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Locatelli M, Buelli S, Pezzotta A, Corna D, Perico L, Tomasoni S, Rottoli D, Rizzo P, Conti D, Thurman JM, Remuzzi G, Zoja C, Morigi M. Shiga toxin promotes podocyte injury in experimental hemolytic uremic syndrome via activation of the alternative pathway of complement. J Am Soc Nephrol 2014; 25:1786-98. [PMID: 24578132 DOI: 10.1681/asn.2013050450] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Shiga toxin (Stx)-producing Escherichia coli is the offending agent of postdiarrhea-associated hemolytic uremic syndrome (HUS), a disorder of glomerular ischemic damage and widespread microvascular thrombosis. We previously documented that Stx induces glomerular complement activation, generating C3a responsible for microvascular thrombosis in experimental HUS. Here, we show that the presence of C3 deposits on podocytes is associated with podocyte damage and loss in HUS mice generated by the coinjection of Stx2 and LPS. Because podocyte adhesion to the glomerular basement membrane is mediated by integrins, the relevance of integrin-linked kinase (ILK) signals in podocyte dysfunction was evaluated. Podocyte expression of ILK increased after the injection of Stx2/LPS and preceded the upregulation of Snail and downregulation of nephrin and α-actinin-4. Factor B deficiency or pretreatment with an inhibitory antibody to factor B protected mice against Stx2/LPS-induced podocyte dysregulation. Similarly, pretreatment with a C3a receptor antagonist limited podocyte loss and changes in ILK, Snail, and α-actinin-4 expression. In cultured podocytes, treatment with C3a reduced α-actinin-4 expression and promoted ILK-dependent nuclear expression of Snail and cell motility. These results suggest that Stx-induced activation of the alternative pathway of complement and generation of C3a promotes ILK signaling, leading to podocyte dysfunction and loss in Stx-HUS.
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Affiliation(s)
- Monica Locatelli
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Simona Buelli
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Anna Pezzotta
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Daniela Corna
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Luca Perico
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Susanna Tomasoni
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Daniela Rottoli
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Paola Rizzo
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Debora Conti
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Denver School of Medicine, Aurora, Colorado; and
| | - Giuseppe Remuzzi
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Carlamaria Zoja
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy
| | - Marina Morigi
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri," Centro Anna Maria Astori, Bergamo, Italy;
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Al Ustwani O, Lohr J, Dy G, LeVea C, Connolly G, Arora P, Iyer R. Eculizumab therapy for gemcitabine induced hemolytic uremic syndrome: case series and concise review. J Gastrointest Oncol 2014; 5:E30-3. [PMID: 24490050 PMCID: PMC3904030 DOI: 10.3978/j.issn.2078-6891.2013.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 06/17/2013] [Indexed: 12/14/2022] Open
Affiliation(s)
- Omar Al Ustwani
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - James Lohr
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Grace Dy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Charles LeVea
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Gregory Connolly
- Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Pradeep Arora
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Renuka Iyer
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
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Abstract
Although new activation and regulatory mechanisms are still being identified, the basic architecture of the complement system has been known for decades. Two major roles of complement are to control certain bacterial infections and to promote clearance of apoptotic cells. In addition, although inappropriate complement activation has long been proposed to cause tissue damage in human inflammatory and autoimmune diseases, whether this is indeed true has been uncertain. However, recent studies in humans, especially those using newly available biological therapeutics, have now clearly demonstrated the pathophysiologic importance of the complement system in several rare diseases. Beyond these conditions, recent genetic studies have strongly supported an injurious role for complement in a wide array of human inflammatory, degenerative, and autoimmune diseases. This review includes an overview of complement activation, regulatory, and effector mechanisms. It then focuses on new understandings gained from genetic studies, ex vivo analyses, therapeutic trials, and animal models as well as on new research opportunities.
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Affiliation(s)
- V Michael Holers
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045;
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55
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Noris M, Remuzzi G. Cardiovascular complications in atypical haemolytic uraemic syndrome. Nat Rev Nephrol 2014; 10:174-80. [DOI: 10.1038/nrneph.2013.280] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Park SJ, Shin JI. Beneficial Effect of Eculizumab on Thrombotic Microangiopathies: Another Point of View. Am J Kidney Dis 2014; 63:166-7. [DOI: 10.1053/j.ajkd.2013.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/30/2013] [Indexed: 11/11/2022]
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Schmidtko J, Peine S. In Reply to ‘Beneficial Effect of Eculizumab on Thrombotic Microangiopathies: Another Point of View’. Am J Kidney Dis 2014; 63:167. [DOI: 10.1053/j.ajkd.2013.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/22/2013] [Indexed: 11/11/2022]
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Jodele S, Fukuda T, Vinks A, Mizuno K, Laskin BL, Goebel J, Dixon BP, Teusink A, Pluthero FG, Lu L, Licht C, Davies SM. Eculizumab therapy in children with severe hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Biol Blood Marrow Transplant 2013; 20:518-25. [PMID: 24370861 DOI: 10.1016/j.bbmt.2013.12.565] [Citation(s) in RCA: 172] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/19/2013] [Indexed: 11/28/2022]
Abstract
We recently observed that dysregulation of the complement system may be involved in the pathogenesis of hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA). These findings suggest that the complement inhibitor eculizumab could be a therapeutic option for this severe HSCT complication with high mortality. However, the efficacy of eculizumab in children with HSCT-TMA and its dosing requirements are not known. We treated 6 children with severe HSCT-TMA using eculizumab and adjusted the dose to achieve a therapeutic level >99 μg/mL. HSCT-TMA resolved over time in 4 of 6 children after achieving therapeutic eculizumab levels and complete complement blockade, as measured by low total hemolytic complement activity (CH50). To achieve therapeutic drug levels and a clinical response, children with HSCT-TMA required higher doses or more frequent eculizumab infusions than currently recommended for children with atypical hemolytic uremic syndrome. Two critically ill patients failed to reach therapeutic eculizumab levels, even after dose escalation, and subsequently died. Our data indicate that eculizumab may be a therapeutic option for HSCT-TMA, but HSCT patients appear to require higher medication dosing than recommended for other conditions. We also observed that a CH50 level ≤ 4 complement activity enzyme units correlated with therapeutic eculizumab levels and clinical response, and therefore CH50 may be useful to guide eculizumab dosing in HSCT patients as drug level monitoring is not readily available.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kana Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Benjamin L Laskin
- Division of Nephrology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jens Goebel
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bradley P Dixon
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley Teusink
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Fred G Pluthero
- Division of Nephrology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Lily Lu
- Division of Nephrology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Rathbone J, Kaltenthaler E, Richards A, Tappenden P, Bessey A, Cantrell A. A systematic review of eculizumab for atypical haemolytic uraemic syndrome (aHUS). BMJ Open 2013; 3:e003573. [PMID: 24189082 PMCID: PMC3822313 DOI: 10.1136/bmjopen-2013-003573] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine the efficacy and safety of eculizumab for patients with atypical haemolytic uraemic syndrome (aHUS), compared with current treatment options. DESIGN A systematic review was performed according to the general principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All study designs were included, except case histories. PARTICIPANTS All patients diagnosed with aHUS were included; no age restrictions were used. INTERVENTIONS Eculizumab compared with current treatment options. IDENTIFICATION OF STUDIES 12 databases were searched. Additional searches were performed through the Food and Drug Administration (FDA) and the Electronic Medicines Compendium websites, Google internet searches and contacting clinical experts. Reference lists of relevant articles were checked for additional studies. RESULTS 2 small, uncontrolled prospective multinational, multicentre studies and one small uncontrolled multinational, multicentre retrospective study were included. No meta-analyses were performed. Compared with baseline measures, thrombotic microangiopathy event-free status was achieved in 84% of patients in the prospective studies. Adverse events, as documented by enrolling investigators were frequent, with upper-respiratory tract infection affecting a third of patients. No deaths or episodes of meningitis or meningococcal septicaemia occurred in the prospective studies. Results of the study extension phases up to 114 weeks indicate that the benefits of the treatment are sustained. CONCLUSIONS Eculizumab is clinically effective for the treatment of aHUS. Further research is needed to evaluate eculizumab, ideally using patient-related clinical outcomes. If randomised studies are not feasible, study investigators should ensure that the threat of bias is minimised in future studies of eculizumab with respect to the reporting of patient recruitment and selection.
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Affiliation(s)
- John Rathbone
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Holers VM. Human C3 glomerulopathy provides unique insights into complement factor H-related protein function. J Clin Invest 2013; 123:2357-60. [PMID: 23728171 DOI: 10.1172/jci69684] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The study in this issue of the JCI by Tortajada et al. demonstrates that a duplication within the gene complement factor H–related 1 (CFHR1; encoding FHR1) leads to the production of an aberrant larger form of the protein. Elegant in vitro studies of the mutant and normal variants demonstrate an unexpected mechanism of action of FHR1, wherein homodimeration and hetero- oligomerization with FHR2 and FHR5 generates more avid molecules that very effectively compete with FH binding to surfaces and impair its ability to regulate local complement activation. As variants of FHRs are linked to many human inflammatory and autoimmune diseases, these and other recently published structure/function studies of these proteins provide key insights into their complement regulatory activities and likely roles in disease.
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Affiliation(s)
- V Michael Holers
- Department of Medicine, Division of Rheumatology, University of Colorado School of Medicine, Aurora, Colorado 80045, USA.
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Asif A, Haqqie SS, Ghate K, Mathew RO, Vachharajani T, Nayer A. Continued Eculizumab Therapy for Persistent Atypical Hemolytic Uremic Syndrome. ACTA ACUST UNITED AC 2013. [DOI: 10.2174/1874303x01306010046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Atypical hemolytic uremic syndrome (atypical HUS) is characterized by endothelial injury and microvascular thrombosis resulting in microangiopathic hemolytic anemia, thrombocytopenia, and ischemic injury to organs, especially the kidney. Activation of complements is involved in the pathogenesis of atypical HUS. Eculizumab, a neutralizing monoclonal antibody directed against complement C5, has shown salutary effects in patients with atypical HUS. In this report, we present a 23-year-old man with atypical HUSwho was treated with eculizumab. During the first four weeks of treatment, eculizumab failed to achieve a remission. Microangiopathic hemolytic anemia and thrombocytopenia persisted, while renal function deteriorated necessitating initiation of hemodialysis. Continuation of eculizumab therapy, however, led to marked improvement in hemolytic anemia, thrombocytopenia, and renal function. After 10 weeks of eculizumab therapy, hemodialysis was discontinued. At 5-month follow-up, serum creatinine was 1.1 mg/dL with continued eculizumab therapy every other week. In addition, platelet count was normal, while there was no evidence of hemolysis. We conclude that in patients with persistent atypical HUS continued treatment with eculizumab can be helpful in achieving remission.
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Sanz AB, Sanchez-Niño MD, Martín-Cleary C, Ortiz A, Ramos AM. Progress in the development of animal models of acute kidney injury and its impact on drug discovery. Expert Opin Drug Discov 2013; 8:879-95. [PMID: 23627598 DOI: 10.1517/17460441.2013.793667] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a clinical syndrome characterized by the acute loss of kidney function. AKI is increasingly frequent and is associated with impaired survival and chronic kidney disease progression. Experimental AKI models have contributed to a better understanding of pathophysiological mechanisms but they have not yet resulted in routine clinical application of novel therapeutic approaches. AREAS COVERED The authors present the advances in experimental AKI models over the last decade. Furthermore, the authors review their current and expected impact on novel drug discovery. EXPERT OPINION New AKI models have been developed in rodents and non-rodents. Non-rodents allow the evaluation of specific aspects of AKI in both bigger animals and simpler organisms such as drosophila and zebrafish. New rodent models have recently reproduced described clinical entities, such as aristolochic and warfarin nephropathies, and have also provided better models for old entities such as thrombotic microangiopathy-induced AKI. Several therapies identified in animal models are now undergoing clinical trials in human AKI, including p53 RNAi and bone-marrow derived mesenchymal stem cells. It is conceivable that further refinement of animal models in combination with ongoing trials and novel trials based on already identified potential targets will eventually yield effective therapies for clinical AKI.
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Affiliation(s)
- Ana B Sanz
- Renal and Vascular Pathology Laboratory, Instituto de Investigación Sanitaria-Fundació Jiménez Díaz/Universidad Autónoma de Madrid (IIS-FJD-UAM), Madrid, Spain
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63
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Ricklin D, Lambris JD. Complement in immune and inflammatory disorders: therapeutic interventions. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2013; 190:3839-47. [PMID: 23564578 PMCID: PMC3623010 DOI: 10.4049/jimmunol.1203200] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the awareness that immune-inflammatory cross-talk is at the heart of many disorders, the desire for novel immunomodulatory strategies in the therapy of such diseases has grown dramatically. As a prime initiator and important modulator of immunological and inflammatory processes, the complement system has emerged as an attractive target for early and upstream intervention in inflammatory diseases and has moved into the spotlight of drug discovery. Although prevalent conditions such as age-related macular degeneration have attracted the most attention, the diverse array of complement-mediated pathologies, with distinct underlying mechanisms, demands a multifaceted arsenal of therapeutic strategies. Fortunately, efforts in recent years have not only introduced the first complement inhibitors to the clinic but also filled the pipelines with promising candidates. With a focus on immunomodulatory strategies, in this review we discuss complement-directed therapeutic concepts and highlight promising candidate molecules.
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Affiliation(s)
- Daniel Ricklin
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, USA
| | - John D. Lambris
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, USA
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Acute Progression of Adult-Onset Atypical Hemolytic-Uremic Syndrome due to CFH Mutation: A Case Report. Case Rep Nephrol 2013; 2013:739820. [PMID: 24558625 PMCID: PMC3914211 DOI: 10.1155/2013/739820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/22/2013] [Indexed: 11/29/2022] Open
Abstract
Atypical hemolytic-uremic syndrome (aHUS), unlike typical HUS, is not due to bacteria but rather to an idiopathic or genetic cause that promotes dysregulation of the alternative complement pathway. It leads to hemolytic anemia, thrombocytopenia, and renal impairment. Although aHUS secondary to a genetic mutation is relatively rare, when occurring due to a mutation in Factor H (CFH), it usually presents with younger onset and has a more severe course, which in the majority ends with end-stage renal failure. Paradoxically to most available data, our case features acute aHUS due to a CFH mutation with late onset (38-year-old) and rapid progression to end-stage renal disease. Due to current data indicating a high risk of graft failure in such patients, the diagnosis of aHUS secondary to a genetic cause has disqualified our patient from a living (family) donor renal transplantation and left her with no other option but to begin permanent renal replacement therapy.
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