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Brodszki N, Frazer-Abel A, Grumach AS, Kirschfink M, Litzman J, Perez E, Seppänen MRJ, Sullivan KE, Jolles S. European Society for Immunodeficiencies (ESID) and European Reference Network on Rare Primary Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN RITA) Complement Guideline: Deficiencies, Diagnosis, and Management. J Clin Immunol 2020; 40:576-591. [PMID: 32064578 PMCID: PMC7253377 DOI: 10.1007/s10875-020-00754-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/20/2020] [Indexed: 12/14/2022]
Abstract
This guideline aims to describe the complement system and the functions of the constituent pathways, with particular focus on primary immunodeficiencies (PIDs) and their diagnosis and management. The complement system is a crucial part of the innate immune system, with multiple membrane-bound and soluble components. There are three distinct enzymatic cascade pathways within the complement system, the classical, alternative and lectin pathways, which converge with the cleavage of central C3. Complement deficiencies account for ~5% of PIDs. The clinical consequences of inherited defects in the complement system are protean and include increased susceptibility to infection, autoimmune diseases (e.g., systemic lupus erythematosus), age-related macular degeneration, renal disorders (e.g., atypical hemolytic uremic syndrome) and angioedema. Modern complement analysis allows an in-depth insight into the functional and molecular basis of nearly all complement deficiencies. However, therapeutic options remain relatively limited for the majority of complement deficiencies with the exception of hereditary angioedema and inhibition of an overactivated complement system in regulation defects. Current management strategies for complement disorders associated with infection include education, family testing, vaccinations, antibiotics and emergency planning.
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Affiliation(s)
- Nicholas Brodszki
- Department of Pediatrics, Children's Hospital, Skåne University Hospital, Lund, Sweden
| | - Ashley Frazer-Abel
- Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anete S Grumach
- Clinical Immunology, Reference Center on Rare Diseases, University Center Health ABC, Santo Andre, SP, Brazil
| | | | - Jiri Litzman
- Department of Clinical Immunology and Allergology, St Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Elena Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, FL, USA
| | - Mikko R J Seppänen
- Rare Disease Center, Children's Hospital, and Adult Primary Immunodeficiency Outpatient Clinic, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, Cardiff University & University Hospital of Wales, Cardiff, UK.
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Sepe V, Gregorini M, Rampino T, Esposito P, Coppo R, Galli F, Libetta C. Vitamin e-loaded membrane dialyzers reduce hemodialysis inflammaging. BMC Nephrol 2019; 20:412. [PMID: 31729973 PMCID: PMC6858730 DOI: 10.1186/s12882-019-1585-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 10/13/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Inflammaging is a persistent, low-grade, sterile, nonresolving inflammatory state, associated with the senescence of the immune system. Such condition downregulates both innate and adaptive immune responses during chronic disorders as type II diabetes, cancer and hemodialysis, accounting for their susceptibility to infections, malignancy and resistance to vaccination. Aim of this study was to investigate hemodialysis inflammaging, by evaluating changes of several hemodialysis treatments on indoleamine 2,3-dioxygenase-1 activity and nitric oxide formation. METHODS We conducted a randomized controlled observational crossover trial. Eighteen hemodialysis patients were treated with 3 different hemodialysis procedures respectively: 1) Low-flux bicarbonate hemodialysis, 2) Low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers, and 3) Hemodialfitration. The control group consisted of 14 hospital staff healthy volunteers. Blood samples were collected from all 18 hemodialysis patients just after the long interdialytic interval, at the end of each hemodialysis treatment period. RESULTS Hemodialysis kynurenine and kynurenine/L - tryptophan blood ratio levels were significantly higher, when compared to the control group, indicating an increased indoleamine 2,3-dioxygenase-1 activity in hemodialysis patients. At the end of the low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers period, L - tryptophan serum levels remained unchanged vs both low-flux bicarbonate hemodialysis and hemodialfitration. Kynurenine levels instead decreased, resulting in a significant reduction of kynurenine/L - tryptophan blood ratio and indoleamine 2,3-dioxygenase-1 activity, when matched to both low-flux bicarbonate hemodialysis and HDF respectively. Serum nitric oxide control group levels, were significantly lower when compared to all hemodialysis patient groups. Interestingly, low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers nitric oxide serum levels from venous line blood samples taken 60 min after starting the hemodialysis session were significantly lower vs serum taken simultaneously from the arterial blood line. CONCLUSIONS The treatment with more biocompatible hemodialysis procedure as low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers, reduced indoleamine 2,3-dioxygenase-1 activity and nitric oxide formation when compared to both low-flux bicarbonate hemodialysis and hemodialfitration. These data suggest that low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers lowering hemodialysis inflammaging, could be associated to changes of proinflammatory signalling a regulated molecular level. TRIAL REGISTRATION NCT Number: NCT02981992; Other Study ID Numbers: 20100014090. First submitted: November 26, 2016. First posted: December 5, 2016. Last Update Posted: December 5, 2016.
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Affiliation(s)
- Vincenzo Sepe
- 0000 0004 1760 3027grid.419425.fUnit of Nephrology and Dialysis, Transplantation; Fondazione IRCCS Policlinico «San Matteo», Viale Camillo Golgi 19, 27100 Pavia, Italy
- 0000 0004 1760 3027grid.419425.fUOC di Nefrologia e Dialisi, Trapianto, Fondazione IRCCS Policlinico «San Matteo», Viale Camillo Golgi, 19, 27100 Pavia, Italy
| | - Marilena Gregorini
- 0000 0004 1760 3027grid.419425.fUnit of Nephrology and Dialysis, Transplantation; Fondazione IRCCS Policlinico «San Matteo», Viale Camillo Golgi 19, 27100 Pavia, Italy
- 0000 0004 1762 5736grid.8982.bChair of Nephrology, University of Pavia, Corso Strada Nuova 65, 27100 Pavia, Italy
| | - Teresa Rampino
- 0000 0004 1760 3027grid.419425.fUnit of Nephrology and Dialysis, Transplantation; Fondazione IRCCS Policlinico «San Matteo», Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Pasquale Esposito
- 0000 0004 1760 3027grid.419425.fUnit of Nephrology and Dialysis, Transplantation; Fondazione IRCCS Policlinico «San Matteo», Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Rosanna Coppo
- 0000 0004 5907 3255grid.478931.0Fondazione Ricerca Molinette, Regina Margherita Hospital 94, Piazza Polonia, 10126 Torino, Italy
| | - Francesco Galli
- 0000 0004 1757 3630grid.9027.cUniversità degli Studi di Perugia, Pharmaceutical Sciences, Branch of Via del Giochetto, building B, 2nd floor, 06123 Perugia, Italy
| | - Carmelo Libetta
- 0000 0004 1760 3027grid.419425.fUnit of Nephrology and Dialysis, Transplantation; Fondazione IRCCS Policlinico «San Matteo», Viale Camillo Golgi 19, 27100 Pavia, Italy
- 0000 0004 1762 5736grid.8982.bChair of Nephrology, University of Pavia, Corso Strada Nuova 65, 27100 Pavia, Italy
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Zipfel PF, Wiech T, Rudnick R, Afonso S, Person F, Skerka C. Complement Inhibitors in Clinical Trials for Glomerular Diseases. Front Immunol 2019; 10:2166. [PMID: 31611870 PMCID: PMC6776600 DOI: 10.3389/fimmu.2019.02166] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/28/2019] [Indexed: 01/16/2023] Open
Abstract
Defective complement action is a cause of several human glomerular diseases including atypical hemolytic uremic syndrome (aHUS), anti-neutrophil cytoplasmic antibody mediated vasculitis (ANCA), C3 glomerulopathy, IgA nephropathy, immune complex membranoproliferative glomerulonephritis, ischemic reperfusion injury, lupus nephritis, membranous nephropathy, and chronic transplant mediated glomerulopathy. Here we summarize ongoing clinical trials of complement inhibitors in nine glomerular diseases and show which inhibitors are used in trials for these renal disorders (http://clinicaltrials.gov).
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Affiliation(s)
- Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.,Friedrich-Schiller-University, Jena, Germany
| | - Thorsten Wiech
- Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ramona Rudnick
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Sara Afonso
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Fermin Person
- Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Skerka
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
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Abstract
Nephrotic syndrome is characterized by edema, proteinuria, hypoalbuminemia, and hyperlipidemia. Minimal change disease, the most common cause in childhood, generally responds to corticosteroids, although most patients experience disease relapses. Focal segmental glomerulosclerosis is usually resistant to corticosteroids and carries a significant risk of kidney failure, necessitating renal transplantation. Nephrotic syndrome may also be secondary to gene mutations and systemic diseases such as lupus. Clinical evaluation involves distinguishing primary and secondary causes and monitoring for disease complications, including blood clots and serious infections such as spontaneous bacterial peritonitis. Immunosuppressive medications are used to prevent relapses and treat corticosteroid-resistant disease.
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Affiliation(s)
- Chia-Shi Wang
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322-1015, USA.
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322-1015, USA
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Abbas F, El Kossi M, Kim JJ, Shaheen IS, Sharma A, Halawa A. Complement-mediated renal diseases after kidney transplantation - current diagnostic and therapeutic options in de novo and recurrent diseases. World J Transplant 2018; 8:203-219. [PMID: 30370231 PMCID: PMC6201327 DOI: 10.5500/wjt.v8.i6.203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/09/2018] [Accepted: 08/28/2018] [Indexed: 02/05/2023] Open
Abstract
For decades, kidney diseases related to inappropriate complement activity, such as atypical hemolytic uremic syndrome and C3 glomerulopathy (a subtype of membranoproliferative glomerulonephritis), have mostly been complicated by worsened prognoses and rapid progression to end-stage renal failure. Alternative complement pathway dysregulation, whether congenital or acquired, is well-recognized as the main driver of the disease process in these patients. The list of triggers include: surgery, infection, immunologic factors, pregnancy and medications. The advent of complement activation blockade, however, revolutionized the clinical course and outcome of these diseases, rendering transplantation a viable option for patients who were previously considered as non-transplantable cases. Several less-costly therapeutic lines and likely better efficacy and safety profiles are currently underway. In view of the challenging nature of diagnosing these diseases and the long-term cost implications, a multidisciplinary approach including the nephrologist, renal pathologist and the genetic laboratory is required to help improve overall care of these patients and draw the optimum therapeutic plan.
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Affiliation(s)
- Fedaey Abbas
- Nephrology Department, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Jin Kim
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ihab Sakr Shaheen
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Hospital for Children, Glasgow G51 4TF, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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The effect on the immunology laboratory of the expansion in complement therapeutics. J Immunol Methods 2018; 461:30-36. [PMID: 30092178 DOI: 10.1016/j.jim.2018.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022]
Abstract
The approval in the US and Europe of Eculizumab in 2007 marked a change in complement therapeutics, and with it the landscape for complement testing in the clinical immunology laboratory changed. The change had begun even before that when C1-Inhibitor preparations were approved in the 1980s in Europe. There are now two classes of approved drugs that may impact the immunology laboratory, with two dozen more with novel modalities and potential indications that are in various stages of development. Every pathway and about every component of complement has been targeted by these drug development programs, and the modalities of the drugs in development are diverse. These developments will likely result in more laboratories offering more complement testing, so this review looks forward to some of those possible changes in testing.
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