carrying vanA and Tn554 family transposon carrying optrA on the backbone of plasmids is worrisome. The dissemination of such plasmids may pose treatment and infection control challenges.
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Affiliation(s)
- Yamuna Devi Bakthavatchalam
- Department of Clinical Microbiology, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Mamta Puraswani
- Department of Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Abel Livingston
- Department of Orthopaedics, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Monisha Priya
- Department of Clinical Microbiology, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Dhanalakshmi Venkatesan
- Department of Clinical Microbiology, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Divya Sharma
- Department of Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Ramya Iyadurai
- Department of Orthopaedics, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Kishore Pichamuthu
- Department of Medicine, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India.
| | - Purva Mathur
- Department of Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India; Intensive Care, Medical ICU, Christian Medical College, Vellore, India.
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KHANDELWAL P, Faruq M, Puraswani M, Sinha A, Hari P, Bagga A. SAT-462 COEXISTING VARIATIONS IN COMPLEMENT REGULATORY GENES INCREASE SUSCEPTIBILITY TO RELAPSE IN ANTI-FACTOR H ASSOCIATED ATYPICAL HEMOLYTIC UREMIC SYNDROME. Kidney Int Rep 2020. [DOI: 10.1016/j.ekir.2020.02.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Puraswani M, Khandelwal P, Saini H, Saini S, Gurjar BS, Sinha A, Shende RP, Maiti TK, Singh AK, Kanga U, Ali U, Agarwal I, Anand K, Prasad N, Rajendran P, Sinha R, Vasudevan A, Saxena A, Agarwal S, Hari P, Sahu A, Rath S, Bagga A. Clinical and Immunological Profile of Anti-factor H Antibody Associated Atypical Hemolytic Uremic Syndrome: A Nationwide Database. Front Immunol 2019; 10:1282. [PMID: 31231391 PMCID: PMC6567923 DOI: 10.3389/fimmu.2019.01282] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 02/23/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Atypical hemolytic uremic syndrome (aHUS), an important cause of acute kidney injury (AKI), is characterized by dysregulation of the alternative complement pathway. Autoantibodies to factor H (FH), a chief regulator of this pathway, account for a distinct subgroup. While high anti-FH titers predict relapse, they do not correlate well with disease activity and their functional characterization is required. Methods: Of 781 patients <18-year-old of aHUS in the nationwide database from 2007 to 2018, 436 (55.8%) had anti-FH antibodies. Clinical features and outcome of patients managed in the last 6-year (n = 317) were compared to before (n = 119). In plasma samples of 44 patients, levels of serial circulating FH immune complexes (CIC), free FH, soluble terminal complement complex (sC5b-9), sheep red blood cell (SRBC) lysis and epitope specificity (n = 8) were examined. Functional renal reserve, ambulatory hypertension, left ventricular hypertrophy (LVH), and proteinuria were evaluated in a subset. Results: Patients presented with markedly elevated anti-FH titers (10,633.2 ± 998.5 AU/ml). Management varied by center, comprising plasma exchange (PEX; 77.5%) and immunosuppression (73.9%). Patients managed in the last 6-year showed better renal survival at mean 28.5 ± 27.3 months (log rank P = 0.022). Mean anti-FH titers stayed 700–1,164 AU/ml during prolonged follow-up, correlating with CIC. Patients with relapse had lower free-FH during remission [Generalized estimating equations (GEE), P = 0.001]; anti-FH levels ≥1,330 AU/ml and free FH ≤440 mg/l predicted relapse (hazards ratio, HR 6.3; P = 0.018). Epitope specificity was similar during onset, remission and relapse. Antibody titer ≥8,000 AU/ml (HR 2.23; P = 0.024), time to PEX ≥14 days (HR 2.09; P = 0.071) and PEX for <14 days (HR 2.60; P = 0.017) predicted adverse renal outcomes. Combined PEX and immunosuppression improved long-term outcomes (HR 0.37; P = 0.026); maintenance therapy reduced risk of relapses (HR 0.11; P < 0.001). At 4.4±2.5 year, median renal reserve was 15.9%; severe ambulatory, masked and pre-hypertension were found in 38, 30, and 18%, respectively. Proteinuria and LVH occurred in 58 and 28% patients, respectively. Conclusion: Prompt recognition and therapy with PEX and immunosuppression, is associated with satisfactory outcomes. Free-FH predicts early relapses in patients with high anti-FH titers. A significant proportion of impaired functional reserve, ambulatory hypertension, proteinuria and LVH highlight the need for vigilant long-term follow-up.
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Affiliation(s)
- Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Bahadur Singh Gurjar
- Immuno Biology Laboratory II, National Institute of Immunology, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - Uma Kanga
- Department of Transplant Immunology and Immunogenetics, All India Institute of Medical Sciences, New Delhi, India
| | - Uma Ali
- Department of Pediatrics, BJ Wadia Hospital for Children, Mumbai, India
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Kanav Anand
- Division of Pediatric Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Padmaraj Rajendran
- Department of Pediatric Nephrology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, India
| | - Rajiv Sinha
- Department of Pediatrics, Institute of Child Health, Kolkata, India
| | - Anil Vasudevan
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Sahu
- National Centre for Cell Science, Pune, India
| | - Satyajit Rath
- National Centre for Cell Science, Pune, India.,Translational Health Science and Technology Institute, Faridabad, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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10
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Bhatia D, Sinha A, Hari P, Sopory S, Saini S, Puraswani M, Saini H, Mitra DK, Bagga A. Rituximab modulates T- and B-lymphocyte subsets and urinary CD80 excretion in patients with steroid-dependent nephrotic syndrome. Pediatr Res 2018; 84:520-526. [PMID: 29983411 DOI: 10.1038/s41390-018-0088-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/29/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rituximab, a monoclonal antibody targeting B lymphocytes, effectively sustains remission in steroid-dependent nephrotic syndrome (SDNS). We studied its effects on lymphocyte subsets and urinary CD80 excretion (uCD80) in patients with SDNS. METHODS Blood and urine samples were collected from 18 SDNS patients before rituximab, and after 1 month and 1 year or at first relapse. T and B lymphocytes and uCD80 were determined by flow cytometry and ELISA, respectively. RESULTS Treatment was associated with reduction in counts of Th17, Th2, and memory T cells, and increased T-regulatory (Treg) cells. The Th17/Treg ratio declined from baseline (median 0.6) to 1 month (0.2, P = 0.006) and increased during relapse (0.3, P = 0.016). Ratios of Th1/Th2 cells at baseline, 1 month after rituximab, and during relapse were 7.7, 14.0 (P = 0.0102), and 8.7, respectively. uCD80 decreased 1 month following rituximab (45.5 vs. 23.0 ng/g creatinine; P = 0.0039). B lymphocytes recovered earlier in relapsers (60.0 vs.183.0 days; P < 0.001). Memory B cells were higher during relapse than remission (29.7 vs.18.0 cells/µL; P = 0.029). CONCLUSION Rituximab-induced sustained remission and B-cell depletion was associated with reduced numbers of Th17 and Th2 lymphocytes, and increased Treg cells; these changes reversed during relapses. Recovery of B cells and memory B cells predicted the occurrence of a relapse.
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Affiliation(s)
- Divya Bhatia
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Shailaja Sopory
- Pediatric Biology Center, Translational Health Science & Technology Institute, Faridabad, India
| | - Savita Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Dipendra K Mitra
- Department of Transplant Immunology & Immunogenetics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
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11
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Gurjar BS, Manikanta Sriharsha T, Bhasym A, Prabhu S, Puraswani M, Khandelwal P, Saini H, Saini S, Verma AK, Chatterjee P, Guchhait P, Bal V, George A, Rath S, Sahu A, Sharma A, Hari P, Sinha A, Bagga A. Characterization of genetic predisposition and autoantibody profile in atypical haemolytic-uraemic syndrome. Immunology 2018; 154:663-672. [PMID: 29485195 PMCID: PMC6050217 DOI: 10.1111/imm.12916] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 10/02/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 12/25/2022] Open
Abstract
We previously reported that Indian paediatric patients with atypical haemolytic-uraemic syndrome (aHUS) showed high frequencies of anti-complement factor H (FH) autoantibodies that are correlated with homozygous deletion of the genes for FH-related proteins 1 and 3 (FHR1 and FHR3) (FHR1/3-/- ). We now report that Indian paediatric aHUS patients without anti-FH autoantibodies also showed modestly higher frequencies of the FHR1/3-/- genotype. Further, when we characterized epitope specificities and binding avidities of anti-FH autoantibodies in aHUS patients, most anti-FH autoantibodies were directed towards the FH cell-surface anchoring polyanionic binding site-containing C-terminal short conservative regions (SCRs) 17-20 with higher binding avidities than for native FH. FH SCR17-20-binding anti-FH autoantibodies also bound the other cell-surface anchoring polyanionic binding site-containing region FH SCR5-8, at lower binding avidities. Anti-FH autoantibody avidities correlated with antibody titres. These anti-FH autoantibody characteristics did not differ between aHUS patients with or without the FHR1/3-/- genotype. Our data suggest a complex matrix of interactions between FHR1-FHR3 deletion, immunomodulation and anti-FH autoantibodies in the aetiopathogenesis of aHUS.
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Affiliation(s)
| | | | - Angika Bhasym
- Regional Centre for BiotechnologyFaridabadIndia
- Department of BiotechnologyManipal Academy of Higher EducationManipalIndia
| | - Savit Prabhu
- Paediatric Biology CentreTranslational Health Science and Technology InstituteFaridabadIndia
| | - Mamta Puraswani
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Priyanka Khandelwal
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Himanshi Saini
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Savita Saini
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | | | | | | | - Vineeta Bal
- National Institute of ImmunologyNew DelhiIndia
- Paediatric Biology CentreTranslational Health Science and Technology InstituteFaridabadIndia
| | - Anna George
- National Institute of ImmunologyNew DelhiIndia
| | - Satyajit Rath
- National Institute of ImmunologyNew DelhiIndia
- Paediatric Biology CentreTranslational Health Science and Technology InstituteFaridabadIndia
- Agharkar Research InstitutePuneIndia
| | - Arvind Sahu
- National Centre for Cell ScienceS. P. Pune University CampusPuneIndia
| | - Amita Sharma
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Pankaj Hari
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Aditi Sinha
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
| | - Arvind Bagga
- Department of PaediatricsAll India Institute of Medical SciencesNew DelhiIndia
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12
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Thergaonkar RW, Narang A, Gurjar BS, Tiwari P, Puraswani M, Saini H, Sinha A, Varma B, Mukerji M, Hari P, Bagga A. Targeted exome sequencing in anti-factor H antibody negative HUS reveals multiple variations. Clin Exp Nephrol 2017; 22:653-660. [PMID: 28939980 DOI: 10.1007/s10157-017-1478-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 07/10/2017] [Accepted: 09/03/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Genetic susceptibility to atypical hemolytic uremic syndrome (aHUS) may lie within genes regulating or activating the alternate complement and related pathways converging on endothelial cell activation. METHODS We tested 32 Indian patients of aHUS negative for antibodies to complement factor H for genetic variations in a panel of 15 genes, i.e., CFH, CFHR1-5, CFI, CFB, C3, CD46, MASP2, DGKE, ADAMTS13, THBD and PLG using next-generation DNA sequencing and for copy number variation in CFHR1-3. RESULTS Despite absence of a public database of exome variations in the Indian population and limited functional studies, we could establish a genetic diagnosis in 6 (18.8%) patients using a stringent scheme of prioritization. One patient carried a likely pathogenic variation. The number of patients carrying possibly pathogenic variation was as follows: 1 variation: 5 patients, 2 variations: 9 patients, 3 variations: 5 patients, 4 variations: 9 patients, 5 variations: 2 patients and 6 variations: 2 patients. Homozygous deletion of CFHR1-3 was present in five patients; none of these carried a diagnostic genetic variation. Patients with or without diagnostic variation did not differ significantly in terms of enrichment of genetic variations that were rare/novel or predicted deleterious, or for possible environmental triggers. CONCLUSION We conclude that genetic testing for multiple genes in patients with aHUS negative for anti-FH antibodies reveals multiple candidate variations that require prioritization. Population data on variation frequency of the Indian population and supportive functional studies are likely to improve diagnostic yield.
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Affiliation(s)
- R W Thergaonkar
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ankita Narang
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | | | - Pradeep Tiwari
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Binuja Varma
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Mitali Mukerji
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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13
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Khandelwal P, Birla S, Bhatia D, Puraswani M, Saini H, Sinha A, Hari P, Sharma A, Bagga A. Mutations in membrane cofactor protein ( CD46) gene in Indian children with hemolytic uremic syndrome. Clin Kidney J 2017; 11:198-203. [PMID: 29644059 PMCID: PMC5888602 DOI: 10.1093/ckj/sfx078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 03/19/2017] [Accepted: 06/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background Mutations in the CD46 gene account for an important proportion of patients with atypical hemolytic uremic syndrome (aHUS) who characteristically show multiple relapses, no response to plasma exchange and low recurrence risk in allograft. We screened for mutations in CD46 in patients with and without circulating anti-factor H (FH) antibodies-associated aHUS. Methods We estimated CD46 surface expression by flow cytometry and sequenced the CD46 gene in 23 and 56 patients with and without circulating anti-FH antibodies, respectively. Human Splicing Finder and PolyPhen2 were used for in silico prediction of pathogenicity. Results Two novel and three known (c.286 +2T > G, c.104G > A and c.565T > G) mutations in CD46 were found in nine (11.4%) patients; one patient had a variant of unknown significance and two patients presented during the first year of life. Novel intronic (c.1127 + 46C > G) and exonic (c.911C > T) mutations are proposed to activate cryptic splicing sites or alter protein conformation. Markedly reduced CD46 surface expression was found in homozygous states in five patients. Conclusion Patients with mutations in CD46 present at all ages, including the first year of life. Mutations in intron 2, (c.286 +2T > G) may be a potential hot spot in Indian children. Flow cytometry for CD46 expression is a satisfactory screening tool enabling early diagnosis.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Birla
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Divya Bhatia
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arundhati Sharma
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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14
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Sinha A, Bajpai J, Saini S, Bhatia D, Gupta A, Puraswani M, Dinda AK, Agarwal SK, Sopory S, Pandey RM, Hari P, Bagga A. Serum-soluble urokinase receptor levels do not distinguish focal segmental glomerulosclerosis from other causes of nephrotic syndrome in children. Kidney Int 2014; 85:649-58. [PMID: 24429405 DOI: 10.1038/ki.2013.546] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 11/16/2013] [Accepted: 11/26/2013] [Indexed: 12/31/2022]
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