1
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Java A, Atkinson J, Hu Z, Pozzi N. Mutations in atypical hemolytic uremic syndrome provide evidence for the role of calcium in complement factor I. Blood 2023; 142:607-610. [PMID: 37363824 PMCID: PMC10447607 DOI: 10.1182/blood.2022019361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/29/2023] [Accepted: 04/26/2023] [Indexed: 06/28/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare thrombotic microangiopathy. Genetic variants in complement proteins are found in ≈60% of patients. Of these patients, ≈15% carry mutations in complement factor I (CFI). Factor I (FI) is a multidomain serine protease that cleaves and thereby inactivates C3b and C4b in the presence of cofactor proteins. Crystal structures have shown that FI possesses 2 calcium-binding domains, low-density lipoprotein receptor class A (LDLRA) 1 and LDLRA2. Yet, the role of calcium in FI is unknown. We determined that 9 genetic variants identified in aHUS (N151S, G162D, G188A, V230E, A240G, G243R, C247G, A258T, and Q260D) cluster around the calcium-binding site of LDLRA1. Using site-directed mutagenesis, we established that the synthesis of all, except A258T, was impaired, implying defective protein folding, perhaps due to loss of calcium binding. To further explore this possibility, we generated 12 alanine mutants that coordinate with the calcium in LDLRA1 and LDLRA2 (K239A, D242A, I244A, D246A, D252A, E253A, Y276A, N279A, E281A, D283A, D289A, and D290A) and are expected to perturb calcium binding. Except for K239A and Y276A, none of the mutants was secreted. These observations suggest that calcium ions play key structural and functional roles in FI.
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Affiliation(s)
- Anuja Java
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - John Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Zheng Hu
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Nicola Pozzi
- Department of Biochemistry and Molecular Biology, Edward A. Doisy Research Center, Saint Louis University School of Medicine, St. Louis, MO
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2
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Yerigeri K, Kadatane S, Mongan K, Boyer O, Burke LLG, Sethi SK, Licht C, Raina R. Atypical Hemolytic-Uremic Syndrome: Genetic Basis, Clinical Manifestations, and a Multidisciplinary Approach to Management. J Multidiscip Healthc 2023; 16:2233-2249. [PMID: 37560408 PMCID: PMC10408684 DOI: 10.2147/jmdh.s245620] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy (TMA) defined by the triad of hemolytic anemia, thrombocytopenia, and acute kidney injury. Microthrombi develop in the glomerular capillaries secondary to endothelial damage and exert shear stress on red blood cells, consume platelets, and contribute to renal dysfunction and failure. Per current understanding of pathophysiology, HUS is classified into infectious, secondary, and atypical disease. The most common etiology is infectious sequelae of Shiga toxin-producing Escherichia coli (STEC); other causative organisms include shigella and salmonella. Secondary HUS arises from cancer, chemotherapy, solid organ and hematopoietic stem cell transplant, pregnancy, or autoimmune disorders. Primary atypical hemolytic-uremic syndrome (aHUS) is associated with genetic mutations in complement and complement regulatory proteins. Under physiologic conditions, complement regulators keep the alternative complement system continuously active at low levels. In times of inflammation, mutations in complement-related proteins lead to uncontrolled complement activity. The hyperactive inflammatory state leads to glomerular endothelial damage, activation of the coagulation cascade, and TMA findings. Atypical hemolytic-uremic syndrome is a rare disorder with a prevalence of 2.21 to 9.4 per million people aged 20 years or younger; children between the ages of 0 and 4 are most affected. Multidisciplinary health care is necessary for timely management of its extra-renal manifestations. These include vascular disease of the heart, brain, and skin, pulmonary hypertension and hemorrhage, and pregnancy complications. Adequate screening is required to monitor for sequelae. First-line treatment is the monoclonal antibody eculizumab, but several organ systems may require specialized interventions and coordination of care with sub-specialists.
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Affiliation(s)
- Keval Yerigeri
- Department of Internal Medicine-Pediatrics, Case Western Reserve University/The MetroHealth System, Cleveland, OH, USA
| | - Saurav Kadatane
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kai Mongan
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Olivia Boyer
- Department of Pediatric Nephrology, Dialysis and Transplantation, Necker-Enfants Malades Hospital, MARHEA reference Center, Imagine Institute, Paris Cité University, Paris, France
| | - Linda L G Burke
- aHUS Global Advocate with aHUS Alliance, Cape Elizabeth, ME, USA
| | - Sidharth Kumar Sethi
- Department of Pediatric Nephrology and Pediatric Renal Transplant Medicine, Kidney and Urology Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Rupesh Raina
- Division of Pediatric Nephrology, Akron Children’s Hospital, Akron, OH, USA
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3
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Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol 2023; 141:85-108. [PMID: 36455925 DOI: 10.1097/aog.0000000000005024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 12/05/2022]
Abstract
The most common thrombotic microangiopathy (TMA) of pregnancy is the well-recognized syndrome of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, rare TMAs, including thrombotic thrombocytopenic purpura, complement-mediated hemolytic-uremic syndrome, and catastrophic antiphospholipid syndrome, may occur during pregnancy or postpartum and present with features similar to those of preeclampsia with severe features. Early recognition and treatment of these infrequently encountered conditions are key for avoiding serious maternal morbidities with long-term sequelae and possible maternal or fetal death. Differentiating between preeclampsia with severe features and these rare TMAs is diagnostically challenging as there is significant overlap in their clinical and laboratory presentation. Given the rarity of these TMAs, high-quality evidence-based recommendations on diagnosis and management during pregnancy are lacking. Using current objective information and recommendations from working groups, this report provides practical clinical approaches to diagnose and manage these rare TMAs. This report also discusses how to manage individuals with a history of these rare TMAs who are planning to conceive. To optimize favorable outcomes, a multidisciplinary approach including obstetricians, maternal-fetal medicine specialists, hematologists, and nephrologists alongside close clinical and laboratory monitoring is vital.
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Fujita Y, Terashita M, Yazawa M, Yamasaki Y, Imamura T, Kibayashi J, Sawai T, Hidaka Y, Ohtani K, Inoue N, Shibagaki Y. Eculizumab for Severe Thrombotic Microangiopathy Secondary to Surgical Invasive Stress and Bleeding. Intern Med 2020; 59:93-99. [PMID: 31902910 PMCID: PMC6995713 DOI: 10.2169/internalmedicine.3315-19] [Citation(s) in RCA: 4] [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: 12/18/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is an extremely rare condition caused by an excessive activation of the complement pathway based on genetic or acquired dysfunctions in complement regulation, leading to thrombotic microangiopathy (TMA). A complement-amplifying condition (CAC) can trigger aHUS occurrence along with complement abnormality. We herein report a case of severe TMA after laparoscopic myomectomy in a healthy woman. This case was eventually diagnosed as complement-mediated TMA secondary to surgical invasive stress as a CAC, with no definitive diagnosis of aHUS despite a genetic test. The patient fully recovered after several eculizumab administrations.
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Affiliation(s)
- Yoko Fujita
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Maho Terashita
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
| | - Yukitaka Yamasaki
- Department of Infectious Disease, St. Marianna University School of Medicine, Japan
| | - Tomonori Imamura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Police Hospital, Japan
| | | | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Japan
| | - Yoshihiko Hidaka
- Department of Molecular Genetics, Wakayama Medical University, Japan
- The Japanese Association for Complement Research, Japan
| | - Katsuki Ohtani
- The Japanese Association for Complement Research, Japan
- Department of Food and Health Sciences, Rakuno Gakuen University, Japan
| | - Norimitsu Inoue
- Department of Molecular Genetics, Wakayama Medical University, Japan
- The Japanese Association for Complement Research, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Japan
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5
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Extra-renal manifestations of atypical hemolytic uremic syndrome. Pediatr Nephrol 2019; 34:1337-1348. [PMID: 30109445 PMCID: PMC8627279 DOI: 10.1007/s00467-018-4039-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 01/31/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare and complex disease resulting from abnormal alternative complement activation with a wide range of clinical presentations. Extra-renal manifestations of aHUS can involve many organ systems, including the peripheral and central nervous, gastrointestinal, cardiovascular, integumentary, pulmonary, as well as the eye. While some of these extra-renal manifestations occur in the acute phase of aHUS, some can also occur as long-term sequelae of unopposed complement activation. Extra-renal symptoms are observed in approximately 20% of patients with aHUS, with the incidence of specific organ system complications ranging from a few case reports to 50% of described patients. Careful monitoring for extra-renal involvement is critical in patients with aHUS, as prompt evaluation and management may decrease the risk of high morbidity and mortality associated with aHUS.
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6
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Berger BE. Atypical hemolytic uremic syndrome: a syndrome in need of clarity. Clin Kidney J 2019; 12:338-347. [PMID: 31198222 PMCID: PMC6543964 DOI: 10.1093/ckj/sfy066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Indexed: 12/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) originally understood to be limited to renal and hematopoietic involvement. Whereas aberrations in complement regulatory proteins (CRPs), C3 or complement factor B (CFB) are detected in ∼60% of patients, a complement-derived pathogenesis that reflects dysregulation of the alternative pathway (AP) of complement activation is present in ∼90% of patients. aHUS remains a diagnosis of exclusion. The discovery of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) and its utility in the diagnosis of thrombotic thrombocytopenic purpura (TTP) has resulted in the appreciation that cases of aHUS have been inappropriately diagnosed as TTP. Thus there has been an evolving appreciation of clinical manifestations of aHUS that renders the appellation aHUS misleading. This article will review the pathogenesis and the evolving clinical presentations of aHUS, present a hypothesis that there can be a phenotypic expression of aHUS due to a complement storm in a disorder where direct endothelial damage occurs and discuss future areas of research to more clearly define the clinical spectrum and management of aHUS.
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Affiliation(s)
- Bruce E Berger
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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7
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Tao J, Lieberman J, Lafayette RA, Kambham N. A rare case of Alport syndrome, atypical hemolytic uremic syndrome and Pauci-immune crescentic glomerulonephritis. BMC Nephrol 2018; 19:355. [PMID: 30541482 PMCID: PMC6291978 DOI: 10.1186/s12882-018-1170-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022] Open
Abstract
Background Renal thrombotic microangiopathy (TMA) is occasionally seen in biopsies with pauci-immune necrotizing crescentic glomerulonephritis (PCGN). Recent study indicated that the complement activation is more prominent in the ANCA-negative glomerulonephritis. Case presentation We report a case of concurrent TMA and PCGN without ANCA positivity. Interestingly, our patient also had biopsy features supportive of Alport syndrome (AS). Genetic studies identified variants and polymorphisms in alternative complement pathway genes that confer substantial risk of developing atypical hemolytic uremic syndrome (aHUS). Conclusions Abnormal activation in complement pathway may represent a common pathogenic link between these three distinct entities.
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Affiliation(s)
- Jianling Tao
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, USA
| | | | - Richard A Lafayette
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University, Stanford, CA, USA.
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8
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Neave L, Scully M. Microangiopathic Hemolytic Anemia in Pregnancy. Transfus Med Rev 2018; 32:230-236. [PMID: 30177429 DOI: 10.1016/j.tmrv.2018.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/23/2018] [Accepted: 08/14/2018] [Indexed: 11/19/2022]
Abstract
Thrombotic microangiopathies (TMAs) are associated with microangiopathic hemolytic anemia and thrombocytopenia, resulting in microvascular thrombosis and end-organ damage. In pregnancy, this may be the result of pregnancy-related TMAs such as preeclampsia; hemolysis, elevated liver enzymes, and low platelets; or pregnancy-associated TMAs, specifically thrombotic thrombocytopenic purpura (TTP) or complement-mediated hemolytic uremic syndrome (CM HUS). TTP and CM HUS are rare disorders, and their diagnosis may be missed, no less because features at presentation may be misdiagnosed as a pregnancy-related TMA, such as hypertension, proteinuria, fetal growth restriction, or in utero fetal death. The mainstay of treatment for pregnancy-associated TMAs is plasma exchange. Presentation is likely in the third trimester for TTP and postpartum for CM HUS. However, both conditions can present in any trimester, unlike pregnancy-related TMAs which rarely present before the second trimester, commonly in the third trimester. Delivery is the mainstay of treatment for pregnancy-related TMAs. More recently, it has become clear that pregnancy may be a trigger for late-onset congenital TTP, as well as immune-mediated TTP, diagnosed by ADAMTS13 analysis. Complement inhibitor therapy is the treatment of choice for CM HUS cases. However, their diagnosis is by exclusion, but complement inhibitor therapy reduces the risk of end-stage renal failure. Subsequent pregnancies can be supported for TTP and CM HUS.
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Affiliation(s)
- Lucy Neave
- Department of Haematology, UCLH, London, UK
| | - Marie Scully
- Department of Haematology, UCLH, Cardiometabolic Programme NIHR UCLH/UCL BRC, London, UK.
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9
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Wada H, Matsumoto T, Suzuki K, Imai H, Katayama N, Iba T, Matsumoto M. Differences and similarities between disseminated intravascular coagulation and thrombotic microangiopathy. Thromb J 2018; 16:14. [PMID: 30008620 PMCID: PMC6040080 DOI: 10.1186/s12959-018-0168-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/21/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction Both disseminated intravascular coagulation (DIC) and thrombotic microangiopathy (TMA) cause microvascular thrombosis associated with thrombocytopenia, bleeding tendency and organ failure. Reports and discussion The frequency of DIC is higher than that of thrombotic thrombocytopenic purpura (TTP). Many patients with TMA are diagnosed with DIC, but only about 15% of DIC patients are diagnosed with TMA. Hyperfibrinolysis is observed in most patients with DIC, and microangiopathic hemolytic anemia is observed in most patients with TMA. Markedly decreased ADAMTS13 activity, the presence of Shiga-toxin-producing Escherichia coli (STEC) and abnormality of the complement system are useful for the diagnosis of TTP, STEC-hemolytic uremic syndrome (HUS)and atypical HUS, respectively. However, there are no specific biomarkers for the diagnosis of DIC. Conclusion Although DIC and TMA are similar appearances, all coagulation, fibrinolysis and platelet systems are activated in DIC, and only platelets are markedly activated in TMA.
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Affiliation(s)
- Hideo Wada
- 1Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Mie 514-8507 Japan
| | - Takeshi Matsumoto
- 2Division of Blood Transfusion Medicine and Cell Therapy, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kei Suzuki
- 3Emergency Critical Care Center, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroshi Imai
- 3Emergency Critical Care Center, Mie University Graduate School of Medicine, Tsu, Japan
| | - Naoyuki Katayama
- 4Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Toshiaki Iba
- 5Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masanori Matsumoto
- 6Department of Blood Transfusion Medicine, Nara Medical University, Nara, Japan
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10
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Zheng JM, Ren XG, Jiang ZH, Chen DJ, Zhao WJ, Li LJ. Lectin-induced renal local complement activation is involved in tubular interstitial injury in diabetic nephropathy. Clin Chim Acta 2018; 482:65-73. [DOI: 10.1016/j.cca.2018.03.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/26/2018] [Accepted: 03/26/2018] [Indexed: 01/05/2023]
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11
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Wu X, Hutson I, Akk AM, Mascharak S, Pham CTN, Hourcade DE, Brown R, Atkinson JP, Harris CA. Contribution of Adipose-Derived Factor D/Adipsin to Complement Alternative Pathway Activation: Lessons from Lipodystrophy. THE JOURNAL OF IMMUNOLOGY 2018. [PMID: 29531168 DOI: 10.4049/jimmunol.1701668] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Factor D (FD) is an essential component of the complement alternative pathway (AP). It is an attractive pharmaceutical target because it is an AP-specific protease circulating in blood. Most components of the complement activation pathways are produced by the liver, but FD is highly expressed by adipose tissue. Two critical questions are: 1) to what degree does adipose tissue contribute to circulating FD levels and 2) what quantity of FD is sufficient to maintain a functional AP? To address these issues, we studied a novel mouse strain with complete lipodystrophy (LD), the fld mouse with partial LD, an FD-deficient mouse, and samples from lipodystrophic patients. FD was undetectable in the serum of LD mice, which also showed minimal AP function. Reconstitution with purified FD, serum mixing experiments, and studies of partial LD mice all demonstrated that a low level of serum FD is sufficient for normal AP activity in the mouse system. This conclusion was further supported by experiments in which wild-type adipose precursors were transplanted into LD mice. Our results indicate that almost all FD in mouse serum is derived from adipose tissue. In contrast, FD levels were reduced ∼50% in the sera of patients with congenital generalized LD. Our studies further demonstrate that a relatively small amount of serum FD is sufficient to facilitate significant time-dependent AP activity in humans and in mice. Furthermore, this observation highlights the potential importance of obtaining nearly complete inhibition of FD in treating alternative complement activation in various autoimmune and inflammatory human diseases.
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Affiliation(s)
- Xiaobo Wu
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110;
| | - Irina Hutson
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Antonina M Akk
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Smita Mascharak
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90095
| | - Christine T N Pham
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110.,Section of Rheumatology, Department of Medicine, St. Louis Veterans Affairs Medical Center, St. Louis, MO 63106
| | - Dennis E Hourcade
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Rebecca Brown
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20814; and
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Charles A Harris
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110; .,Section of Endocrinology, Department of Medicine, St. Louis Veterans Affairs Medical Center, St. Louis, MO 63106
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12
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Andries G, Karass M, Yandrapalli S, Linder K, Liu D, Nelson J, Pawar R, Chugh S. Atypical hemolytic uremic syndrome in first trimester pregnancy successfully treated with eculizumab. Exp Hematol Oncol 2017; 6:4. [PMID: 28101432 PMCID: PMC5237177 DOI: 10.1186/s40164-017-0064-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/06/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome is a rare disorder which is known to cause acute thrombotic microangiopathy during pregnancy with poor maternal and fetal outcomes. Atypical hemolytic uremic syndrome is caused mostly by dysregulation of alternative complement pathway secondary to genetic mutations. Most of the cases reported have been in the post-partum period. We report a rare case of a patient who presents with thrombotic microangiopathy in the first trimester of her eleventh pregnancy and was successfully treated with eculizumab. CASE PRESENTATION A 30-year-old woman presented at 10 weeks of gestation with hypertension, hemolytic anemia, thrombocytopenia, and acute kidney injury, consistent with thrombotic microangiopathy. She was managed initially with daily plasmapheresis. However, her kidney function did not recover, requiring hemodialysis. ADAMTS13 activity was later found to be within normal limit, hence diagnosis of atypical hemolytic uremic syndrome was strongly considered at that time and she was immediately treated with anti-C5 humanized monoclonal antibody (eculizumab). The patient responded well (resolution of thrombotic microangiopathy and recovery of renal function) to eculizumab, with continued remission after discharge and successfully delivered a healthy baby at term without any peripartum complications. CONCLUSION Early recognition of atypical hemolytic uremic syndrome is often difficult as several other conditions also manifest as thrombotic microangiopathy during pregnancy, causing delay in initiating appropriate treatment. Our case suggests that treatment of atypical hemolytic uremic syndrome in early trimester of pregnancy with eculizumab results in good outcome to mother and fetus.
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Affiliation(s)
- Gabriela Andries
- Division of Internal Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Michael Karass
- Division of Internal Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Srikanth Yandrapalli
- Division of Internal Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Katherine Linder
- Division of Internal Medicine, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Delong Liu
- Division of Hematology and Oncology, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - John Nelson
- Division of Hematology and Oncology, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Rahul Pawar
- Division of Nephrology, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Savneek Chugh
- Division of Nephrology, New York Medical College, Westchester Medical Center, Valhalla, NY 10595 USA
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13
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Parente R, Clark SJ, Inforzato A, Day AJ. Complement factor H in host defense and immune evasion. Cell Mol Life Sci 2016; 74:1605-1624. [PMID: 27942748 PMCID: PMC5378756 DOI: 10.1007/s00018-016-2418-4] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 12/30/2022]
Abstract
Complement is the major humoral component of the innate immune system. It recognizes pathogen- and damage-associated molecular patterns, and initiates the immune response in coordination with innate and adaptive immunity. When activated, the complement system unleashes powerful cytotoxic and inflammatory mechanisms, and thus its tight control is crucial to prevent damage to host tissues and allow restoration of immune homeostasis. Factor H is the major soluble inhibitor of complement, where its binding to self markers (i.e., particular glycan structures) prevents complement activation and amplification on host surfaces. Not surprisingly, mutations and polymorphisms that affect recognition of self by factor H are associated with diseases of complement dysregulation, such as age-related macular degeneration and atypical haemolytic uremic syndrome. In addition, pathogens (i.e., non-self) and cancer cells (i.e., altered-self) can hijack factor H to evade the immune response. Here we review recent (and not so recent) literature on the structure and function of factor H, including the emerging roles of this protein in the pathophysiology of infectious diseases and cancer.
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Affiliation(s)
- Raffaella Parente
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Simon J Clark
- Division of Evolution and Genomic Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Antonio Inforzato
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy. .,Department of Medical Biotechnologies and Translational Medicine, University of Milan, Via Vanvitelli 32, 20129, Milan, Italy.
| | - Anthony J Day
- Wellcome Trust Centre for Cell-Matrix Research, Division of Cell-Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.
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14
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Novikov P, Kozlovskaya N, Moiseev S, Shilov E, Bobkova I, Schreiber A, Tsvetkov D, Gollasch M, Mah N, El Amrani K, Kurtz A. Therapeutic Complement Targeting in ANCA-Associated Vasculitides and Thrombotic Microangiopathy. Biomed Hub 2016; 1:1-11. [PMID: 31988889 PMCID: PMC6945915 DOI: 10.1159/000453106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/26/2016] [Indexed: 11/19/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of systemic autoimmune disorders characterized by necrotizing inflammation of medium-to-small vessels, a relative paucity of immune deposits, and an association with detectable circulating ANCAs. AAVs include granulomatosis with polyangiitis (renamed from Wegener's granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Until recently, AAVs have not been viewed as complement-mediated disorders. However, recent findings predominantly from animal studies demonstrated a crucial role of the complement system in the pathogenesis of AAVs. Complement activation or defects in its regulation have been described in an increasing number of acquired or genetically driven forms of thrombotic microangiopathy. Coinciding with this expanding spectrum of complement-mediated diseases, the question arises as to which AAV patients might benefit from a complement-targeted therapy. Therapies directed against the complement system point to the necessity of a genetic workup of genes of complement components and regulators in patients with AAV. Genetic testing together with pluripotent stem cells and bioinformatics tools may broaden our approach to the treatment of patients with aggressive forms of AAV.
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Affiliation(s)
- Pavel Novikov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Sergey Moiseev
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Eugene Shilov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Irina Bobkova
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Adrian Schreiber
- Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine at the Charité and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Nephrology and Intensive Care Medicine, Campus Virchow, Berlin, Germany
| | - Dmitry Tsvetkov
- Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine at the Charité and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Nephrology and Intensive Care Medicine, Campus Virchow, Berlin, Germany
| | - Maik Gollasch
- Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine at the Charité and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Nephrology and Intensive Care Medicine, Campus Virchow, Berlin, Germany
- Koch Metchnikoff Forum, Section Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nancy Mah
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Khadija El Amrani
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Kurtz
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
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