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Campistol JM, Arias M, Ariceta G, Blasco M, Espinosa L, Espinosa M, Grinyó JM, Macía M, Mendizábal S, Praga M, Román E, Torra R, Valdés F, Vilalta R, Rodríguez de Córdoba S. An update for atypical haemolytic uraemic syndrome: diagnosis and treatment. A consensus document. Nefrologia 2015; 35:421-47. [PMID: 26456110 DOI: 10.1016/j.nefro.2015.07.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a clinical entity defined as the triad of nonimmune haemolytic anaemia, thrombocytopenia, and acute renal failure, in which the underlying lesions are mediated by systemic thrombotic microangiopathy (TMA). Different causes can induce the TMA process that characterizes HUS. In this document we consider atypical HUS (aHUS) a sub-type of HUS in which the TMA phenomena are the consequence of the endotelial damage in the microvasculature of the kidneys and other organs due to a disregulation of the activity of the complement system. In recent years, a variety of aHUs-related mutations have been identified in genes of the the complement system, which can explain approximately 60% of the aHUS cases, and a number of mutations and polymorphisms have been functionally characterized. These findings have stablished that aHUS is a consequence of the insufficient regulation of the activiation of the complement on cell surfaces, leading to endotelial damage mediated by C5 and the complement terminal pathway. Eculizumab is a monoclonal antibody that inhibits the activation of C5 and blocks the generation of the pro-inflammatory molecule C5a and the formation of the cell membrane attack complex. In prospective studies in patients with aHUS, the use of Eculizumab has shown a fast and sustained interruption of the TMA process and it has been associated with significative long-term improvements in renal function, the interruption of plasma therapy and important reductions in the need of dialysis. According to the existing literature and the accumulated clinical experience, the Spanish aHUS Group published a consensus document with recommendations for the treatment of aHUs (Nefrologia 2013;33[1]:27-45). In the current online version of this document, we update the aetiological classification of TMAs, the pathophysiology of aHUS, its differential diagnosis and its therapeutic management.
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Affiliation(s)
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
| | - Miguel Blasco
- Servicio de Nefrología, Hospital Clínic, Barcelona, España
| | - Laura Espinosa
- Servicio de Nefrología Pediátrica, Hospital La Paz, Madrid, España
| | - Mario Espinosa
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, España
| | - Josep M Grinyó
- Servicio de Nefrología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Manuel Macía
- Servicio de Nefrología, Hospital Virgen de la Candelaria, Santa Cruz de Tenerife, España
| | | | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Elena Román
- Servicio de Nefrología Pediátrica, Hospital La Fe, Valencia, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Fundació Puigvert, Barcelona, España
| | - Francisco Valdés
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, España
| | - Ramón Vilalta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
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Foltyn Zadura A, Memon AA, Stojanovich L, Perricone C, Conti F, Valesini G, Bogdanovic G, Hillarp A, Shoenfeld Y, Sundquist J, Leffler J, Svensson PJ, Trouw LA, Blom AM. Factor H Autoantibodies in Patients with Antiphospholipid Syndrome and Thrombosis. J Rheumatol 2015; 42:1786-93. [PMID: 26276971 DOI: 10.3899/jrheum.150185] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Autoantibodies to complement factor H (FH) are associated with atypical hemolytic uremic syndrome, but can also be detected in patients with rheumatoid arthritis and in patients positive for lupus anticoagulants and thus potentially antiphospholipid syndrome (APS). To our knowledge, no data are available on the association between the presence of FH autoantibodies in APS and clinical manifestations. METHODS We determined FH autoantibody levels using ELISA in 2 cohorts of patients with primary (PAPS) and secondary APS (SAPS) from Serbia and Italy, and an additional cohort including patients with venous thromboembolism (VTE) from Sweden. RESULTS FH autoantibodies were detected in 13.7% of patients (n = 73) with PAPS and 30.3% of patients (n = 33) with SAPS in the Serbian cohort. FH autoantibody frequency in the Italian cohort was 33.3% (n = 15) and 36% (n = 25) in PAPS and SAPS, respectively. Both FH autoantibody levels and frequencies observed in both APS cohorts were significantly higher than in matched healthy controls (5%). Further, patients with PAPS with venous thrombosis in the Serbian cohort had significantly higher levels of FH autoantibodies. Therefore, we analyzed a dedicated Swedish thrombosis cohort and found that patients with FH autoantibody positivity had higher risk of VTE recurrence (HR 2.0, 95% CI 1.2-3.3, p = 0.011) compared with the reference group of FH autoantibody-negative patients. CONCLUSION Overall, the data indicate that in patients with APS and recurrent venous thrombosis, there are increased levels of FH autoantibodies, a finding associated with poor clinical outcome.
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Affiliation(s)
- Anna Foltyn Zadura
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Ashfaque A Memon
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Ljudmila Stojanovich
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Carlo Perricone
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Fabrizio Conti
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Guido Valesini
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Gordana Bogdanovic
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Andreas Hillarp
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Yehuda Shoenfeld
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Jan Sundquist
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Jonatan Leffler
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Peter J Svensson
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Leendert A Trouw
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University
| | - Anna M Blom
- From the Department of Translational Medicine, and Department of Clinical Sciences, Lund University; Center for Primary Health Care Research, Skåne University Hospital, Malmö; Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital, Halmstad, Sweden; Internal Medicine, "Bezhanijska Kosa," University Medical Center, Belgrade, Serbia; Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Aviv, Israel; Telethon Kids Institute, University of Western Australia, Perth, Australia; Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.A. Foltyn Zadura, MSc, Department of Translational Medicine, Lund University; A.A. Memon, PhD, Center for Primary Health Care Research, Skåne University Hospital; L. Stojanovich, MD, PhD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; C. Perricone, MD; F. Conti, MD, PhD; G. Valesini, MD, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma; G. Bogdanovic, MD, PHD, Internal Medicine, "Bezhanijska Kosa," University Medical Center; A. Hillarp, PhD, Department of Clinical Chemistry and Transfusion Medicine, Halland Hospital; Y. Shoenfeld, MD, PhD, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center; J. Sundquist, MD, PhD, Center for Primary Health Care Research, Skåne University Hospital; J. Leffler, PhD, Telethon Kids Institute, University of Western Australia; P.J. Svensson, MD, PhD, Department of Translational Medicine, Lund University; L.A. Trouw, PhD, Department of Rheumatology, Leiden University Medical Center; A.M. Blom, PhD, Department of Translational Medicine, Lund University.
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Complement factor H, FHR-3 and FHR-1 variants associate in an extended haplotype conferring increased risk of atypical hemolytic uremic syndrome. Mol Immunol 2015; 67:276-86. [PMID: 26163426 DOI: 10.1016/j.molimm.2015.06.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/05/2015] [Accepted: 06/10/2015] [Indexed: 12/31/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a severe thrombotic microangiopathy affecting the renal microvasculature and is associated with complement dysregulation caused by mutations or autoantibodies. Disease penetrance and severity is modulated by inheritance of "risk" polymorphisms in the complement genes MCP, CFH and CFHR1. We describe the prevalence of mutations, the frequency of risk polymorphisms and the occurrence of anti-FH autoantibodies in a Spanish aHUS cohort (n=367). We also report the identification of a polymorphism in CFHR3 (c.721C>T; rs379370) that is associated with increased risk of aHUS (OR=1.78; CI 1.22-2.59; p=0.002), and is most frequently included in an extended risk haplotype spanning the CFH-CFHR3-CFHR1 genes. This extended haplotype integrates polymorphisms in the promoter region of CFH and CFHR3, and is associated with poorer evolution of renal function and decreased FH levels. The CFH-CFHR3-CFHR1 aHUS-risk haplotype seems to be the same as was previously associated with protection against meningococcal infections, suggesting that the genetic variability in this region is limited to a few extended haplotypes, each with opposite effects in various human diseases. These results suggest that the combination of quantitative and qualitative variations in the complement proteins encoded by CFH, CFHR3 and CFHR1 genes is key for the association of these haplotypes with disease.
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Lee JM, Park YS, Lee JH, Park SJ, Shin JI, Park YH, Yoo KH, Cho MH, Kim SY, Kim SH, Namgoong MK, Lee SJ, Lee JH, Cho HY, Han KH, Kang HG, Ha IS, Bae JS, Kim NKD, Park WY, Cheong HI. Atypical hemolytic uremic syndrome: Korean pediatric series. Pediatr Int 2015; 57:431-8. [PMID: 25443527 DOI: 10.1111/ped.12549] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare disease with a genetic predisposition. Few studies have evaluated the disease in the Asian population. We studied a Korean pediatric cohort to delineate the clinical characteristics and genotypes. METHODS A multicenter cohort of 51 Korean children with aHUS was screened for mutations using targeted exome sequencing covering 46 complement related genes. Anti-complement-factor-H autoantibody (anti-CFH) titers were measured. Multiplex ligation-dependent probe amplification assay was performed to detect deletions in the complement factor-H related protein genes (CFHR) in the patients as well as in 100 healthy Korean controls. We grouped the patients according to etiology and compared the clinical features using Mann-Whitney U-test and chi-squared test. RESULTS Fifteen patients (group A, 29.7%) had anti-CFH, and mutations were detected in 11 (group B, 21.6%), including one with combined mutations. The remaining 25 (group C, 49.0%) were negative for both. The prevalence of anti-CFH was higher than the worldwide level. Group A had a higher onset age than group B, although the difference was not significant. Group B had the worst renal outcome. Gene frequencies of homozygous CFHR1 deletion were 73.3%, 2.7% and 1% in group A, group B + C and the control, respectively. CONCLUSIONS The incidence of anti-CFH in the present Korean aHUS cohort was high. Clinical outcomes largely conformed to the previous reports. Although the sample size was limited, this cohort provides a reassessment of clinicogenetic features of aHUS in Korean children.
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Affiliation(s)
- Jiwon M Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Se Jin Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University, Seoul, Korea
| | - Yong-Hoon Park
- Department of Pediatrics, Yeungnam University College of Medicine, Daegu, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University Hospital, Daegu, Korea
| | - Su-Young Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Mee Kyung Namgoong
- Department of Pediatrics, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Seung Joo Lee
- Department of Pediatrics, Ehwa University Mokdong Hospital, Seoul, Korea
| | - Jun Ho Lee
- Department of Pediatrics, Bundang CHA Hospital, Seongnam, Korea
| | - Hee Yeon Cho
- Department of Pediatrics, Samsung Medical Center, Seoul, Korea
| | - Kyoung Hee Han
- Department of Pediatrics, Jeju University Hospital, Jeju, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jun-Seok Bae
- Samsung Genome Institute, Samsung Medical Center, Seoul, Korea.,Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Nayoung K D Kim
- Samsung Genome Institute, Samsung Medical Center, Seoul, Korea
| | - Woong-Yang Park
- Samsung Genome Institute, Samsung Medical Center, Seoul, Korea.,Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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56
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Yoshida Y, Miyata T, Matsumoto M, Shirotani-Ikejima H, Uchida Y, Ohyama Y, Kokubo T, Fujimura Y. A novel quantitative hemolytic assay coupled with restriction fragment length polymorphisms analysis enabled early diagnosis of atypical hemolytic uremic syndrome and identified unique predisposing mutations in Japan. PLoS One 2015; 10:e0124655. [PMID: 25951460 PMCID: PMC4423893 DOI: 10.1371/journal.pone.0124655] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 03/17/2015] [Indexed: 01/19/2023] Open
Abstract
For thrombotic microangiopathies (TMAs), the diagnosis of atypical hemolytic uremic syndrome (aHUS) is made by ruling out Shiga toxin-producing Escherichia coli (STEC)-associated HUS and ADAMTS13 activity-deficient thrombotic thrombocytopenic purpura (TTP), often using the exclusion criteria for secondary TMAs. Nowadays, assays for ADAMTS13 activity and evaluation for STEC infection can be performed within a few hours. However, a confident diagnosis of aHUS often requires comprehensive gene analysis of the alternative complement activation pathway, which usually takes at least several weeks. However, predisposing genetic abnormalities are only identified in approximately 70% of aHUS. To facilitate the diagnosis of complement-mediated aHUS, we describe a quantitative hemolytic assay using sheep red blood cells (RBCs) and human citrated plasma, spiked with or without a novel inhibitory anti-complement factor H (CFH) monoclonal antibody. Among 45 aHUS patients in Japan, 24% (11/45) had moderate-to-severe (≥50%) hemolysis, whereas the remaining 76% (34/45) patients had mild or no hemolysis (<50%). The former group is largely attributed to CFH-related abnormalities, and the latter group has C3-p.I1157T mutations (16/34), which were identified by restriction fragment length polymorphism (RFLP) analysis. Thus, a quantitative hemolytic assay coupled with RFLP analysis enabled the early diagnosis of complement-mediated aHUS in 60% (27/45) of patients in Japan within a week of presentation. We hypothesize that this novel quantitative hemolytic assay would be more useful in a Caucasian population, who may have a higher proportion of CFH mutations than Japanese patients.
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Affiliation(s)
- Yoko Yoshida
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Toshiyuki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | | | - Yumiko Uchida
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshifumi Ohyama
- Molecular and Cellular Biology Laboratory, Graduate School of Medical Life Science, Yokohama City University, Yokohama, Japan
| | - Tetsuro Kokubo
- Molecular and Cellular Biology Laboratory, Graduate School of Medical Life Science, Yokohama City University, Yokohama, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
- * E-mail:
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57
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Blanc C, Togarsimalemath SK, Chauvet S, Le Quintrec M, Moulin B, Buchler M, Jokiranta TS, Roumenina LT, Fremeaux-Bacchi V, Dragon-Durey MA. Anti-factor H autoantibodies in C3 glomerulopathies and in atypical hemolytic uremic syndrome: one target, two diseases. THE JOURNAL OF IMMUNOLOGY 2015; 194:5129-38. [PMID: 25917093 DOI: 10.4049/jimmunol.1402770] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Autoantibodies targeting factor H (FH), which is a main alternative complement pathway regulatory protein, have been well characterized in atypical hemolytic uremic syndrome (aHUS) but have been less well described in association with alternative pathway-mediated glomerulopathies (GP). In this study, we studied 17 patients presenting with GP who were positive for anti-FH IgG. Clinical data were collected and biological characteristics were compared with those of patients presenting with anti-FH Ab-associated aHUS. In contrast to the aHUS patients, the GP patients had no circulating FH-containing immune complexes, and their anti-FH IgG had a weaker affinity for FH. Functional studies demonstrated that these Abs induced no perturbations in FH cell surface protection or the binding of FH to its ligand. However, anti-FH IgG samples isolated from three patients were able to affect the factor I cofactor activity of FH. Epitope mapping identified the N-terminal domain of FH as the major binding site for GP patient IgG. No homozygous deletions of the CFHR1 and CFHR3 genes, which are frequently associated with the anti-FH Ab in aHUS patients, were found in the GP patients. Finally, anti-FH Abs were frequently associated with the presence of C3 nephritic factor in child GP patients and with monoclonal gammopathy in adult GP patients, who frequently showed Ig Lchain restriction during reactivity against factor H. These data provide deeper insights into the pathophysiological differences between aHUS and GP, demonstrating heterogeneity of anti-FH IgG.
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Affiliation(s)
- Caroline Blanc
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Université Paris Diderot, 75013 Paris, France
| | - Shambhuprasad Kotresh Togarsimalemath
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75970 Paris Cedex 20, France
| | - Sophie Chauvet
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - Moglie Le Quintrec
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75970 Paris Cedex 20, France
| | - Bruno Moulin
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire Hautepierre, 67098 Strasbourg, France
| | - Matthias Buchler
- Service de Néphrologie, Immunologie Clinique, Hôpital Bretonneau, 37044 Tours, France
| | - T Sakari Jokiranta
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, 00014 Helsinki, Finland; and
| | - Lubka T Roumenina
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France
| | - Véronique Fremeaux-Bacchi
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75908 Paris, France
| | - Marie-Agnès Dragon-Durey
- INSERM Unité Mixte de Recherche S1138, "Complément et Maladies" Équipe 10, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 75006 Paris, France; Service de Néphrologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75970 Paris Cedex 20, France; Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75908 Paris, France
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58
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Nester CM, Barbour T, de Cordoba SR, Dragon-Durey MA, Fremeaux-Bacchi V, Goodship THJ, Kavanagh D, Noris M, Pickering M, Sanchez-Corral P, Skerka C, Zipfel P, Smith RJH. Atypical aHUS: State of the art. Mol Immunol 2015; 67:31-42. [PMID: 25843230 DOI: 10.1016/j.molimm.2015.03.246] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 12/12/2022]
Abstract
Tremendous advances in our understanding of the thrombotic microangiopathies (TMAs) have revealed distinct disease mechanisms within this heterogeneous group of diseases. As a direct result of this knowledge, both children and adults with complement-mediated TMA now enjoy higher expectations for long-term health. In this update on atypical hemolytic uremic syndrome, we review the clinical characteristics; the genetic and acquired drivers of disease; the broad spectrum of environmental triggers; and current diagnosis and treatment options. Many questions remain to be addressed if additional improvements in patient care and outcome are to be achieved in the coming decade.
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Affiliation(s)
- Carla M Nester
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Division of Nephrology, Stead Family Department of Pediatrics, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Thomas Barbour
- Centre for Complement and Inflammation Research, Department of Medicine, Imperial College, London W12 0NN, UK
| | | | - Marie Agnes Dragon-Durey
- Assistance Publique - Hopitaux de Paris, Service d'Immunologie Biologique, Hopital Europeen Georges Pompidou, Paris, France
| | - Veronique Fremeaux-Bacchi
- Assistance Publique - Hopitaux de Paris, Service d'Immunologie Biologique, Hopital Europeen Georges Pompidou, Paris, France
| | - Tim H J Goodship
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - David Kavanagh
- Assistance Publique - Hopitaux de Paris, Service d'Immunologie Biologique, Hopital Europeen Georges Pompidou, Paris, France
| | - Marina Noris
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò", Ranica, Bergamo, Italy
| | - Matthew Pickering
- Centre for Complement and Inflammation Research, Department of Medicine, Imperial College, London W12 0NN, UK
| | - Pilar Sanchez-Corral
- Unidad de Investigación and Ciber de Enfermedades Raras, Hospital Universitario de La Paz_IdiPAZ, Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Christine Skerka
- Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Peter Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany; Friedrich Schiller University, Jena, Germany
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Division of Nephrology, Stead Family Department of Pediatrics, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
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59
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Loirat C, Frémeaux-Bacchi V. Anti-factor H autoantibody-associated hemolytic uremic syndrome: the earlier diagnosed and treated, the better. Kidney Int 2015; 85:1019-22. [PMID: 24786877 DOI: 10.1038/ki.2013.447] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Atypical hemolytic uremic syndrome (HUS) secondary to anti-factor H autoantibodies has a poor prognosis. The study by Sinha et al. of a large cohort of Indian children makes a substantial contribution to improved management of this form of HUS by showing that standardized titration of anti-factor H autoantibodies is applicable worldwide and that early treatment initiation and guidance of maintenance treatment by autoantibody titer monitoring significantly improve outcomes.
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Affiliation(s)
- Chantal Loirat
- 1] Department of Pediatric Nephrology, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Paris, France [2] Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Véronique Frémeaux-Bacchi
- 1] Laboratory of Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France [2] INSERM Unité Mixte de Recherche en Santé 872, Paris, France
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60
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Bhattacharjee A, Reuter S, Trojnár E, Kolodziejczyk R, Seeberger H, Hyvärinen S, Uzonyi B, Szilágyi Á, Prohászka Z, Goldman A, Józsi M, Jokiranta TS. The major autoantibody epitope on factor H in atypical hemolytic uremic syndrome is structurally different from its homologous site in factor H-related protein 1, supporting a novel model for induction of autoimmunity in this disease. J Biol Chem 2015; 290:9500-10. [PMID: 25659429 PMCID: PMC4392255 DOI: 10.1074/jbc.m114.630871] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Indexed: 01/26/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is characterized by complement attack against host cells due to mutations in complement proteins or autoantibodies against complement factor H (CFH). It is unknown why nearly all patients with autoimmune aHUS lack CFHR1 (CFH-related protein-1). These patients have autoantibodies against CFH domains 19 and 20 (CFH19–20), which are nearly identical to CFHR1 domains 4 and 5 (CFHR14–5). Here, binding site mapping of autoantibodies from 17 patients using mutant CFH19–20 constructs revealed an autoantibody epitope cluster within a loop on domain 20, next to the two buried residues that are different in CFH19–20 and CFHR14–5. The crystal structure of CFHR14–5 revealed a difference in conformation of the autoantigenic loop in the C-terminal domains of CFH and CFHR1, explaining the variation in binding of autoantibodies from some aHUS patients to CFH19–20 and CFHR14–5. The autoantigenic loop on CFH seems to be generally flexible, as its conformation in previously published structures of CFH19–20 bound to the microbial protein OspE and a sialic acid glycan is somewhat altered. Cumulatively, our data suggest that association of CFHR1 deficiency with autoimmune aHUS could be due to the structural difference between CFHR1 and the autoantigenic CFH epitope, suggesting a novel explanation for CFHR1 deficiency in the pathogenesis of autoimmune aHUS.
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Affiliation(s)
- Arnab Bhattacharjee
- From the Department of Bacteriology and Immunology, Medicum, and Immunobiology Research Program Unit, University of Helsinki and Helsinki University Hospital, 00014 University of Helsinki, Finland, the Institute of Biotechnology and
| | - Stefanie Reuter
- the Junior Research Group for Cellular Immunobiology, Leibniz Institute for Natural Product, Research and Infection Biology-Hans Knöll Institute, 07745 Jena, Germany
| | - Eszter Trojnár
- the Research Laboratory, 3rd Department of Internal Medicine, Semmelweis University, 1125 Budapest, Hungary, and
| | - Robert Kolodziejczyk
- the Institute of Biotechnology and Division of Biochemistry and Biotechnology, Department of Biosciences, University of Helsinki, 00014 University of Helsinki, Finland
| | - Harald Seeberger
- the Junior Research Group for Cellular Immunobiology, Leibniz Institute for Natural Product, Research and Infection Biology-Hans Knöll Institute, 07745 Jena, Germany
| | - Satu Hyvärinen
- From the Department of Bacteriology and Immunology, Medicum, and Immunobiology Research Program Unit, University of Helsinki and Helsinki University Hospital, 00014 University of Helsinki, Finland
| | | | - Ágnes Szilágyi
- the Research Laboratory, 3rd Department of Internal Medicine, Semmelweis University, 1125 Budapest, Hungary, and
| | - Zoltán Prohászka
- the Research Laboratory, 3rd Department of Internal Medicine, Semmelweis University, 1125 Budapest, Hungary, and
| | - Adrian Goldman
- the Institute of Biotechnology and Division of Biochemistry and Biotechnology, Department of Biosciences, University of Helsinki, 00014 University of Helsinki, Finland
| | - Mihály Józsi
- the Junior Research Group for Cellular Immunobiology, Leibniz Institute for Natural Product, Research and Infection Biology-Hans Knöll Institute, 07745 Jena, Germany, MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, Eötvös Loránd University, 1117 Budapest, Hungary
| | - T Sakari Jokiranta
- From the Department of Bacteriology and Immunology, Medicum, and Immunobiology Research Program Unit, University of Helsinki and Helsinki University Hospital, 00014 University of Helsinki, Finland
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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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62
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Verhave JC, Wetzels JFM, van de Kar NCAJ. Novel aspects of atypical haemolytic uraemic syndrome and the role of eculizumab. Nephrol Dial Transplant 2014; 29 Suppl 4:iv131-41. [PMID: 25165180 DOI: 10.1093/ndt/gfu235] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The haemolytic uraemic syndrome (HUS) is part of a spectrum of thrombotic microangiopathies. The most common etiologies of HUS are the ones seen in childhood caused by an infection of Shiga toxin-producing Escherichia coli, HUS caused by an infection with Streptococcus pneumoniae and HUS due to abnormalities in the alternative pathway of the complement system. In the past decade, enormous progress has been made in understanding the pathogenesis in the latter group of patients. The analysis of genes that encode for complement regulatory proteins and the development of assays for measuring the activity of ADAMTS13 and the detection of antibodies against factor H contributed significantly to the diagnostic tools in patients with HUS. These assays have made it possible to clearly differentiate between thrombotic thrombocytopenic purpura and various forms of HUS. With the introduction of eculizumab, a monoclonal anti-C5 inhibitor, in the clinical arena as effective treatment of most complement-mediated forms of HUS, a new era of treatment in HUS has begun. We review the recent advances in HUS, with the focus on treatment. We discuss unsolved questions, which should be addressed in future studies.
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Affiliation(s)
- Jacobien C Verhave
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole C A J van de Kar
- Department of Paediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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63
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Syndrome hémolytique et urémique atypique : pour qui l’éculizumab ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0928-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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64
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Tsai HM. A Mechanistic Approach to the Diagnosis and Management of Atypical Hemolytic Uremic Syndrome. Transfus Med Rev 2014; 28:187-97. [DOI: 10.1016/j.tmrv.2014.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 08/25/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
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65
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Józsi M, Reuter S, Nozal P, López-Trascasa M, Sánchez-Corral P, Prohászka Z, Uzonyi B. Autoantibodies to complement components in C3 glomerulopathy and atypical hemolytic uremic syndrome. Immunol Lett 2014; 160:163-71. [DOI: 10.1016/j.imlet.2014.01.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/20/2014] [Accepted: 01/24/2014] [Indexed: 01/27/2023]
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66
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Abstract
Hemolytic uremic syndrome (HUS) is a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. The atypical form of HUS is a disease characterized by complement overactivation. Inherited defects in complement genes and acquired autoantibodies against complement regulatory proteins have been described. Incomplete penetrance of mutations in all predisposing genes is reported, suggesting that a precipitating event or trigger is required to unmask the complement regulatory deficiency. The underlying genetic defect predicts the prognosis both in native kidneys and after renal transplantation. The successful trials of the complement inhibitor eculizumab in the treatment of atypical HUS will revolutionize disease management.
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Affiliation(s)
- David Kavanagh
- The Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK.
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Successful treatment of DEAP-HUS with eculizumab. Pediatr Nephrol 2014; 29:841-51. [PMID: 24249282 DOI: 10.1007/s00467-013-2654-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 09/07/2013] [Accepted: 10/03/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Deficiency of complement factor H-related (CFHR) proteins and CFH autoantibody-positive hemolytic uremic syndrome (DEAP-HUS) represents a unique subgroup of complement-mediated atypical HUS (aHUS). Autoantibodies to the C-terminus of CFH block CFH surface recognition and mimic mutations found in the genetic form of (CFH-mediated) aHUS. CFH autoantibodies are found in 10-15 % of aHUS patients and occur--so far unexplained--almost exclusively in the background of CFHR1 or CFHR3/CFHR1 deletions. METHODS As a well-defined role for eculizumab in the treatment of complement-mediated aHUS is becoming established, its role in DEAP-HUS is less conspicuous, where a B-cell-depleting and immunosuppressive treatment strategy is being proposed in the literature. RESULTS We here show eculizumab to be safe and effective in maintaining a disease-free state, without recurrence, in a previously plasma-therapy-dependent DEAP-HUS patient, and in another patient in whom, although showing a good clinical response to plasma therapy, the therapy was hampered by allergic reactions to fresh frozen plasma and contend there is a rationale for the use of eculizumab in concert with an immunosuppressive strategy in the treatment of DEAP-HUS. Considering the high rate of early relapse, the possible coexistence and contribution of both known and unknown complement-gene mutations, the probable pathogenic role of CFHR1 as a complement alternative pathway (CAP) regulator, the experimental nature of measuring and using anti-CFH autoantibodies to guide management, and until the positive reports of immunosuppression in addition to plasma therapy are confirmed in prospective studies, we feel that a complement-directed therapy should not be neglected in DEAP-HUS. Serial CFH autoantibody titer testing may become a valuable tool to monitor treatment response, and weaning patients off eculizumab may become an option once CFH autoantibody levels are depleted. CONCLUSIONS A prospective study of eculizumab treatment in a larger cohort of DEAP-HUS patients is required to validate the applicability of our positive experience.
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Dragon-Durey MA, Blanc C, Roumenina LT, Poulain N, Ngo S, Bordereau P, Frémeaux-Bacchi V. Anti-factor H autoantibodies assay. Methods Mol Biol 2014; 1100:249-256. [PMID: 24218265 DOI: 10.1007/978-1-62703-724-2_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Non-Shiga-toxin-associated hemolytic uremic syndrome (atypical HUS) is a rare form of thrombotic microangiopathy which associates hemolytic anemia, thrombocytopenia, and acute renal failure. In 10 % of cases the disease is linked to presence of autoantibodies directed against Factor H (FH), the main plasmatic alternative complement pathway regulatory protein. Their presence induces an acquired functional FH deficiency. The anti-FH autoantibodies screening must be performed at the very onset of the disease in all cases of HUS, in order, first, to make the proper diagnosis as early as possible, and second to support an appropriate therapy including early plasma exchanges and immunosuppressive treatments. Thus, anti-CFH IgG represents a diagnostic marker and the titer determination is useful for assessing disease evolution, because changes precede clinical symptoms, and for monitoring of treatment. Presence of anti-FH IgG has been recently reported to be associated with other clinical context such as C3 glomerulopathies, but their pathogenicity in these conditions remains to be assessed. Here we describe the ELISA assay allowing the detection of these autoantibodies and report the analysis which can be performed concomitantly to improve the diagnosis.
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Long-term remission of atypical HUS with anti-factor H antibodies after cyclophosphamide pulses. Pediatr Nephrol 2014; 29:75-83. [PMID: 23868108 DOI: 10.1007/s00467-013-2558-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 04/23/2013] [Accepted: 05/22/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anti-complement factor H (CFH) autoantibody (Ab)-associated atypical hemolytic uremic syndrome (aHUS) has a poor prognosis, but no consensus exists on its treatment. METHODS We report the follow-up of four children with anti-CFH Ab (8,000 to >32,000 arbitrary units)-associated aHUS after plasma exchanges (PEs), prednisone, and cyclophosphamide pulse therapy with the evolution of anti-CFH Ab titers and kidney function. RESULTS Patient 1 received PEs + prednisone + cyclophosphamide pulses after two relapses following PEs and then PEs + rituximab. The other three patients were treated with PEs + prednisone + cyclophosphamide pulses as a first-line therapy. In our four patients, the induction protocol combining PEs + prednisone + cyclophosphamide pulses led to a rapid and sustained remission up to 6 years, 4 years and 4 months without any maintenance therapy. Kidney function was normal and anti-CFH Ab titer decreased, but remained detectable during remission without any clinical or biological signs of relapse. CONCLUSIONS We demonstrate the long-term efficiency and safety of cyclophosphamide pulses combined with PEs and prednisone in anti-CFH Ab-associated aHUS leading to a prolonged decrease in anti-CFH Ab titers and prevention of relapses without the need for maintenance therapy.
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Watson R, Lindner S, Bordereau P, Hunze EM, Tak F, Ngo S, Zipfel PF, Skerka C, Dragon-Durey MA, Marchbank KJ. Standardisation of the factor H autoantibody assay. Immunobiology 2014; 219:9-16. [DOI: 10.1016/j.imbio.2013.06.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/11/2013] [Accepted: 06/11/2013] [Indexed: 02/08/2023]
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Abstract
Factor H-related proteins (CFHRs) are plasma glycoproteins related in structure and antigenicity to each other and to the complement inhibitory protein factor H. Such proteins are found in most mammals but their number and domain composition vary. This chapter summarizes our current knowledge on the human factor H-related proteins. In contrast to factor H, they have no strong complement inhibitory activity, although for some of them regulatory or complement modulatory activity has been reported. A common feature of CFHRs is that they bind to the C3b component of complement. Novel links between CFHRs and various diseases (C3 glomerulopathies, atypical hemolytic uremic syndrome and age-related macular degeneration) have been revealed in recent years, but we are still far from understanding their biological function.
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Sinha A, Gulati A, Saini S, Blanc C, Gupta A, Gurjar BS, Saini H, Kotresh ST, Ali U, Bhatia D, Ohri A, Kumar M, Agarwal I, Gulati S, Anand K, Vijayakumar M, Sinha R, Sethi S, Salmona M, George A, Bal V, Singh G, Dinda AK, Hari P, Rath S, Dragon-Durey MA, Bagga A. Prompt plasma exchanges and immunosuppressive treatment improves the outcomes of anti-factor H autoantibody-associated hemolytic uremic syndrome in children. Kidney Int 2013; 85:1151-60. [PMID: 24088957 DOI: 10.1038/ki.2013.373] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 07/22/2013] [Accepted: 08/01/2013] [Indexed: 02/06/2023]
Abstract
Antibodies to complement factor H are an uncommon cause of hemolytic uremic syndrome (HUS). Information on clinical features and outcomes in children is limited. In order to explore this we studied a multicenter cohort of 138 Indian children with anti-complement factor H antibody associated HUS, constituting 56% of patients with HUS. Antibody titers were high (mean 7054 AU/ml) and correlated inversely with levels of complement C3, but not complement factor H. Homozygous deletion of the CFHR1 gene was found in 60 of 68 patients. Therapies included dialysis in 119 children, 105 receiving plasma exchanges and 26 intravenous immunoglobulin. Induction immunosuppression consisted of 87 children receiving prednisolone with or without intravenous cyclophosphamide or rituximab. Antibody titers fell significantly following plasma exchanges and increased during relapses. Adverse outcome (stage 4-5 CKD or death) was seen in 36 at 3 months and 41 by last follow up, with relapse in 14 of 122 available children. Significant independent risk factors for adverse outcome were an antibody titer over 8000 AU/ml, low C3 and delay in plasma exchange. Combined plasma exchanges and induction immunosuppression resulted in significantly improved renal survival: one adverse outcome prevented for every 2.6 patients treated. Maintenance immunosuppressive therapy, of prednisolone with either mycophenolate mofetil or azathioprine, significantly reduced the risk of relapses. Thus, prompt use of immunosuppressive agents and plasma exchanges are useful for improving outcomes in pediatric patients with anti-complement factor H-associated HUS.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ashima Gulati
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Caroline Blanc
- Laboratoire d'Immunologie, Hôpital Européen Georges Pompidou, INSERM UMRS 872, team 13 and Paris Descartes University, Paris, France
| | - Aarti Gupta
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Shambhuprasad T Kotresh
- Laboratoire d'Immunologie, Hôpital Européen Georges Pompidou, INSERM UMRS 872, team 13 and Paris Descartes University, Paris, France
| | - Uma Ali
- Department of Pediatrics, BJ Wadia Hospital for Children, Mumbai, India
| | - Divya Bhatia
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Alpana Ohri
- Department of Pediatrics, BJ Wadia Hospital for Children, Mumbai, India
| | | | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Sanjeev Gulati
- Department of Nephrology, Fortis Hospitals, New Delhi, India
| | - Kanav Anand
- Division of Pediatric Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - M Vijayakumar
- Department of Pediatric Nephrology, Mehta Children's Hospital, Chennai, India
| | | | - Sidharth Sethi
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Maud Salmona
- Laboratoire d'Immunologie, Hôpital Européen Georges Pompidou, INSERM UMRS 872, team 13 and Paris Descartes University, Paris, France
| | - Anna George
- National Institute of Immunology, New Delhi, India
| | - Vineeta Bal
- National Institute of Immunology, New Delhi, India
| | - Geetika Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Amit K Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Marie-Agnes Dragon-Durey
- Laboratoire d'Immunologie, Hôpital Européen Georges Pompidou, INSERM UMRS 872, team 13 and Paris Descartes University, Paris, France
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Zuber J, Le Quintrec M, Morris H, Frémeaux-Bacchi V, Loirat C, Legendre C. Targeted strategies in the prevention and management of atypical HUS recurrence after kidney transplantation. Transplant Rev (Orlando) 2013; 27:117-25. [PMID: 23937869 DOI: 10.1016/j.trre.2013.07.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 07/09/2013] [Indexed: 02/07/2023]
Abstract
Atypical hemolytic and uremic syndrome (aHUS) is associated with a high rate of recurrence and poor outcomes after kidney transplantation. Fortunately, recent advances in the understanding of the pathogenesis of aHUS have permitted an individualized risk assessment of post-transplant recurrence. Acquired or inherited dysregulation of the alternative complement pathway, thought to be the driving force of the disease, is identified in most aHUS patients. Notably, depending on the mutations involved, the risk of recurrence greatly varies, highlighting the importance of undertaking etiological investigations prior to kidney transplantation. In those with moderate to high risk of recurrence, the use of a prophylactic therapy, consisting in either plasmapheresis or eculizumab therapies, represents a major stride forward in the prevention of aHUS recurrence after kidney transplantation. In those who experience aHUS recurrence, a growing number of observations suggest that eculizumab therapy outperforms curative plasma therapy. The optimal duration of both prophylactic and curative therapies remains an important, yet unaddressed, issue. In this respect, the kidney transplant recipients, continuously exposed to endothelial-insulting factors, referred here as to triggers, might have a sustained high risk of recurrence. A global therapeutic approach should thus attempt to reduce exposure to these triggers.
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Affiliation(s)
- Julien Zuber
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service de Transplantation Rénale adulte, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, France.
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Alberti M, Valoti E, Piras R, Bresin E, Galbusera M, Tripodo C, Thaiss F, Remuzzi G, Noris M. Two patients with history of STEC-HUS, posttransplant recurrence and complement gene mutations. Am J Transplant 2013; 13:2201-6. [PMID: 23731345 DOI: 10.1111/ajt.12297] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 03/29/2013] [Accepted: 04/10/2013] [Indexed: 01/25/2023]
Abstract
Hemolytic uremic syndrome (HUS) is a disease of microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. About 90% of cases are secondary to infections by Escherichia coli strains producing Shiga-like toxins (STEC-HUS), while 10% are associated with mutations in genes encoding proteins of complement system (aHUS). We describe two patients with a clinical history of STEC-HUS, who developed end-stage renal disease (ESRD) soon after disease onset. They received a kidney transplant but lost the graft for HUS recurrence, a complication more commonly observed in aHUS. Before planning a second renal transplantation, the two patients underwent genetic screening for aHUS-associated mutations that revealed the presence of a heterozygous CFI mutation in patient #1 and a heterozygous MCP mutation in patient #2, and also in her mother who donated the kidney. This finding argues that the two cases originally diagnosed as STEC-HUS had indeed aHUS triggered by STEC infection on a genetic background of impaired complement regulation. Complement gene sequencing should be performed before kidney transplantation in patients who developed ESRD following STEC-HUS since they may be undiagnosed cases of aHUS, at risk of posttransplant recurrence. Furthermore, genetic analysis of donors is mandatory before living-related transplantation to exclude carriers of HUS-predisposing mutations.
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Affiliation(s)
- M Alberti
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Disease Aldo e Cele Daccò and Centro Anna Maria Astori, Bergamo, Italy
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76
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Skerka C, Chen Q, Fremeaux-Bacchi V, Roumenina LT. Complement factor H related proteins (CFHRs). Mol Immunol 2013; 56:170-80. [PMID: 23830046 DOI: 10.1016/j.molimm.2013.06.001] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023]
Abstract
Factor H related proteins comprise a group of five plasma proteins: CFHR1, CFHR2, CFHR3, CFHR4 and CFHR5, and each member of this group binds to the central complement component C3b. Mutations, genetic deletions, duplications or rearrangements in the individual CFHR genes are associated with a number of diseases including atypical hemolytic uremic syndrome (aHUS), C3 glomerulopathies (C3 glomerulonephritis (C3GN), dense deposit disease (DDD) and CFHR5 nephropathy), IgA nephropathy, age related macular degeneration (AMD) and systemic lupus erythematosus (SLE). Although complement regulatory functions were attributed to most of the members of the CFHR protein family, the precise role of each CFHR protein in complement activation and the exact contribution to disease pathology is still unclear. Recent publications show that CFHR proteins form homo- as well as heterodimers. Genetic abnormalities within the CFHR gene locus can result in hybrid proteins with affected dimerization or recognition domains which cause defective functions. Here we summarize the recent data about CFHR genes and proteins in order to better understand the role of CFHR proteins in complement activation and in complement associated diseases.
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Affiliation(s)
- Christine Skerka
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.
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Abstract
A new study reports that recessive loss-of-function mutations in the gene encoding diacylglycerol kinase ε result in atypical hemolytic-uremic syndrome. Notably, mutations in DGKE are not associated with activation of the complement pathway, the only other identified cause of this disorder so far, and have important implications for patient management.
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Affiliation(s)
- Susan E Quaggin
- Division of Nephrology at the Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Determining the population frequency of the CFHR3/CFHR1 deletion at 1q32. PLoS One 2013; 8:e60352. [PMID: 23613724 PMCID: PMC3629053 DOI: 10.1371/journal.pone.0060352] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/25/2013] [Indexed: 01/04/2023] Open
Abstract
In this study we have used multiplex ligation-dependent probe amplification (MLPA) to measure the copy number of CFHR3 and CFHR1 in DNA samples from 238 individuals from the UK and 439 individuals from the HGDP-CEPH Human Genome Diversity Cell Line Panel. We have then calculated the allele frequency and frequency of homozygosity for the copy number polymorphism represented by the CFHR3/CFHR1 deletion. There was a highly significant difference between geographical locations in both the allele frequency (X2 = 127.7, DF = 11, P-value = 4.97x10-22) and frequency of homozygosity (X2 = 142.3, DF = 22, P-value = 1.33x10-19). The highest frequency for the deleted allele (54.7%) was seen in DNA samples from Nigeria and the lowest (0%) in samples from South America and Japan. The observed frequencies in conjunction with the known association of the deletion with AMD, SLE and IgA nephropathy is in keeping with differences in the prevalence of these diseases in African and European Americans. This emphasises the importance of identifying copy number polymorphism in disease.
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Eculizumab in the treatment of atypical haemolytic uraemic syndrome and other complement-mediated renal diseases. Curr Opin Pediatr 2013; 25:225-31. [PMID: 23486421 DOI: 10.1097/mop.0b013e32835df4a3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review considers the use of eculizumab in the treatment of atypical haemolytic uraemic syndrome (aHUS) as well as the other complement-mediated renal diseases, including dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). In addition, a brief discussion of the effectiveness of eculizumab for the prevention of antibody-mediated rejection (AMR) in the setting of renal transplant and the treatment of shiga toxin associated haemolytic uraemic syndrome (STEC HUS) is also provided. RECENT FINDINGS No randomized controlled trials exist to support the use of eculizumab in renal disease. The results of two unpublished, prospective adult and adolescent trials support its utility in aHUS, whereas retrospective data support the effectiveness in paediatric aHUS. These two data sets form the basis of the sole renal indication for eculizumab. One small, single-centre trial and a growing number of case reports support the use of eculizumab in C3 glomerulopathy (C3G). There are limited trial data in AMR and renal transplant. Finally, there are conflicting data for the use of eculizumab in STEC HUS. SUMMARY The cumulative published data establish the effectiveness of eculizumab in a select group of renal diseases that have at the centre of their disease either abnormal complement control or maladaptive complement activation.
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Rusai K, Zaller V, Szilagyi A, Kain R, Prohaszka Z, Cook HT, Aufricht C, Arbeiter K. A rare case: childhood-onset C3 glomerulonephritis due to homozygous factor H deficiency. CEN Case Rep 2013; 2:234-238. [PMID: 28509298 DOI: 10.1007/s13730-013-0070-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 02/18/2013] [Indexed: 12/25/2022] Open
Abstract
C3 glomerulopathy is a recently described pathological entity including dense deposit disease and C3 glomerulonephritis (C3GN). In some cases, C3 glomerulopathy is associated with defects or even complete deficiency of factor H. However, complete factor H deficiency among patients with C3GN is rare, and paediatric cases have not yet been described. Here, we report a child with homozygous factor H deficiency who presented with haematuria and minor proteinuria, together with undetectable plasma C3 levels, at the age of 10 years. Kidney biopsy demonstrated C3GN. Detailed complement analysis revealed complete factor H deficiency due to a homozygous CFH mutation. Furthermore, there was a complete deletion of CFHR-1/-3. During follow-up, the patient has had recurrent episodes of macro-haematuria and minor proteinuria, but during 4 years of follow-up, no deterioration of renal function has been observed. Mutations of factor H in C3GN have been described; however, complete CFH deficiency is rare in these patients. Furthermore, clinical presentation usually occurs in adulthood. Therefore, this case presents a rare manifestation of the disease and might contribute to the early detection of similar cases also in childhood.
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Affiliation(s)
- Krisztina Rusai
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Vera Zaller
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Agnes Szilagyi
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Kútvölgyi út 4, Budapest, 1125, Hungary
| | - Renate Kain
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Zoltan Prohaszka
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Kútvölgyi út 4, Budapest, 1125, Hungary
| | - H Terence Cook
- Centre for Complement and Inflammation Research, Imperial College, South Kensington Campus, London, SW7 2AZ, UK
| | - Christoph Aufricht
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Klaus Arbeiter
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Complement dysregulation and disease: from genes and proteins to diagnostics and drugs. Immunobiology 2013; 217:1034-46. [PMID: 22964229 DOI: 10.1016/j.imbio.2012.07.021] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 07/20/2012] [Accepted: 07/21/2012] [Indexed: 12/21/2022]
Abstract
During the last decade, numerous studies have associated genetic variations in complement components and regulators with a number of chronic and infectious diseases. The functional characterization of these complement protein variants, in addition to recent structural advances in understanding of the assembly, activation and regulation of the AP C3 convertase, have provided important insights into the pathogenic mechanisms involved in some of these complement related disorders. This knowledge has identified potential targets for complement inhibitory therapies which are demonstrating efficacy and generating considerable expectation in changing the natural history of these diseases. Comprehensive understanding of the genetic and non-genetic risk factors contributing to these disorders will also result in targeting of the right patient groups in a stratified medicine approach through better diagnostics and individually tailored treatments, thereby improving management of patients.
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Abstract
‘C3 glomerulopathy’ is a recent disease classification comprising several rare types of glomerulonephritis (GN), including dense deposit disease (DDD), C3 glomerulonephritis (C3GN) and CFHR5 nephropathy. These disorders share the key histological feature of isolated complement C3 deposits in the glomerulus. A common aetiology involving dysregulation of the alternative pathway (AP) of complement has been elucidated in the past decade, with genetic defects and/or autoantibodies able to be identified in a proportion of patients. We review the clinical and histological features of C3 glomerulopathy, relating these to underlying molecular mechanisms. The role of uncontrolled C3 activation in pathogenesis is emphasized, with important lessons from animal models. Methods, advantages and limitations of gene testing in the assessment of individuals or families with C3 glomerulopathy are discussed. While no therapy has yet been shown consistently effective, clinical evaluation of agents targeting specific components of the complement system is ongoing. However, limits to current knowledge regarding the natural history and the appropriate timing and duration of proposed therapies need to be addressed.
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Affiliation(s)
- Thomas D Barbour
- Centre for Complement & Inflammation Research (CCIR), Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London W12 0NN, UK
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Bresin E, Rurali E, Caprioli J, Sanchez-Corral P, Fremeaux-Bacchi V, Rodriguez de Cordoba S, Pinto S, Goodship THJ, Alberti M, Ribes D, Valoti E, Remuzzi G, Noris M. Combined complement gene mutations in atypical hemolytic uremic syndrome influence clinical phenotype. J Am Soc Nephrol 2013; 24:475-86. [PMID: 23431077 DOI: 10.1681/asn.2012090884] [Citation(s) in RCA: 271] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Several abnormalities in complement genes reportedly contribute to atypical hemolytic uremic syndrome (aHUS), but incomplete penetrance suggests that additional factors are necessary for the disease to manifest. Here, we sought to describe genotype-phenotype correlations among patients with combined mutations, defined as mutations in more than one complement gene. We screened 795 patients with aHUS and identified single mutations in 41% and combined mutations in 3%. Only 8%-10% of patients with mutations in CFH, C3, or CFB had combined mutations, whereas approximately 25% of patients with mutations in MCP or CFI had combined mutations. The concomitant presence of CFH and MCP risk haplotypes significantly increased disease penetrance in combined mutated carriers, with 73% penetrance among carriers with two risk haplotypes compared with 36% penetrance among carriers with zero or one risk haplotype. Among patients with CFH or CFI mutations, the presence of mutations in other genes did not modify prognosis; in contrast, 50% of patients with combined MCP mutation developed end stage renal failure within 3 years from onset compared with 19% of patients with an isolated MCP mutation. Patients with combined mutations achieved remission with plasma treatment similar to patients with single mutations. Kidney transplant outcomes were worse, however, for patients with combined MCP mutation compared with an isolated MCP mutation. In summary, these data suggest that genotyping for the risk haplotypes in CFH and MCP may help predict the risk of developing aHUS in unaffected carriers of mutations. Furthermore, screening patients with aHUS for all known disease-associated genes may inform decisions about kidney transplantation.
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Affiliation(s)
- Elena Bresin
- Clinical Research Center for Rare Diseases, “Aldo e Cele Daccò,” Mario Negri Institute for Pharmacological Research, Ranica, Bergamo, Italy
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84
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Hofer J, Janecke AR, Zimmerhackl LB, Riedl M, Rosales A, Giner T, Cortina G, Haindl CJ, Petzelberger B, Pawlik M, Jeller V, Vester U, Gadner B, van Husen M, Moritz ML, Würzner R, Jungraithmayr T. Complement factor H-related protein 1 deficiency and factor H antibodies in pediatric patients with atypical hemolytic uremic syndrome. Clin J Am Soc Nephrol 2012; 8:407-15. [PMID: 23243267 DOI: 10.2215/cjn.01260212] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES This study evaluated the relevance of complement factor H (CFH)-related protein (CFHR) 1 deficiency in pediatric patients with atypical hemolytic uremic syndrome (aHUS) by evaluating both the frequency of deletions in CFHR1 and the presence of complement factor H (CFH) antibodies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 116 patients (mainly from central Europe) and 118 healthy blood donors were included from 2001 to 2012. The presence of CFHR1 gene deletions was determined in 90 pediatric patients with aHUS and 118 controls by an easy, fast, and cheap PCR assay; 100 patients with aHUS and 42 controls were tested for CFH antibodies by ELISA. Questionnaires were administered to evaluate the clinical and laboratory data. RESULTS Homozygous deletion in CFHR1 was detected in 32% of the patients with aHUS tested, compared with 2.5% of controls (P<0.001). CFH antibodies were present in 25% of the patients and none of the controls. CFH antibodies were detected in 82% of patients with homozygous CFHR1 gene deletion and in 6% of patients without. CFH antibody-positive patients with aHUS showed a significantly lower platelet nadir at disease onset and significantly less frequent involvement of the central nervous system than did antibody-negative patients. Antibody-positive patients also received plasma therapy more often. CONCLUSION Homozygous deletion in CFHR1 is strongly associated with occurrence of CFH antibodies in pediatric patients with aHUS. However, despite this apparent genetic disease predisposition, it cannot be considered an exclusive cause for aHUS. Initial presentation of Shiga toxin-negative HUS with severe thrombocytopenia and no central nervous system complications in pediatric patients is especially suspicious for CFH antibody aHUS.
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Affiliation(s)
- Johannes Hofer
- Department of Pediatrics I, Innsbruck Medical University, Innsbruck, Austria
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85
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Abstract
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare syndrome of hemolysis, thrombocytopenia, and renal insufficiency. Genetic mutations in the alternate pathway of complement are well recognized as the cause in more than 60% of patients affected by this thrombotic microangiopathy. The identification of aHUS as a disease of the alternate pathway of complement enables directed therapeutic intervention both in the acute and chronic setting and may include one or all of the following: plasma therapy, complement blockade, and liver transplantation. Because aHUS shares many of the presenting characteristics of the other thrombotic microangiopathies, and confirmatory genetic results are not available at the time of presentation, the diagnosis relies heavily on the recognition of a clinical syndrome consistent with the diagnosis in the absence of signs of an alternate cause of thrombotic microangiopathy. Limited understanding of the epidemiology, genetics, and clinical features of aHUS has the potential to delay diagnosis and treatment. To advance our understanding, a more complete characterization of the unique phenotypical features of aHUS is needed. Further studies to identify additional genetic loci for aHUS and more robust biomarkers of both active and quiescent disease are required. Advances in these areas will undoubtedly improve the care of patients with aHUS.
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86
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Noone D, Al-Matrafi J, Tinckam K, Zipfel PF, Herzenberg AM, Thorner PS, Pluthero FG, Kahr WHA, Filler G, Hebert D, Harvey E, Licht C. Antibody mediated rejection associated with complement factor h-related protein 3/1 deficiency successfully treated with eculizumab. Am J Transplant 2012; 12:2546-53. [PMID: 22681773 DOI: 10.1111/j.1600-6143.2012.04124.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody mediated rejection (AMR) activates the classical complement pathway and can be detrimental to graft survival. AMR can be accompanied by thrombotic microangiopathy (TMA). Eculizumab, a monoclonal C5 antibody prevents induction of the terminal complement cascade (TCC) and has recently emerged as a therapeutic option for AMR. We present a highly sensitized 13-year-old female with end-stage kidney disease secondary to spina bifida-associated reflux nephropathy, who developed severe steroid-, ATG- and plasmapheresis-resistant AMR with TMA 1 week post second kidney transplant despite previous desensitization therapy with immunoglobulin infusions. Eculizumab rescue therapy resulted in a dramatic improvement in biochemical (C3; creatinine) and hematological (platelets) parameters within 6 days. The patient was proven to be deficient in complement Factor H-related protein 3/1 (CFHR3/1), a plasma protein that regulates the complement cascade at the level of C5 conversion and has been involved in the pathogenesis of atypical hemolytic uremic syndrome caused by CFH autoantibodies (DEAP-HUS). CFHR1 deficiency may have worsened the severe clinical progression of AMR and possibly contributed to the development of donor-specific antibodies. Thus, screening for CFHR3/1 deficiency should be considered in patients with severe AMR associated with TMA.
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Affiliation(s)
- D Noone
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, ON, Canada
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87
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Blanc C, Roumenina LT, Ashraf Y, Hyvärinen S, Sethi SK, Ranchin B, Niaudet P, Loirat C, Gulati A, Bagga A, Fridman WH, Sautès-Fridman C, Jokiranta TS, Frémeaux-Bacchi V, Dragon-Durey MA. Overall neutralization of complement factor H by autoantibodies in the acute phase of the autoimmune form of atypical hemolytic uremic syndrome. THE JOURNAL OF IMMUNOLOGY 2012; 189:3528-37. [PMID: 22922817 DOI: 10.4049/jimmunol.1200679] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Complement is a major innate immune surveillance system. One of its most important regulators is the plasma protein factor H (FH). FH inactivation by mutations or by autoantibodies is associated with a thrombotic microangiopathy disease, atypical hemolytic uremic syndrome. In this study, we report the characterization of blood samples from 19 anti-FH Ab-positive atypical hemolytic uremic syndrome patients collected at the acute phase of the disease. Analyses of the functional consequences and epitope mapping, using both fluid phase and solid phase approaches, were performed. The anti-FH Abs perturbed FH-mediated cell protection (100%), inhibited FH interaction with C3 (46%), and caused C3 consumption (47%). The Abs were directed against multiple FH epitopes located at the N and C termini. In all tested patients, high titers of FH-containing circulating immune complexes were detected. The circulating immune complex titers correlated with the disease stage better than did the Ab titers. Our results show that anti-FH autoantibodies induce neutralization of FH at acute phase of the disease, leading to an overall impairment of several functions of FH, extending the role of autoantibodies beyond the impairment of the direct cell surface protection.
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Affiliation(s)
- Caroline Blanc
- INSERM Unité Mixte de Recherche en Santé 872, Centre de Recherche des Cordeliers, 75006 Paris, France
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88
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Foltyn Zadura A, Zipfel PF, Bokarewa MI, Sturfelt G, Jönsen A, Nilsson SC, Hillarp A, Saxne T, Trouw LA, Blom AM. Factor H autoantibodies and deletion of Complement Factor H-Related protein-1 in rheumatic diseases in comparison to atypical hemolytic uremic syndrome. Arthritis Res Ther 2012; 14:R185. [PMID: 22894814 PMCID: PMC3580581 DOI: 10.1186/ar4016] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 08/15/2012] [Indexed: 12/18/2022] Open
Abstract
Introduction Complement activation is involved in rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and atypical hemolytic uremic syndrome (aHUS). Autoantibodies to complement inhibitor factor H (FH), particularly in association with deletions of the gene coding for FH-related protein 1 (CFHR1), are associated with aHUS. Methods Autoantibodies against FH, factor I (FI) and C4b-binding protein (C4BP) were measured by ELISA, while CFHR1 homozygous deletion was determined with Western blotting of sera. Epitopes for FH autoantibodies were mapped using recombinant fragments of FH. Results FH autoantibodies were detected in SLE (6.7%, n = 60, RA patients (16.5%, n = 97 in the Swedish cohort and 9.2%, n = 217 in the Dutch cohort) and thrombosis patients positive for the lupus anticoagulants (LA+) test (9.4%, n = 64) compared with aHUS patients (11.7%, n = 103). In the control groups (n = 354), an average of 4% of individuals were positive for FH autoantibodies. The frequencies observed in both RA cohorts and LA+ patients were statistically significantly higher than in controls. We also found that an average of 15.2% of the FH-autoantibody positive individuals in all studied disease groups had homozygous deficiency of CFHR1 compared with 3.8% of the FH autoantibody negative patients. The levels of FH autoantibodies varied in individual patients over time. FH autoantibodies found in LA+, SLE and RA were directed against several epitopes across FH in contrast to those found in aHUS, which bound mainly to the C-terminus. Autoantibodies against FI and C4BP were detected in some patients and controls but they were not associated with any of the diseases analyzed in this study. Conclusions Autoantibodies against FH are not specific for aHUS but are present at a significant frequency in rheumatic diseases where they could be involved in pathophysiological mechanisms.
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89
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Kopp A, Strobel S, Tortajada A, Rodríguez de Córdoba S, Sánchez-Corral P, Prohászka Z, López-Trascasa M, Józsi M. Atypical hemolytic uremic syndrome-associated variants and autoantibodies impair binding of factor h and factor h-related protein 1 to pentraxin 3. THE JOURNAL OF IMMUNOLOGY 2012; 189:1858-67. [PMID: 22786770 DOI: 10.4049/jimmunol.1200357] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a renal disease associated with complement alternative pathway dysregulation and is characterized by endothelial injury. Pentraxin 3 (PTX3) is a soluble pattern recognition molecule expressed by endothelial cells and upregulated under inflammatory conditions. PTX3 activates complement, but it also binds the complement inhibitor factor H. In this study, we show that native factor H, factor H-like protein 1, and factor H-related protein 1 (CFHR1) bind to PTX3 and that PTX3-bound factor H and factor H-like protein 1 maintain their complement regulatory activities. PTX3, when bound to extracellular matrix, recruited functionally active factor H. Residues within short consensus repeat 20 of factor H that are relevant for PTX3 binding were identified using a peptide array. aHUS-associated factor H mutations within this binding site caused a reduced factor H binding to PTX3. Similarly, seven of nine analyzed anti-factor H autoantibodies isolated from aHUS patients inhibited the interaction between factor H and PTX3, and five autoantibodies also inhibited PTX3 binding to CFHR1. Moreover, the aHUS-associated CFHR1*B variant showed reduced binding to PTX3 in comparison with CFHR1*A. Thus, the interactions of PTX3 with complement regulators are impaired by certain mutations and autoantibodies affecting factor H and CFHR1, which could result in an enhanced local complement-mediated inflammation, endothelial cell activation, and damage in aHUS.
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Affiliation(s)
- Anne Kopp
- Junior Research Group Cellular Immunobiology, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute, 07745 Jena, Germany
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90
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Barbour T, Johnson S, Cohney S, Hughes P. Thrombotic microangiopathy and associated renal disorders. Nephrol Dial Transplant 2012; 27:2673-85. [PMID: 22802583 PMCID: PMC3398067 DOI: 10.1093/ndt/gfs279] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 04/07/2012] [Indexed: 12/17/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a pathological process involving thrombocytopenia, microangiopathic haemolytic anaemia and microvascular occlusion. TMA is common to haemolytic uraemic syndrome (HUS) associated with shiga toxin or invasive pneumococcal infection, atypical HUS (aHUS), thrombotic thrombocytopenic purpura (TTP) and other disorders including malignant hypertension. HUS complicating infection with shiga toxin-producing Escherichia coli (STEC) is a significant cause of acute renal failure in children worldwide, occurring sporadically or in epidemics. Studies in aHUS have revealed genetic and acquired factors leading to dysregulation of the alternative complement pathway. TTP has been linked to reduced activity of the ADAMTS13 cleaving protease (typically with an autoantibody to ADAMTS13) with consequent disruption of von Willebrand factor multimer processing. However, the convergence of pathogenic pathways and clinical overlap create diagnostic uncertainty, especially at initial presentation. Furthermore, recent developments are challenging established management protocols. This review addresses the current understanding of molecular mechanisms underlying TMA, relating these to clinical presentation with an emphasis on renal manifestations. A diagnostic and therapeutic approach is presented, based on international guidelines, disease registries and published trials. Early treatment remains largely empirical, consisting of plasma replacement/exchange with the exception of childhood STEC-HUS or pneumococcal sepsis. Emerging therapies such as the complement C5 inhibitor eculizumab for aHUS and rituximab for TTP are discussed, as is renal transplantation for those patients who become dialysis-dependent as a result of aHUS.
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Affiliation(s)
- Thomas Barbour
- Imperial College, Centre for Complement and Inflammation Research, London, UK.
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91
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Alachkar N, Bagnasco SM, Montgomery RA. Eculizumab for the treatment of two recurrences of atypical hemolytic uremic syndrome in a kidney allograft. Transpl Int 2012; 25:e93-5. [PMID: 22591029 DOI: 10.1111/j.1432-2277.2012.01497.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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92
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Kopp A, Hebecker M, Svobodová E, Józsi M. Factor h: a complement regulator in health and disease, and a mediator of cellular interactions. Biomolecules 2012; 2:46-75. [PMID: 24970127 PMCID: PMC4030870 DOI: 10.3390/biom2010046] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 01/23/2012] [Accepted: 01/26/2012] [Indexed: 12/12/2022] Open
Abstract
Complement is an essential part of innate immunity as it participates in host defense against infections, disposal of cellular debris and apoptotic cells, inflammatory processes and modulation of adaptive immune responses. Several soluble and membrane-bound regulators protect the host from the potentially deleterious effects of uncontrolled and misdirected complement activation. Factor H is a major soluble regulator of the alternative complement pathway, but it can also bind to host cells and tissues, protecting them from complement attack. Interactions of factor H with various endogenous ligands, such as pentraxins, extracellular matrix proteins and DNA are important in limiting local complement-mediated inflammation. Impaired regulatory as well as ligand and cell recognition functions of factor H, caused by mutations or autoantibodies, are associated with the kidney diseases: atypical hemolytic uremic syndrome and dense deposit disease and the eye disorder: age-related macular degeneration. In addition, factor H binds to receptors on host cells and is involved in adhesion, phagocytosis and modulation of cell activation. In this review we discuss current concepts on the physiological and pathophysiological roles of factor H in light of new data and recent developments in our understanding of the versatile roles of factor H as an inhibitor of complement activation and inflammation, as well as a mediator of cellular interactions. A detailed knowledge of the functions of factor H in health and disease is expected to unravel novel therapeutic intervention possibilities and to facilitate the development or improvement of therapies.
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Affiliation(s)
- Anne Kopp
- Junior Research Group Cellular Immunobiology, Leibniz Institute for Natural Product Research and Infection Biology, Jena 07745, Germany.
| | - Mario Hebecker
- Junior Research Group Cellular Immunobiology, Leibniz Institute for Natural Product Research and Infection Biology, Jena 07745, Germany.
| | - Eliška Svobodová
- Junior Research Group Cellular Immunobiology, Leibniz Institute for Natural Product Research and Infection Biology, Jena 07745, Germany.
| | - Mihály Józsi
- Junior Research Group Cellular Immunobiology, Leibniz Institute for Natural Product Research and Infection Biology, Jena 07745, Germany.
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93
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Loirat C, Saland J, Bitzan M. Management of hemolytic uremic syndrome. Presse Med 2012; 41:e115-35. [PMID: 22284541 DOI: 10.1016/j.lpm.2011.11.013] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 12/19/2022] Open
Abstract
2011 has been a special year for hemolytic uremic syndrome (HUS): on the one hand, the dramatic epidemic of Shiga toxin producing E. coli -associated HUS in Germany brought the disease to the attention of the general population, on the other hand it has been the year when eculizumab, the first complement blocker available for clinical practice, was demonstrated as the potential new standard of care for atypical HUS. Here we review the therapeutic options presently available for the various forms of hemolytic uremic syndrome and show how recent knowledge has changed the therapeutic approach and prognosis of atypical HUS.
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Affiliation(s)
- Chantal Loirat
- Assistance publique-Hôpitaux de Paris, Hôpital Robert-Debré, Nephrology Department, 75019 Paris, France.
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94
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Leban N, Abarrategui-Garrido C, Fariza-Requejo E, Amiñoso-Carbonero C, Pinto S, Chibani JB, Khelil AH, Sánchez-Corral P. Factor H and CFHR1 polymorphisms associated with atypical Haemolytic Uraemic Syndrome (aHUS) are differently expressed in Tunisian and in Caucasian populations. Int J Immunogenet 2011; 39:110-3. [DOI: 10.1111/j.1744-313x.2011.01071.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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95
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Novel developments in thrombotic microangiopathies: is there a common link between hemolytic uremic syndrome and thrombotic thrombocytic purpura? Pediatr Nephrol 2011; 26:1947-56. [PMID: 21671028 DOI: 10.1007/s00467-011-1923-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 04/05/2011] [Accepted: 04/11/2011] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMA) represent a spectrum of related disorders associated with newly formed thrombi that block perfusion and thus affect the function of either renal or neurological organs and tissue. Recent years have seen a dramatic development in the field of TMA and for the two major forms hemolytic uremic syndrome (HUS) and thrombocytopenic purpura (TTP), new genetic causes and also autoimmune forms have been identified. This development indicates a similar pathophysiology and suggests that the two acute disorders are based on common principles. HUS is primarily a kidney disease and TTP also develops in the kidney and at neurological sites. In HUS thrombi formation is likely due to a deregulated complement activation and inappropriate platelet activity. In TTP thrombi formation occurs because of inappropriate processing of released multimers of von Willebrand Factor (vWF). Defining both the similarities and the unique features of each disorder will open up new ways and concepts that are relevant for diagnosis, for therapy, and for the prognostic outcome of kidney transplantations. Here we summarize the most relevant topics and timely issues that were presented and discussed at the 4th International Workshop on Thrombotic Microangiopathies held in Weimar in October 2009 (www.hus-ttp.de).
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96
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Abstract
Hemolytic uremic syndrome (HUS) is defined by the triad of mechanical hemolytic anemia, thrombocytopenia and renal impairment. Atypical HUS (aHUS) defines non Shiga-toxin-HUS and even if some authors include secondary aHUS due to Streptococcus pneumoniae or other causes, aHUS designates a primary disease due to a disorder in complement alternative pathway regulation. Atypical HUS represents 5 -10% of HUS in children, but the majority of HUS in adults. The incidence of complement-aHUS is not known precisely. However, more than 1000 aHUS patients investigated for complement abnormalities have been reported. Onset is from the neonatal period to the adult age. Most patients present with hemolytic anemia, thrombocytopenia and renal failure and 20% have extra renal manifestations. Two to 10% die and one third progress to end-stage renal failure at first episode. Half of patients have relapses. Mutations in the genes encoding complement regulatory proteins factor H, membrane cofactor protein (MCP), factor I or thrombomodulin have been demonstrated in 20-30%, 5-15%, 4-10% and 3-5% of patients respectively, and mutations in the genes of C3 convertase proteins, C3 and factor B, in 2-10% and 1-4%. In addition, 6-10% of patients have anti-factor H antibodies. Diagnosis of aHUS relies on 1) No associated disease 2) No criteria for Shigatoxin-HUS (stool culture and PCR for Shiga-toxins; serology for anti-lipopolysaccharides antibodies) 3) No criteria for thrombotic thrombocytopenic purpura (serum ADAMTS 13 activity > 10%). Investigation of the complement system is required (C3, C4, factor H and factor I plasma concentration, MCP expression on leukocytes and anti-factor H antibodies; genetic screening to identify risk factors). The disease is familial in approximately 20% of pedigrees, with an autosomal recessive or dominant mode of transmission. As penetrance of the disease is 50%, genetic counseling is difficult. Plasmatherapy has been first line treatment until presently, without unquestionable demonstration of efficiency. There is a high risk of post-transplant recurrence, except in MCP-HUS. Case reports and two phase II trials show an impressive efficacy of the complement C5 blocker eculizumab, suggesting it will be the next standard of care. Except for patients treated by intensive plasmatherapy or eculizumab, the worst prognosis is in factor H-HUS, as mortality can reach 20% and 50% of survivors do not recover renal function. Half of factor I-HUS progress to end-stage renal failure. Conversely, most patients with MCP-HUS have preserved renal function. Anti-factor H antibodies-HUS has favourable outcome if treated early.
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Affiliation(s)
- Chantal Loirat
- Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Université Paris VII, Pediatric Nephrology Department, Paris, France.
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97
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Abstract
Hemolytic uremic syndrome (HUS) is defined by the triad of mechanical hemolytic anemia, thrombocytopenia and renal impairment. Atypical HUS (aHUS) defines non Shiga-toxin-HUS and even if some authors include secondary aHUS due to Streptococcus pneumoniae or other causes, aHUS designates a primary disease due to a disorder in complement alternative pathway regulation. Atypical HUS represents 5 -10% of HUS in children, but the majority of HUS in adults. The incidence of complement-aHUS is not known precisely. However, more than 1000 aHUS patients investigated for complement abnormalities have been reported. Onset is from the neonatal period to the adult age. Most patients present with hemolytic anemia, thrombocytopenia and renal failure and 20% have extra renal manifestations. Two to 10% die and one third progress to end-stage renal failure at first episode. Half of patients have relapses. Mutations in the genes encoding complement regulatory proteins factor H, membrane cofactor protein (MCP), factor I or thrombomodulin have been demonstrated in 20-30%, 5-15%, 4-10% and 3-5% of patients respectively, and mutations in the genes of C3 convertase proteins, C3 and factor B, in 2-10% and 1-4%. In addition, 6-10% of patients have anti-factor H antibodies. Diagnosis of aHUS relies on 1) No associated disease 2) No criteria for Shigatoxin-HUS (stool culture and PCR for Shiga-toxins; serology for anti-lipopolysaccharides antibodies) 3) No criteria for thrombotic thrombocytopenic purpura (serum ADAMTS 13 activity > 10%). Investigation of the complement system is required (C3, C4, factor H and factor I plasma concentration, MCP expression on leukocytes and anti-factor H antibodies; genetic screening to identify risk factors). The disease is familial in approximately 20% of pedigrees, with an autosomal recessive or dominant mode of transmission. As penetrance of the disease is 50%, genetic counseling is difficult. Plasmatherapy has been first line treatment until presently, without unquestionable demonstration of efficiency. There is a high risk of post-transplant recurrence, except in MCP-HUS. Case reports and two phase II trials show an impressive efficacy of the complement C5 blocker eculizumab, suggesting it will be the next standard of care. Except for patients treated by intensive plasmatherapy or eculizumab, the worst prognosis is in factor H-HUS, as mortality can reach 20% and 50% of survivors do not recover renal function. Half of factor I-HUS progress to end-stage renal failure. Conversely, most patients with MCP-HUS have preserved renal function. Anti-factor H antibodies-HUS has favourable outcome if treated early.
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98
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Boyer O, Niaudet P. Hemolytic uremic syndrome: new developments in pathogenesis and treatment. Int J Nephrol 2011; 2011:908407. [PMID: 21876803 PMCID: PMC3159990 DOI: 10.4061/2011/908407] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 06/14/2011] [Indexed: 12/27/2022] Open
Abstract
Hemolytic uremic syndrome is defined by the characteristic triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. In children, most cases of HUS are caused by Shiga-toxin-producing bacteria, especially Escherichia coli O157:H7. Common vehicles of transmission include ground beef, unpasteurized milk, and municipal or swimming water. Shiga-toxin-associated HUS is a main cause of acute renal failure in young children. Management remains supportive as there is at present no specific therapy to ameliorate the prognosis. Immediate outcome is most often favourable but long-term renal sequelae are frequent due to nephron loss. Atypical HUS represents 5% of cases. In the past 15 years, mutations in complement regulators of the alternative pathway have been identified in almost 60% of cases, leading to excessive complement activation. The disease has a relapsing course and more than half of the patients either die or progress to end-stage renal failure. Recurrence after renal transplantation is frequent.
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Affiliation(s)
- Olivia Boyer
- Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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99
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Factor H-related protein 1 neutralizes anti-factor H autoantibodies in autoimmune hemolytic uremic syndrome. Kidney Int 2011; 80:397-404. [DOI: 10.1038/ki.2011.152] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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100
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Complement factor I in health and disease. Mol Immunol 2011; 48:1611-20. [DOI: 10.1016/j.molimm.2011.04.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 02/02/2023]
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