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Abstract
The thrombotic microangiopathies (TMAs) are a group of diseases characterised by microangiopathic haemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. Traditionally, TMAs have been classified as either thrombotic thrombocytopenic purpura (TTP) or haemolytic uremic syndrome (HUS) based on the clinical presentation, with neurological involvement predominating in the former and acute kidney injury in the latter. However, as our understanding of the pathogenesis of these conditions has increased, it has become clear that this is an over-simplification; there is significant overlap in the clinical presentation of TTP and HUS, there are different forms of HUS, and TMAs can occur in other, diverse clinical scenarios. This review will discuss recent developments in the diagnosis of HUS, focusing on the different forms of HUS and how to diagnose and manage these potentially life-threatening diseases.
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Affiliation(s)
- Neil S Sheerin
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Emily Glover
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
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52
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Knoop M, Haller H, Menne J. [Human genetics in atypical hemolytic uremic syndrome-its role in diagnosis and treatment]. Internist (Berl) 2019; 59:799-804. [PMID: 29995248 DOI: 10.1007/s00108-018-0455-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The atypical hemolytic uremic syndrome (aHUS), one of the three major forms of thrombotic microangiopathy, is characterized by genetic alterations in the area of the complement cascade, which can be detected in 40%-60% of all patients with aHUS. Mutations in over 10 different genes have now been identified. The most frequent and clinically relevant of these are mutations that result in a decreased or absent function of factor H, the formation of hybrid genes, or the formation of autoantibodies against factor H. Although genetics are not required for the diagnosis of aHUS, it is of great importance for the decision on how long to treat with the C5 inhibitor eculizumab. Also, knowledge of genetic alterations is absolutely essential if a living related donor is considered, in order to protect the living donor and recipient from developing aHUS.
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Affiliation(s)
- M Knoop
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - J Menne
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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53
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Wijnsma KL, Duineveld C, Volokhina EB, van den Heuvel LP, van de Kar NCAJ, Wetzels JFM. Safety and effectiveness of restrictive eculizumab treatment in atypical haemolytic uremic syndrome. Nephrol Dial Transplant 2019; 33:635-645. [PMID: 29106598 DOI: 10.1093/ndt/gfx196] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/10/2017] [Indexed: 11/12/2022] Open
Abstract
Background Atypical haemolytic uremic syndrome (aHUS) is a rare but severe form of thrombotic microangiopathy as a consequence of complement dysregulation. aHUS has a poor outcome with high mortality and >50% of patients developing end-stage renal disease. Since the end of 2012, these outcomes have greatly improved with the introduction of eculizumab. Currently the duration of treatment is debated. Most guidelines advise lifelong treatment. However, there is no hard evidence to support this advice. Historically, a substantial number of aHUS patients were weaned of plasma therapy, often without disease recurrence. Moreover, the long-term consequences of eculizumab treatment are unknown. In this retrospective study we describe 20 patients who received a restrictive treatment regimen. Methods All aHUS patients who presented in the Radboud University Medical Center, Nijmegen, The Netherlands, between 2012 and 2016 and who received eculizumab are described. Clinical, diagnostic and follow-up data were gathered and reviewed. Results Twenty patients (14 adults, 6 children) with aHUS have received eculizumab. Eculizumab was tapered in all and stopped in 17 patients. aHUS recurrence occurred in five patients. Due to close monitoring, recurrence was detected early and eculizumab was restarted. No clinical sequela such as proteinuria or progressive kidney dysfunction was detected subsequently. In total, eculizumab has been discontinued in 13 patients without aHUS recurrence, of which 5 are event free for >1 year. With this strategy ∼€11.4 million have been saved. Conclusions A restrictive eculizumab regimen in aHUS appears safe and effective. Prospective studies should further evaluate the most optimal treatment strategy.
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Affiliation(s)
- Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lambertus P van den Heuvel
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pediatrics, University Hospital Leuven, Leuven, Belgium
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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54
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Le Clech A, Frémeaux-Bacchi V, Fakhouri F. The authors reply. Kidney Int 2019; 96:517-518. [DOI: 10.1016/j.kint.2019.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/23/2019] [Indexed: 11/29/2022]
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55
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Schönermarck U, Ries W, Schröppel B, Pape L, Dunaj-Kazmierowska M, Burst V, Mitzner S, Basara N, Starck M, Schmidbauer D, Mellmann A, Dittmer R, Jeglitsch M, Haas CS. Relative incidence of thrombotic thrombocytopenic purpura and haemolytic uraemic syndrome in clinically suspected cases of thrombotic microangiopathy. Clin Kidney J 2019; 13:208-216. [PMID: 32296526 PMCID: PMC7147316 DOI: 10.1093/ckj/sfz066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/29/2019] [Indexed: 12/27/2022] Open
Abstract
Background Data are lacking on the relative incidence of thrombotic thrombocytopenic purpura (TTP), haemolytic uraemic syndrome (HUS) caused by Shiga toxin–producing Escherichia coli (STEC) and atypical HUS (aHUS) in patients presenting with thrombotic microangiopathies (TMAs). Methods This was a prospective, cross-sectional, multicentre and non-interventional epidemiological study. Patients fulfilling criteria for TMAs (platelet consumption, microangiopathic haemolytic anaemia and organ dysfunction) were included in the study. The primary objective was to assess the relative incidence of TTP, STEC-HUS, aHUS and ‘other’ physician-defined diagnoses. The secondary objective was to develop an algorithm to predict a severe deficiency in ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity (≤10%) using routine laboratory parameters. A post hoc classification using the recent Kidney Disease: Improving Global Outcomes diagnostic criteria was then undertaken to further classify patient groups. Results aHUS was diagnosed with a relative incidence of 61%, whereas TTP, STEC-HUS and ‘other’ were diagnosed in 13, 6 and 20% of patients, respectively. In the post hoc analysis, 27% of patients with a TMA were classified as ‘primary aHUS’ and 53% as ‘secondary aHUS’. Multivariate analysis revealed that severe deficiency in ADAMTS13 activity (≤10%) was unlikely to underlie TMA if platelet and serum creatinine were above threshold values of 30 × 109/L and 1.8 mg/dL, respectively (negative predictive value of 92.3 and 98.1, respectively, if one or both values were above the threshold). Conclusions In this study, aHUS was the most common single diagnosis among patients presenting with a TMA. In the absence of an ADAMTS13 activity result, platelet count and serum creatinine may aid in the differential diagnosis.
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Affiliation(s)
- Ulf Schönermarck
- Medizinische Klinik IV, Klinikum der Universität, LMU, Munich, Germany
| | - Wolfgang Ries
- Internal Medicine, Diakonissenkrankenhaus, Flensburg, Germany
| | - Bernd Schröppel
- Medical Clinic I, Section of Nephrology, University of Ulm, Ulm, Germany
| | - Lars Pape
- Pediatric Nephrology, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Volker Burst
- Department II of Internal Medicine, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany.,Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Steffen Mitzner
- Division of Nephrology, Rostock University Medical Centre, Rostock, Germany.,Fraunhofer IZI Project Group 'Extracorporeal Immunomodulation', Rostock, Germany
| | - Nadezda Basara
- Medizinische Klinik I, St. Franziskus-Hospital, Flensburg, Germany
| | - Michael Starck
- Clinic for Hematology, Clinic Munich-Schwabing, Munich, Germany
| | | | | | | | | | - Christian S Haas
- Internal Medicine, Nephrology and Intensive Care Medicine, Phillips University of Marburg, Marburg, Germany
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56
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Atypical and secondary hemolytic uremic syndromes have a distinct presentation and no common genetic risk factors. Kidney Int 2019; 95:1443-1452. [DOI: 10.1016/j.kint.2019.01.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/01/2019] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
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57
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Valoti E, Alberti M, Iatropoulos P, Piras R, Mele C, Breno M, Cremaschi A, Bresin E, Donadelli R, Alizzi S, Amoroso A, Benigni A, Remuzzi G, Noris M. Rare Functional Variants in Complement Genes and Anti-FH Autoantibodies-Associated aHUS. Front Immunol 2019; 10:853. [PMID: 31118930 PMCID: PMC6504697 DOI: 10.3389/fimmu.2019.00853] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/02/2019] [Indexed: 01/06/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by microangiopathic hemolytic anemia, thrombocytopenia and renal failure. It is caused by genetic or acquired defects of the complement alternative pathway. Factor H autoantibodies (anti-FHs) have been reported in 10% of aHUS patients and are associated with the deficiency of factor H-related 1 (FHR1). However, FHR1 deficiency is not enough to cause aHUS, since it is also present in about 5% of Caucasian healthy subjects. In this study we evaluated the prevalence of genetic variants in CFH, CD46, CFI, CFB, C3, and THBD in aHUS patients with anti-FHs, using healthy subjects with FHR1 deficiency, here defined “supercontrols,” as a reference group. “Supercontrols” are more informative than general population because they share at least one risk factor (FHR1 deficiency) with aHUS patients. We analyzed anti-FHs in 305 patients and 30 were positive. The large majority were children (median age: 7.7 [IQR, 6.6–9.9] years) and 83% lacked FHR1 (n = 25, cases) due to the homozygous CFHR3-CFHR1 deletion (n = 20), or the compound heterozygous CFHR3-CFHR1 and CFHR1-CFHR4 deletions (n = 4), or the heterozygous CFHR3-CFHR1 deletion combined with a frameshift mutation in CFHR1 that generates a premature stop codon (n = 1). Of the 960 healthy adult subjects 48 had the FHR1 deficiency (“supercontrols”). Rare likely pathogenetic variants in CFH, THBD, and C3 were found in 24% of cases (n = 6) compared to 2.1% of the “supercontrols” (P-value = 0.005). We also found that the CFH H3 and the CD46GGAAC haplotypes are not associated with anti-FHs aHUS, whereas these haplotypes are enriched in aHUS patients without anti-FHs, which highlights the differences in the genetic basis of the two forms of the disease. Finally, we confirm that common infections are environmental factors that contribute to the development of anti-FHs aHUS in genetically predisposed individuals, which fits with the sharp peak of incidence during scholar-age. Further studies are needed to fully elucidate the complex genetic and environmental factors underlying anti-FHs aHUS and to establish whether the combination of anti-FHs with likely pathogenetic variants or other risk factors influences disease outcome and response to therapies.
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Affiliation(s)
- Elisabetta Valoti
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Marta Alberti
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Paraskevas Iatropoulos
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Rossella Piras
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Caterina Mele
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Matteo Breno
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Alessandra Cremaschi
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Elena Bresin
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Roberta Donadelli
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Alizzi
- Azienda Ospedaliera-Universitaria, Città della Salute e della Scienza and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Azienda Ospedaliera-Universitaria, Città della Salute e della Scienza and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ariela Benigni
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.,'L. Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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58
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Java A, Pozzi N, Love-Gregory LD, Heusel JW, Sung YJ, Hu Z, Bertram P, Liszewski MK, Cline LM, Ren Z, Atkinson JP. A Multimodality Approach to Assessing Factor I Genetic Variants in Atypical Hemolytic Uremic Syndrome. Kidney Int Rep 2019; 4:1007-1017. [PMID: 31312772 PMCID: PMC6609824 DOI: 10.1016/j.ekir.2019.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Anuja Java
- Department of Medicine, Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Nicola Pozzi
- Department of Biochemistry and Molecular Biology, Edward A. Doisy Research Center, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Latisha D Love-Gregory
- Genomic and Pathology Services, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan W Heusel
- Genomic and Pathology Services, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Yun Ju Sung
- Department of Medicine, Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Zheng Hu
- Department of Medicine, Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Paula Bertram
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - M Kathryn Liszewski
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Laura M Cline
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Zhen Ren
- Department of Medicine, Division of Allergy and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - John P Atkinson
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Galbusera M, Noris M, Gastoldi S, Bresin E, Mele C, Breno M, Cuccarolo P, Alberti M, Valoti E, Piras R, Donadelli R, Vivarelli M, Murer L, Pecoraro C, Ferrari E, Perna A, Benigni A, Portalupi V, Remuzzi G. An Ex Vivo Test of Complement Activation on Endothelium for Individualized Eculizumab Therapy in Hemolytic Uremic Syndrome. Am J Kidney Dis 2019; 74:56-72. [PMID: 30851964 DOI: 10.1053/j.ajkd.2018.11.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022]
Abstract
RATIONALE & OBJECTIVE Although primary atypical hemolytic uremic syndrome (aHUS) is associated with abnormalities in complement genes and antibodies to complement factor H, the role of complement in secondary aHUS remains debatable. We evaluated the usefulness of an ex vivo test to: (1) detect complement activation within the endothelium in primary and secondary aHUS, (2) differentiate active disease from remission, (3) monitor the effectiveness of eculizumab therapy, and (4) identify relapses during eculizumab dosage tapering and after discontinuation of treatment. STUDY DESIGN Case series. SETTING & PARTICIPANTS 121 patients with primary aHUS and 28 with secondary aHUS. Serum samples were collected during acute episodes, following remission, and during eculizumab treatment and were assessed using a serum-induced ex vivo C5b-9 endothelial deposition test. RESULTS Serum-induced C5b-9 deposition on cultured microvascular endothelium was quantified by calculating the endothelial area covered by C5b-9 staining; values were expressed as percentage of C5b-9 deposits induced by a serum pool from healthy controls. Testing with adenosine diphosphate-activated endothelium demonstrated elevated C5b-9 deposits for all untreated patients with aHUS independent of disease activity, while testing with unstimulated endothelium demonstrated deposits only in active disease. Similar findings were observed in secondary aHUS. Serum-induced C5b-9 deposits on activated and unstimulated endothelium normalized during eculizumab treatment. 96% (22/23) of patients receiving eculizumab at extended 3- or 4-week dosing intervals demonstrated normal C5b-9 deposits on activated endothelium, despite most patients having CH50Eq (serum complement activity) > 20 UEq/mL, indicating that adequate complement control was achieved even with incomplete blockade of circulating C5. During eculizumab dosage tapering or after treatment discontinuation, all patients experiencing relapses versus only 6% (1/17) of those in stable remission had elevated C5b-9 deposits on unstimulated endothelium. LIMITATIONS The C5b-9 endothelial deposition test can be performed in only specialized laboratories. Findings on eculizumab dosage tapering need to be confirmed with longitudinal monitoring of C5b-9 deposition. CONCLUSIONS The C5b-9 endothelial deposition assay may represent an advance in our ability to monitor aHUS activity and individualize therapy.
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Affiliation(s)
- Miriam Galbusera
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy.
| | - Sara Gastoldi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Elena Bresin
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Caterina Mele
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Matteo Breno
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Paola Cuccarolo
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Marta Alberti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Elisabetta Valoti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Rossella Piras
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Luisa Murer
- Unit of Pediatric Nephrology, Dialysis and Transplantation, Azienda Ospedaliera di Padova, Padua, Italy
| | - Carmine Pecoraro
- Pediatric Nephrology Unit, Santobono-Pausilipon Hospital, Naples, Italy
| | - Elisa Ferrari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Valentina Portalupi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò and Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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61
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Abbas F, El Kossi M, Kim JJ, Shaheen IS, Sharma A, Halawa A. Complement-mediated renal diseases after kidney transplantation - current diagnostic and therapeutic options in de novo and recurrent diseases. World J Transplant 2018; 8:203-219. [PMID: 30370231 PMCID: PMC6201327 DOI: 10.5500/wjt.v8.i6.203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/09/2018] [Accepted: 08/28/2018] [Indexed: 02/05/2023] Open
Abstract
For decades, kidney diseases related to inappropriate complement activity, such as atypical hemolytic uremic syndrome and C3 glomerulopathy (a subtype of membranoproliferative glomerulonephritis), have mostly been complicated by worsened prognoses and rapid progression to end-stage renal failure. Alternative complement pathway dysregulation, whether congenital or acquired, is well-recognized as the main driver of the disease process in these patients. The list of triggers include: surgery, infection, immunologic factors, pregnancy and medications. The advent of complement activation blockade, however, revolutionized the clinical course and outcome of these diseases, rendering transplantation a viable option for patients who were previously considered as non-transplantable cases. Several less-costly therapeutic lines and likely better efficacy and safety profiles are currently underway. In view of the challenging nature of diagnosing these diseases and the long-term cost implications, a multidisciplinary approach including the nephrologist, renal pathologist and the genetic laboratory is required to help improve overall care of these patients and draw the optimum therapeutic plan.
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Affiliation(s)
- Fedaey Abbas
- Nephrology Department, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Jin Kim
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ihab Sakr Shaheen
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Hospital for Children, Glasgow G51 4TF, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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62
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Hertig A. Atypical haemolytic and uraemic syndrome: how can we protect the kidneys? Nephrol Dial Transplant 2018; 33:1708-1711. [DOI: 10.1093/ndt/gfy136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/20/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexandre Hertig
- Department of Nephrology and Kidney Transplantation, Sorbonne Université, AP-HP, Hôpital Tenon, Paris, France
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Abbas F, El Kossi M, Kim JJ, Sharma A, Halawa A. Thrombotic microangiopathy after renal transplantation: Current insights in de novo and recurrent disease. World J Transplant 2018; 8:122-141. [PMID: 30211021 PMCID: PMC6134269 DOI: 10.5500/wjt.v8.i5.122] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 06/26/2018] [Accepted: 07/10/2018] [Indexed: 02/05/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is one of the most devastating sequalae of kidney transplantation. A number of published articles have covered either de novo or recurrent TMA in an isolated manner. We have, hereby, in this article endeavored to address both types of TMA in a comparative mode. We appreciate that de novo TMA is more common and its prognosis is poorer than recurrent TMA; the latter has a genetic background, with mutations that impact disease behavior and, consequently, allograft and patient survival. Post-transplant TMA can occur as a recurrence of the disease involving the native kidney or as de novo disease with no evidence of previous involvement before transplant. While atypical hemolytic uremic syndrome is a rare disease that results from complement dysregulation with alternative pathway overactivity, de novo TMA is a heterogenous set of various etiologies and constitutes the vast majority of post-transplant TMA cases. Management of both diseases varies from simple maneuvers, e.g., plasmapheresis, drug withdrawal or dose modification, to lifelong complement blockade, which is rather costly. Careful donor selection and proper recipient preparation, including complete genetic screening, would be a pragmatic approach. Novel therapies, e.g., purified products of the deficient genes, though promising in theory, are not yet of proven value.
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Affiliation(s)
- Fedaey Abbas
- Nephrology Department, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Renal Unit, Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Jin Kim
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Transplant Surgery, Royal Liverpool University Hospitals, Liverpool UK L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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64
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Affiliation(s)
- Venkat Ram Rakesh Mundra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Román E, Mendizábal S, Jarque I, de la Rubia J, Sempere A, Morales E, Praga M, Ávila A, Górriz JL. Secondary thrombotic microangiopathy and eculizumab: A reasonable therapeutic option. Nefrologia 2018; 37:478-491. [PMID: 28946961 DOI: 10.1016/j.nefro.2017.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/03/2017] [Accepted: 01/14/2017] [Indexed: 12/16/2022] Open
Abstract
Understanding the role of the complement system in the pathogenesis of atypical haemolytic uraemic syndrome and other thrombotic microangiopathies (TMA) has led to the use of anti-complement therapy with eculizumab in these diseases, in addition to its original use in patients with paroxysmal nocturnal haemoglobinuria andatypical haemolytic uraemic syndrome. Scientific evidence shows that both primary and secondary TMAs with underlying complement activation are closely related. For this reasons, control over the complement system is a therapeutic target. There are 2scenarios in which eculizumab is used in patients with TMA: primary or secondary TMA that is difficult to differentiate (including incomplete clinical presentations) and complement-mediated damage in various processes in which eculizumab proves to be efficacious. This review summarises the evidence on the role of the complement activation in the pathophysiology of secondary TMAs and the efficacy of anti-complement therapy in TMAs secondary to pregnancy, drugs, transplant, humoral rejection, systemic diseases and glomerulonephritis. Although experience is scarce, a good response to eculizumab has been reported in patients with severe secondary TMAs refractory to conventional treatment. Thus, the role of the anti-complement therapy as a new treatment option in these patients should be investigated.
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Affiliation(s)
- Elena Román
- Servicio de Nefrología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Santiago Mendizábal
- Servicio de Nefrología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Isidro Jarque
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario Dr. Peset, Valencia, España
| | - Amparo Sempere
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Enrique Morales
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Ana Ávila
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
| | - José Luis Górriz
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
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Fakhouri F, Loirat C. Anticomplement Treatment in Atypical and Typical Hemolytic Uremic Syndrome. Semin Hematol 2018; 55:150-158. [DOI: 10.1053/j.seminhematol.2018.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/13/2018] [Indexed: 01/06/2023]
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67
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Safety and effectiveness of eculizumab for adult patients with atypical hemolytic-uremic syndrome in Japan: interim analysis of post-marketing surveillance. Clin Exp Nephrol 2018; 23:65-75. [PMID: 29959568 PMCID: PMC6344388 DOI: 10.1007/s10157-018-1609-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022]
Abstract
Background Eculizumab has been available for the treatment of atypical hemolytic–uremic syndrome (aHUS) in Japan since 2013. To assess safety and effectiveness of eculizumab in adult aHUS patients in the real-life setting, we performed interim analysis of a post-marketing surveillance mandated by Japanese regulations. Methods This study enrolled any patient who was diagnosed with TMA excluding Shiga toxin-producing Escherichia coli-HUS or thrombotic thrombocytopenic purpura based on Japanese clinical guide published in 2013 as inclusion criteria and treated with eculizumab. Although the term aHUS was redefined to denote only complement-mediated HUS in the guide revised in 2016, the patients with TMA caused by other causes (secondary TMA) were included. Patient outcomes and safety were evaluated at 6 months, 12 months, and annually thereafter. Results Thirty-three patients with aHUS and 27 patients with secondary TMA were enrolled. Median treatment duration of aHUS was 24weeks. Complement genes variants were detected in 11 of 18 patients with aHUS (61.1%). Among the 29 aHUS patients with available baseline data, platelet count (PLT), lactic dehydrogenase and serum creatinine (SCr) improved within 1-month after eculizumab initiation. TMA event-free status, complete TMA response, PLT normalization, and SCr decrease were achieved in 67.9% (19/28), 27.8% (5/18), 56.5% (13/23), and 57.1% (16/28) of patients, respectively. Thirty-three and 11 adverse reactions were observed in patients with aHUS (13/33 patients) and secondary TMA (6/27 patients), respectively. Conclusions This interim analysis confirmed the acceptable safety profile and effectiveness of eculizumab for Japanese adult aHUS patients in real-world settings. Electronic supplementary material The online version of this article (10.1007/s10157-018-1609-8) contains supplementary material, which is available to authorized users.
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68
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Kawanishi T, Hasegawa J, Kono M, Ishiwatari A, Ogawa T, Abe Y, Endo M, Ishigooka H, Okumi M, Tanabe K, Wakai S, Shirakawa H. Thrombotic microangiopathy after kidney transplantation successfully treated with eculizumab: A case report. TRANSPLANTATION REPORTS 2018. [DOI: 10.1016/j.tpr.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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De Novo Atypical Haemolytic Uremic Syndrome after Kidney Transplantation. Case Rep Nephrol 2018; 2018:1727986. [PMID: 29732228 PMCID: PMC5872611 DOI: 10.1155/2018/1727986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/23/2018] [Accepted: 02/14/2018] [Indexed: 11/29/2022] Open
Abstract
De novo thrombotic microangiopathy (TMA) can occur after kidney transplantation. An abnormality of the alternative pathway of complement must be suspected and searched for, even in presence of a secondary cause. We report the case of a 23-year-old female patient who was transplanted with a kidney from her mother for end-stage renal disease secondary to Hinman syndrome. Early after transplantation, she presented with 2 episodes of severe pyelonephritis, associated with acute kidney dysfunction and biological and histological features of TMA. Investigations of the alternative pathway of the complement system revealed atypical haemolytic uremic syndrome secondary to complement factor I mutation, associated with mutations in CD46 and complement factor H related protein genes. Plasma exchanges followed by eculizumab injections allowed improvement of kidney function without, however, normalization of creatinine.
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70
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Gaggl M, Aigner C, Csuka D, Szilágyi Á, Prohászka Z, Kain R, Haninger N, Knechtelsdorfer M, Sunder-Plassmann R, Sunder-Plassmann G, Schmidt A. Maternal and Fetal Outcomes of Pregnancies in Women with Atypical Hemolytic Uremic Syndrome. J Am Soc Nephrol 2018; 29:1020-1029. [PMID: 29282226 PMCID: PMC5827586 DOI: 10.1681/asn.2016090995] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/08/2017] [Indexed: 11/03/2022] Open
Abstract
Atypical HUS (aHUS) is a disorder most commonly caused by inherited defects of the alternative pathway of complement, or the proteins that regulate this pathway, and life-threatening episodes of aHUS can be provoked by pregnancy. We retrospectively and prospectively investigated 27 maternal and fetal pregnancy outcomes in 14 women with aHUS from the Vienna Thrombotic Microangiopathy Cohort. Seven pregnancies (26%) were complicated by pregnancy-associated aHUS (p-aHUS), of which three appeared to be provoked by infection, bleeding, and curettage, and three individuals were considered to have preeclampsia/HELLP syndrome before the definitive diagnosis of p-aHUS was made. Mutations in genes that encode the complement alternative pathway proteins or the molecules that regulate this pathway were detected in 71% of the women, with no relationship to pregnancy outcome. Twenty-one pregnancies (78%) resulted in a live birth, two preterm infants were stillborn, and four pregnancies resulted in early spontaneous abortions. Although short-term renal outcome was good in most women, long-term renal outcome was poor; among the 14 women, four had CKD stage 1-4, five had received a renal allograft, and three were dialysis-dependent at study end. We prospectively followed nine pregnancies of four women and treated six of these pregnancies with prophylactic plasma infusions (one pregnancy resulted in p-aHUS, one intrauterine fetal death occurred, and seven pregancies were uneventful). Our study emphasizes the frequency of successful pregnancies in women with aHUS. Close monitoring of such pregnancies for episodes of thrombotic microangiopathy is essential but, the best strategy to prevent these episodes remains unclear.
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Affiliation(s)
- Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III,
| | - Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III
| | - Dorottya Csuka
- Research Laboratory, 3rd Department of Medicine, Semmelweis University, Budapest, Hungary; and
| | - Ágnes Szilágyi
- Research Laboratory, 3rd Department of Medicine, Semmelweis University, Budapest, Hungary; and
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Medicine, Semmelweis University, Budapest, Hungary; and
| | | | | | | | - Raute Sunder-Plassmann
- Genetics Laboratory, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Alice Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III
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71
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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72
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Transplant glomerulopathy. Mod Pathol 2018; 31:235-252. [PMID: 29027535 DOI: 10.1038/modpathol.2017.123] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
In the renal allograft, transplant glomerulopathy represents a morphologic lesion and not a specific diagnosis. The hallmark pathologic feature is glomerular basement membrane reduplication by light microscopy or electron microscopy in the absence of immune complex deposits. Transplant glomerulopathy results from chronic, recurring endothelial cell injury that can be mediated by HLA alloantibodies (donor-specific antibodies), various autoantibodies, cell-mediated immune injury, thrombotic microangiopathy, or chronic hepatitis C. Clinically, transplant glomerulopathy may be silent, detectable on protocol biopsy, or present with overt manifestations, including up to nephrotic range proteinuria, hypertension, and declining glomerular filtration rate. In either case, transplant glomerulopathy is associated with reduced graft survival. This review details the morphologic features of transplant glomerulopathy found on light microscopy, immunofluorescence microscopy, and electron microscopy. The pathophysiology of the causes and risk factors are discussed. Clinical manifestations are emphasized and potential therapeutic modalities are examined.
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73
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Claes KJ, Massart A, Collard L, Weekers L, Goffin E, Pochet JM, Dahan K, Morelle J, Adams B, Broeders N, Stordeur P, Abramowicz D, Bosmans JL, Van Hoeck K, Janssens P, Pipeleers L, Peeters P, Van Laecke S, Levtchenko E, Sprangers B, van den Heuvel L, Godefroid N, Van de Walle J. Belgian consensus statement on the diagnosis and management of patients with atypical hemolytic uremic syndrome. Acta Clin Belg 2018; 73:80-89. [PMID: 29058539 DOI: 10.1080/17843286.2017.1345185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Kathleen J Claes
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Annick Massart
- Department of Nephrology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Laurent Weekers
- Department of Internal Medicine, Division of Nephrology, ULg, CHU Liège, Liège, Belgium
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Michel Pochet
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Karin Dahan
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institut de Génétique et de Pathologie, IPG, Gosselies, Belgium
| | - Johann Morelle
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Brigitte Adams
- Queen Fabiola Children’s University Hospital, Brussels, Belgium
| | - Nilufer Broeders
- Department of Nephrology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Stordeur
- Immunobiology Clinic, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, University Hospital Antwerp, Antwerp, Belgium
| | | | - Koen Van Hoeck
- Department of Pediatrics, University Hospital Antwerp, Antwerp, Belgium
| | - Peter Janssens
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussels, Brussels, Belgium
| | - Lissa Pipeleers
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussels, Brussels, Belgium
| | - Patrick Peeters
- Department of Nephrology, University Hospital Ghent, Ghent, Belgium
| | | | - Elena Levtchenko
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Nathalie Godefroid
- Pediatric Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Johan Van de Walle
- Department of Pediatric Nephrology, University Hospital Ghent, Ghent, Belgium
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Routine use of clinical exome-based next-generation sequencing for evaluation of patients with thrombotic microangiopathies. Mod Pathol 2017; 30:1739-1747. [PMID: 28752844 PMCID: PMC5716882 DOI: 10.1038/modpathol.2017.90] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023]
Abstract
Next-generation sequencing is increasingly used for clinical evaluation of patients presenting with thrombotic microangiopathies because it allows for simultaneous interrogation of multiple complement and coagulation pathway genes known to be associated with disease. However, the diagnostic yield is undefined in routine clinical practice. Historic studies relied on case-control cohorts, did not apply current guidelines for variant pathogenicity assessment, and used targeted gene enrichment combined with next-generation sequencing. A clinically enhanced exome, targeting ~54 Mb, was sequenced for 73 patients. Variant analysis and interpretation were performed on genes with biological relevance in thrombotic microangiopathy (C3,CD46, CFB, CFH, CFI, DGKE, and THBD). CFHR3-CFHR1 deletion status was also assessed using multiplex ligation-dependent probe amplification. Variants were classified using American College of Medical Genetics and Genomics guidelines. We identified 5 unique novel and 14 unique rare variants in 25% (18/73) of patients, including a total of 5 pathogenic, 4 likely pathogenic, and 15 variants of uncertain clinical significance. Nine patients had homozygous deletions in CFHR3-CFHR1. The diagnostic yield, defined as the presence of a pathogenic variant, likely pathogenic variant or homozygous deletion of CFHR3-CFHR1, was 25% for all patients tested. Variants of uncertain clinical significance were identified in 21% (15/73) of patients.These results illustrate the expected diagnositic yield in the setting of thrombotic microangiopathies through the application of standardized variant interpretation, and highlight the utility of such an approach. Sequencing a clinically enhanced exome to enable targeted, disease-specific variant analysis is a viable approach. The moderate rate of variants of uncertain clinical significance highlights the paucity of data surrounding the variants in our cohort and illustrates the need for expanded variant curation resources to aid in thrombotic microangiopathy-related disease variant classification.
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75
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Garg N, Rennke HG, Pavlakis M, Zandi-Nejad K. De novo thrombotic microangiopathy after kidney transplantation. Transplant Rev (Orlando) 2017; 32:58-68. [PMID: 29157988 DOI: 10.1016/j.trre.2017.10.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 10/22/2017] [Accepted: 10/23/2017] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA) is a serious complication of transplantation that adversely affects kidney transplant recipient and allograft survival. Post-transplant TMA is usually classified into two categories: 1) recurrent TMA and 2) de novo TMA. Atypical hemolytic uremic syndrome (aHUS) resulting from dysregulation and over-activation of the alternate complement pathway is a rare disease but the most common diagnosis associated with recurrence in the allografts. De novo TMA, on the other hand, represents an overwhelming majority of the cases of post-transplant TMA and is a substantially more heterogeneous entity than recurrent aHUS. Here, we review the etio-pathogenesis, diagnosis and treatment options for de novo post-transplant TMA. It is usually in the setting of calcineurin inhibitor use, mammalian target of rapamycin inhibitor use, or antibody mediated rejection; recently genetic mutations in complement regulatory genes for Factor H and Factor I similar to those described in aHUS have been reported in up to a third of these patients. Systemic signs of TMA are frequently absent, and a renal allograft biopsy is often needed to establish the diagnosis. Although withdrawal of the offending agents is usually the first line of treatment and resolution of laboratory abnormalities has been documented with this approach in several case reports and case series, available retrospective data demonstrate lack of benefit in long-term graft outcomes. Co-stimulation blockage with belatacept provides an effective alternate immunosuppressive strategy for these patients. Anti-complement therapy with eculizumab is effective in some cases; further work is required to define which patients with TMA (with and without concomitant antibody-mediated rejection) would benefit from receiving this treatment, and what biomarkers can be used to identify them.
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Affiliation(s)
- Neetika Garg
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, United States.
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Martha Pavlakis
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, United States
| | - Kambiz Zandi-Nejad
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, United States
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76
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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77
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Early Versus Late Diagnosis of Complement Factor I Deficiency: Clinical Consequences Illustrated in Two Families with Novel Homozygous CFI Mutations. J Clin Immunol 2017; 37:781-789. [PMID: 28942469 DOI: 10.1007/s10875-017-0447-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
The complement system is an important effector arm of innate immunity and plays a crucial role in the defense against common pathogens. But effective defense and maintenance of homeostasis requires a careful balance between complement activation and regulation. Factor I (FI) is one of the most important regulators of the complement system. Complete FI deficiency is a rare autosomal recessive disorder typically resulting in severe, recurrent infection by encapsulated bacteria. In the present study, we describe two patients from unrelated families with complete FI deficiency diagnosed at very different ages: Patient 1 is a 60-year-old man who had experienced several severe infections (pneumonia, meningitis, sepsis) since childhood, one of which caused significant and permanent neurologic sequelae. In contrast, patient 2 was diagnosed at the age of 4 years after a single infectious episode (otitis media) and through detection of a flat beta2 peak on serum protein electrophoresis. This early diagnosis of FI deficiency enabled prompt implementation of a therapeutic intervention consisting of vaccination with encapsulated bacteria and prophylactic antibiotics. The two patients had novel homozygous mutations in the CFI gene (p.Gly162Asp and p.His380Arg) that disrupted protein function. Interestingly, p.His380Arg is the first mutation described affecting a residue of the highly conserved FI catalytic triad (His380, Asp429, and Ser525). This study illustrates the importance of early versus late diagnosis of FI deficiency and, in general, highlights the clinical relevance of prompt detection of complement system deficiencies.
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78
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Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C. Haemolytic uraemic syndrome. Lancet 2017; 390:681-696. [PMID: 28242109 DOI: 10.1016/s0140-6736(17)30062-4] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
Haemolytic uraemic syndrome is a form of thrombotic microangiopathy affecting predominantly the kidney and characterised by a triad of thrombocytopenia, mechanical haemolytic anaemia, and acute kidney injury. The term encompasses several disorders: shiga toxin-induced and pneumococcus-induced haemolytic uraemic syndrome, haemolytic uraemic syndrome associated with complement dysregulation or mutation of diacylglycerol kinase ɛ, haemolytic uraemic syndrome related to cobalamin C defect, and haemolytic uraemic syndrome secondary to a heterogeneous group of causes (infections, drugs, cancer, and systemic diseases). In the past two decades, experimental, genetic, and clinical studies have helped to decipher the pathophysiology of these various forms of haemolytic uraemic syndrome and undoubtedly improved diagnostic approaches. Moreover, a specific mechanism-based treatment has been made available for patients affected by atypical haemolytic uraemic syndrome due to complement dysregulation. Such treatment is, however, still absent for several other disease types, including shiga toxin-induced haemolytic uraemic syndrome.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, and INSERM UMR S1064, Nantes, France
| | - Julien Zuber
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology and Renal Transplantation, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, and INSERM UMR S1138, Complément et Maladies, Centre de Recherche des Cordeliers, Paris, France
| | - Chantal Loirat
- Assistance Publique-Hôpitaux de Paris, Department of Pediatric Nephrology, Hôpital Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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Münch J, Bachmann A, Grohmann M, Mayer C, Kirschfink M, Lindner TH, Bergmann C, Halbritter J. Effective immunosuppressive management with belatacept and eculizumab in post-transplant aHUS due to a homozygous deletion of CFHR1/ CFHR3 and the presence of CFH antibodies. Clin Kidney J 2017; 10:742-746. [PMID: 29225802 PMCID: PMC5716210 DOI: 10.1093/ckj/sfx053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/08/2017] [Indexed: 01/29/2023] Open
Abstract
Atypical haemolytic uraemic syndrome (aHUS) may clinically present as acute renal graft failure resulting from excessive activation of the complement cascade. While mutations of complement-encoding genes predispose for aHUS, it is generally thought to require an additional insult (e.g. drugs) to trigger and manifest the full-blown clinical syndrome. Calcineurin inhibitors (CNIs) used for immunosuppression act as potential triggers, especially in the post-transplantation setting. Therefore, CNI-free immunosuppressive regimens may be beneficial. We report on a 58-year-old woman who developed aHUS with acute graft failure within 20 days after renal transplantation. Genetic investigation revealed a homozygous deletion of the CFH-related 1 (CFHR1) and CFHR3 genes in addition to the presence of autoantibodies against complement factor H (CFH). The patient was treated with plasmapheresis and administration of the complement component 5 (C5) antibody eculizumab, and her immunosuppressive regimen was switched from CNI (tacrolimus) to the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor belatacept. Renal graft function recovered and stabilized over an 18-month follow-up period. We describe the successful management of post-transplant aHUS using a CNI-free immunosuppressive regimen based on eculizumab and belatacept. Ideally, adequate molecular diagnostics, performed prior to transplantation, can identify relevant genetic risk factors for graft failure and help to select patients for individualized immunosuppressive regimens.
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Affiliation(s)
- Johannes Münch
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | - Anette Bachmann
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | - Maik Grohmann
- Center for Human Genetics, Bioscientia, Ingelheim, Germany
| | - Christof Mayer
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | | | - Tom H Lindner
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | | | - Jan Halbritter
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
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80
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Yamamoto T, Watarai Y, Futamura K, Okada M, Tsujita M, Hiramitsu T, Goto N, Narumi S, Takeda A, Kobayashi T. Efficacy of Eculizumab Therapy for Atypical Hemolytic Uremic Syndrome Recurrence and Antibody-Mediated Rejection Progress After Renal Transplantation With Preformed Donor-Specific Antibodies: Case Report. Transplant Proc 2017; 49:159-162. [PMID: 28104125 DOI: 10.1016/j.transproceed.2016.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) develops as the result of unregulated complement progression and precipitates de novo thrombotic microangiopathy. Plasma therapy is used to control the progression of the complement cascade, but that therapy is not effective in all patients and is accompanied by risk of infection and/or allergy. Eculizumab has been reported as an efficient therapy for aHUS. We report the case of a 35-year old woman who underwent effective eculizumab therapy for aHUS recurrence and antibody-mediated rejection (AMR) progress after renal transplantation with preformed donor-specific antibodies (DSA). She developed end-stage renal disease due to suspicious IgA nephropathy at age 33 years. Kidney transplantation was performed at age 35 years, and aHUS recurred 2 weeks later, leading to the progressive hemolytic anemia and renal dysfunction. Therefore, she underwent plasma therapy several times. Because it was difficult to continue to plasma therapy for severe allergy, eculizumab was proposed as an alternate therapy. Treatment with eculizumab was initiated 36 days after renal transplantation. After 3 years of eculizumab treatment, and without plasma therapy, schistocytes decreased, haptoglobin increased to within normal limits, creatinine levels stabilized, and no further episodes of diarrhea were reported. At protocol biopsy 1 year after transplantation, she was diagnosed with C4d-negative subclinical AMR. However, her pathologic findings at follow-up biopsy 3 years after transplantation were recovered. We conclude that eculizumab alone, without plasma therapy, is sufficient to treat recurrence of aHUS and AMR due to DSA after renal transplantation and to maintain long-term graft function.
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Affiliation(s)
- T Yamamoto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
| | - Y Watarai
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - K Futamura
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - M Okada
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - M Tsujita
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - T Hiramitsu
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - N Goto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - S Narumi
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - A Takeda
- Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - T Kobayashi
- Department of Kidney Transplant Surgery, Aichi Medical University, Nagakute, Japan
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In 2013, we developed diagnostic criteria to enable early diagnosis and timely initiation of appropriate treatment for aHUS. Recent clinical and molecular findings have resulted in several proposed classifications and definitions of thrombotic microangiopathy and aHUS. Based on recent advances in this field and the emerging international consensus to exclude secondary TMAs from the definition of aHUS, we have redefined aHUS and proposed diagnostic algorithms, differential diagnosis, and therapeutic strategies for aHUS.
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83
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Okumi M, Tanabe K. Prevention and treatment of atypical haemolytic uremic syndrome after kidney transplantation. Nephrology (Carlton) 2017; 21 Suppl 1:9-13. [PMID: 26988663 DOI: 10.1111/nep.12776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Atypical haemolytic uraemic syndrome is a rare disorder characterized by an over-activated, dysregulated alternative complement pathway due to genetic mutation and environmental triggers. Atypical haemolytic uraemic syndrome is a serious, life-threatening disease characterized by thrombotic microangiopathy, which causes haemolytic anaemia, thrombocytopaenia, and acute renal failure. Since recurrences of atypical haemolytic uraemic syndrome frequently lead to end-stage kidney disease even in renal allografts, kidney transplantation for patients with end-stage kidney disease secondary to atypical haemolytic uraemic syndrome has long been contraindicated. However, over the past several years, advancements in the management of atypical haemolytic uraemic syndrome have allowed successful kidney transplantation in these patients. The key factor of this success is eculizumab, a humanized anti-C5 monoclonal antibody, which inhibits terminal membrane-attack complex formation and thrombotic microangiopathy progression. In the setting of kidney transplantation, there are different possible triggers of post-transplant atypical haemolytic uraemic syndrome recurrence, such as brain-death related injury, ischaemia-reperfusion injury, infections, the use of immunosuppressive drugs, and rejection. Principal strategies are to prevent endothelial damage that could potentially activate alternative complement pathway activation and subsequently lead to atypical haemolytic uraemic syndrome recurrence in kidney allograft. Published data shows that prophylactic eculizumab therapy is highly effective for the prevention of post-transplant atypical haemolytic uraemic syndrome recurrence, and prompt treatment with eculizumab as soon as recurrence is diagnosed is important to maintain renal allograft function. Further study to determine the optimal dosing and duration of prophylactic therapy and treatment of post-transplant atypical haemolytic uraemic syndrome recurrence is needed.
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Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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84
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Ikeda T, Okumi M, Unagami K, Kanzawa T, Sawada A, Kawanishi K, Omoto K, Ishida H, Tanabe K. Two cases of kidney transplantation-associated thrombotic microangiopathy successfully treated with eculizumab. Nephrology (Carlton) 2017; 21 Suppl 1:35-40. [PMID: 26970541 DOI: 10.1111/nep.12768] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is relatively rare and requires immediate intervention to avoid irreversible organ damage or death; however, consensus regarding the treatment approach is lacking. Atypical haemolytic uraemic syndrome (aHUS) is a rare disease caused by dysregulation of the alternative complement pathway resulting in TMA. aHUS is histologically similar to TA-TMA; approximately 60% of TA-TMA patients have complement dysregulation. Eculizumab, a humanized anti-C5 monoclonal antibody, inhibits terminal membrane-attack complex formation and TMA progression. Eculizumab has been successfully used to treat aHUS post-transplant. We present two cases of kidney TA-TMA due to unknown causes, suspected antibody-mediated rejection, or calcineurin inhibitor (CNI)-related toxicity that developed on day 1 or 2 post-kidney transplantation. Low platelet count and haemoglobin level with red cell fragments were detected. Despite steroid pulse, plasma exchange (PE), and intravenous immunoglobulin therapy, TA-TMA did not improve; therefore, eculizumab was administered despite no genetic testing. Laboratory data, including renal function, improved immediately. TA-TMA treatment primarily involves PE initiation or CNI discontinuation; eculizumab can be used to safely treat TA-TMA and then be ceased in the short term. Therefore, eculizumab administration might be beneficial for kidney TA-TMA as early as the diagnosis of refractory to PE.
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Affiliation(s)
- Takashi Ikeda
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kohei Unagami
- Internal Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Anri Sawada
- Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kunio Kawanishi
- Surgical Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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85
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Riella LV, Djamali A, Pascual J. Chronic allograft injury: Mechanisms and potential treatment targets. Transplant Rev (Orlando) 2017; 31:1-9. [DOI: 10.1016/j.trre.2016.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 10/05/2016] [Indexed: 01/05/2023]
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86
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Kato H, Nangaku M, Hataya H, Sawai T, Ashida A, Fujimaru R, Hidaka Y, Kaname S, Maruyama S, Yasuda T, Yoshida Y, Ito S, Hattori M, Miyakawa Y, Fujimura Y, Okada H, Kagami S. Clinical guides for atypical hemolytic uremic syndrome in Japan. Pediatr Int 2016; 58:549-55. [PMID: 27460397 DOI: 10.1111/ped.13044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/27/2016] [Indexed: 01/16/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In 2013, we developed diagnostic criteria to enable early diagnosis and timely initiation of appropriate treatment for aHUS. Recent clinical and molecular findings have resulted in several proposed classifications and definitions of thrombotic microangiopathy and aHUS. Based on recent advances in this field and the emerging international consensus to exclude secondary TMAs from the definition of aHUS, we have redefined aHUS and proposed diagnostic algorithms, differential diagnosis, and therapeutic strategies for aHUS.
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Affiliation(s)
- Hideki Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akira Ashida
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Rika Fujimaru
- Department of Pediatrics, Osaka City General Hospital, Miyakojima, Osaka, Japan
| | - Yoshihiko Hidaka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Shinya Kaname
- First Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | | | - Yoko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Kanazawa, Yokohama, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Yoshitaka Miyakawa
- Department of General Internal Medicine, Faculty of Medicine, Saitama Medical University, Iruma, Saitama, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Iruma, Saitama, Japan
| | - Shoji Kagami
- Department of Pediatrics, Graduate School of Medical Sciences, Tokushima University, Tokushima, Japan
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87
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Teoh CW, Riedl M, Licht C. The alternative pathway of complement and the thrombotic microangiopathies. Transfus Apher Sci 2016; 54:220-31. [PMID: 27160864 DOI: 10.1016/j.transci.2016.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thrombotic microangiopathies (TMA) are disorders defined by microangiopathic hemolytic anemia, non-immune thrombocytopenia and have multi-organ involvement including the kidneys, brain, gastrointestinal, respiratory tract and skin. Emerging evidence points to the central role of complement dysregulation in leading to microvascular endothelial injury which is crucial for the development of TMAs. This key insight has led to the development of complement-targeted therapy. Eculizumab is an anti-C5 monoclonal antibody, which has revolutionized the treatment of atypical hemolytic uremic syndrome. Several other anti-complement therapeutic agents are currently in development, offering a potential armamentarium of therapies available to treat complement-mediated TMAs. The development of sensitive, reliable and easy to perform assays to monitor complement activity and therapeutic efficacy will be key to devising an individualized treatment regime with the potential of safely weaning or discontinuing treatment in the appropriate clinical setting.
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Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Magdalena Riedl
- Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
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88
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Genetic analysis and functional characterization of novel mutations in a series of patients with atypical hemolytic uremic syndrome. Mol Immunol 2016; 71:10-22. [DOI: 10.1016/j.molimm.2016.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/19/2015] [Accepted: 01/02/2016] [Indexed: 11/21/2022]
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89
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Muff-Luett M, Nester CM. The Genetics of Ultra-Rare Renal Disease. J Pediatr Genet 2016; 5:33-42. [PMID: 27617140 DOI: 10.1055/s-0036-1572515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/02/2015] [Indexed: 12/14/2022]
Abstract
The complement-mediated renal diseases are a group of ultra-rare renal diseases that disproportionately affect children and young adults and frequently lead to irreversible renal failure. Genetic mutations in alternate pathway of complement genes are pathomechanistically involved in a significant number of these unique diseases. Here, we review our current understanding of the role of genetics in the primary complement-mediated renal diseases affecting children, with a focus on atypical hemolytic uremic syndrome and C3 glomerulopathy. Also, included is a brief discussion of the related diseases whose relationship to complement abnormality has been suspected but not yet confirmed. Advances in genetics have transformed both treatment and outcomes in these historically difficult to treat, highly morbid diseases.
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Affiliation(s)
- Melissa Muff-Luett
- Division of Pediatric Nephrology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Carla M Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States; Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, United States
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90
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Okumi M, Omoto K, Unagami K, Ishida H, Tanabe K. Eculizumab for the treatment of atypical hemolytic uremic syndrome recurrence after kidney transplantation associated with complement factor H mutations: a case report with a 5-year follow-up. Int Urol Nephrol 2016; 48:817-8. [PMID: 26865178 DOI: 10.1007/s11255-016-1234-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/28/2016] [Indexed: 01/11/2023]
Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan.
| | - Kazuya Omoto
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Kohei Unagami
- Department of Internal Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Kazunari Tanabe
- Department of Urology, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
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91
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An international consensus approach to the management of atypical hemolytic uremic syndrome in children. Pediatr Nephrol 2016; 31:15-39. [PMID: 25859752 DOI: 10.1007/s00467-015-3076-8] [Citation(s) in RCA: 343] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 01/26/2015] [Accepted: 02/16/2015] [Indexed: 12/19/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) emerged during the last decade as a disease largely of complement dysregulation. This advance facilitated the development of novel, rational treatment options targeting terminal complement activation, e.g., using an anti-C5 antibody (eculizumab). We review treatment and patient management issues related to this therapeutic approach. We present consensus clinical practice recommendations generated by HUS International, an international expert group of clinicians and basic scientists with a focused interest in HUS. We aim to address the following questions of high relevance to daily clinical practice: Which complement investigations should be done and when? What is the importance of anti-factor H antibody detection? Who should be treated with eculizumab? Is plasma exchange therapy still needed? When should eculizumab therapy be initiated? How and when should complement blockade be monitored? Can the approved treatment schedule be modified? What approach should be taken to kidney and/or combined liver-kidney transplantation? How should we limit the risk of meningococcal infection under complement blockade therapy? A pressing question today regards the treatment duration. We discuss the need for prospective studies to establish evidence-based criteria for the continuation or cessation of anticomplement therapy in patients with and without identified complement mutations.
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92
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Characteristics and Outcomes of Renal Transplant Recipients with Hemolytic Uremic Syndrome in the United States. Transplant Direct 2015; 1. [PMID: 26949736 PMCID: PMC4775084 DOI: 10.1097/txd.0000000000000555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) accounts for <1% of renal transplants in the US. There are limited data on the characteristics and outcomes of HUS in pediatric and adult kidney transplant recipients in the US. METHODS This study included all renal transplant recipients identified with HUS (N=1,233) as a cause of end-stage renal disease between 1987 and 2013 using the UNOS/OPTN database. The cohort was divided into two age groups: pediatric (N=447) and adult (N=786). Main outcomes were acute rejection rate at one-year, allograft and patient survival, and recurrence of HUS post-transplant. Both age groups were then compared with a propensity score (1:2 ratio) matched control group with an alternative primary kidney disease (non-HUS cohort: pediatric [N= 829] and adult [N=1,547]). RESULTS In pediatric cohort, when compared to the PS matched controls, acute rejection, death censored allograft and patient survival was similar in the HUS group. However, in the adult cohort, the graft and patient survivals were significantly worse in the HUS group. HUS was associated with allograft loss (HR=1.40, 95%CI 1.14-1.71) in adult recipients. Patients with HUS recurrence had significantly lower allograft and patient survival rates compared to the non-recurrent group in both age groups. Acute rejection was one of the major predictor of HUS recurrence in adults (OR=2.64, 95%CI 1.25-5.60). Calcineurin inhibitors (CNI) were not associated HUS recurrence in both age groups. CONCLUSION Pediatric HUS-patients, unlike adult recipients, have similar outcomes compared to the PS matched controls. Recurrence of HUS is associated with poor allograft and patient survival in pediatric and adult patients. Use of CNIs seem to be safe as a part of maintenance immunosuppression post-transplantation. A comprehensive national registry is urgently needed.
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93
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Blasco Pelicano M, Rodríguez de Córdoba S, Campistol Plana JM. Síndrome hemolítico urémico atípico. Med Clin (Barc) 2015; 145:438-45. [DOI: 10.1016/j.medcli.2014.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/25/2014] [Accepted: 08/29/2014] [Indexed: 12/15/2022]
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94
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Bulut C, Oguz EG, Canbakan B, Ayli D. BK virus-related thrombotic microangiopathy in a kidney transplant recipient. INDIAN JOURNAL OF TRANSPLANTATION 2015. [DOI: 10.1016/j.ijt.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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95
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Mallett A, Hughes P, Szer J, Tuckfield A, Van Eps C, Cambell SB, Hawley C, Burke J, Kausman J, Hewitt I, Parnham A, Ford S, Isbel N. Atypical haemolytic uraemic syndrome treated with the complement inhibitor eculizumab: the experience of the Australian compassionate access cohort. Intern Med J 2015; 45:1054-65. [DOI: 10.1111/imj.12864] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 07/19/2015] [Indexed: 02/03/2023]
Affiliation(s)
- A. Mallett
- Department of Renal Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - P. Hughes
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - J. Szer
- Department of Clinical Haematology and BMT Service; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - A. Tuckfield
- Department of Clinical Haematology and BMT Service; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - C. Van Eps
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - S. B. Cambell
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - C. Hawley
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - J. Burke
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - J. Kausman
- Department of Nephrology; The Royal Children's Hospital Melbourne; Melbourne Victoria Australia
| | - I. Hewitt
- Department of Nephrology; Princess Margaret Hospital for Children; Perth Western Australia Australia
| | - A. Parnham
- Department of Nephrology; Gold Coast Hospital; Gold Coast Queensland Australia
| | - S. Ford
- Department of Nephrology; Monash Medical Centre; Melbourne Victoria Australia
| | - N. Isbel
- Centre for Kidney Disease Research; Centre for Chronic Disease; CKD.QLD; School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
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97
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Kavanagh D, Yu Y, Schramm EC, Triebwasser M, Wagner EK, Raychaudhuri S, Daly MJ, Atkinson JP, Seddon JM. Rare genetic variants in the CFI gene are associated with advanced age-related macular degeneration and commonly result in reduced serum factor I levels. Hum Mol Genet 2015; 24:3861-70. [PMID: 25788521 PMCID: PMC4459386 DOI: 10.1093/hmg/ddv091] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/09/2015] [Indexed: 12/13/2022] Open
Abstract
To assess a potential diagnostic and therapeutic biomarker for age-related macular degeneration (AMD), we sequenced the complement factor I gene (CFI) in 2266 individuals with AMD and 1400 without, identifying 231 individuals with rare genetic variants. We evaluated the functional impact by measuring circulating serum factor I (FI) protein levels in individuals with and without rare CFI variants. The burden of very rare (frequency <1/1000) variants in CFI was strongly associated with disease (P = 1.1 × 10−8). In addition, we examined eight coding variants with counts ≥5 and saw evidence for association with AMD in three variants. Individuals with advanced AMD carrying a rare CFI variant had lower mean FI compared with non-AMD subjects carrying a variant (P < 0.001). Further new evidence that FI levels drive AMD risk comes from analyses showing individuals with a CFI rare variant and low FI were more likely to have advanced AMD (P = 5.6 × 10−5). Controlling for covariates, low FI increased the risk of advanced AMD among those with a variant compared with individuals without advanced AMD with a rare CFI variant (OR 13.6, P = 1.6 × 10−4), and also compared with control individuals without a rare CFI variant (OR 19.0, P = 1.1 × 10−5). Thus, low FI levels are strongly associated with rare CFI variants and AMD. Enhancing FI activity may be therapeutic and measuring FI provides a screening tool for identifying patients who are most likely to benefit from complement inhibitory therapy.
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Affiliation(s)
- David Kavanagh
- Institute of Genetic Medicine, Newcastle University, International Centre for Life, Newcastle upon Tyne, UK
| | - Yi Yu
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, MA, USA
| | - Elizabeth C Schramm
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Triebwasser
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Erin K Wagner
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, MA, USA
| | - Soumya Raychaudhuri
- Partners HealthCare Center for Personalized Genetic Medicine, Boston, MA, USA, Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA, Division of Genetics, Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Mark J Daly
- Partners HealthCare Center for Personalized Genetic Medicine, Boston, MA, USA, Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA, Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Johanna M Seddon
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, MA, USA, Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA and Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, MA, USA
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98
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Broeders EN, Stordeur P, Rorive S, Dahan K. A 'silent', new polymorphism of factor H and apparent de novo atypical haemolytic uraemic syndrome after kidney transplantation. BMJ Case Rep 2014; 2014:bcr-2014-207630. [PMID: 25538218 DOI: 10.1136/bcr-2014-207630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The pathophysiology of atypical haemolytic-uraemic syndrome (aHUS) occurring de novo after renal transplantation may include genetic mutations of regulators of complement activation, but they are still rarely determined. A 41-year-old female renal transplant recipient presented two very different episodes of thrombotic microangiopathy. The first episode was associated with antibody-mediated rejection and the second was an isolated, acute aHUS, successfully treated with eculizumab. The diagnosis included a genetic analysis and we found a synonymous variant in the Complement Factor H (CFH) gene, c2634C>T (p.His878=) and low factor H (FH) activity during both events. In conclusion, the diagnosis of aHUS should be considered when TMA is associated with an AMR episode. In this setting, a silent polymorphism of factor H may be responsible for these rare cases of "de novo" aHUS after transplantation.
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Affiliation(s)
- Emine N Broeders
- Département de Néphrologie, Dialyse et Transplantation Rénale, Cliniques Universitaires de Bruxelles, ULB-Hôpital Erasme, Brussels, Belgium
| | - Patrick Stordeur
- Clinique d'Immunobiologie, ULB-Hôpital Erasme, Brussels, Belgium
| | - Sandrine Rorive
- Laboratoire d'Anatomie Pathologique, ULB-Hôpital Erasme, Brussels, Belgium
| | - Karin Dahan
- Département de Génétique Humaine, Institut de Pathologie et de Génétique, Gosselies, Belgium
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99
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Alasfar S, Alachkar N. Atypical hemolytic uremic syndrome post-kidney transplantation: two case reports and review of the literature. Front Med (Lausanne) 2014; 1:52. [PMID: 25593925 PMCID: PMC4292050 DOI: 10.3389/fmed.2014.00052] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 11/29/2014] [Indexed: 01/09/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disorder characterized by over-activation and dysregulation of the alternative complement pathway. Its estimated prevalence is 1–2 per million. The disease is characterized by thrombotic microangiopathy, which causes anemia, thrombocytopenia, and acute renal failure. aHUS has more severe course compared to typical (infection-induced) HUS and is frequently characterized by relapses that leads to end stage renal disease. For a long time, kidney transplantation for these patients was contraindicated because of high rate of recurrence and subsequent renal graft loss. The post-kidney transplantation recurrence rate largely depends on the pathogenetic mechanisms involved. However, over the past several years, advancements in the understanding and therapeutics of aHUS have allowed successful kidney transplantation in these patients. Eculizumab, which is a complement C5 antibody that inhibits complement factor 5a and subsequent formation of the membrane-attack complex, has been used in prevention and treatment of post-transplant aHUS recurrence. In this paper, we present two new cases of aHUS patients who underwent successful kidney transplantation in our center with the use of prophylactic and maintenance eculizumab therapy that have not been published before. The purpose of reporting these two cases is to emphasize the importance of using eculizumab as a prophylactic therapy to prevent aHUS recurrence post-transplant in high-risk patients. We will also review the current understanding of the genetics of aHUS, the pathogenesis of its recurrence after kidney transplantation, and strategies for prevention and treatment of post-transplant aHUS recurrence.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine , Baltimore, MD , USA
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100
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Abstract
Hemolytic uremic syndrome (HUS) is a disease characterized by hemolysis, thrombocytopenia, and acute kidney injury, although other organs may be involved. Most cases are due to infection with Shiga toxin-producing Escherichia coli (STEC). Early identification and initiation of best supportive care, with microbiological input to identify the pathogen, result in a favorable outcome in most patients. The remaining 10% of HUS cases are classed together as atypical HUS and have a diverse etiology. The majority are due to inherited or acquired abnormalities that lead to a failure to control complement activation. Atypical HUS occurring in other situations (for example, related to pregnancy or kidney transplantation) may also involve excessive complement activation. Plasma therapies can reverse defective complement control, and it is now possible to specifically target complement activation. This has led to improved outcomes in patients with atypical forms of HUS. We will review our current understanding of the pathogenesis of HUS and how this has led to advances in patient care.
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Affiliation(s)
- David Kavanagh
- Institute of Genetic Medicine, Newcastle UniversityNewcastle upon TyneUK
| | - Shreya Raman
- Department of Histopathology, Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Neil S. Sheerin
- Institute of Cellular Medicine, Newcastle UniversityNewcastle upon TyneUK
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