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Wang C, Chen J, Han X, Sun M, Fang X, Zhai Y, Miao Q, Zhang Z, Tang X, Liu J, Shen Q, Xu H. Protein-losing enteropathy as a new phenotype in atypical hemolytic uremic syndrome caused by CD46 gene mutation. Pediatr Nephrol 2024:10.1007/s00467-024-06451-0. [PMID: 39097532 DOI: 10.1007/s00467-024-06451-0] [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: 03/05/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a life-threatening thrombotic microangiopathy. Genetic defects in the alternative complement (AP) pathway have been identified in 60-70% of individuals. Eculizumab is recommended as a first-line therapy. METHODS We collected the clinical data of a pediatric patient with aHUS accompanied by protein-losing enteropathy (PLE). Genetic testing was performed. Related literature on aHUS combined with PLE was reviewed. RESULTS A 15-year-old Chinese girl was diagnosed with aHUS at 3.7 years of age and experienced five episodes; her symptoms completely resolved with plasma treatment. Severe gastrointestinal symptoms and hypoalbuminemia presented after the first episode, and PLE was diagnosed. A novel homozygous CD46 variant was identified, and FACS revealed significantly decreased CD46 expression. She presented at a recent relapse with persistent GI symptoms and headache and progressed to chronic kidney failure; peritoneal dialysis was initiated. Eculizumab was given 8 months after the last recurrence. Surprisingly, PLE was cured. Afterward, dialysis was discontinued, and eGFR recovered to 44.8 ml/min/1.73 m2. A review of the literature indicated that PLE with thrombosis was caused by CD55 variants via hyperactivation of the AP system. We report an aHUS patient with PLE caused by CD46 variants. Symptoms of both PLE and aHUS were significantly alleviated in our patient and patients with CD55 variants treated with eculizumab, indicating that PLE was a new symptom of aHUS in our patient with a CD46 variant. CONCLUSIONS Our case expands the phenotype of aHUS caused by a CD46 mutation and provides evidence of the efficacy of eculizumab after a long phase of chronic kidney failure.
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Affiliation(s)
- Chunyan Wang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xinli Han
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Manqing Sun
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xiaoyan Fang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Yihui Zhai
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Qianfan Miao
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Zhiqing Zhang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xiaoshan Tang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Jiaojiao Liu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
- National Key Laboratory of Kidney Diseases, Beijing, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China.
- National Key Laboratory of Kidney Diseases, Beijing, China.
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Tanaka K, Fujita N, Hibino S. Prophylactic amoxicillin for the prevention of meningococcal infection in infants with atypical hemolytic uremic syndrome under treatment with eculizumab: a report of two cases. CEN Case Rep 2020; 9:247-251. [PMID: 32240525 DOI: 10.1007/s13730-020-00465-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/16/2020] [Indexed: 11/30/2022] Open
Abstract
Eculizumab, a humanized monoclonal antibody to complement C5, is a therapeutic drug for atypical hemolytic-uremic syndrome (aHUS) that inhibits the terminal pathway of complement. Patients on eculizumab therapy may become more susceptible to infection with capsule-forming bacteria, including meningococci. Therefore, meningococcal vaccination is required for patients who are on eculizumab therapy. However, the means to prevent meningococcal infection in infants who cannot be vaccinated with the available meningococcal vaccine have not yet been established internationally. In two infants with aHUS at 4-5 months after birth, prophylactic oral amoxicillin was administered, and meningococcal infection was not detected during the period between the initiation of eculizumab therapy and the administration of meningococcal vaccine. Neither adverse events related to amoxicillin nor thrombotic microangiopathy occurred during the treatment. Thus, oral administration of amoxicillin may be effective for preventing meningococcal infection under treatment with eculizumab in infants who have not received meningococcal vaccination.
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Affiliation(s)
- Kazuki Tanaka
- Department of Nephrology, Aichi Children's Health and Medical Center, 7-426 Morioka-cho, Obu, Aichi, 474-8710, Japan.
| | - Naoya Fujita
- Department of Nephrology, Aichi Children's Health and Medical Center, 7-426 Morioka-cho, Obu, Aichi, 474-8710, Japan
| | - Satoshi Hibino
- Department of Nephrology, Aichi Children's Health and Medical Center, 7-426 Morioka-cho, Obu, Aichi, 474-8710, Japan
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3
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Haskin O, Falush Y, Davidovits M. Is eculizumab indicated in patients with atypical hemolytic uremic syndrome already on prolonged dialysis? A case report and review of the literature. Pediatr Nephrol 2019; 34:2601-2604. [PMID: 31520126 DOI: 10.1007/s00467-019-04341-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/10/2019] [Accepted: 08/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Eculizumab has caused a revolution in the treatment and prognosis of atypical hemolytic uremic syndrome. Early initiation of treatment is recommended to increase chances of renal recovery. CASE-DIAGNOSIS/TREATMENT We describe a boy with atypical hemolytic uremic syndrome who started eculizumab therapy after being on dialysis for 4.5 months, with complete anuria. With treatment, he was weaned off dialysis. CONCLUSION We review the evidence in the literature and discuss the possible mechanism by which eculizumab induces renal recovery even in patients already on prolonged dialysis. This case report highlights the importance of a treatment trial with eculizumab, even in patients already on prolonged dialysis.
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Affiliation(s)
- Orly Haskin
- Department of Pediatric Nephrolgy, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yafa Falush
- Department of Pediatric Nephrolgy, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah Tikva, Israel
| | - Miriam Davidovits
- Department of Pediatric Nephrolgy, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rondeau E, Cataland SR, Al-Dakkak I, Miller B, Webb NJA, Landau D. Eculizumab Safety: Five-Year Experience From the Global Atypical Hemolytic Uremic Syndrome Registry. Kidney Int Rep 2019; 4:1568-1576. [PMID: 31890998 PMCID: PMC6933459 DOI: 10.1016/j.ekir.2019.07.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/13/2019] [Accepted: 07/20/2019] [Indexed: 02/03/2023] Open
Abstract
Introduction Eculizumab has transformed outcomes for patients with atypical hemolytic uremic syndrome (aHUS). Its efficacy and safety profile was well characterized in the clinical trial program. The long-term safety profile was not previously assessed or compared against nontreated patients in an observational registry setting. Methods The Global aHUS Registry recruits patients with clinical diagnoses of aHUS. This analysis includes baseline characteristics and targeted safety events from adult and pediatric patients who were "ever treated" versus "never treated" with eculizumab in the first 5 years of the registry, through January 26, 2017. Results Overall, 1321 patients (adult, n = 842; pediatric, n = 479; ever treated, n = 865; never treated, n = 456) were enrolled. A higher proportion of ever-treated versus never-treated adult and pediatric patients had renal, cardiovascular, pulmonary, central nervous system, gastrointestinal symptoms, and hepatic impairment. No differences in safety event rates between ever-treated and never-treated patients were observed, except serious infections in pediatric patients (5.15 versus 1.12 events/100 patient-years for ever- and never-treated patients, respectively). Deaths were more frequent in adult (4.7% and 9.9% of ever- and never-treated patients) compared with pediatric patients (1.8% of ever-treated patients; no deaths in never-treated patients).Three meningococcal infections were reported in ever-treated patients; 1 infection led to a fatal outcome. Conclusion In this large observational dataset covering 5 years of registry enrollment, no new safety concerns were identified for adult or pediatric eculizumab-treated patients with aHUS, confirming a positive benefit-risk profile in a real-world setting.
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Affiliation(s)
- Eric Rondeau
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, and Sorbonne Université, Paris, France
| | - Spero R Cataland
- Division of Hematology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Imad Al-Dakkak
- Global Epidemiology, Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Benjamin Miller
- Global Epidemiology, Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Nicholas J A Webb
- Department of Paediatric Nephrology, University of Manchester, Royal Manchester Children's Hospital, Manchester, UK
| | - Daniel Landau
- Schneider Children's Medical Center, Sackler School of Medicine, Petach Tikva, Israel
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Bomfim GF, Cau SBA, Bruno AS, Fedoce AG, Carneiro FS. Hypertension: a new treatment for an old disease? Targeting the immune system. Br J Pharmacol 2019; 176:2028-2048. [PMID: 29969833 PMCID: PMC6534786 DOI: 10.1111/bph.14436] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/14/2018] [Accepted: 06/24/2018] [Indexed: 12/22/2022] Open
Abstract
Arterial hypertension represents a serious public health problem, being a major cause of morbidity and mortality worldwide. The availability of many antihypertensive therapeutic strategies still fails to adequately treat around 20% of hypertensive patients, who are considered resistant to conventional treatment. In the pathogenesis of hypertension, immune system mechanisms are activated and both the innate and adaptive immune responses play a crucial role. However, what, when and how the immune system is triggered during hypertension development is still largely undefined. In this context, this review highlights scientific advances in the manipulation of the immune system in order to attenuate hypertension and end-organ damage. Here, we discuss the potential use of immunosuppressants and immunomodulators as pharmacological tools to control the activation of the immune system, by non-specific and specific mechanisms, to treat hypertension and improve end-organ damage. Nevertheless, more clinical trials should be performed with these drugs to establish their therapeutic efficacy, safety and risk-benefit ratio in hypertensive conditions. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.
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Affiliation(s)
| | - Stefany Bruno Assis Cau
- Department of Pharmacology, Institute of Biological ScienceFederal University of Minas GeraisBelo HorizonteMGBrazil
| | - Alexandre Santos Bruno
- Department of Pharmacology, Institute of Biological ScienceFederal University of Minas GeraisBelo HorizonteMGBrazil
| | - Aline Garcia Fedoce
- Department of Pharmacology, Ribeirão Preto Medical SchoolUniversity of São PauloSão PauloBrazil
| | - Fernando S Carneiro
- Department of Pharmacology, Ribeirão Preto Medical SchoolUniversity of São PauloSão PauloBrazil
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Yoshida Y, Kato H, Ikeda Y, Nangaku M. Pathogenesis of Atypical Hemolytic Uremic Syndrome. J Atheroscler Thromb 2018; 26:99-110. [PMID: 30393246 PMCID: PMC6365154 DOI: 10.5551/jat.rv17026] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a type of thrombotic microangiopathy (TMA) defined by thrombocytopenia, microangiopathic hemolytic anemia, and renal failure. aHUS is caused by uncontrolled complement activation in the alternative pathway (AP). A variety of genetic defects in complement-related factors or acquired autoantibodies to the complement regulators have been found in 50 to 60% of all cases. Recently, however, the classification and diagnosis of aHUS are becoming more complicated. One reason for this is that some factors, which have not been regarded as complement-related factors, have been reported as predisposing factors for phenotypic aHUS. Given that genotype is highly correlated with the phenotype of aHUS, careful analysis of underlying genetic abnormalities or acquired factors is needed to predict the prognosis or to decide an optimal treatment for the disease. Another reason is that complement dysregulation in the AP have also been found in a part of other types of TMA such as transplantation-related TMA and pregnancy-related complication. Based on these findings, it is now time to redefine aHUS according to the genetic or acquired background of abnormalities.Here, we review the pathogeneses and the corresponding phenotypes of aHUS and complement-related TMAs.
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Affiliation(s)
- Yoko Yoshida
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
| | - Hideki Kato
- Department of Prevention of Diabetes and Lifestyle-Related Diseases Graduate School of Medicine, the University of Tokyo
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital
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7
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Chen FY, Chen CH, Lin CC. Hypertensive Crisis and Refractory Hypertension Caused by Atypical Hemolytic Uremic Syndrome and Effect of Eculizumab. ACTA CARDIOLOGICA SINICA 2018; 34:446-449. [PMID: 30271097 PMCID: PMC6160511 DOI: 10.6515/acs.201809_34(5).20180326d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 03/26/2018] [Indexed: 12/26/2022]
Affiliation(s)
| | - Chen-Huan Chen
- Department of Medicine
- Department of Medical Education, Taipei Veterans General Hospital
- Institute of Public Health
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Ching Lin
- Department of Medicine
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
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8
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Fujisawa M, Kato H, Yoshida Y, Usui T, Takata M, Fujimoto M, Wada H, Uchida Y, Kokame K, Matsumoto M, Fujimura Y, Miyata T, Nangaku M. Clinical characteristics and genetic backgrounds of Japanese patients with atypical hemolytic uremic syndrome. Clin Exp Nephrol 2018; 22:1088-1099. [PMID: 29511899 PMCID: PMC6437120 DOI: 10.1007/s10157-018-1549-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/22/2018] [Indexed: 01/08/2023]
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is caused by complement overactivation, and its presentation and prognosis differ according to the underlying molecular defects. The aim of this study was to characterize the genetic backgrounds of aHUS patients in Japan and to elucidate the associations between their genetic backgrounds, clinical findings, and outcomes. Methods We conducted a nationwide epidemiological survey of clinically diagnosed aHUS patients and examined 118 patients enrolled from 1998 to 2016 in Japan. We screened variants of seven genes related to complement and coagulation, as well as positivity for anti-CFH antibodies, and assessed clinical manifestations, laboratory findings, and clinical course. Results The most frequent genetic abnormalities were in C3 (31%) and the frequency of CFH variants was relatively low (10%) compared to Western countries. The predominant variant in this cohort was C3 p.I1157T (23%), which was related to favorable outcomes despite frequent relapses. A total of 72% of patients received plasma therapy, while 42% were treated with eculizumab. The prognosis of Japanese aHUS patients was relatively favorable, with a total mortality rate of 5.4% and a renal mortality rate of 15%. Conclusions The common occurrence of genotype C3, especially the p.I1157T variant was the characteristic of the genetic backgrounds of Japanese aHUS patients that differed from those of Caucasian patients. In addition, the favorable prognosis of patients with the unique C3 p.I1157T variant indicates that understanding the clinical characteristics of individual gene alterations is important for predicting prognosis and determining therapeutic strategies in aHUS. Electronic supplementary material The online version of this article (10.1007/s10157-018-1549-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Madoka Fujisawa
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideki Kato
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yoko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomoko Usui
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Munenori Takata
- Clinical Research Support Center (CresCent), The University of Tokyo, Tokyo, Japan
| | - Mika Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Mie, Japan
| | - Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yumiko Uchida
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
| | | | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Atypical hemolytic uremic syndrome in the setting of complement-amplifying conditions: case reports and a review of the evidence for treatment with eculizumab. J Nephrol 2016; 30:347-362. [PMID: 27848226 PMCID: PMC5437142 DOI: 10.1007/s40620-016-0357-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/14/2016] [Indexed: 01/20/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare, genetic, progressive, life-threatening form of thrombotic microangiopathy (TMA) predominantly caused by dysregulation of the alternative pathway of the complement system. Complement-amplifying conditions (CACs), including pregnancy complications [preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome], malignant hypertension, autoimmune diseases, transplantation, and others, are associated with the onset of TMA in up to 69 % of cases of aHUS. CACs activate the alternative pathway of complement and may be comorbid with aHUS or may unmask a previously undiagnosed case. In this review, three case reports are presented illustrating the onset and diagnosis of aHUS in the setting of different CACs (pregnancy complications, malignant hypertension, renal transplantation). The report also reviews the evidence for a variety of CACs, including those mentioned above as well as infections and drug-induced TMA, and the overlap with aHUS. Finally, we introduce an algorithm for diagnosis and treatment of aHUS in the setting of CACs. If TMA persists despite initial management for the specific CAC, aHUS should be considered. The terminal complement inhibitor eculizumab should be initiated for all patients with confirmed diagnosis of aHUS, with or without a comorbid CAC.
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11
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Neonatal atypical hemolytic uremic syndrome from a factor H mutation treated with eculizumab. Clin Nephrol 2016; 84:181-5. [PMID: 25816809 PMCID: PMC4839031 DOI: 10.5414/cn108532] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 12/25/2022] Open
Abstract
Background: Atypical hemolytic uremic syndrome (aHUS) results from an inherited dysregulation of the alternative complement pathway leading to thrombotic microangiopathy consisting of hemolytic anemia, thrombocytopenia, and renal injury. The complement inhibitor eculizumab is an approved treatment, but its reported use in neonates – who have an inherently high risk of infection – is limited. Case diagnosis/treatment: A 28-day-old female presented with gross hematuria and hypertension. aHUS was suspected based on anemia with schistocytes, thrombocytopenia, low C3, and acute kidney injury requiring peritoneal dialysis. A septic work-up initiated on day 2 for hypothermia and respiratory failure was negative. There was no improvement after 6 days of plasma therapy. Despite being < 6 weeks old she was vaccinated with pneumococcal-13 conjugate, meningococcal (groups C and Y) polysaccharide, and Haemophilus b tetanus toxoid conjugate vaccines and started on penicillin prophylaxis. After 1 dose of eculizumab 300 mg, dialysis was discontinued and her hematological parameters improved. Genetic testing revealed a complement factor H mutation. After 11 months of follow-up, she remains on eculizumab and penicillin without recurrence of aHUS or any infectious complications. Conclusions: Eculizumab is a safe and effective treatment option for aHUS even in neonates at high risk for infection.
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12
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Abstract
The biology of atypical hemolytic uremic syndrome has been shown to involve inability to limit activation of the alternative complement pathway, with subsequent damage to systemic endothelial beds and the vasculature, resulting in the prototypic findings of a thrombotic microangiopathy. Central to this process is the formation of the terminal membrane attack complex C5b-9. Recently, application of a monoclonal antibody that specifically binds to C5, eculizumab, became available to treat patients with atypical hemolytic uremic syndrome, replacing plasma exchange or infusion as primary therapy. This review focuses on the evidence, based on published clinical trials, case series, and case reports, on the efficacy and safety of this approach.
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Affiliation(s)
- Lilian M Pereira Palma
- Pediatric Nephrology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Craig B Langman
- The Feinberg School of Medicine, Northwestern University, and the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Rodriguez-Osorio L, Ortiz A. Timing of eculizumab therapy for C3 glomerulonephritis. Clin Kidney J 2015; 8:449-52. [PMID: 26251715 PMCID: PMC4515909 DOI: 10.1093/ckj/sfv065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 01/02/2023] Open
Abstract
Eculizumab is an anti-C5 antibody that inhibits C5 cleavage and prevents the generation of the terminal complement complex C5b-9. Eculizumab is licensed to treat paroxysmal nocturnal haemoglobinuria or atypical haemolytic uraemic syndrome (aHUS). Clinical trials are ongoing for C3 glomerulopathy. Given the unfamiliarity of physicians with these rare diseases and the variability of clinical presentation, a delayed initiation of eculizumab therapy is common. Thus, the question arises as to what extent improvement of kidney function may be expected when patients have been dialysis dependent for weeks or months already when eculizumab is initiated. Furthermore, given the high cost and potential adverse effects of eculizumab, the question arises of when to stop therapy because of futility when patients with kidney-only manifestations remain dialysis dependent. In literature reports, eculizumab was stopped as early as after 3 weeks because the patient remained dialysis dependent. In this issue of CKJ, Inman et al. report on eculizumab-induced reversal of dialysis-dependent kidney failure from C3 glomerulonephritis, illustrating both the potential benefit of eculizumab for this complement-mediated disease and the need for lengthy therapy—dialysis independency was reached after 5 months of eculizumab. Indeed, there are reports of renal function recovery when eculizumab was initiated after 4 months on dialysis and of recovery of renal function 2.0–3.5 months after initiation of eculizumab in dialysis-dependent patients with C3 glomerulopathy or aHUS.
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Affiliation(s)
- Laura Rodriguez-Osorio
- IIS-Fundacion Jimenez Diaz, School of Medicine , Universidad Autonoma de Madrid , Madrid , Spain ; Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN , Madrid , Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine , Universidad Autonoma de Madrid , Madrid , Spain ; Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN , Madrid , Spain
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Miyata T, Uchida Y, Ohta T, Urayama K, Yoshida Y, Fujimura Y. Atypical haemolytic uraemic syndrome in a Japanese patient with DGKE genetic mutations. Thromb Haemost 2015; 114:862-3. [PMID: 26018111 DOI: 10.1160/th15-01-0007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/23/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Toshiyuki Miyata
- Dr. Toshiyuki Miyata, Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan, Tel.: +81 6 6833 5012, Fax: +81 6 6835 1176, E-mail:
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