|
1
|
Wildes DM, Harvey S, Costigan CS, Sweeney C, Twomey É, Awan A, Gorman KM. Eculizumab in STEC-HUS: a paradigm shift in the management of pediatric patients with neurological involvement. Pediatr Nephrol 2024; 39:315-324. [PMID: 37491519 DOI: 10.1007/s00467-023-06102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Eculizumab for the treatment of atypical hemolytic uremic syndrome (HUS) is a standard of care. Central nervous system (CNS) involvement in Shiga toxin-producing Escherichia coli (STEC)-HUS is associated with increased morbidity and mortality. There is no consensus on the use of plasma exchange and/or eculizumab. We report a series (n = 4) of children with CNS involvement in STEC-HUS with excellent outcomes after treatment with eculizumab only and supportive therapies. METHODS A retrospective chart review of patients with CNS involvement in STEC-HUS is managed with supportive therapies and eculizumab only. RESULTS Four patients (75% female) with a median age of 5 years and 11 months (IQR: 23.5-105.5 months) were admitted to a tertiary pediatric nephrology center with CNS involvement in STEC-HUS. Neurological symptoms presented between days 2 and 7 of illness and included ataxia, altered mental status, visual symptoms, and seizures. All had an abnormal MRI brain. All received two doses of eculizumab, 1 week apart (dosing according to weight). Resolution of neurological symptoms was evident at a mean of 60 h post-administration (range: 24-72 h). All patients have complete kidney and neurological recovery at 12-month follow-up. CONCLUSION We present a case series of four children with STEC-HUS and CNS involvement, managed with eculizumab only, in lieu of plasma exchange (as per our previous policy). The marked improvement in symptoms in our cohort supports the use of eculizumab, rather than plasma exchange in the CNS involvement of STEC-HUS.
Collapse
Affiliation(s)
- Dermot Michael Wildes
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland.
| | - Susan Harvey
- Department of Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Caoimhe Suzanne Costigan
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
| | - Clodagh Sweeney
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
| | - Éilis Twomey
- Department of Paediatric Radiology, Children's Health Ireland, Dublin, Ireland
| | - Atif Awan
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Department of Paediatrics and Child Health, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland
| | - Kathleen Mary Gorman
- Department of Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| |
Collapse
|
|
2
|
Caffarelli C, Santamaria F, Piro E, Basilicata S, Delle Cave V, Cipullo M, Bernasconi S, Corsello G. New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine. Ital J Pediatr 2022; 48:189. [PMID: 36435791 PMCID: PMC9701393 DOI: 10.1186/s13052-022-01374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.
Collapse
Affiliation(s)
- Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, Via Gramsci 14, Parma, Italy.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ettore Piro
- Department of Sciences for Health Promotion and Mother and Child Care G. D'Alessandro, University of Palermo, Palermo, Italy
| | - Simona Basilicata
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valeria Delle Cave
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Marilena Cipullo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | | | - Giovanni Corsello
- Department of Sciences for Health Promotion and Mother and Child Care G. D'Alessandro, University of Palermo, Palermo, Italy
| |
Collapse
|
|
3
|
Buelli S, Locatelli M, Carminati CE, Corna D, Cerullo D, Imberti B, Perico L, Brigotti M, Abbate M, Zoja C, Benigni A, Remuzzi G, Morigi M. Shiga Toxin 2 Triggers C3a-Dependent Glomerular and Tubular Injury through Mitochondrial Dysfunction in Hemolytic Uremic Syndrome. Cells 2022; 11:cells11111755. [PMID: 35681450 PMCID: PMC9179250 DOI: 10.3390/cells11111755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/13/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
Shiga toxin (Stx)-producing Escherichia coli is the predominant offending agent of post-diarrheal hemolytic uremic syndrome (HUS), a rare disorder of microvascular thrombosis and acute kidney injury possibly leading to long-term renal sequelae. We previously showed that C3a has a critical role in the development of glomerular damage in experimental HUS. Based on the evidence that activation of C3a/C3a receptor (C3aR) signaling induces mitochondrial dysregulation and cell injury, here we investigated whether C3a caused podocyte and tubular injury through induction of mitochondrial dysfunction in a mouse model of HUS. Mice coinjected with Stx2/LPS exhibited glomerular podocyte and tubular C3 deposits and C3aR overexpression associated with cell damage, which were limited by C3aR antagonist treatment. C3a promoted renal injury by affecting mitochondrial wellness as demonstrated by data showing that C3aR blockade reduced mitochondrial ultrastructural abnormalities and preserved mitochondrial mass and energy production. In cultured podocytes and tubular cells, C3a caused altered mitochondrial fragmentation and distribution, and reduced anti-oxidant SOD2 activity. Stx2 potentiated the responsiveness of renal cells to the detrimental effects of C3a through increased C3aR protein expression. These results indicate that C3aR may represent a novel target in Stx-associated HUS for the preservation of renal cell integrity through the maintenance of mitochondrial function.
Collapse
Affiliation(s)
- Simona Buelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
- Correspondence: ; Tel.: +39-035-42131; Fax: +39-035-319-331
| | - Monica Locatelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Claudia Elisa Carminati
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Daniela Corna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Domenico Cerullo
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Barbara Imberti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Luca Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Maurizio Brigotti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40126 Bologna, Italy;
| | - Mauro Abbate
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| | - Marina Morigi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Via Stezzano 87, 24126 Bergamo, Italy; (M.L.); (C.E.C.); (D.C.); (D.C.); (B.I.); (L.P.); (M.A.); (C.Z.); (A.B.); (G.R.); (M.M.)
| |
Collapse
|
|
4
|
Costigan C, Raftery T, Carroll AG, Wildes D, Reynolds C, Cunney R, Dolan N, Drew RJ, Lynch BJ, O’Rourke DJ, Stack M, Sweeney C, Shahwan A, Twomey E, Waldron M, Riordan M, Awan A, Gorman KM. Neurological involvement in children with hemolytic uremic syndrome. Eur J Pediatr 2022; 181:501-512. [PMID: 34378062 PMCID: PMC8821508 DOI: 10.1007/s00431-021-04200-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
Our objective was to establish the rate of neurological involvement in Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STEC-HUS) and describe the clinical presentation, management and outcome. A retrospective chart review of children aged ≤ 16 years with STEC-HUS in Children's Health Ireland from 2005 to 2018 was conducted. Laboratory confirmation of STEC infection was required for inclusion. Neurological involvement was defined as encephalopathy, focal neurological deficit, and/or seizure activity. Data on clinical presentation, management, and outcome were collected. We identified 240 children with HUS; 202 had confirmed STEC infection. Neurological involvement occurred in 22 (11%). The most common presentation was seizures (73%). In the neurological group, 19 (86%) were treated with plasma exchange and/or eculizumab. Of the 21 surviving children with neurological involvement, 19 (91%) achieved a complete neurological recovery. A higher proportion of children in the neurological group had renal sequelae (27% vs. 12%, P = .031). One patient died from multi-organ failure.Conclusion: We have identified the rate of neurological involvement in a large cohort of children with STEC-HUS as 11%. Neurological involvement in STEC-HUS is associated with good long-term outcome (complete neurological recovery in 91%) and a low case-fatality rate (4.5%) in our cohort. What is Known: • HUS is associated with neurological involvement in up to 30% of cases. • Neurological involvement has been reported as predictor of poor outcome, with associated increased morbidity and mortality. What is New: • The incidence of neurological involvement in STEC-HUS is 11%. • Neurological involvement is associated with predominantly good long-term outcome (90%) and a reduced case-fatality rate (4.5%) compared to older reports.
Collapse
Affiliation(s)
- Caoimhe Costigan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Tara Raftery
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Anne G. Carroll
- Department of Radiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Dermot Wildes
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Claire Reynolds
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Robert Cunney
- Department of Clinical Microbiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niamh Dolan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Richard J. Drew
- Department of Clinical Microbiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland
| | - Bryan J. Lynch
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Declan J. O’Rourke
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Maria Stack
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Clodagh Sweeney
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Amre Shahwan
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Eilish Twomey
- Department of Radiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Mary Waldron
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Michael Riordan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Atif Awan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Kathleen M. Gorman
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| |
Collapse
|
|
5
|
Ruggenenti P, Di Marco F, Cortinovis M, Lorini L, Sala S, Novelli L, Raimondi F, Gastoldi S, Galbusera M, Donadelli R, Mele C, Piras R, Noris M, Portalupi V, Cappelletti L, Carrara C, Tomatis F, Bernardi S, Perna A, Peracchi T, Diadei O, Benigni A, Remuzzi G. Eculizumab in patients with severe coronavirus disease 2019 (COVID-19) requiring continuous positive airway pressure ventilator support: Retrospective cohort study. PLoS One 2021; 16:e0261113. [PMID: 34928990 PMCID: PMC8687582 DOI: 10.1371/journal.pone.0261113] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/24/2021] [Indexed: 12/30/2022] Open
Abstract
Background Complement activation contributes to lung dysfunction in coronavirus disease 2019 (COVID-19). We assessed whether C5 blockade with eculizumab could improve disease outcome. Methods In this single-centre, academic, unblinded study two 900 mg eculizumab doses were added-on standard therapy in ten COVID-19 patients admitted from February 2020 to April 2020 and receiving Continuous-Positive-Airway-Pressure (CPAP) ventilator support from ≤24 hours. We compared their outcomes with those of 65 contemporary similar controls. Primary outcome was respiratory rate at one week of ventilator support. Secondary outcomes included the combined endpoint of mortality and discharge with chronic complications. Results Baseline characteristics of eculizumab-treated patients and controls were similar. At baseline, sC5b-9 levels, ex vivo C5b-9 and thrombi deposition were increased. Ex vivo tests normalised in eculizumab-treated patients, but not in controls. In eculizumab-treated patients respiratory rate decreased from 26.8±7.3 breaths/min at baseline to 20.3±3.8 and 18.0±4.8 breaths/min at one and two weeks, respectively (p<0.05 for both), but did not change in controls. Between-group changes differed significantly at both time-points (p<0.01). Changes in respiratory rate correlated with concomitant changes in ex vivo C5b-9 deposits at one (rs = 0.706, p = 0.010) and two (rs = 0.751, p = 0.032) weeks. Over a median (IQR) period of 47.0 (14.0–121.0) days, four eculizumab-treated patients died or had chronic complications versus 52 controls [HRCrude (95% CI): 0.26 (0.09–0.72), p = 0.010]. Between-group difference was significant even after adjustment for age, sex and baseline serum creatinine [HRAdjusted (95% CI): 0.30 (0.10–0.84), p = 0.023]. Six patients and 13 controls were discharged without complications [HRCrude (95% CI): 2.88 (1.08–7.70), p = 0.035]. Eculizumab was tolerated well. The main study limitations were the relatively small sample size and the non-randomised design. Conclusions In patients with severe COVID-19, eculizumab safely improved respiratory dysfunction and decreased the combined endpoint of mortality and discharge with chronic complications. Findings need confirmation in randomised controlled trials.
Collapse
Affiliation(s)
- Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Fabiano Di Marco
- Unit of Pulmonary Medicine, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Luca Lorini
- Intensive Care Unit, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Silvia Sala
- Intensive Care Unit, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Novelli
- Unit of Pulmonary Medicine, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Raimondi
- Unit of Pulmonary Medicine, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Sara Gastoldi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Miriam Galbusera
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Caterina Mele
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Rossella Piras
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Valentina Portalupi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Laura Cappelletti
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Camillo Carrara
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Federica Tomatis
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
- School of Nephrology, Università degli Studi di Milano, Milan, Italy
| | - Silvia Bernardi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
- School of Nephrology, Università degli Studi di Milano, Milan, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Tobia Peracchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Olimpia Diadei
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- * E-mail:
| |
Collapse
|
|
6
|
Nozaki Y. New Insights Into Novel Therapeutic Targets in ANCA-Associated Vasculitis. Front Immunol 2021; 12:631055. [PMID: 33868250 PMCID: PMC8047311 DOI: 10.3389/fimmu.2021.631055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/18/2021] [Indexed: 11/13/2022] Open
Abstract
Biologics targeting inflammation-related molecules in the immune system have been developed to treat rheumatoid arthritis (RA), and these RA treatments have provided revolutionary advances. Biologics may also be an effective treatment for anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis, particularly in patients with resistance to standard treatments. Despite the accumulation of clinical experience and the increasing understanding of the pathogenesis of vasculitis, it is becoming more difficult to cure vasculitis. The treatment of vasculitis with biologics has been examined in clinical trials, and this has also enhanced our understanding of the pathogenesis of vasculitis. A humanized anti-interleukin-5 monoclonal antibody known as mepolizumab was recently demonstrated to provide clinical benefit in the management of eosinophilic granulomatosis with polyangiitis in refractory and relapsing disease, and additional new drugs for vasculitis are being tested in clinical trials, while others are in abeyance. This review presents the new findings regarding biologics in addition to the conventional immunosuppressive therapy for ANCA-associated vasculitis.
Collapse
Affiliation(s)
- Yuji Nozaki
- Department of Hematology and Rheumatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| |
Collapse
|
|
7
|
Monet-Didailler C, Chevallier A, Godron-Dubrasquet A, Allard L, Delmas Y, Contin-Bordes C, Brissaud O, Llanas B, Harambat J. Outcome of children with Shiga toxin-associated haemolytic uraemic syndrome treated with eculizumab: a matched cohort study. Nephrol Dial Transplant 2021; 35:2147-2153. [PMID: 31411695 DOI: 10.1093/ndt/gfz158] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/27/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment with eculizumab in Shiga toxin-associated haemolytic and uraemic syndrome (STEC-HUS) remains controversial despite its increasing utilization. The aim of our study was to evaluate the outcomes of children treated with eculizumab for STEC-HUS in a single-centre matched cohort study. METHODS Data were retrospectively collected from medical records of children diagnosed with STEC-HUS. The outcomes of patients treated with eculizumab for STEC-HUS were compared with those of a control group of untreated patients matched for age, sex and severity of acute kidney injury with a 1:2 matching scheme. RESULTS Eighteen children (median age 40.6 months) with STEC-HUS treated with eculizumab were compared with 36 matched control patients (median age 36.4 months) who did not receive eculizumab. All patients survived in the two groups. Within 1 month of HUS onset, the evolution of haematological and renal parameters did not differ between the two groups. At 12 months of follow-up, renal outcome was not significantly different between the two groups. At the last follow-up, the prevalence of decreased glomerular filtration rate in the eculizumab group (27%) was not statistically different from that in controls (38%), as was the prevalence of proteinuria and high blood pressure. Children who received eculizumab more often had extrarenal sequelae during follow-up. Eculizumab treatment appeared to be safe in children with STEC-HUS. CONCLUSION The benefit of eculizumab on renal and extrarenal outcomes in STEC-HUS could not be established based on our findings. However, efficacy and safety are not best assessed by the observational design and small sample size of our study. Randomized controlled trials are thus required to determine the efficacy of eculizumab in this indication.
Collapse
Affiliation(s)
- Catherine Monet-Didailler
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Audrey Chevallier
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Astrid Godron-Dubrasquet
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Lise Allard
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Yahsou Delmas
- Service de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Cécile Contin-Bordes
- Laboratoire d'Immunologie et Immunogénétique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Olivier Brissaud
- Service de Réanimation Pédiatrique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Brigitte Llanas
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Jérôme Harambat
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| |
Collapse
|
|
8
|
Molecular basis and outcomes of atypical haemolytic uraemic syndrome in Czech children. Eur J Pediatr 2020; 179:1739-1750. [PMID: 32424742 DOI: 10.1007/s00431-020-03666-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 03/31/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
Atypical haemolytic uraemic syndrome is an ultra-rare, life-threatening disease. Causative variants in genes that encode complement factors can be identified in 40-70% of cases. We performed genetic analysis of 21 Czech children with atypical haemolytic uraemic syndrome. Genetic or acquired predisposition to the disease was identified in the majority of our patients: CFHR1 and CFHR3 deletions in 14/21 (67%; 13 of them were positive for anti-complement factor H antibodies), variants in complement genes or DGKE in 13/21 (62%). Multiple genetic findings were identified in eight patients (38%). The incidence of atypical haemolytic uraemic syndrome in the Czech paediatric population was estimated to be 0.092 (CI 0.053-0.131) cases per million inhabitants and 0.92 (CI 0.53-1.32) cases per 100,000 births for the entire reporting period. Ten patients were initially treated with plasma exchange and eight with eculizumab or with a combination of eculizumab and plasma exchange. At the last follow-up, 20 patients were alive and one patient had end-stage renal disease.Conclusion: The incidence of atypical haemolytic uraemic syndrome in the Czech paediatric population corresponds to the reported incidence in Europe. We detected the unusually high rate of CFHR1/CFHR3 deletions associated with anti-complement factor H antibodies in Czech paediatric patients. Treatment by eculizumab led to superior outcomes and prevention of the disease relapses compared with plasma exchange therapy. Our results may help to understand the polygenic nature of atypical haemolytic uraemic syndrome as a disease that results from a combination of various risk factors. What is Known: • Atypical haemolytic uraemic syndrome (aHUS) is considered a polygenic and multifactorial disease. Genetic predisposition to aHUS is identified in 40-70% of children. • Anti-complement factor H antibodies are usually found in 6-25% of affected children. What is New: • Potentially causative genetic or acquired factors were confirmed in the majority of patients. The prevailing finding was the unusually high rate of CFHR1/CFHR3 deletions associated with anti-complement factor H antibodies (62% of patients). • The incidence of aHUS in Czech children is 0.092 (CI 0.053-0.131) cases per million inhabitants and 0.92 (CI 0.53-1.32) cases per 100,000 births for the entire reporting period.
Collapse
|
|
9
|
Balestracci A, Meni Bataglia L, Toledo I, Beaudoin L, Alvarado C. C3 levels and acute outcomes in Shiga toxin-related hemolytic uremic syndrome. Pediatr Nephrol 2020; 35:331-339. [PMID: 31475299 DOI: 10.1007/s00467-019-04334-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/24/2019] [Accepted: 08/07/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The correlation between complement activation and severity of hemolytic uremic syndrome related to Shiga toxin-producing Escherichia coli (STEC-HUS) has been examined in few studies, with conflicting results. We investigated whether C3 levels on admission are associated with worse acute outcomes. METHODS Demographic, clinical, and laboratory variables were compared between dialyzed and non-dialyzed patients and between those with or without extrarenal complications. Univariate and multivariate analyses were performed; odds ratio (OR) and 95% confidence interval (95%CI) were calculated. C3 concentrations were correlated with dialysis length (Spearman test) and ROC curves with area under the curves (AUC) were calculated to identify C3 concentrations able to discriminate patients with dialysis requirements and complicated course. RESULTS Among 49 children, 33 had normal and 16 had decreased C3 concentrations. Higher hemoglobin, lactic dehydrogenase, urea and creatinine and lower albumin, sodium, and C3 and C4 concentrations at admission were associated with dialysis requirement; only creatinine remained significant (p = 0.03, OR 2.1, 95%CI 1.34-2.7) by multivariate analysis. Patients with a complicated course presented higher leukocyte count, hemoglobin and lactic dehydrogenase and lower albumin, sodium, and C3 and C4. In the multivariate analysis, leukocyte count (p = 0.02, OR 2.6, 95%CI 1.4-4.3) and C3 concentration (p = 0.039, OR 1.7, 95%CI 1.1-2.73) were independently associated with a complicated disease. C3 levels correlated with dialysis length (r = - 0.42, p = 0.002); nevertheless, they were unable to discriminate dialysis requirement (AUC = 0.25, 95%CI 0.11-0.38) and extrarenal complications (AUC = 0.24, 95%CI 0.11-0.4). CONCLUSIONS Our study suggests that decreased C3 levels at admission are associated with a more complicated STEC-HUS episode.
Collapse
Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina.
| | - Luciana Meni Bataglia
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| | - Caupolican Alvarado
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP - 1270, Autonomous City of Buenos Aires, Argentina
| |
Collapse
|
|
10
|
Harkins VJ, McAllister DA, Reynolds BC. Shiga-Toxin E. coli Hemolytic Uremic Syndrome: Review of Management and Long-term Outcome. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00208-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Purpose of Review
We review the pathophysiology of Shiga-Toxin Enteropathogenic–Hemolytic Uremic Syndrome (STEC-HUS), strategies to ameliorate or prevent evolution of STEC-HUS, management and the improved recognition of long-term adverse outcomes.
Recent Findings
Following on from the preclinical evidence of a role for the complement system in STEC-HUS, the use of complement blocking agents has been the major focus of most recent clinical research. Novel therapies to prevent or lessen HUS have yet to enter the clinical arena. The long-term outcomes of STEC-HUS, similarly to other causes of AKI, are not as benign as previously thought.
Summary
Optimizing supportive care in STEC-HUS is the only current recommended treatment. The administration of early isotonic fluids may reduce the severity and duration of STEC-HUS. The role of complement blockade in the management of STEC-HUS remains unclear. The long-term sequelae from STEC-HUS are significant and patients with apparent full renal recovery remain at risk.
Collapse
|
|
11
|
Abstract
The thrombotic microangiopathies (TMAs) are a group of diseases characterised by microangiopathic haemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. Traditionally, TMAs have been classified as either thrombotic thrombocytopenic purpura (TTP) or haemolytic uremic syndrome (HUS) based on the clinical presentation, with neurological involvement predominating in the former and acute kidney injury in the latter. However, as our understanding of the pathogenesis of these conditions has increased, it has become clear that this is an over-simplification; there is significant overlap in the clinical presentation of TTP and HUS, there are different forms of HUS, and TMAs can occur in other, diverse clinical scenarios. This review will discuss recent developments in the diagnosis of HUS, focusing on the different forms of HUS and how to diagnose and manage these potentially life-threatening diseases.
Collapse
Affiliation(s)
- Neil S Sheerin
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Emily Glover
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| |
Collapse
|
|
12
|
Buelli S, Zoja C, Remuzzi G, Morigi M. Complement Activation Contributes to the Pathophysiology of Shiga Toxin-Associated Hemolytic Uremic Syndrome. Microorganisms 2019; 7:microorganisms7010015. [PMID: 30634669 PMCID: PMC6352217 DOI: 10.3390/microorganisms7010015] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/21/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
Shiga toxin (Stx)-producing Escherichia coli (STEC) infections have become a threat to public health globally because of the severe illnesses that they can trigger, such as hemorrhagic colitis and the post-diarrheal hemolytic uremic syndrome (HUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Glomerular endothelial cells are primary targets of Stx which, after binding to its specific receptor globotriaosylceramide, upregulates proinflammatory proteins involved both in the recruitment and adhesion of leukocytes and thrombus formation at the site of endothelial injury. In this review, we discuss the role of complement activation in promoting glomerular microvascular dysfunction, providing evidence from experimental models and patients with STEC-HUS. Within the glomerulus, an important target for Stx-induced complement activation is the podocyte, a cell type that is in close contact with endothelial cells and participates in maintaining the filtration barrier. Recently, podocyte injury and loss have been indicated as potential risk factors for long-term renal sequelae in patients with STEC-HUS. Therapeutic approaches targeting the complement system, that may be useful options for patients with STEC-HUS, will also be discussed.
Collapse
Affiliation(s)
- Simona Buelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy.
| | - Marina Morigi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| |
Collapse
|
|
13
|
Keenswijk W, Raes A, De Clerck M, Vande Walle J. Is Plasma Exchange Efficacious in Shiga Toxin‐Associated Hemolytic Uremic Syndrome? A Narrative Review of Current Evidence. Ther Apher Dial 2018; 23:118-125. [DOI: 10.1111/1744-9987.12768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/01/2018] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Werner Keenswijk
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
- Department of PediatricsDiakonessenhuis Utrecht The Netherlands
| | - Ann Raes
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
| | - Marieke De Clerck
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
| |
Collapse
|
|
14
|
Hemolytic-uremic syndrome after Escherichia coli urinary tract infection in humans: systematic review of the literature. J Nephrol 2018; 31:919-924. [PMID: 30328581 DOI: 10.1007/s40620-018-0543-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/29/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intestinal infections caused by a shigatoxin-positive Escherichia coli (mostly of the serogroups O26, O45, O103, O111, O121, O145 and especially O157) are a common cause of hemolytic-uremic syndrome. Hemolytic-uremic syndrome was first linked with an E. coli urinary tract infection 40 years ago. METHODS We conducted a systematic review of the literature addressing the association between E. coli urinary tract infection and hemolytic-uremic syndrome. RESULTS For the final analysis, we retained 23 original reports published since 1979. Five unselected pediatric case series addressed the possible occurrence of hemolytic-uremic syndrome after an acute symptomatic E. coli urinary tract infection among 266 cases and found the mentioned association in 8 (3.0%) cases. We also found 28 individual cases (17 females and 11 males) of hemolytic-uremic syndrome preceded by an E. coli urinary tract infection: 16 children aged from 2 days to 6.0 years and 12 adults aged from 22 to 75 years. Testing for shigatoxin, performed in 19 cases, was positive in 15 cases. E. coli serotyping was performed in 18 cases: testing for serotype O157, O103 and O145 was positive in one, one and two cases, respectively, while testing for serotype O26, O45, O111 and O121 was always negative. CONCLUSIONS Hemolytic-uremic syndrome rarely occurs after an acute E. coli urinary tract infection. It affects both children and adults and is mostly caused by germs that are shigatoxin-positive.
Collapse
|
|
15
|
Eculizumab in STEC-HUS: need for a proper randomized controlled trial. Pediatr Nephrol 2018; 33:1277-1281. [PMID: 29774464 DOI: 10.1007/s00467-018-3972-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
Hemolytic uremic syndrome caused by Shiga toxin-producing E. coli (STEC-HUS) is often associated with a severe morbidity including neurological involvement and a mortality of 1-5%. Although STEC-HUS is often self-limited, improvement of treatment strategies is needed for cases with complications and, among others, plasma exchange/plasmapheresis and use of antibiotics have been advocated. With the availability of the complement blocker eculizumab, now a standard treatment of atypical HUS, several series have addressed its use in STEC-HUS, with variable response; randomized controlled trials are lacking.In this issue of Pediatric Nephrology, Pecheron et al. present a cohort of 33 pediatric patients with severe HUS treated with eculizumab. Neurological involvement was observed in 85% of the patients and 94% required dialysis. Most patients (55%) did not benefit from eculizumab and renal dysfunction as well as neurological sequelae did not resolve. In a subgroup of patients, however, rapid neurological improvement was described. In the post-hoc-defined group of patients with favorable outcome, there was a trend towards more sustained complement inhibition, although this finding was not significant compared to patients with an unfavorable outcome.Because multiple interventions were used and the study did not include any control group, future controlled studies are urgently needed to resolve the debate as to whether eculizumab can be an effective treatment for both prevention and treatment of complications in STEC-HUS.
Collapse
|