1
|
Tatematsu Y, Imaizumi T, Michihata N, Kato N, Kumazawa R, Matsui H, Fushimi K, Yasunaga H, Maruyama S. Annual trends in atypical haemolytic uremic syndrome management in Japan and factors influencing early diagnosis and treatment: a retrospective study. Sci Rep 2024; 14:18265. [PMID: 39107421 PMCID: PMC11303750 DOI: 10.1038/s41598-024-68736-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 07/26/2024] [Indexed: 08/10/2024] Open
Abstract
Atypical haemolytic uremic syndrome (aHUS) is a rare disorder characterised by complement-mediated thrombotic microangiopathy (TMA). Despite clinical guidelines, the diagnosis and treatment of aHUS in its early stages remains challenging. This study examined the annual trends in aHUS clinical practices in Japan and explored factors influencing early diagnosis and treatment. Using data from the 2011-2020 Diagnosis Procedure Combination database, 3096 cases with the HUS disease code were identified, of which 217 were confirmed as aHUS and treated with eculizumab or plasma exchange. Early initiation, defined as starting eculizumab or plasma exchange within 7 days of admission, was the focus of the study. Our study revealed no significant changes over time in the number of aHUS diagnoses, cases treated with eculizumab, or early initiation cases. Early initiation cases underwent haemodialysis earlier and had ADAMTS13 activity measured earlier, shorter hospital stays, and lower hospitalisation costs than late initiation cases. In conclusion, we found no increase in the number of newly diagnosed aHUS cases or early treatment initiation over time. Early recognition of TMA and differentiation of the causative disease are crucial for identifying potential aHUS cases, which may lead to better patient prognoses.
Collapse
Affiliation(s)
- Yoshitaka Tatematsu
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Ryosuke Kumazawa
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
| |
Collapse
|
2
|
Maruyama S, Ikeda Y, Kaname S, Kato N, Matsumoto M, Ishikawa Y, Shimono A, Miyakawa Y, Nangaku M, Shibagaki Y, Okada H. Eculizumab for adult patients with atypical haemolytic-uraemic syndrome: full dataset analysis of Japanese post-marketing surveillance. J Nephrol 2024:10.1007/s40620-024-01921-y. [PMID: 38809358 DOI: 10.1007/s40620-024-01921-y] [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: 08/27/2023] [Accepted: 02/10/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Eculizumab has been approved for atypical haemolytic-uraemic syndrome (aHUS) in Japan since 2013. Post-marketing surveillance enrolled patients with aHUS who received ≥ 1 dose of eculizumab to assess eculizumab safety and effectiveness. METHODS We evaluated serious adverse events and effectiveness endpoints, i.e., haematologic normalization, a decrease of ≥ 25% in serum creatinine (sCr) levels, and complete thrombotic microangiopathy (TMA) response in adult patients with aHUS without other underlying diseases. In addition, the difference of baseline characteristics between patients who did and did not meet effectiveness endpoints was examined. RESULTS In this safety and effectiveness analysis, 79 adult patients were included; median age was 54.0 years, median treatment duration was 30 weeks. Total exposure time of eculizumab was 75.51 patient-years, and 94 serious adverse events were reported in 39 patients. No unexpected safety signals were identified in this population. Mean platelet count, lactate dehydrogenase and estimated glomerular filtration rate significantly improved after 7 days of treatment. Complete TMA response, haematologic normalization and the improvement of sCr levels were met by 35.3%, 40.4% and 51.3% of patients, respectively. Median treatment duration was shorter in patients who did not achieve complete TMA response (6 weeks) than in patients who did (114 weeks). Multivariate analysis suggested that the time from the most recent TMA episode to start of eculizumab treatment was negatively associated with kidney function improvement. CONCLUSIONS No unexpected safety signals of eculizumab were identified in Japanese patients with aHUS in a real-world setting. Renal outcomes were negatively associated with the time from the most recent TMA episode to the initiation of eculizumab treatment.
Collapse
Affiliation(s)
- Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-City, Tokyo, 181-8611, Japan
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, 840 Shijyo-cho, Kashihara City, Nara, 634-8522, Japan
| | - Yumiko Ishikawa
- Alexion Pharma GK, 3-1-1 Shibaura, Minato-Ku, Tokyo, 108-0023, Japan
| | - Akihiko Shimono
- Alexion Pharma GK, 3-1-1 Shibaura, Minato-Ku, Tokyo, 108-0023, Japan
| | - Yoshitaka Miyakawa
- Department of Haematology, Saitama Medical University, 38 Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, 38 Moroyama, Iruma-Gun, Saitama, 350-0495, Japan
| |
Collapse
|
3
|
Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
Collapse
Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
| |
Collapse
|
4
|
Ito S, Saito A, Sakurai A, Watanabe K, Karakawa S, Miyamura T, Yokosuka T, Ueki H, Goto H, Yagasaki H, Kinoshita M, Ozeki M, Yokoyama N, Teranishi H. Eculizumab treatment in paediatric patients diagnosed with aHUS after haematopoietic stem cell transplantation: a HSCT-TMA case series from Japanese aHUS post-marketing surveillance. Bone Marrow Transplant 2024; 59:315-324. [PMID: 38102212 PMCID: PMC10920193 DOI: 10.1038/s41409-023-02161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/26/2023] [Accepted: 11/22/2023] [Indexed: 12/17/2023]
Abstract
Haematopoietic stem-cell transplantation (HSCT)-associated thrombotic microangiopathy (HSCT-TMA) is a serious complication with high mortality. Accumulating evidence suggests that complement dysregulation is potentially involved in the development of HSCT-TMA. We retrospectively analysed the clinical characteristics and outcomes of thirteen paediatric patients who were diagnosed with atypical haemolytic uremic syndrome and treated with eculizumab to manage HSCT-TMA during post-marketing surveillance in Japan. The median time from HSCT to TMA was 31 days (Interquartile range, IQR;21-58) and the median doses of eculizumab was three (IQR;2-5). Seven patients (54%) were alive at the last follow-up while six died due to complications related to HSCT. Six of seven survivors initiated eculizumab after insufficient response to plasma therapy. Following eculizumab treatment, median platelet counts and LDH levels in all survivors significantly improved and renal function improved in 4/7 patients. All survivors possessed potential risk factors of complement overactivation. During the follow-up period after eculizumab discontinuation (median;111.5 days, IQR;95-555), no TMA recurrence was observed. In this analysis, eculizumab showed benefit in over half of this paediatric patient population. Ongoing clinical studies are expected to optimize the treatment regimen of terminal complement pathway inhibitor, and it may become a therapeutic option for paediatric HSCT-TMA in the future.
Collapse
Affiliation(s)
- Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Atsuro Saito
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, 1-6-7 Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Ayako Sakurai
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Iida-cho, Narita, Chiba, 286-8523, Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Shuhei Karakawa
- Department of Pediatrics, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-15 Yamadaoka Suita-shi, Osaka, 565-0871, Japan
| | - Tomoko Yokosuka
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Hideaki Ueki
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Iida-cho, Narita, Chiba, 286-8523, Japan
| | - Hiroaki Goto
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Hiroshi Yagasaki
- Pediatrics, Nihon University Itabashi hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173- 8610, Japan
| | - Mariko Kinoshita
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki, 889-1692, Japan
| | - Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Norifumi Yokoyama
- Department of Pediatrics, Gifu Municipal Hospital, 7-1 Kashima-cho, Gifu, Gifu, 500-8513, Japan
| | | |
Collapse
|
5
|
Nakamura Y, Kato N, Tatematsu Y, Arai Y, Mori N, Shibata K, Yamazaki M, Yasui H, Fujiwara S, Yamakawa T, Maruyama S. Clinical characteristics of anti-GBM disease with thrombotic microangiopathy: a case report and literature review. CEN Case Rep 2024; 13:37-44. [PMID: 37213063 PMCID: PMC10201029 DOI: 10.1007/s13730-023-00797-4] [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: 12/22/2022] [Accepted: 05/12/2023] [Indexed: 05/23/2023] Open
Abstract
The coexistence of anti-glomerular basement membrane (anti-GBM) disease with thrombotic microangiopathy (TMA) is rarely encountered, and the clinical characteristics of this phenomenon are not well known.A 76-year-old Japanese woman with a history of idiopathic pulmonary disease was diagnosed with anti-GBM disease due to rapidly progressive glomerulonephritis and a positive anti-GBM antibody test result. We treated the patient with hemodialysis, glucocorticoids, and plasmapheresis. During treatment, the patient suddenly became comatose. TMA was then diagnosed because of thrombocytopenia and microangiopathic hemolytic anemia. The activity of a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS-13) was retained at 48%. Although we continued the treatment, the patient died of respiratory failure. An autopsy revealed the cause of respiratory failure to be an acute exacerbation of interstitial pneumonia. The clinical findings of the renal specimen indicated anti-GBM disease; however, there were no lesions suggestive of TMA. A genetic test did not reveal an apparent genetic mutation of the atypical hemolytic uremic syndrome.We conducted a literature review of past case reports of anti-GBM disease with TMA. The following clinical characteristics were obtained. First, 75% of the cases were reported in Asia. Second, TMA tended to appear during the treatment course for anti-GBM disease and usually resolved within 12 weeks. Third, ADAMTS-13 activity was retained above 10% in 90% of the cases. Fourth, central nervous system manifestations occurred in more than half of the patients. Fifth, the renal outcome was very poor. Further studies are required to understand the pathophysiology of this phenomenon.
Collapse
Affiliation(s)
- Yoshihiro Nakamura
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan.
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshitaka Tatematsu
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshifumi Arai
- Department of Pathology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Nozomi Mori
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Katsuaki Shibata
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Michiko Yamazaki
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Hirotoshi Yasui
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shinji Fujiwara
- Department of Hematology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Taishi Yamakawa
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| |
Collapse
|
6
|
Wada H, Teranishi H, Shimono A, Kato N, Maruyama S, Matsumoto M. Application of a scoring system in Japanese patients diagnosed with atypical hemolytic uremic syndrome to assess the relationship between the score and clinical responses to eculizumab. Thromb J 2023; 21:43. [PMID: 37072821 PMCID: PMC10114489 DOI: 10.1186/s12959-023-00489-0] [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: 01/25/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is caused by complement dysregulation and is generally diagnosed by exclusion from other disorders of thrombotic microangiopathy (TMA). Eculizumab, a terminal complement inhibitor, has been approved for aHUS treatment since 2013 in Japan. Recently, a scoring system was published to support diagnosis of aHUS. Herein we modified this scoring system to apply it to patients diagnosed with aHUS and treated with eculizumab, and assessed the association between the score and clinical responses to eculizumab. METHODS One hundred eighty-eight Japanese patients who were clinically diagnosed with aHUS, treated with eculizumab, and enrolled in post-marketing surveillance (PMS) were included in this analysis. Some of parameters in the original scoring system were replaced with clinically similar parameters collected in the PMS to modify the system, hereafter referred to as the TMA/aHUS score, which ranges from -15 to 20 points. Treatment responses within 90 days after eculizumab initiation were also assessed, and the relationship between treatment response and TMA/aHUS scores calculated at TMA onset was explored. RESULTS The median (range) TMA/aHUS score was 10 (3-16). Receiver operating characteristic curve analysis showed that the cutoff value of TMA/aHUS score to predict treatment response to eculizumab was estimated as 10, and negative predictive value indicated that ≥ 5 points was appropriate to consider assessing the treatment response to eculizumab; 185 (98%) patients had ≥ 5 points and 3 (2%) had < 5 points. Among the patients with ≥ 5 points, 96.1% showed partial response and 31.1% showed complete response. One of the three patients with < 5 points met partial response criteria. No significant difference in the TMA/aHUS scores was observed between survivors and non-survivors, suggesting that the score was not appropriate to predict the outcome (i.e., survival/death) in patients treated with eculizumab. CONCLUSION Almost all patients clinically diagnosed with aHUS scored ≥ 5 points and responded to eculizumab. The TMA/aHUS score system could become a supporting tool for the clinical diagnosis of aHUS and probability of response to treatment with a C5 inhibitor. TRIAL REGISTRATION This study was conducted as per good PMS practice guidelines for drugs (MHLW Ministerial Ordinance No. 171 of 2004).
Collapse
Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Hinaga, Yokkaichi, Mie, 5450-132, Japan.
| | | | | | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Tsurumai-Cho 65, Showa-ku, Nagoya, Aichi, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Tsurumai-Cho 65, Showa-ku, Nagoya, Aichi, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Shijyo-Cho 840, Kashihara, Nara, Japan
| |
Collapse
|
7
|
CFH-CFHR1 hybrid genes in two cases of atypical hemolytic uremic syndrome. J Hum Genet 2023; 68:427-430. [PMID: 36755127 DOI: 10.1038/s10038-023-01129-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare complement-mediated disease that manifests as the triad of thrombotic microangiopathy. We identified two aHUS patients with neither anti-complement factor H (CFH) antibodies nor causative variants of seven aHUS-related genes (CFH, CFI, CFB, C3, MCP, THBD, and DGKE); however, their plasma showed increased levels of hemolysis by hemolytic assay, which strongly suggests CFH-related abnormalities. Using a copy number variation (CNV) analysis of the CFH/CFHR gene cluster, we identified CFH-CFHR1 hybrid genes in these patients. We verified the absence of aHUS-related abnormal CNVs of the CFH gene in control genomes of 2036 individuals in the general population, which suggests that pathogenicity is related to these hybrid genes. Our study emphasizes that, for patients suspected of having aHUS, it is important to perform an integrated analysis based on a clinical examination, functional analysis, and detailed genetic investigation.
Collapse
|
8
|
Comparison of outcomes after plasma therapy or eculizumab in pediatric patients with atypical hemolytic uremic syndrome. Clin Exp Nephrol 2023; 27:161-170. [PMID: 36336723 DOI: 10.1007/s10157-022-02293-y] [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: 06/10/2022] [Accepted: 10/27/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare and life-threatening disease. For decades, plasma therapy was used to manage patients with aHUS. Since eculizumab, a recombinant humanized anti-C5 monoclonal antibody, was approved for treatment of aHUS, it has been used to treat patients with aHUS. Here, we examined the effectiveness of eculizumab and plasma therapy, respectively in the treatment of pediatric patients with aHUS. METHODS Data were collected from questionnaires sent to 75 institutions known to be treating thrombotic microangiopathy (TMA). RESULTS A total of 24 patients were evaluable, in which no recurrence of TMA was reported at last observation. There were four therapy groups: two patients receiving supportive therapy, one receiving plasma therapy alone, 17 switching from plasma therapy to eculizumab (therapy switched), and four receiving eculizumab alone. Among 17 patients of therapy-switched group, only one patient achieved complete remission at the end of plasma therapy, 15 patients achieved complete remission after eculizumab initiation, and two patients reached end-stage renal disease. Adverse events were reported in nine cases; among these, meningococcal infection, anaphylaxis, and eculizumab-related infusion reaction were reported among those treated with eculizumab. CONCLUSION This study provided substantial evidence from a Japanese population that the conversion from plasma therapy to eculizumab therapy should be considered in patients with aHUS who show an incomplete response to plasma therapy. In addition, although no new safety events were detected, careful attention should be paid to meningococcal infection, eculizumab-related infusion reactions and allergic reactions with administration of eculizumab.
Collapse
|
9
|
Raina R, Sethi SK, Dragon-Durey MA, Khooblall A, Sharma D, Khandelwal P, Shapiro R, Boyer O, Yap HK, Bagga A, Licht C. Systematic review of atypical hemolytic uremic syndrome biomarkers. Pediatr Nephrol 2022; 37:1479-1493. [PMID: 35118546 DOI: 10.1007/s00467-022-05451-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Observing biomarkers that affect alternative pathway dysregulation components may be effective in obtaining a new and more rapid diagnostic portrayal of atypical hemolytic uremic syndrome. We have conducted a systematic review on the aHUS biomarkers: C3, C5a, C5b-9, factor B, complement factor B, H, and I, CH50, AH50, D-dimer, as well as anti-CFH antibodies. METHODS An exhaustive literature search was conducted for aHUS patient population plasma/serum, collected/reported at the onset of diagnosis. A total of 60 studies were included with the data on 837 aHUS subjects, with at least one biomarker reported. RESULTS The biomarkers C3 [mean (SD): 72.1 (35.0), median: 70.5 vs. reference range: 75-175 mg/dl, n = 752]; CH50 [28.3 (32.1), 24.3 vs. 30-75 U/ml, n = 63]; AH50 [27.6% (30.2%), 10% vs. ≥ 46%, n = 23]; and CFB [13.1 (6.6), 12.4, vs. 15.2-42.3 mg/dl, n = 19] were lower among aHUS subjects as compared with the reference range. The biomarkers including C4 [mean (SD): 20.4 (9.5), median: 20.5 vs. reference range: 14-40 mg/dl, n = 343]; C4d [7.2 (6.5), 4.8 vs. ≤ 9.8 μg/ml, n = 108]; CFH [40.2 (132.3), 24.5 vs. 23.6-43.1 mg/dl, n = 123 subjects]; and CFI [8.05 (5.01), 6.55 mg/dl vs. 4.4-18.1 mg/dl, n = 38] were all observed to be within the reference range among aHUS subjects. The biomarkers C5a [mean (SD): 54.9 (32.9), median: 48.8 vs. reference range: 10.6-26.3 mg/dl, n = 117]; C5b-9 [466.0 (401.4), 317 (186-569.7) vs. ≤ 250 ng/ml, n = 174]; Bb [2.6 (2.1), 1.9 vs. ≤ 1.6 μg/ml, n = 77] and D-dimer [246 (65.05), 246 vs. < 2.2 ng/ml, 2, n = 2 subjects] were higher among patients with aHUS compared with the reference range. CONCLUSION If a comprehensive complement profile were built using our data, aHUS would be identified by low levels of C3, CH50, AH50, and CFB along with increased levels of C5a, C5b-9, Bb, anti-CFH autoantibodies, and D-dimer. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
| | - Sidharth K Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | | | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Divya Sharma
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Olivia Boyer
- Service de Néphrologie Pédiatrique, AP-HP, Centre de Référence de maladies rénales rares de l'enfant et de l'adulte (MARHEA), Hôpital Necker - Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France.,Institut Imagine, Laboratoire des maladies rénales héréditaires, INSERM UMR 1163, Université de Paris, Paris, France
| | - Hui Kim Yap
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Kent Ridge, Singapore.,Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Christoph Licht
- Cell Biology Program, SickKids Research Institute, Toronto, ON, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
10
|
Ito S, Hataya H, Ashida A, Hamada R, Ishikawa T, Ishikawa Y, Shimono A, Konomoto T, Miyazawa T, Ogura M, Tanaka K, Kagami S. Eculizumab for paediatric patients with atypical haemolytic uraemic syndrome: full dataset analysis of post-marketing surveillance in Japan. Nephrol Dial Transplant 2022; 38:414-424. [PMID: 35438790 PMCID: PMC9923705 DOI: 10.1093/ndt/gfac150] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Eculizumab was approved for atypical haemolytic uraemic syndrome (aHUS) in Japan in 2013. Post-marketing surveillance (PMS) was mandated by regulatory authorities to assess the safety and effectiveness of eculizumab in patients with aHUS in a real-world setting. METHODS Paediatric patients in the PMS cohort who were <18 years of age at the first administration of eculizumab and diagnosed with aHUS [excluding Shiga toxin-producing Escherichia coli HUS, thrombotic thrombocytopaenic purpura and secondary thrombotic microangiopathy (TMA)] were included in the effectiveness and safety analysis. Clinical endpoints of effectiveness [complete TMA response, TMA event-free status, platelet (PLT) count and lactate dehydrogenase (LDH) normalization, serum creatinine (sCr) decrease and estimated glomerular filtration rate (eGFR) improvement] were analysed in patients treated with at least one dose of eculizumab. Serious adverse events (SAEs) were also evaluated. RESULTS A total of 40 paediatric patients (median age 5 years) were included. The median eculizumab treatment duration was 66 weeks. PLT count, LDH and eGFR significantly improved at 10 days post-treatment. Complete TMA response, haematologic normalization, sCr decrease, eGFR improvement and TMA event-free status were achieved by 73.3%, 73.3%, 70.0%, 78.3% and 77.5% of patients, respectively. Discontinuation criteria were met by 18 patients: 13 patients maintained treatment discontinuation at the end of observation and 5 patients, including 1 patient with aHUS relapse, continued the treatment but extended the treatment interval. During eculizumab treatment, 59 SAEs (0.66/person-year) were reported. Although four deaths were reported, none of them were related to eculizumab. CONCLUSION Eculizumab was well tolerated and effective for paediatric patients with aHUS in the real-world setting in Japan.
Collapse
Affiliation(s)
| | - Hiroshi Hataya
- Department of General Paediatrics, Department of Nephrology, Tokyo Metropolitan Children's Medical Centre, Tokyo, Japan
| | - Akira Ashida
- Department of Paediatrics, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Centre, Tokyo, Japan
| | | | | | | | - Takao Konomoto
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | | | - Masao Ogura
- Division of Nephrology and Rheumatology, Department of Medical Subspecialties, National Centre for Child Health and Development, Tokyo, Japan
| | - Kazuki Tanaka
- Department of Nephrology, Aichi Children's Health and Medical Centre, Aichi, Japan
| | | |
Collapse
|
11
|
Kawano N, Abe T, Ikeda N, Nagahiro Y, Kawano S, Tochigi T, Nakaike T, Yamashita K, Kubo K, Yamanaka A, Terasaka S, Marutsuka K, Mashiba K, Kikuchi I, Shimoda K, Matsumoto M, Ochiai H. Clinical features and outcomes of four atypical hemolytic uremic syndrome cases at a single institution in Miyazaki Prefecture from 2015 to 2019. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although atypical hemolytic uremic syndrome (aHUS) is a life-threatening clinical entity that was characterized by thrombotic microangiopathy (TMA) with the activation of the complement system and the efficient treatment of eculizumab, the clinical features of aHUS have been unclear because of the rare incidence.
Case presentation
We retrospectively analyzed 4 aHUS cases at a single institution during 2015–2019. Here, we presented 4 aHUS cases with renal transplantation (one case), influenza/acute interstitial pneumonia/disseminated intravascular coagulation (two cases), and severe fever with thrombocytopenia syndrome (one case), respectively. Initial clinical symptoms were microangiopathic hemolytic anemia (four cases), renal dysfunction (four cases), thrombocytopenia (four cases), and pulmonary hemorrhage (three cases) consisted with TMA features. Subsequent further examinations ruled out thrombotic thrombocytopenic purpura, Shiga toxin-producing E.coli-induced hemolytic uremic syndrome, and secondary TMA. Taken these findings together, we made the clinical diagnosis of aHUS. Furthermore, all cases also presented the high levels of plasma soluble C5b-9 (871.1 ng/ml, 1144.3 ng/ml, 929.2 ng/ml, and 337.5 ng/ml), suggesting persistent activation of complementary system. Regarding the treatment, plasma exchange (PE) (four cases) and eculizumab (two cases) therapy were administered for aHUS cases. Consequently, case 2 and case 4 were still alive with 768 days and 235 days, respectively. The other two cases were dead at 34 days and 13 days, respectively. Finally, although the previous reported genetic pathogenetic mutations were not detected in our cases, multiple genetic variants of complement factors were detected as CFH (H402Y, E936D), and THBD (A473V) in case 1, CFH (V62I, H402Y, V837I) in case 2, and CFH (H402Y, E 936D) and THBD (A473V) in case 3, CFH (V62I, H402Y, E936D) and THBD (473V) in case 4, respectively.
Conclusions
Because of still high mortality in our study, an urgent diagnosis of aHUS and subsequent immediate treatment including PE and eculizumab should be essential in clinical practice. Furthermore, the multiple genetic variants and the triggers may be related to one of the pathogenesis of aHUS. Thus, we assume that such a case-oriented study would be highly useful to the physicians who directly care for aHUS cases in clinical practice.
Collapse
|
12
|
Katsuno T, Ito Y, Kagami S, Kitamura H, Maruyama S, Shimizu A, Sugiyama H, Sato H, Yokoyama H, Kashihara N. A nationwide cross-sectional analysis of thrombotic microangiopathy in the Japan Renal Biopsy Registry (J-RBR). Clin Exp Nephrol 2020; 24:789-797. [PMID: 32415379 DOI: 10.1007/s10157-020-01896-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 04/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There have been only a few large-scale cohort studies that have reviewed accumulated cases of thrombotic microangiopathy (TMA). The aim of this study was to collect and analyze TMA cases based on the renal biopsy, as a nationwide survey in Japan. METHODS In this cross-sectional study, large nationwide data from the Japan Renal Biopsy Registry (J-RBR) were used. Among the patients registered in the J-RBR online system from July 2007 to July 2017, TMA cases were extracted and epidemiological data and clinical findings were investigated. RESULTS Out of the 38,495 patients enrolled in a period of 10 years, 152 (0.39%) cases had been diagnosed with TMA. The patient age was widely distributed, including 9.2%, 66.4%, and 24.3% for children, adults, and the elderly, respectively. There were various causes of TMA. Among them, hemolytic uremic syndrome (HUS)/thrombotic thrombocytopenic purpura (TTP) (16.4%), connective tissue disease (CTD)-related (17.1%), and drug-induced (16.4%) were frequently observed. The background factors of TMA were different in children and adults. In a comparison between groups consisting of HUS/TTP, CTD-related, and drug-induced, the HUS/TTP group was significantly younger (p = 0.01), and the drug-induced TMA group tended to have a high urinary protein positive rate (p = 0.05). A comparative analysis according to the age group showed significantly higher serum creatinine levels in the elderly (p < 0.01). CONCLUSION This is the first report of epidemiological and clinical data of biopsy-proven TMA in Japan. The characteristics of TMA with diversity based on the underlying disease and age group were reported.
Collapse
Affiliation(s)
- Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazaki, Nagakute, 480-1195, Japan.
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazaki, Nagakute, 480-1195, Japan
| | - Shoji Kagami
- Department of Pediatrics, Tokushima University Graduate School of Medicine, Tokushima, Japan
| | - Hiroshi Kitamura
- Department of Pathology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Sato
- Department of Internal Medicine, Sendai Hospital of East Japan Railway Company, Sendai, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University, Uchinada, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| |
Collapse
|
13
|
Ichikawa Y, Murata M, Aoki M, Nakajima J, Isshiki Y, Sawada Y, Fukushima K, Oshima K. Streptococcus pneumoniae-associated thrombotic microangiopathy in an immunosuppressed adult. Open Med (Wars) 2020; 15:204-210. [PMID: 32258416 PMCID: PMC7101476 DOI: 10.1515/med-2020-0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 02/20/2020] [Indexed: 11/15/2022] Open
Abstract
A 62-year-old male who was receiving prednisolone and methotrexate for scleroderma and rheumatoid arthritis complained of diarrhea and vomiting, and was transferred to our hospital for detailed examination and treatment of renal dysfunction and thrombocytopenia. Hemolytic anemia and crushed erythrocytes were found during the patient’s course; therefore, we suspected thrombotic microangiopathy (TMA). His ADAMTS13 activity was 60.3% and his ADAMTS13 inhibitor was under 0.5. In addition, his blood culture was positive for Streptococcus pneumoniae, and we finally diagnosed Streptococcus pneumoniae-associated TMA (pTMA). The patient was treated with antibiotics and hemodialysis. The patient recovered and was discharged on the 45th hospital day. Adult pTMA cases are remarkably rare. We herein report a successfully treated adult case of pTMA.
Collapse
Affiliation(s)
- Yumi Ichikawa
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
| | - Masato Murata
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| | - Jun Nakajima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| | - Yuta Isshiki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| | - Yusuke Sawada
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| | - Kazunori Fukushima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine , 3-19-15 Showamachi, Maebashi, 371-8511 , Gunma , Japan
- Emergency Medical Center, Gunma University Hospital , 3-19-15 Showa-machi, Maebashi, 371-8511 , Gunma , Japan
| |
Collapse
|
14
|
Lee H, Kang E, Kang HG, Kim YH, Kim JS, Kim HJ, Moon KC, Ban TH, Oh SW, Jo SK, Cho H, Choi BS, Hong J, Cheong HI, Oh D. Consensus regarding diagnosis and management of atypical hemolytic uremic syndrome. Korean J Intern Med 2020; 35:25-40. [PMID: 31935318 PMCID: PMC6960041 DOI: 10.3904/kjim.2019.388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/04/2019] [Indexed: 12/13/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is defined by specific clinical characteristics, including microangiopathic hemolytic anemia, thrombocytopenia, and pathologic evidence of endothelial cell damage, as well as the resulting ischemic end-organ injuries. A variety of clinical scenarios have features of TMA, including infection, pregnancy, malignancy, autoimmune disease, and medications. These overlapping manifestations hamper differential diagnosis of the underlying pathogenesis, despite recent advances in understanding the mechanisms of several types of TMA syndrome. Atypical hemolytic uremic syndrome (aHUS) is caused by a genetic or acquired defect in regulation of the alternative complement pathway. It is important to consider the possibility of aHUS in all patients who exhibit TMA with triggering conditions because of the incomplete genetic penetrance of aHUS. Therapeutic strategies for aHUS are based on functional restoration of the complement system. Eculizumab, a monoclonal antibody against the terminal complement component 5 inhibitor, yields good outcomes that include prevention of organ damage and premature death. However, there remain unresolved challenges in terms of treatment duration, cost, and infectious complications. A consensus regarding diagnosis and management of TMA syndrome would enhance understanding of the disease and enable treatment decision-making.
Collapse
Affiliation(s)
- Hajeong Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Junshik Hong
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hae Il Cheong
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, CHA University School of Medicine, Seongnam, Korea
- Correspondence to Doyeun Oh, M.D. Department of Internal Medicine, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea Tel: +82-31-780-5217, Fax: +82-31-780-5221, E-mail:
| |
Collapse
|
15
|
Sakurai S, Kato H, Yoshida Y, Sugawara Y, Fujisawa M, Yasumoto A, Matsumoto M, Fujimura Y, Yatomi Y, Nangaku M. Profiles of Coagulation and Fibrinolysis Activation-Associated Molecular Markers of Atypical Hemolytic Uremic Syndrome in the Acute Phase. J Atheroscler Thromb 2019; 27:353-362. [PMID: 31484852 PMCID: PMC7192816 DOI: 10.5551/jat.49494] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim: Atypical hemolytic uremic syndrome (aHUS), characterized by thrombotic microangiopathy (TMA), is a genetic, life-threatening disease which needs many differential diagnoses. This study aimed to reveal coagulation and fibrinolysis profiles in aHUS and secondary TMA patients. Furthermore, we investigated whether aHUS patients progress to, and meet, disseminated intravascular coagulation (DIC) criteria. Methods: The acute phase samples were available in 15 aHUS and 20 secondary TMA patients. We measured PT-ratio, activated partial thromboplastin time (APTT), fibrinogen, fibrin degradation product (FDP), fibrin monomer complex (FMC), antithrombin (AT), plasmin-α2 plasmin inhibitor complex (PIC), and von Willebrand factor antigen (VWF:Ag). We examined and compared these tests among aHUS, secondary TMA patients, and healthy volunteer (HV), and evaluated whether patients with aHUS and secondary TMA met DIC criteria. Results: PT-ratio, APTT, FDP, FMC and PIC in patients with aHUS and secondary TMA were higher than those in HV. Fibrinogen and AT showed no significant difference among three groups. VWF:Ag was higher in only aHUS patients. No tests showed significant difference between aHUS and secondary TMA patients. Three aHUS patients out of 15 met DIC criteria. Conclusion: We revealed the profiles and distributions of coagulation and fibrinolysis tests of aHUS and secondary TMA patients. All tests were enhanced compared to HV; however, our results showed the no specificities in distinguishing aHUS from secondary TMA patients. We also clarified that some aHUS patients fulfilled DIC diagnostic criteria, indicating that DIC itself cannot be an exclusion criterion of aHUS.
Collapse
Affiliation(s)
- Satoko Sakurai
- Division of Nephrology and Endocrinology, the University of Tokyo Graduate School of Medicine
| | - Hideki Kato
- Division of Nephrology and Endocrinology, the University of Tokyo Graduate School of Medicine
| | - Yoko Yoshida
- Division of Nephrology and Endocrinology, the University of Tokyo Graduate School of Medicine
| | - Yuka Sugawara
- Division of Nephrology and Endocrinology, the University of Tokyo Graduate School of Medicine
| | - Madoka Fujisawa
- Division of Nephrology and Endocrinology, the University of Tokyo Graduate School of Medicine
| | - Atsushi Yasumoto
- Department of Clinical Laboratory Medicine, the University of Tokyo Graduate School of Medicine
| | | | | | - Yutaka Yatomi
- Department of Clinical Laboratory Medicine, the University of Tokyo Graduate School of Medicine
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Graduate School of Medicine
| |
Collapse
|
16
|
Bagga A, Khandelwal P, Mishra K, Thergaonkar R, Vasudevan A, Sharma J, Patnaik SK, Sinha A, Sethi S, Hari P, Dragon-Durey MA. Hemolytic uremic syndrome in a developing country: Consensus guidelines. Pediatr Nephrol 2019; 34:1465-1482. [PMID: 30989342 DOI: 10.1007/s00467-019-04233-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/06/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is a leading cause of acute kidney injury in children. Although international guidelines emphasize comprehensive evaluation and treatment with eculizumab, access to diagnostic and therapeutic facilities is limited in most developing countries. The burden of Shiga toxin-associated HUS in India is unclear; school-going children show high prevalence of anti-factor H (FH) antibodies. The aim of the consensus meeting was to formulate guidelines for the diagnosis and management of HUS in children, specific to the needs of the country. METHODS Four workgroups performed literature review and graded research studies addressing (i) investigations, biopsy, genetics, and differential diagnosis; (ii) Shiga toxin, pneumococcal, and infection-associated HUS; (iii) atypical HUS; and (iv) complement blockade. Consensus statements developed by the workgroups were discussed during a consensus meeting in March 2017. RESULTS An algorithm for classification and evaluation was developed. The management of Shiga toxin-associated HUS is supportive; prompt plasma exchanges (PEX) is the chief therapy in patients with atypical HUS. Experts recommend that patients with anti-FH-associated HUS be managed with a combination of PEX and immunosuppressive medications. Indications for eculizumab include incomplete remission with plasma therapy, life-threatening features, complications of PEX or vascular access, inherited defects in complement regulation, and recurrence of HUS in allografts. Priorities for capacity building in regional and national laboratories are highlighted. CONCLUSIONS Limited diagnostic capabilities and lack of access to eculizumab prevent the implementation of international guidelines for HUS in most developing countries. We propose practice guidelines for India, which will perhaps be applicable to other developing countries.
Collapse
Affiliation(s)
- Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Ranjeet Thergaonkar
- Department of Pediatrics, Indian Naval Hospital Ship, Kalyani, Visakhapatnam, India
| | - Anil Vasudevan
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | - Saroj Kumar Patnaik
- Department of Pediatrics, Army Hospital Research & Referral, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sidharth Sethi
- Department of Nephrology, Medanta Hospital, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Marie-Agnes Dragon-Durey
- Laboratory of Immunology, Hopital Europeen Georges Pompidou, INSERM UMRS 1138, Paris Descartes University, Paris, France
| | | |
Collapse
|
17
|
Sharma J, Banerjee S. Summary of 'Hemolytic uremic syndrome in a developing country: Consensus guidelines'. ACTA ACUST UNITED AC 2019. [DOI: 10.4103/ajpn.ajpn_21_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
18
|
Saida K, Ogura M, Kano Y, Ishimori S, Yoshikawa T, Nagata H, Sato M, Kamei K, Ishikura K. Treatment of hemolytic uremic syndrome related to Bordetella pertussis infection -is plasma exchange or eculizumab use necessary? BMC Nephrol 2018; 19:365. [PMID: 30558570 PMCID: PMC6297948 DOI: 10.1186/s12882-018-1168-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/03/2018] [Indexed: 11/23/2022] Open
Abstract
Background Bordetella pertussis infection is a known trigger of atypical hemolytic uremic syndrome (HUS). For patients suspected of having atypical HUS, prompt plasma exchange/infusion (PE/PI) or eculizumab (ECZ) treatment is recommended. Case presentation We report a 1-month-old female infant who was admitted with a severe cough and a B. pertussis-positive sputum culture. She was born at 38 weeks gestation and did not have a family history of renal diseases. Hemophagocytic syndrome was suspected and she was transferred to our hospital 17 days after her initial admission. One day later, she developed acute kidney injury and was diagnosed with HUS triggered by B. pertussis infection. Her plasma complement levels were low and her kidney function continued to worsen over the next few days. However, prior to starting ECZ treatment, her kidney function improved spontaneously; she did not receive PE/PI or ECZ. She was discharged 46 days after her initial hospitalization, without complications. A genetic workup revealed no mutations in CFH, CFI, CFB, C3, MCP, THBD, or DGKE. Conclusions This case demonstrates that B. pertussis infection-related HUS may resolve spontaneously. The decision to treat during the acute phase is challenging because B. pertussis often affects infants suspected of having atypical HUS. However, ECZ may not be the first treatment option for patients with B. pertussis infection-related HUS unless they show an indicated genetic abnormality; if ECZ is used, early discontinuation should be considered.
Collapse
Affiliation(s)
- Ken Saida
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yuji Kano
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Kakogawa Central City Hospital, Hyogo, Japan
| | - Takahisa Yoshikawa
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Hiroko Nagata
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Katagiri D, Hinoshita F. Gemcitabine-induced thrombotic microangiopathy with nephrotic syndrome. CEN Case Rep 2018; 7:217-220. [PMID: 29766468 PMCID: PMC6181898 DOI: 10.1007/s13730-018-0332-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/16/2018] [Indexed: 12/17/2022] Open
Abstract
We encountered a case of gemcitabine (GEM)-induced secondary thrombotic microangiopathy (TMA) with nephrotic syndrome. Advanced pancreatic cancer with liver metastasis had originally been diagnosed. Renal biopsy showed focal reduplication of the glomerular basement membrane, endothelial cell swelling, and narrowed capillary lumens with fragmented erythrocytes and fibrin deposition, compatible with TMA. Regular monitoring of renal function during GEM treatment and discontinuation of treatment if acute kidney injury (AKI) might occur is crucial, because AKI combined with TMA is life-threatening.
Collapse
Affiliation(s)
- Daisuke Katagiri
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fumihiko Hinoshita
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, 162-8655, Tokyo, Japan.
| |
Collapse
|
21
|
Ito S, Hidaka Y, Inoue N, Kaname S, Kato H, Matsumoto M, Miyakawa Y, Mizuno M, Okada H, Shimono A, Matsuda T, Maruyama S, Fujimura Y, Nangaku M, Kagami S. Safety and effectiveness of eculizumab for pediatric patients with atypical hemolytic-uremic syndrome in Japan: interim analysis of post-marketing surveillance. Clin Exp Nephrol 2018; 23:112-121. [PMID: 30039480 PMCID: PMC6344608 DOI: 10.1007/s10157-018-1610-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/18/2018] [Indexed: 01/18/2023]
Abstract
Background In 2013, eculizumab was approved for treatment of the atypical hemolytic–uremic syndrome (aHUS) in Japan, which was defined as a thrombotic microangiopathy (TMA) excluding Shiga toxin-producing Escherichia coli-HUS and thrombotic thrombocytopenic purpura. Simultaneously, post-marketing surveillance was started to assess its safety and effectiveness. In 2016, Japanese clinical guide redefined terms to limit the use of “aHUS” to complement-mediated HUS only. Accordingly, TMA with other causes was defined as secondary TMA. Here we report the interim analysis of post-marketing surveillance of pediatric patients with aHUS and secondary TMA. Methods Pediatric patients treated with eculizumab from approval to 15 March 2017 were included in this observational real-world study. Clinical endpoints of effectiveness were TMA event–free status, complete TMA response, platelet count normalization, and improvement of estimated glomerular filtration rate (eGFR). Adverse reactions to eculizumab were also analyzed. Results In 27 pediatric patients with aHUS, median age at diagnosis was 4 years. Complement genes’ variants were detected in 14 of 21 patients (66.7%). Median time from diagnosis to eculizumab initiation was 2.0 days. TMA event–free status, complete TMA response, platelet normalization, and improvement in eGFR were achieved in 85.2, 36.4, 78.3, and 75.0% of patients, respectively. Three patients with aHUS died. Twenty-four and 10 adverse reactions were reported in 31 aHUS patients and 17 secondary TMA patients, respectively; however, no eculizumab-related death or meningococcal infection was reported. Conclusions This interim analysis confirmed that eculizumab is well-tolerated and effective for Japanese pediatric patients with aHUS in a real-world setting. Electronic supplementary material The online version of this article (10.1007/s10157-018-1610-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Yoshihiko Hidaka
- Clinical Division of Pediatrics, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Norimitsu Inoue
- Department of Tumor Immunology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hideki Kato
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yoshitaka Miyakawa
- Department of General Internal Medicine, Thrombosis and Hemostasis Center, Saitama Medical University Hospital, 38 Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Masashi Mizuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hirokazu Okada
- Saitama Medical University, 38 Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Akihiko Shimono
- Alexion Pharma GK, 1-18-14 Ebisu, Shibuya-ku, Tokyo, 150-0013, Japan
| | - Takahisa Matsuda
- Alexion Pharma GK, 1-18-14 Ebisu, Shibuya-ku, Tokyo, 150-0013, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yoshihiro Fujimura
- Japanese Red Cross Kinki Block Blood Center, 7-5-17, Saitoasagi, Ibaraki, Osaka, 567-0085, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shoji Kagami
- Department of Pediatrics, Institute of Health Biosciences, The University of Tokushima Graduate School, Kuramoto cho 3-chome, Tokushima, 770-8503, Japan
| |
Collapse
|
22
|
Kume S, Nagasu H, Nangaku M, Nishiyama A, Nakamoto H, Kashihara N. Summary of the 2018 ISN Frontiers Meeting: Kidney Disease and Cardiovascular Disease. Kidney Int Rep 2018. [PMCID: PMC6035142 DOI: 10.1016/j.ekir.2018.04.002] [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] [Indexed: 11/29/2022] Open
Abstract
International Society of Nephrology (ISN) Frontiers meetings build on the success of the ISN Nexus and Forefronts series by bringing together basic scientists, clinicians, and practitioners in a unique setting. This new event was organized to make more innovative science available to a global audience by removing regional barriers in accessing the latest knowledge. The first ISN Frontiers meeting was organized in partnership between the Japanese Society of Nephrology and the Japanese Society for Dialysis Therapy, which was held in Tokyo in February 2018. The meeting focused on the topic “Kidney Disease & Cardiovascular Disease,” which covered a broad range of scientific and clinical fields, including nephrology, cardiovascular diseases, dialysis, transplantation, chronic kidney disease (CKD)–mineral bone disease (MBD), diabetes, pediatric nephrology, nutrition, pharmacology, and nursing. A total of 1584 active physicians and scientists from 64 countries attended the meeting, and a number of leading physician scientists from different and related disciplines of clinical and basic research described and reviewed recent discoveries. This report summarizes the main highlights of the meeting lectures.
Collapse
Affiliation(s)
- Shinji Kume
- Department of Medicine, Shiga University of Medical Science, Shiga, Japan
- Correspondence: Shinji Kume, Department of Medicine, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga 520-2192, Japan.
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Kagawa University, Kagawa, Japan
| | - Hidetomo Nakamoto
- Department of General Internal Medicine, Saitama Medical University, Saitama, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| |
Collapse
|
23
|
Safety and effectiveness of eculizumab for adult patients with atypical hemolytic-uremic syndrome in Japan: interim analysis of post-marketing surveillance. Clin Exp Nephrol 2018; 23:65-75. [PMID: 29959568 PMCID: PMC6344388 DOI: 10.1007/s10157-018-1609-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022]
Abstract
Background Eculizumab has been available for the treatment of atypical hemolytic–uremic syndrome (aHUS) in Japan since 2013. To assess safety and effectiveness of eculizumab in adult aHUS patients in the real-life setting, we performed interim analysis of a post-marketing surveillance mandated by Japanese regulations. Methods This study enrolled any patient who was diagnosed with TMA excluding Shiga toxin-producing Escherichia coli-HUS or thrombotic thrombocytopenic purpura based on Japanese clinical guide published in 2013 as inclusion criteria and treated with eculizumab. Although the term aHUS was redefined to denote only complement-mediated HUS in the guide revised in 2016, the patients with TMA caused by other causes (secondary TMA) were included. Patient outcomes and safety were evaluated at 6 months, 12 months, and annually thereafter. Results Thirty-three patients with aHUS and 27 patients with secondary TMA were enrolled. Median treatment duration of aHUS was 24weeks. Complement genes variants were detected in 11 of 18 patients with aHUS (61.1%). Among the 29 aHUS patients with available baseline data, platelet count (PLT), lactic dehydrogenase and serum creatinine (SCr) improved within 1-month after eculizumab initiation. TMA event-free status, complete TMA response, PLT normalization, and SCr decrease were achieved in 67.9% (19/28), 27.8% (5/18), 56.5% (13/23), and 57.1% (16/28) of patients, respectively. Thirty-three and 11 adverse reactions were observed in patients with aHUS (13/33 patients) and secondary TMA (6/27 patients), respectively. Conclusions This interim analysis confirmed the acceptable safety profile and effectiveness of eculizumab for Japanese adult aHUS patients in real-world settings. Electronic supplementary material The online version of this article (10.1007/s10157-018-1609-8) contains supplementary material, which is available to authorized users.
Collapse
|
24
|
Ono M, Ohashi N, Namikawa A, Katahashi N, Ishigaki S, Tsuji N, Isobe S, Iwakura T, Sakao Y, Tsuji T, Kato A, Fujigaki Y, Shimizu A, Yasuda H. A Rare Case of Lupus Nephritis Presenting as Thrombotic Microangiopathy with Diffuse Pseudotubulization Possibly Caused by Atypical Hemolytic Uremic Syndrome. Intern Med 2018; 57:1617-1623. [PMID: 29434134 PMCID: PMC6028688 DOI: 10.2169/internalmedicine.0228-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
A 31-year-old woman was admitted to our hospital for thrombotic microangiopathy (TMA). She was diagnosed with systemic lupus erythematosus (SLE) and class V lupus nephritis. She had no aggravated SLE activity, Shiga toxin positivity, ADAMTS13 abnormality, or other causes of secondary TMA. Plasma exchange partially improved TMA, and eculizumab was introduced for suspected atypical hemolytic uremic syndrome (aHUS), as eculizumab was effective in suppressing the TMA activity. A kidney biopsy revealed diffusely organized crescents (pseudotubulization) with glomerular and arteriolar endothelial injury and subepithelial immune deposits. Thus, this was a rare case of lupus nephritis presenting as TMA with pseudotubulization possibly caused by aHUS.
Collapse
Affiliation(s)
- Masafumi Ono
- Blood Purification Unit, Hamamatsu University School of Medicine, Japan
| | - Naro Ohashi
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Akio Namikawa
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Naoko Katahashi
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Sayaka Ishigaki
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Naoko Tsuji
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Shinsuke Isobe
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Takamasa Iwakura
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | | | - Takayuki Tsuji
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Akira Shimizu
- Department of Pathology, Nihon University School of Medicine, Japan
| | - Hideo Yasuda
- Division of Nephrology, First Department of Medicine, Hamamatsu University School of Medicine, Japan
| |
Collapse
|
25
|
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.
Collapse
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.
| |
Collapse
|
26
|
Clinical features in a series of 258 Japanese pediatric patients with thrombotic microangiopathy. Clin Exp Nephrol 2018; 22:924-930. [DOI: 10.1007/s10157-018-1531-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/31/2017] [Indexed: 01/12/2023]
|
27
|
Yamada S, Yamashita H, Nakano M, Hatano H, Sasaki T, Takahashi Y, Kaneko H. Thrombotic Microangiopathy with Polymyositis/Dermatomyositis: Three Case Reports and a Literature Review. Intern Med 2018; 57:2259-2265. [PMID: 30068898 PMCID: PMC6120848 DOI: 10.2169/internalmedicine.0512-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) rarely accompany polymyositis/dermatomyositis. We treated three patients with dermatomyositis combined with TMA. A literature review identified 13 previously reported cases. Exacerbation of myositis at the time of the TMA onset was observed in 62.5% of all patients, suggesting that the TMA onset may be associated with autoantibody production. We also found that cases of TMA with polymyositis/dermatomyositis often had a poor treatment response rate (37.5%). Furthermore, even if treatment was effective, the mortality rate associated with subsequent complications was high, and the survival rate was low (18.8%). Therefore, careful attention should be paid to patient management after TMA treatment.
Collapse
Affiliation(s)
- Saeko Yamada
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| | - Masahiro Nakano
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| | - Hiroaki Hatano
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| | - Toshiharu Sasaki
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| | - Yuko Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Japan
| |
Collapse
|
28
|
Kato H, Nangaku M, Okada H, Kagami S. Controversies of the classification of TMA and the terminology of aHUS. Clin Exp Nephrol 2017; 22:979-980. [PMID: 29282571 DOI: 10.1007/s10157-017-1524-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Hideki Kato
- Division of Nephrology and Endocrinology, School of Medicine, The University of Tokyo, 7-3-1 Hongo,Bunkyo, Tokyo, 113-8655, Japan.
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, School of Medicine, The University of Tokyo, 7-3-1 Hongo,Bunkyo, Tokyo, 113-8655, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Iruma, Saitama, Japan
| | - Shoji Kagami
- Department of Pediatrics, Graduate School of Medical Sciences, Tokushima University, Tokushima, Tokushima, Japan
| |
Collapse
|
29
|
Krishnappa V, Gupta M, Elrifai M, Moftakhar B, Ensley MJ, Vachharajani TJ, Sethi SK, Raina R. Atypical Hemolytic Uremic Syndrome: A Meta-Analysis of Case Reports Confirms the Prevalence of Genetic Mutations and the Shift of Treatment Regimens. Ther Apher Dial 2017; 22:178-188. [DOI: 10.1111/1744-9987.12641] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/16/2017] [Accepted: 09/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates; Akron Ohio USA
- Department of Internal Medicine and Nephrology; Cleveland Clinic Akron General; Akron Ohio USA
| | - Mohit Gupta
- Department of Nephrology; Weill Cornell Medicine/NewYork Presbyterian; New York USA
- Department of Internal Medicine and Nephrology; Cleveland Clinic Akron General; Akron Ohio USA
| | - Mohamed Elrifai
- Cleveland Clinic Akron General/Akron Nephrology Associates; Akron Ohio USA
| | - Bahar Moftakhar
- Department of Internal Medicine; Summa Health System; Akron Ohio USA
| | - Michael J Ensley
- Department of Political Science; Kent State University; Kent Ohio USA
| | - Tushar J Vachharajani
- Division of Nephrology and Hypertension; Salisbury VA Health Care System; Salisbury NC USA
| | | | - Rupesh Raina
- Cleveland Clinic Akron General/Akron Nephrology Associates; Akron Ohio USA
- Department of Internal Medicine and Nephrology; Cleveland Clinic Akron General; Akron Ohio USA
| |
Collapse
|
30
|
Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) 2017 in Japan. Int J Hematol 2017; 106:3-15. [DOI: 10.1007/s12185-017-2264-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/21/2017] [Accepted: 05/21/2017] [Indexed: 01/12/2023]
|
31
|
|
32
|
Mizuno M, Suzuki Y, Ito Y. Complement regulation and kidney diseases: recent knowledge of the double-edged roles of complement activation in nephrology. Clin Exp Nephrol 2017; 22:3-14. [DOI: 10.1007/s10157-017-1405-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/14/2017] [Indexed: 12/28/2022]
|