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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024:S0085-2538(24)00389-2. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center Boston, Massachusetts, USA; Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Department of Renal Medicine, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Department of Medicine and Nephrology, Albert Einstein College Medicine, Bronx, New York, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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Antonucci L, Thurman JM, Vivarelli M. Complement inhibitors in pediatric kidney diseases: new therapeutic opportunities. Pediatr Nephrol 2024; 39:1387-1404. [PMID: 37733095 DOI: 10.1007/s00467-023-06120-8] [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: 05/02/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 09/22/2023]
Abstract
Historically, the complement system (classical, lectin, alternative, and terminal pathways) is known to play a crucial role in the etiopathogenesis of many kidney diseases. Direct or indirect activation in these settings is revealed by consumption of complement proteins at the serum level and kidney tissue deposition seen by immunofluorescence and electron microscopy. The advent of eculizumab has shown that complement inhibitors may improve the natural history of certain kidney diseases. Since then, the number of available therapeutic molecules and experimental studies on complement inhibition has increased exponentially. In our narrative review, we give a summary of the main complement inhibitors that have completed phase II and phase III studies or are currently used in adult and pediatric nephrology. The relevant full-text works, abstracts, and ongoing trials (clinicaltrials.gov site) are discussed. Data and key clinical features are reported for eculizumab, ravulizumab, crovalimab, avacopan, danicopan, iptacopan, pegcetacoplan, and narsoplimab. Many of these molecules have been shown to be effective in reducing proteinuria and stabilizing kidney function in different complement-mediated kidney diseases. Thanks to their efficacy and target specificity, these novel drugs may radically improve the outcome of complement-mediated kidney diseases, contributing to an improvement in our understanding of their underlying pathophysiology.
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Affiliation(s)
- Luca Antonucci
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
- Ph.D. Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
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Yesilbas O, Yozgat CY, Akinci N, Sonmez S, Tekin E, Talebazadeh F, Jafarov U, Temur HO, Yozgat Y. Acute Myocarditis and Eculizumab Caused Severe Cholestasis in a 17-Month-Old Child Who Has Hemolytic Uremic Syndrome Associated with Shiga Toxin-Producing Escherichia coli. J Pediatr Intensive Care 2020; 10:216-220. [PMID: 34395040 DOI: 10.1055/s-0040-1713111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/02/2020] [Indexed: 10/23/2022] Open
Abstract
Cardiovascular involvement is uncommon in pediatric patients with hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC-HUS). In this case report we presented a case of 17-month-old toddler who had a sporadic type of STEC-HUS complicated by acute myocarditis. The patient was successfully treated by a single dose of eculizumab after six doses of therapeutic plasma exchange (TPE) were inefficient to prevent the cardiac complication. Hepatotoxicity was observed after a single dose of eculizumab. Hepatic and cholestatic enzyme levels slowly returned to normal within 6 months. To the best of our knowledge, this is the first case of myocarditis/cardiomyopathy treated with eculizumab in STEC-HUS. This case illustrates the need for vigilance regarding myocardial involvement and eculizumab-induced hepatotoxicity in STEC-HUS.
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Affiliation(s)
- Osman Yesilbas
- Department of Pediatric Critical Care Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Nurver Akinci
- Department of Pediatric Nephrology, Bezmialem Vakif University, Istanbul, Turkey
| | - Sirin Sonmez
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Eser Tekin
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Faraz Talebazadeh
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Uzeyir Jafarov
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Hafize Otcu Temur
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Yilmaz Yozgat
- Department of Pediatric Cardiology, Bezmialem Vakif University, Istanbul, Turkey
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Kelen D, Chiodini B, Godart V, Adams B, Stordeur P, Ismaili K. Case Report: Neonatal Unexplained HUS Treated With Complement Inhibitor Eculizumab. Front Pediatr 2020; 8:579607. [PMID: 33681093 PMCID: PMC7930232 DOI: 10.3389/fped.2020.579607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Hemolytic uremic syndrome (HUS) is rare in neonates. It is probably an under-recognized condition in the early postnatal period as it presents similarly to the most common perinatal asphyxia and to differentiate the two conditions is challenging. We describe the clinical presentation of a potential new subtype of neonatal HUS triggered by hypoxic-ischemic event. Our patient was successfully treated by a single dose of Eculizumab as early as at 9 days of life. Case Report: A 35-weeks infant was born with low hemoglobin and subsequently developed respiratory distress, hypotension, and acidosis. Blood transfusion was administered, acidosis corrected, neurological examination remained reassuring. Few hours later he developed renal failure, macroscopic hematuria, hemobilia, thrombocytopenia and coagulopathy refractory to platelet and fresh frozen plasma transfusions. No infection was found. Haptoglobin was non-measurable, and schistocytes present, complement factors C3, C4 and B were low, FBb increased. HUS was suspected. A single dose of Eculizumab™ was administered on day 9 of life. No genetic mutation of atypical HUS was found. He was discharged with improving renal function and developing cholestasis. Conclusion: In neonates with hemolytic anemia, thrombocytopenia, hematuria and renal failure, HUS should be suspected. In neonatal HUS Eculizumab should be considered as first-line therapy and discontinuation can be considered if no genetic mutation is found and clinical condition improves. In very young patients, cholestasis could appear as potential side effect of Eculizumab™.
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Affiliation(s)
- Dorottya Kelen
- Neonatal Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Benedetta Chiodini
- Department of Pediatric Nephrology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Valérie Godart
- Neonatal Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Brigitte Adams
- Department of Pediatric Nephrology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Stordeur
- Belgian National Reference Centre for the Complement System, Laboratory of Immunology, LHUB-ULB, Université Libre de Bruxelles, Brussels, Belgium
| | - Khalid Ismaili
- Department of Pediatric Nephrology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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