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Shajari A, Zare Ahmadabadi A, Ashrafi MM, Mahdavi T, Mirzaee M, Mohkam M, Sharafian S, Tamiji M, Jamee M. Inborn errors of immunity with kidney and urinary tract disorders: a review. Int Urol Nephrol 2024; 56:1965-1972. [PMID: 38198013 PMCID: PMC11090940 DOI: 10.1007/s11255-023-03907-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/02/2023] [Indexed: 01/11/2024]
Abstract
Human inborn errors of immunity (IEIs), previously referred to as primary immunodeficiency disorders (PIDs), are a heterogeneous spectrum of inherited abnormalities of the immune system with different organ involvement. The number of identified IEIs is rapidly increasing, highlighting the non-negligible role of an interdisciplinary approach in clinical diagnosis. Kidney disorders are one of the important comorbidities in some of the affected patients and play a significant role in the diagnosis and course of disease. According to recent studies, 22 types of human IEI with renal manifestations have been identified so far, including immunodeficiency with congenital thrombocytopenia, thymic defects with additional congenital anomalies, complement deficiencies, type 1 interferonopathies, immunity related to non-hematopoietic tissues, congenital neutropenia's, common variable immunodeficiency disorder (CVID) phenotype and immuno-osseous dysplasia. Based on this classification, we herein review IEIs with renal features and explain the genetic defect, inheritance, and type of renal manifestations.
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Affiliation(s)
- Ahmad Shajari
- Department of Pediatric Nephrology, Islamic Azad University of Yazd, Yazd, Iran
| | - Atefe Zare Ahmadabadi
- Immunology and Allergy Department, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Moein Ashrafi
- Immunology and Allergy Department, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tolue Mahdavi
- Department of Allergy and Clinical Immunology, Rasool E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahbubeh Mirzaee
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Mohkam
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samin Sharafian
- Immunology and Allergy Department, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Tamiji
- Department of Computer Science, Rice University, Houston, TX, USA
| | - Mahnaz Jamee
- Laboratory for Pediatric Immunology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands.
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Meuleman MS, Duval A, Grunenwald A, Rezola Artero M, Dermani M, Peliconi J, Revel M, Vieira-Martins P, Courbebaisse M, Parfait B, Lebeaux D, Friedlander G, Roumenina L, Chauvet S, Frémeaux-Bacchi V, Dragon-Durey MA. Usefulness and analytical performances of complement multiplex assay for measuring complement biomarkers in plasma. Clin Chim Acta 2024; 554:117750. [PMID: 38176523 DOI: 10.1016/j.cca.2023.117750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/27/2023] [Accepted: 12/27/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION The complement system is involved in numerous diseases, through diverse mechanisms and degree of activation. With the emergence of complement targeting therapeutic, simple and accessible tools to evaluate the extent of complement activation are strongly needed. METHODS We evaluated two multiplex panels, measuring complement activation fragments (C4a, C3a, C5a, Bb, Ba, sC5b9) and intact components or regulators (C1q, C2, C3, C4, C5, FD, FP, FH, FI). The specificity of each measurement was assessed by using complement proteins depleted sera and plasma collected from patients with complement deficiencies. Normal values distribution was estimated using 124 plasma samples from healthy donors and complement activation profile was assessed in plasma collected from 31 patients with various complement-mediated disorders. RESULTS We observed good inter-assay variation. All tested protein deficiencies were accurately detected. We established assay-specific reference values for each analyte. Except for C3, C4 and C4a, the majority of the measurements were in good agreement with references methods or published data. CONCLUSION Our study substantiates the utility of the Complement Multiplex assay as a tool for measuring complement activation and deficiencies. Quantifying complement cleavage fragments in patients exhibiting classical or alternative pathway activation allowed evaluating the activation state of the whole cascade.
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Affiliation(s)
- Marie-Sophie Meuleman
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France; Laboratory of Immunology, Georges Pompidou European Hospital, APHP, Paris, France
| | - Anna Duval
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France; Department of Nephrology, Strasbourg University Hospital, Strasbourg, France
| | - Anne Grunenwald
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France; Department of Nephrology, Poissy Intercommunal Hospital, Poissy, France
| | - Mikel Rezola Artero
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France
| | - Mohamed Dermani
- Laboratory of Immunology, Georges Pompidou European Hospital, APHP, Paris, France
| | - Julie Peliconi
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France
| | - Margot Revel
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France
| | - Paula Vieira-Martins
- Laboratory of Immunology, Georges Pompidou European Hospital, APHP, Paris, France
| | - Marie Courbebaisse
- Paris Cité University, Physiology Department, European Georges-Pompidou Hospital, APHP, INSERM U1151, Paris, France
| | - Béatrice Parfait
- Centre de Ressources Biologiques - site Cochin, Fédération des CRB/PRB, DMU BioPhyGen, AP-HP.Centre-Université Paris Cité, Hôpital Cochin, Paris, France
| | - David Lebeaux
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Genetics of Biofilms Laboratory, 75015 Paris, France; Service de Microbiologie, Unité Mobile d'Infectiologie, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | | | - Lubka Roumenina
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France
| | - Sophie Chauvet
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France; Paris Cité University, Paris, France; Department of Nephrology, Georges Pompidou European Hospital, APHP, Paris, France
| | - Véronique Frémeaux-Bacchi
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France; Laboratory of Immunology, Georges Pompidou European Hospital, APHP, Paris, France
| | - Marie-Agnès Dragon-Durey
- Centre de Recherche des Cordeliers, Sorbonne Université, Inserm, Université Paris Cité, Inflammation, Complement and Cancer Team, Paris, France; Laboratory of Immunology, Georges Pompidou European Hospital, APHP, Paris, France; Paris Cité University, Paris, France.
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Ávila A, Cao M, Espinosa M, Manrique J, Morales E. Recommendations for the individualised management of atypical hemolytic uremic syndrome in adults. Front Med (Lausanne) 2023; 10:1264310. [PMID: 38105887 PMCID: PMC10722909 DOI: 10.3389/fmed.2023.1264310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Background Despite significant advances in therapeutic management of atypical hemolytic uremic syndrome (aHUS), guidelines are not timely updated and achieving a consensus on management recommendations remains a topic of ongoing discussion. Methods A Scientific Committee with five experts was set up. A literature review was conducted and publications addressing the classification of aHUS, patient profiles and therapeutic approach were selected. Recommendations were proposed at an initial meeting, evaluated through an online questionnaire and validated during a second meeting. Results Patients with confirmed or clear suspicion of aHUS should be treated with C5 inhibitors within 24 h of the diagnosis or suspicion of aHUS. Treatment monitoring and the decision to interrupt treatment should be individualised according to the risk of relapse and each patient's evolution. aHUS with a genetic variant or associated with pregnancy should be treated for at least 6-12 months; de novo aHUS associated with kidney transplant until renal function is recovered and genetic variants are ruled out; aHUS associated with malignant hypertension until genetic variants are ruled out; aHUS associated with non-kidney transplant, autoimmune diseases, infection-or drug-induced until the thrombotic microangiopathy is resolved. Patients with a high risk of relapse should be treated for longer than 6-12 months. Conclusion These recommendations provides physicians who are not familiar with the disease with recommendations for the management of aHUS in adults. The experts who participated advocate early treatment, maintenance for at least 6-12 months and treatment interruption guided by genetic background, trigger factors, risk of relapse and evolution.
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Affiliation(s)
- Ana Ávila
- Department of Nephrology, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Mercedes Cao
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Joaquín Manrique
- Department of Nephrology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
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Galvez C, Krall P, Rojas A, Oh J, Cano F. HUS with mutations in CFH and STEC infection treated with eculizumab in a 4-year-old girl. Pediatr Nephrol 2023; 38:1195-1203. [PMID: 35969277 DOI: 10.1007/s00467-022-05694-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome secondary to Shiga-toxin-producing Escherichia coli infection (STEC-HUS) generally shows a favorable outcome. Few cases develop extra-renal complications, since neurological involvement is an important cause of morbidity and mortality. The role of complement in STEC-HUS has been recently highlighted, and the use of eculizumab in severe cases has been communicated. HUS results from environmental and genetic factors, but the simultaneous occurrence of STEC and complement mutations remains undetermined. METHODS A pediatric case with severe STEC-HUS carrying CFH mutations, with favorable response to eculizumab is analyzed. RESULTS STEC-HUS was diagnosed in a 4-year-old girl with classic HUS, including low C3. Peritoneal dialysis was started due to hypertension, oligoanuria, and pleural effusion. She evolved with generalized tonic-clonic seizures and required mechanical ventilation. MRI reported multiple supra- and infratentorial ischemic lesions with laminar/striatal cortical necrosis and leukoencephalopathy. After two eculizumab doses, a significative stabilization in diuresis, blood pressure, creatinine, and C3 was achieved. At the third week, episodes of massive digestive bleeding and a life-threatening condition required a colectomy thus preserving the ileocecal valve. Due to atypical evolution, a genetic study was considered, identifying two heterozygous variants (CFH S1191L/V1197A). CONCLUSION STEC-HUS in patients with a genetic predisposition has been previously reported, but the low frequency of occurrence makes it a rare disease. As in the present case, patients with atypical course might benefit from genetic analysis to evaluate early eculizumab initiation and to better understand its phenotype. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Carla Galvez
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile
| | - Paola Krall
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile.,Institute of Medicine, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Alejandro Rojas
- Institute of Medicine, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Jun Oh
- Department of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Cano
- Department of Pediatrics and Child Surgery, Faculty of Medicine, University of Chile, Santiago de Chile, Chile.
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Cammett TJ, Garlo K, Millman EE, Rice K, Toste CM, Faas SJ. Exploratory Prognostic Biomarkers of Complement-Mediated Thrombotic Microangiopathy (CM-TMA) in Adults with Atypical Hemolytic Uremic Syndrome (aHUS): Analysis of a Phase III Study of Ravulizumab. Mol Diagn Ther 2023; 27:61-74. [PMID: 36329366 DOI: 10.1007/s40291-022-00620-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinically validated biomarkers for monitoring of patients with complement-mediated thrombotic microangiopathy (CM-TMA) including atypical hemolytic uremic syndrome (aHUS) are unavailable. Improved characterization of biomarkers in patients with aHUS may inform treatment and monitoring for patients with CM-TMA. METHODS This analysis used data collected from 55/56 (98.2 %) adult patients with aHUS enrolled in the global Phase III study of ravulizumab (NCT02949128). Baseline (pre-treatment) patient serum, plasma and urine biomarker levels were compared with the maximum observed levels in normal donors and evaluated for associations with pre-treatment plasma exchange/infusion and dialysis status. Biomarkers were also assessed for associations with key clinical measures at baseline and with changes at 26 and 52 weeks from treatment initiation via linear regression analyses. RESULTS Complement-specific urine levels (factor Ba and sC5b-9) were elevated in >85 % of patients and are significantly associated with pre-treatment kidney dysfunction. Baseline levels of other evaluated biomarkers were elevated in >70 % of patients with aHUS, except for plasma sC5b-9 and serum sVCAM-1. Lower levels of urine complement markers at baseline are significantly associated with improvements in total urine protein and estimated glomerular filtration rate at 26 and 52 weeks of treatment. Clinical assessment of complement activation by a receiver operating characteristic analysis of Ba and sC5b-9 was more sensitive and specific in urine matrix than plasma. CONCLUSION This analysis identified a set of biomarkers that may show utility in the prognosis of CM-TMA, including their potential for measuring and predicting response to anti-C5 therapy. Further studies are required to enhance patient risk stratification and improve management of these vulnerable patients. CLINICAL TRIALS REGISTRATION NCT02949128, ClinicalTrials.gov.
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Affiliation(s)
| | | | | | - Kara Rice
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | - Susan J Faas
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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Genest DS, Patriquin CJ, Licht C, John R, Reich HN. Renal Thrombotic Microangiopathy: A Review. Am J Kidney Dis 2022; 81:591-605. [PMID: 36509342 DOI: 10.1053/j.ajkd.2022.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA), a pathological lesion observed in a wide spectrum of diseases, is triggered by endothelial injury and/or dysfunction. Although TMA lesions are often accompanied by clinical features of microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury, renal-limited forms of TMA are not infrequently encountered in clinical practice. The presence of renal-limited manifestations can be diagnostically challenging, often delaying the initiation of targeted therapy. Prompt investigation and empirical treatment of TMA is warranted to reduce associated morbidity and mortality. Major advances have been made with respect to the pathophysiology of primary TMA entities, with the subsequent development of novel diagnostic tools and lifesaving therapies for diseases like thrombotic thrombocytopenic purpura and complement-mediated TMA. This article will review the clinical presentation and pathologic hallmarks of TMA involving the kidney, and the disease-specific mechanisms that contribute to the endothelial injury that characterizes TMA lesions. Diagnostic approach and both empirical and disease-specific treatment strategies will be discussed, along with the potential role for emerging targeted disease-specific therapies.
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Affiliation(s)
- Dominique Suzanne Genest
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rohan John
- Division of Laboratory Medicine and Pathology, University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Heather N Reich
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Thompson GL, Kavanagh D. Diagnosis and treatment of thrombotic microangiopathy. Int J Lab Hematol 2022; 44 Suppl 1:101-113. [PMID: 36074708 PMCID: PMC9544907 DOI: 10.1111/ijlh.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic haemolytic anaemia and end organ damage. TMAs have varying underlying pathophysiology and can therefore present with an array of clinical presentations. Renal involvement is common as the kidney is particularly susceptible to the endothelial damage and microvascular occlusion. TMAs require rapid assessment, diagnosis, and commencement of appropriate treatment due to the high morbidity and mortality associated with them. Ground-breaking research into the pathogenesis of TMAs over the past 20 years has driven the successful development of targeted therapeutics revolutionizing patient outcomes. This review outlines the clinical presentations, pathogenesis, diagnostic tests and treatments for TMAs.
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Affiliation(s)
- Gemma L Thompson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Tanaka C, Naito Y, Suehiro S, Sano C, Ohta R. Device-Related Thrombotic Microangiopathy in an Elderly Patient With a History of Aortic Surgery. Cureus 2022; 14:e27937. [PMID: 36120189 PMCID: PMC9467496 DOI: 10.7759/cureus.27937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is caused by several diseases, including infections, congenital and autoimmune diseases, and malignancies, usually requiring admission to intensive care. The primary pathophysiology of TMA is microvascular thrombosis, and its diagnosis is based on the presence of hemolysis, thrombocytopenia, schistocytes in a blood smear, and organ damage. Among secondary TMAs, device-related TMA could be difficult to diagnose if device implementation was performed years ago. We report the case of an 87-year-old woman with a chief complaint of dyspnea diagnosed with device-related TMA. In device-related TMA, thrombogenesis/thrombocytopenia is triggered by hemolysis/fragmented red blood cells. However, in other TMAs, thrombogenesis or thrombocytopenia is preceded by hemolysis and the presence of fragmented red blood cells. Thus, rapid plasma exchange is necessary to address TMA pathogenesis. TMA can be managed in a community hospital if the facility has access to plasma exchange. It is possible to treat complex TMAs even in community hospitals by carefully considering their pathophysiology. Additionally, improving the quality of general practice in community hospitals will allow for more effective diagnosis and treatment of TMAs.
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