1
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Wei X, Tu Y, Bu S, Guo G, Wang H, Wang Z. Unraveling the Intricate Web: Complement Activation Shapes the Pathogenesis of Sepsis-Induced Coagulopathy. J Innate Immun 2024; 16:337-353. [PMID: 38815564 PMCID: PMC11249610 DOI: 10.1159/000539502] [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: 02/21/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Sepsis-associated coagulopathy specifically refers to widespread systemic coagulation activation accompanied by a high risk of hemorrhage and organ damage, which in severe cases manifests as disseminated intravascular coagulation (DIC), or even develops into multiple organ dysfunction syndrome (MODS). The complement system and the coagulation system as the main columns of innate immunity and hemostasis, respectively, undergo substantial activation after sepsis. SUMMARY Dysfunction of the complement, coagulation/fibrinolytic cascades caused by sepsis leads to "thromboinflammation," which ultimately amplifies the systemic inflammatory response and accelerates the development of MODS. Recent studies have revealed that massive activation of the complement system exacerbates sepsis-induced coagulation and even results in DIC, which suggests that inhibition of complement activation may have therapeutic potential in the treatment of septic coagulopathy. KEY MESSAGES Sepsis-associated thrombosis involves the upregulation or activation of procoagulant factors, down-regulation or inactivation of anticoagulant factors, and impairment of the fibrinolytic mechanism. This review aims to summarize the latest literature and analyze the underlying molecular mechanisms of the activation of the complement system on the abnormal coagulation cascades in sepsis.
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Affiliation(s)
- Xin Wei
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ye Tu
- Department of Pharmacy, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuhong Bu
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guimei Guo
- Department of Pediatric Nephrology and Rheumatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongbin Wang
- Master Program of Pharmaceutical Scieneces College of Graduate Studies, Department of Pharmaceutical and Biomedical Sciences College of Pharmacy, Department of Basic Science College of Medicine, California Northstate University, Elk Grove, CA, USA
| | - Zhibin Wang
- Department of Critical Care Medicine, School of Anesthesiology, Naval Medical University, Shanghai, China
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2
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [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: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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3
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Liang Y, Liu D, Zhan J, Liu X, Li P, Ma X, Hou H, Wang P. Polystyrene microplastics induce kidney injury via gut barrier dysfunction and C5a/C5aR pathway activation. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2024; 342:122909. [PMID: 38036092 DOI: 10.1016/j.envpol.2023.122909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/21/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
Microplastic is an emerging environmental pollutant with potential health risks. Recent studies have shown that microplastic could impair gut homeostasis in mammals. Although it has been widely demonstrated that gut dyshomeostasis could impact renal health through the gut-kidney axis, the effects of microplastic-induced gut dyshomeostasis on renal health and underlying mechanisms are still largely unknown. In the current work, we found that polystyrene microplastics (PS-MPs) treatment impaired the gut barrier, increased urinary complement-activated product C5a levels and renal C5aR expression, leading to chronic kidney disease-related symptoms in mice. Restoring the gut barrier using an antibiotic mixture effectively alleviated PS-MPs-induced kidney injury, indicating the involvement of the gut-kidney axis in PS-MPs-induced renal injury. Moreover, it also mitigated PS-MPs-induced alterations in urinary C5a levels and renal C5aR expression, suggesting that the renal C5a/C5aR pathway might be involved in PS-MPs' impacts on the gut-kidney axis. Further experiments using a C5aR inhibitor, PMX53, verified the vital role of renal C5a/C5aR pathway activation in the development of kidney injury induced by PS-MPs. Collectively, our results suggest that PS-MPs induce kidney injury in mice by impairing the gut barrier, increasing C5a levels, and ultimately activating the renal C5a/C5aR pathway, highlighting the crucial role of the gut-kidney axis in PS-MPs-induced kidney injury.
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Affiliation(s)
- Yiran Liang
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China; College of Chemistry and Biological Engineering, University of Science and Technology Beijing, No. 30, Xueyuan Road, Beijing, 100083, People's Republic of China
| | - Donghui Liu
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China
| | - Jing Zhan
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China
| | - Xueke Liu
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China
| | - Peize Li
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China
| | - Xiaoran Ma
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China
| | - Haonan Hou
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China
| | - Peng Wang
- College of Science, China Agricultural University, No. 2, West Yuanmingyuan Road, Beijing, 100193, People's Republic of China.
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4
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Liu X, Hu Y, Yu X, Tan Y, Yu F, Chen M, Zhao M. Differential contributions of the C5b-9 and C5a/C5aR pathways to microvascular and macrovascular thrombosis in complement-mediated thrombotic microangiopathy patients. Clin Immunol 2024; 259:109871. [PMID: 38101498 DOI: 10.1016/j.clim.2023.109871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/18/2023] [Accepted: 10/31/2023] [Indexed: 12/17/2023]
Abstract
To clarify the role of the C5a/C5aR (C5a receptor) and C5b-9 pathways in macrovascular thrombosis (MAT) and renal microthrombosis (MIT), 73 renal biopsy-proven complement-mediated thrombotic microangiopathy (C-TMA) patients were enrolled; 9 patients with pure MAT and 13 patients with pure MIT were selected for further study. Twenty-five external C-TMA patients were selected as the validation cohort. Plasma C5a and sC5b-9 (soluble C5b-9) levels were significantly higher in patients with MAT than in those with MIT (P = 0.008, P = 0.041, respectively). The mean optical density of C5aR1 in the kidney was significantly higher in MAT patients than in those with MIT (P < 0.001). Both urinary sC5b-9 levels (MIT: P < 0.001, MAT: P = 0.004) and renal deposition of C5b-9 (MIT: P < 0.001, MAT: P = 0.001) were significantly higher in C-TMA patients compared to normal control, but were similar between MAT and MIT groups. In the correlation analysis within 22C-TMA patients, urinary sC5b-9 levels and renal deposition of C5b-9 were positively correlated to renal MIT formation (P = 0.009 and P = 0.031, respectively). Furthermore, the renal citrullinated histone H3 (CitH3)- and neutrophil elastase (NE)-positive area ratios were both significantly higher in the MAT group than in the MIT group (P = 0.006 and P = 0.020, respectively). Therefore, the local C5b-9 and C5a/C5aR1 pathways might have differential contributions to MIT and MAT formation in the disease.
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Affiliation(s)
- Xiaotian Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China
| | - Yifang Hu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China
| | - Xiaojuan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China; Department of Nephrology, Peking University International Hospital, Beijing 102206, PR China.
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology; Key laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing 100034, PR China; Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100034, PR China
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5
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Miwa T, Sato S, Golla M, Song WC. Expansion of Anticomplement Therapy Indications from Rare Genetic Disorders to Common Kidney Diseases. Annu Rev Med 2024; 75:189-204. [PMID: 37669567 DOI: 10.1146/annurev-med-042921-102405] [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] [Indexed: 09/07/2023]
Abstract
Complement constitutes a major part of the innate immune system. The study of complement in human health has historically focused on infection risks associated with complement protein deficiencies; however, recent interest in the field has focused on overactivation of complement as a cause of immune injury and the development of anticomplement therapies to treat human diseases. The kidneys are particularly sensitive to complement injury, and anticomplement therapies for several kidney diseases have been investigated. Overactivation of complement can result from loss-of-function mutations in complement regulators; gain-of-function mutations in key complement proteins such as C3 and factor B; or autoantibody production, infection, or tissue stresses, such as ischemia and reperfusion, that perturb the balance of complement activation and regulation. Here, we provide a high-level review of the status of anticomplement therapies, with an emphasis on the transition from rare diseases to more common kidney diseases.
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Affiliation(s)
- Takashi Miwa
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
| | - Sayaka Sato
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
| | - Madhu Golla
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
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6
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Fakhouri F, Schwotzer N, Frémeaux-Bacchi V. How I diagnose and treat atypical hemolytic uremic syndrome. Blood 2023; 141:984-995. [PMID: 36322940 DOI: 10.1182/blood.2022017860] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Our understanding and management of atypical hemolytic uremic syndrome (aHUS) have dramatically improved in the last decade. aHUS has been established as a prototypic disease resulting from a dysregulation of the complement alternative C3 convertase. Subsequently, prospective nonrandomized studies and retrospective series have shown the efficacy of C5 blockade in the treatment of this devastating disease. C5 blockade has become the cornerstone of the treatment of aHUS. This therapeutic breakthrough has been dulled by persistent difficulties in the positive diagnosis of aHUS, and the latter remains, to date, a diagnosis by exclusion. Furthermore, the precise spectrum of complement-mediated renal thrombotic microangiopathy is still a matter of debate. Nevertheless, long-term management of aHUS is increasingly individualized and lifelong C5 blockade is no longer a paradigm that applies to all patients with this disease. The potential benefit of complement blockade in other forms of HUS, notably secondary HUS, remains uncertain.
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Affiliation(s)
- Fadi Fakhouri
- Department of Medicine, Service of Nephrology and Hypertension, Lausanne University Hospital and Université de Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Department of Medicine, Service of Nephrology and Hypertension, Lausanne University Hospital and Université de Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Laboratory of Immunology, Paris University, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Paris, France
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7
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Linde IL, Prestwood TR, Qiu J, Pilarowski G, Linde MH, Zhang X, Shen L, Reticker-Flynn NE, Chiu DKC, Sheu LY, Van Deursen S, Tolentino LL, Song WC, Engleman EG. Neutrophil-activating therapy for the treatment of cancer. Cancer Cell 2023; 41:356-372.e10. [PMID: 36706760 PMCID: PMC9968410 DOI: 10.1016/j.ccell.2023.01.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 11/02/2022] [Accepted: 01/05/2023] [Indexed: 01/27/2023]
Abstract
Despite their cytotoxic capacity, neutrophils are often co-opted by cancers to promote immunosuppression, tumor growth, and metastasis. Consequently, these cells have received little attention as potential cancer immunotherapeutic agents. Here, we demonstrate in mouse models that neutrophils can be harnessed to induce eradication of tumors and reduce metastatic seeding through the combined actions of tumor necrosis factor, CD40 agonist, and tumor-binding antibody. The same combination activates human neutrophils in vitro, enabling their lysis of human tumor cells. Mechanistically, this therapy induces rapid mobilization and tumor infiltration of neutrophils along with complement activation in tumors. Complement component C5a activates neutrophils to produce leukotriene B4, which stimulates reactive oxygen species production via xanthine oxidase, resulting in oxidative damage and T cell-independent clearance of multiple tumor types. These data establish neutrophils as potent anti-tumor immune mediators and define an inflammatory pathway that can be harnessed to drive neutrophil-mediated eradication of cancer.
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Affiliation(s)
- Ian L Linde
- Program in Immunology, Stanford University, Stanford, CA 94305, USA; Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Tyler R Prestwood
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Jingtao Qiu
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Genay Pilarowski
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Miles H Linde
- Program in Immunology, Stanford University, Stanford, CA 94305, USA
| | - Xiangyue Zhang
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Lei Shen
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | | | | | - Lauren Y Sheu
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Simon Van Deursen
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Lorna L Tolentino
- Department of Pathology, Stanford University, Stanford, CA 94305, USA
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edgar G Engleman
- Program in Immunology, Stanford University, Stanford, CA 94305, USA; Department of Pathology, Stanford University, Stanford, CA 94305, USA.
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8
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Schubart A, Flohr S, Junt T, Eder J. Low-molecular weight inhibitors of the alternative complement pathway. Immunol Rev 2023; 313:339-357. [PMID: 36217774 PMCID: PMC10092480 DOI: 10.1111/imr.13143] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Dysregulation of the alternative complement pathway predisposes individuals to a number of diseases. It can either be evoked by genetic alterations in or by stabilizing antibodies to important pathway components and typically leads to severe diseases such as paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, C3 glomerulopathy, and age-related macular degeneration. In addition, the alternative pathway may also be involved in many other diseases where its amplifying function for all complement pathways might play a role. To identify specific alternative pathway inhibitors that qualify as therapeutics for these diseases, drug discovery efforts have focused on the two central proteases of the pathway, factor B and factor D. Although drug discovery has been challenging for a number of reasons, potent and selective low-molecular weight (LMW) oral inhibitors have now been discovered for both proteases and several molecules are in clinical development for multiple complement-mediated diseases. While the clinical development of these inhibitors initially focuses on diseases with systemic and/or peripheral tissue complement activation, the availability of LMW inhibitors may also open up the prospect of inhibiting complement in the central nervous system where its activation may also play an important role in several neurodegenerative diseases.
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Affiliation(s)
- Anna Schubart
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Stefanie Flohr
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Tobias Junt
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Jörg Eder
- Novartis Institutes for BioMedical Research, Basel, Switzerland
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9
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Schmidt CQ, Smith RJH. Protein therapeutics and their lessons: Expect the unexpected when inhibiting the multi-protein cascade of the complement system. Immunol Rev 2023; 313:376-401. [PMID: 36398537 PMCID: PMC9852015 DOI: 10.1111/imr.13164] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Over a century after the discovery of the complement system, the first complement therapeutic was approved for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). It was a long-acting monoclonal antibody (aka 5G1-1, 5G1.1, h5G1.1, and now known as eculizumab) that targets C5, specifically preventing the generation of C5a, a potent anaphylatoxin, and C5b, the first step in the eventual formation of membrane attack complex. The enormous clinical and financial success of eculizumab across four diseases (PNH, atypical hemolytic uremic syndrome (aHUS), myasthenia gravis (MG), and anti-aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorder (NMOSD)) has fueled a surge in complement therapeutics, especially targeting diseases with an underlying complement pathophysiology for which anti-C5 therapy is ineffective. Intensive research has also uncovered challenges that arise from C5 blockade. For example, PNH patients can still face extravascular hemolysis or pharmacodynamic breakthrough of complement suppression during complement-amplifying conditions. These "side" effects of a stoichiometric inhibitor like eculizumab were unexpected and are incompatible with some of our accepted knowledge of the complement cascade. And they are not unique to C5 inhibition. Indeed, "exceptions" to the rules of complement biology abound and have led to unprecedented and surprising insights. In this review, we will describe initial, present and future aspects of protein inhibitors of the complement cascade, highlighting unexpected findings that are redefining some of the mechanistic foundations upon which the complement cascade is organized.
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Affiliation(s)
- Christoph Q. Schmidt
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany
| | - Richard J. H. Smith
- Departments of Internal Medicine and Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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10
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Pryzdial ELG, Leatherdale A, Conway EM. Coagulation and complement: Key innate defense participants in a seamless web. Front Immunol 2022; 13:918775. [PMID: 36016942 PMCID: PMC9398469 DOI: 10.3389/fimmu.2022.918775] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/06/2022] [Indexed: 12/30/2022] Open
Abstract
In 1969, Dr. Oscar Ratnoff, a pioneer in delineating the mechanisms by which coagulation is activated and complement is regulated, wrote, “In the study of biological processes, the accumulation of information is often accelerated by a narrow point of view. The fastest way to investigate the body’s defenses against injury is to look individually at such isolated questions as how the blood clots or how complement works. We must constantly remind ourselves that such distinctions are man-made. In life, as in the legal cliché, the devices through which the body protects itself form a seamless web, unwrinkled by our artificialities.” Our aim in this review, is to highlight the critical molecular and cellular interactions between coagulation and complement, and how these two major component proteolytic pathways contribute to the seamless web of innate mechanisms that the body uses to protect itself from injury, invading pathogens and foreign surfaces.
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Affiliation(s)
- Edward L. G. Pryzdial
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, BC, Canada
- *Correspondence: Edward L. G. Pryzdial, ; Edward M. Conway,
| | - Alexander Leatherdale
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Edward M. Conway
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Edward L. G. Pryzdial, ; Edward M. Conway,
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11
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Estrada CC, Cardona S, Guo Y, Revelo MP, D'Agati VD, Koganti S, Devaraj J, He JC, Heeger PS, Mallipattu SK. Endothelial-specific loss of Krüppel-Like Factor 4 triggers complement-mediated endothelial injury. Kidney Int 2022; 102:58-77. [PMID: 35483525 DOI: 10.1016/j.kint.2022.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 12/20/2022]
Abstract
Thrombotic microangiopathy (TMA) in the kidney represents the most severe manifestation of kidney microvascular endothelial injury. Despite the source of the inciting event, the diverse clinical forms of kidney TMA share dysregulation of endothelial cell transcripts and complement activation. Here, we show that endothelial-specific knockdown of Krüppel-Like Factor 4 (Klf4)ΔEC, an anti-inflammatory and antithrombotic zinc-finger transcription factor, increases the susceptibility to glomerular endothelial injury and microangiopathy in two genetic murine models that included endothelial nitric oxide synthase knockout mice and aged mice (52 weeks), as well as in a pharmacologic model of TMA using Shiga-toxin 2. In all models, Klf4ΔEC mice exhibit increased pro-thrombotic and pro-inflammatory transcripts, as well as increased complement factors C3 and C5b-9 deposition and histologic features consistent with subacute TMA. Interestingly, complement activation in Klf4ΔEC mice was accompanied by reduced expression of a key KLF4 transcriptional target and membrane bound complement regulatory gene, Cd55. To assess a potential mechanism by which KLF4 might regulate CD55 expression, we performed in silico chromatin immunoprecipitation enrichment analysis of the CD55 promotor and found KLF4 binding sites upstream from the CD55 transcription start site. Using patient-derived kidney biopsy specimens, we found glomerular expression of KLF4 and CD55 was reduced in patients with TMA as compared to control biopsies of the unaffected pole of patient kidneys removed due to kidney cancer. Thus, our data support that endothelial Klf4 is necessary for maintenance of a quiescent glomerular endothelial phenotype and its loss increases susceptibility to complement activation and induction of prothrombotic and pro-inflammatory pathways.
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Affiliation(s)
- Chelsea C Estrada
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA; Renal Section, Northport Veterans Affairs Medical Center, Northport, New York, USA
| | - Stephanie Cardona
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Yiqing Guo
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Monica P Revelo
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University, New York, New York, USA
| | - Siva Koganti
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Jason Devaraj
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - John C He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter S Heeger
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sandeep K Mallipattu
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York, USA; Renal Section, Northport Veterans Affairs Medical Center, Northport, New York, USA.
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12
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Fakhouri F, Schwotzer N, Golshayan D, Frémeaux-Bacchi V. The Rational Use of Complement Inhibitors in Kidney Diseases. Kidney Int Rep 2022; 7:1165-1178. [PMID: 35685323 PMCID: PMC9171628 DOI: 10.1016/j.ekir.2022.02.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 12/14/2022] Open
Abstract
The development of complement inhibitors represented one of the major breakthroughs in clinical nephrology in the last decade. Complement inhibition has dramatically transformed the outcome of one of the most severe kidney diseases, the atypical hemolytic uremic syndrome (aHUS), a prototypic complement-mediated disorder. The availability of complement inhibitors has also opened new promising perspectives for the management of several other kidney diseases in which complement activation is involved to a variable extent. With the rapidly growing number of complement inhibitors tested in a rapidly increasing number of indications, a rational use of this innovative and expensive new therapeutic class has become crucial. The present review aims to summarize what we know, and what we still ignore, regarding complement activation and therapeutic inhibition in kidney diseases. It also provides some clues and elements of thoughts for a rational approach of complement modulation in kidney diseases.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Service de Néphrologie et d'hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Switzerland
| | - Déla Golshayan
- Centre de Transplantation d'organes, Département de Médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Université de Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Immunologie, Paris University, Paris, France
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13
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Wang C, Wang Z, Zhang W. The potential role of complement alternative pathway activation in hypertensive renal damage. Exp Biol Med (Maywood) 2022; 247:797-804. [PMID: 35473318 DOI: 10.1177/15353702221091986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypertensive renal damage is a common secondary kidney disease caused by poor control of blood pressure. Recent evidence has revealed abnormal activation of the complement alternative pathway (AP) in hypertensive patients and animal models and that this phenomenon is related to hypertensive renal damage. Conditions in the setting of hypertension, including high renin concentration, reduced binding of factor H to the glomerular basement membrane, and abnormal local synthesis of complement proteins, potentially promote the AP activation in the kidney. The products of the AP activation promote the phenotypic transition of mesangial cells and tubular cells, attack endothelial cells and recruit immunocytes to worsen hypertensive renal damage. The effects of complement inhibition on hypertensive renal damage are contradictory. Although clinical data support the use of C5 monoclonal antibody in malignant hypertension, pharmacological inhibition in hypertensive animals provides little benefit to kidney function. Therefore, the role of the complement AP in the pathogenesis of hypertensive renal damage and the value of complement inhibition in hypertensive renal damage treatment must be further explored.
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Affiliation(s)
- Chongjian Wang
- Division of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhiyu Wang
- Division of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wen Zhang
- Division of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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14
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3'mRNA sequencing reveals pro-regenerative properties of c5ar1 during resolution of murine acetaminophen-induced liver injury. NPJ Regen Med 2022; 7:10. [PMID: 35087052 PMCID: PMC8795215 DOI: 10.1038/s41536-022-00206-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 12/20/2021] [Indexed: 12/16/2022] Open
Abstract
Murine acetaminophen-induced acute liver injury (ALI) serves as paradigmatic model for drug-induced hepatic injury and regeneration. As major cause of ALI, acetaminophen overdosing is a persistent therapeutic challenge with N-acetylcysteine clinically used to ameliorate parenchymal necrosis. To identify further treatment strategies that serve patients with poor N-acetylcysteine responses, hepatic 3′mRNA sequencing was performed in the initial resolution phase at 24 h/48 h after sublethal overdosing. This approach disclosed 45 genes upregulated (≥5-fold) within this time frame. Focusing on C5aR1, we observed in C5aR1-deficient mice disease aggravation during resolution of intoxication as evidenced by increased liver necrosis and serum alanine aminotransferase. Moreover, decreased hepatocyte compensatory proliferation and increased caspase-3 activation at the surroundings of necrotic cores were detectable in C5aR1-deficient mice. Using a non-hypothesis-driven approach, herein pro-regenerative/-resolving effects of C5aR1 were identified during late acetaminophen-induced ALI. Data concur with protection by the C5a/C5aR1-axis during hepatectomy and emphasize the complex role of inflammation during hepatic regeneration and repair.
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15
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Aiello S, Gastoldi S, Galbusera M, Ruggenenti P, Portalupi V, Rota S, Rubis N, Liguori L, Conti S, Tironi M, Gamba S, Santarsiero D, Benigni A, Remuzzi G, Noris M. C5a and C5aR1 are key drivers of microvascular platelet aggregation in clinical entities spanning from aHUS to COVID-19. Blood Adv 2022; 6:866-881. [PMID: 34852172 PMCID: PMC8945302 DOI: 10.1182/bloodadvances.2021005246] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/19/2021] [Indexed: 11/20/2022] Open
Abstract
Unrestrained activation of the complement system till the terminal products, C5a and C5b-9, plays a pathogenetic role in acute and chronic inflammatory diseases. In endothelial cells, complement hyperactivation may translate into cell dysfunction, favoring thrombus formation. The aim of this study was to investigate the role of the C5a/C5aR1 axis as opposed to C5b-9 in inducing endothelial dysfunction and loss of antithrombogenic properties. In vitro and ex vivo assays with serum from patients with atypical hemolytic uremic syndrome (aHUS), a prototype rare disease of complement-mediated microvascular thrombosis due to genetically determined alternative pathway dysregulation, and cultured microvascular endothelial cells, demonstrated that the C5a/C5aR1 axis is a key player in endothelial thromboresistance loss. C5a added to normal human serum fully recapitulated the prothrombotic effects of aHUS serum. Mechanistic studies showed that C5a caused RalA-mediated exocytosis of von Willebrand factor (vWF) and P-selectin from Weibel-Palade bodies, which favored further vWF binding on the endothelium and platelet adhesion and aggregation. In patients with severe COVID-19 who suffered from acute activation of complement triggered by severe acute respiratory syndrome coronavirus 2 infection, we found the same C5a-dependent pathogenic mechanisms. These results highlight C5a/C5aR1 as a common prothrombogenic effector spanning from genetic rare diseases to viral infections, and it may have clinical implications. Selective C5a/C5aR1 blockade could have advantages over C5 inhibition because the former preserves the formation of C5b-9, which is critical for controlling bacterial infections that often develop as comorbidities in severely ill patients. The ACCESS trial registered at www.clinicaltrials.gov as #NCT02464891 accounts for the results related to aHUS patients treated with CCX168.
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Affiliation(s)
- Sistiana Aiello
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Sara Gastoldi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Miriam Galbusera
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Piero Ruggenenti
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Valentina Portalupi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Stefano Rota
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Nadia Rubis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Lucia Liguori
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Sara Conti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Matteo Tironi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Sara Gamba
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Donata Santarsiero
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; and
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16
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Lewis LA, Gulati S, Zelek WM, Morgan BP, Song WC, Zheng B, Nowak N, DeOliveira RB, Sanchez B, DeSouza Silva L, Schuurman J, Beurskens F, Ram S, Rice PA. Efficacy of an Experimental Gonococcal Lipooligosaccharide Mimitope Vaccine Requires Terminal Complement. J Infect Dis 2021; 225:1861-1864. [PMID: 34971376 PMCID: PMC9113499 DOI: 10.1093/infdis/jiab630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 12/30/2021] [Indexed: 01/02/2023] Open
Abstract
A safe and effective vaccine against multidrug-resistant gonorrhea is urgently needed. An experimental peptide vaccine called TMCP2 that mimics an oligosaccharide epitope in gonococcal lipooligosaccharide, when adjuvanted with glucopyranosyl lipid adjuvant-stable emulsion, elicits bactericidal immunoglobulin G and hastens clearance of gonococci in the mouse vaginal colonization model. In this study, we show that efficacy of TMCP2 requires an intact terminal complement pathway, evidenced by loss of activity in C9-/- mice or when C7 function was blocked. In conclusion, TMCP2 vaccine efficacy in the mouse vagina requires membrane attack complex. Serum bactericidal activity may serve as a correlate of protection for TMCP2.
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Affiliation(s)
- Lisa A Lewis
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA,Correspondence: Lisa A. Lewis, Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Lazare Research Bldg, Room 214, 364 Plantation St, Worcester MA 01605 ()
| | - Sunita Gulati
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Wioleta M Zelek
- Systems Immunity Research Institute and Dementia Research Institute, Henry Wellcome Building for Biomedical Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - B Paul Morgan
- Systems Immunity Research Institute and Dementia Research Institute, Henry Wellcome Building for Biomedical Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Wen-Chao Song
- Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bo Zheng
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Nancy Nowak
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Rosane B DeOliveira
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Bryan Sanchez
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Leandro DeSouza Silva
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | | | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Peter A Rice
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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17
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Complement and the prothrombotic state. Blood 2021; 139:1954-1972. [PMID: 34415298 DOI: 10.1182/blood.2020007206] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
In 2007 and 2009 the regulatory approval of the first-in-class complement inhibitor Eculizumab has revolutionized the clinical management of two rare, life-threatening clinical conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). While being completely distinct diseases affecting blood cells and the glomerulus, PNH and aHUS remarkably share several features in their etiology and clinical presentation. An imbalance between complement activation and regulation at host surfaces underlies both diseases precipitating in severe thrombotic events that are largely resistant to anti-coagulant and/or anti-platelet therapies. Inhibition of the common terminal complement pathway by Eculizumab prevents the frequently occurring thrombotic events responsible for the high mortality and morbidity observed in patients not treated with anti-complement therapy. While many in vitro and ex vivo studies elaborate numerous different molecular interactions between complement activation products and hemostasis, this review focuses on the clinical evidence that links these two fields in humans. Several non-infectious conditions with known complement involvement are scrutinized for common patterns concerning a prothrombotic statues and the occurrence of certain complement activation levels. Next to PNH and aHUS, germline encoded CD59 or CD55 deficiency (the latter causing the disease Complement Hyperactivation, Angiopathic thrombosis, and Protein-Losing Enteropathy; CHAPLE), autoimmune hemolytic anemia (AIHA), (catastrophic) anti-phospholipid syndrome (APS, CAPS) and C3 glomerulopathy are considered. Parallels and distinct features among these conditions are discussed against the background of thrombosis, complement activation, and potential complement diagnostic and therapeutic avenues.
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18
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Muniz TP, Patriquin CJ, Saibil SD. Presumed complement-mediated, checkpoint inhibitor-induced, thrombotic microangiopathy in a patient with metastatic melanoma. BMJ Case Rep 2021; 14:14/7/e242075. [PMID: 34312126 PMCID: PMC8314688 DOI: 10.1136/bcr-2021-242075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are associated with a variety of immune-related adverse events (irAEs), but haematological irAEs are rare. We report a case of presumed complement-mediated thrombotic microangiopathy (CM-TMA) in a 78-year-old man with metastatic melanoma following treatment with ICIs. Following two doses of combination nivolumab and ipilimumab therapy, he developed microangiopathic haemolytic anaemia, thrombocytopenia and increased creatinine. ADAMTS13 activity was preserved, CH50 was high, haptoglobin was depleted and a blood film demonstrated fragments. Given this constellation of findings, a diagnosis of CM-TMA was made. Immunotherapy was held and the patient received steroids and supportive care. Six months after his last dose of immunotherapy, he has no evidence of melanoma or CM-TMA. CM-TMA should be suspected in patients on ICI with unexplained anaemia and thrombocytopenia with preserved ADAMTS13 activity. Suspicion of complement dysregulation may have therapeutic implications, such as the necessity of complement pathway inhibition.
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Affiliation(s)
- Thiago P Muniz
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Christopher J Patriquin
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Samuel D Saibil
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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19
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Chouaki Benmansour N, Carvelli J, Vivier E. Complement cascade in severe forms of COVID-19: Recent advances in therapy. Eur J Immunol 2021; 51:1652-1659. [PMID: 33738806 PMCID: PMC8250085 DOI: 10.1002/eji.202048959] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/21/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
The complement system is an essential component of the innate immune system. The three complement pathways (classical, lectin, alternative) are directly or indirectly activated by the SARS‐CoV‐2 (severe acute respiratory syndrome coronavirus 2). In the most severe forms of COVID‐19, overactivation of the complement system may contribute to the cytokine storm, endothelial inflammation (endotheliitis) and thrombosis. No antiviral drug has yet been shown to be effective in COVID‐19. Therefore, immunotherapies represent a promising therapeutic in the immunopathological phase (following the viral phase) of the disease. Complement blockade, mostly C5a‐C5aR axis blockade, may prevent acute respiratory distress syndrome (ARDS) from worsening or progression to death. Clinical trials are underway.
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Affiliation(s)
- Nassima Chouaki Benmansour
- Assistance Publique des Hôpitaux de Marseille, France.,Département universitaire de médecine générale, Aix Marseille Université, Marseille, France.,Institut Paoli Calmette, Marseille, France
| | - Julien Carvelli
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Réanimation des Urgences, France.,Aix Marseille Université, Marseille, France
| | - Eric Vivier
- Innate Pharma Research labs, Marseille, France.,Aix Marseille Univ, CNRS, INSERM, CIML, Marseille, France.,Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Marseille-Immunopole, Marseille, France
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20
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Chouaki Benmansour N, Carvelli J, Vivier É. [Involvement of the complement cascade in severe forms of COVID-19]. Med Sci (Paris) 2021; 37:333-341. [PMID: 33835019 DOI: 10.1051/medsci/2021021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The complement system is an essential component of the innate immune system. Its excessive activation during COVID-19 contributes to cytokine storm, disease-specific endothelial inflammation (endotheliitis) and thrombosis that comes with the disease. Targeted therapies of complement inhibition in COVID-19, in particular blocking the C5a-C5aR1 axis have to be taken into account in the establishment of potential biomarkers and development of therapeutic strategies in the most severe forms of the disease.
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Affiliation(s)
- Nassima Chouaki Benmansour
- Assistance Publique des Hôpitaux de Marseille, 80 rue Brochier, 13005 Marseille, France - Département universitaire de médecine générale, Aix-Marseille Université, 27 boulevard Jean Moulin, 13385 Marseille Cedex 05, France - Institut Paoli Calmettes, 232 boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - Julien Carvelli
- Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Réanimation des urgences, 264 rue Saint-Pierre, 13005 Marseille, France - Aix-Marseille Université, 27 boulevard Jean Moulin, 13385 Marseille Cedex 05, France
| | - Éric Vivier
- Innate Pharma, 117 avenue de Luminy, BP 30191, 13276 Marseille Cedex 9, France - Aix Marseille Université, CNRS, Inserm, CIML, Parc Scientifique et Technologique de Luminy, Case 906, 13288 Marseille Cedex 09, France - Assistance Publique des Hôpitaux de Marseille, Marseille Immunopole, Hôpital de la Timone, 264 rue Saint Pierre, 13385 Marseille Cedex 5, France
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21
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Koopman JJE, van Essen MF, Rennke HG, de Vries APJ, van Kooten C. Deposition of the Membrane Attack Complex in Healthy and Diseased Human Kidneys. Front Immunol 2021; 11:599974. [PMID: 33643288 PMCID: PMC7906018 DOI: 10.3389/fimmu.2020.599974] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022] Open
Abstract
The membrane attack complex-also known as C5b-9-is the end-product of the classical, lectin, and alternative complement pathways. It is thought to play an important role in the pathogenesis of various kidney diseases by causing cellular injury and tissue inflammation, resulting in sclerosis and fibrosis. These deleterious effects are, consequently, targeted in the development of novel therapies that inhibit the formation of C5b-9, such as eculizumab. To clarify how C5b-9 contributes to kidney disease and to predict which patients benefit from such therapy, knowledge on deposition of C5b-9 in the kidney is essential. Because immunohistochemical staining of C5b-9 has not been routinely conducted and never been compared across studies, we provide a review of studies on deposition of C5b-9 in healthy and diseased human kidneys. We describe techniques to stain deposits and compare the occurrence of deposits in healthy kidneys and in a wide spectrum of kidney diseases, including hypertensive nephropathy, diabetic nephropathy, membranous nephropathy, IgA nephropathy, lupus nephritis, C3 glomerulopathy, and thrombotic microangiopathies such as the atypical hemolytic uremic syndrome, vasculitis, interstitial nephritis, acute tubular necrosis, kidney tumors, and rejection of kidney transplants. We summarize how these deposits are related with other histological lesions and clinical characteristics. We evaluate the prognostic relevance of these deposits in the light of possible treatment with complement inhibitors.
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Affiliation(s)
- Jacob J E Koopman
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Mieke F van Essen
- Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Helmut G Rennke
- Division of Renal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Aiko P J de Vries
- Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Cees van Kooten
- Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
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22
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Shaughnessy J, Tran Y, Zheng B, DeOliveira RB, Gulati S, Song WC, Maclean JM, Wycoff KL, Ram S. Development of Complement Factor H-Based Immunotherapeutic Molecules in Tobacco Plants Against Multidrug-Resistant Neisseria gonorrhoeae. Front Immunol 2020; 11:583305. [PMID: 33193396 PMCID: PMC7649208 DOI: 10.3389/fimmu.2020.583305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/24/2020] [Indexed: 01/15/2023] Open
Abstract
Novel therapeutics against the global threat of multidrug-resistant Neisseria gonorrhoeae are urgently needed. Gonococci possess several mechanisms to evade killing by human complement, including binding of factor H (FH), a key inhibitor of the alternative pathway. FH comprises 20 short consensus repeat (SCR) domains organized in a head-to-tail manner as a single chain. N. gonorrhoeae binds two regions in FH; domains 6 and 7 and domains 18 through 20. We designed a novel anti-infective immunotherapeutic molecule that fuses domains 18-20 of FH containing a D-to-G mutation in domain 19 at position 1119 (called FH*) with human IgG1 Fc. FH*/Fc retained binding to gonococci but did not lyse human erythrocytes. Expression of FH*/Fc in tobacco plants was undertaken as an alternative, economical production platform. FH*/Fc was expressed in high yields in tobacco plants (300-600 mg/kg biomass). The activities of plant- and CHO-cell produced FH*/Fc against gonococci were similar in vitro and in the mouse vaginal colonization model of gonorrhea. The addition of flexible linkers [e.g., (GGGGS)2 or (GGGGS)3] between FH* and Fc improved the bactericidal efficacy of FH*/Fc 2.7-fold. The linkers also improved PMN-mediated opsonophagocytosis about 11-fold. FH*/Fc with linker also effectively reduced the duration and burden of colonization of two gonococcal strains tested in mice. FH*/Fc lost efficacy: i) in C6-/- mice (no terminal complement) and ii) when Fc was mutated to abrogate complement activation, suggesting that an intact complement was necessary for FH*/Fc function in vivo. In summary, plant-produced FH*/Fc represent promising prophylactic or adjunctive immunotherapeutics against multidrug-resistant gonococci.
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Affiliation(s)
- Jutamas Shaughnessy
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Y Tran
- Planet Biotechnology, Inc., Hayward, CA, United States
| | - Bo Zheng
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Rosane B. DeOliveira
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Sunita Gulati
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | | | | | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, United States
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23
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Song WC, FitzGerald GA. COVID-19, microangiopathy, hemostatic activation, and complement. J Clin Invest 2020; 130:3950-3953. [PMID: 32459663 PMCID: PMC7410042 DOI: 10.1172/jci140183] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics
- Institute for Translational Medicine and Therapeutics, and
| | - Garret A. FitzGerald
- Department of Systems Pharmacology and Translational Therapeutics
- Institute for Translational Medicine and Therapeutics, and
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Noris M, Remuzzi G. Terminal complement effectors in atypical hemolytic uremic syndrome: C5a, C5b-9, or a bit of both? Kidney Int 2020; 96:13-15. [PMID: 31229026 DOI: 10.1016/j.kint.2019.02.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/28/2019] [Indexed: 11/30/2022]
Abstract
The role of the terminal complement pathway as the cause of atypical hemolytic uremic syndrome (aHUS) is widely recognized, but the relative contribution of the effectors C5a/C5aR1 and C5b-9 to disease pathogenesis has not been defined. Using FHR/R mice carrying a factor H mutation that causes cell surface complement alternative pathway dysregulation, Ueda documented that in FHR/R mice, C5b-9 causes renal thrombotic microangiopathy (TMA) whereas C5a/C5aR drives macrovascular thrombosis. This commentary addresses the implications and limitations of this study.
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Affiliation(s)
- Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy.
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases "Aldo e Cele Daccò," Ranica, Bergamo, Italy
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Ryan M, Donato BMK, Irish W, Gasteyger C, L'Italien G, Laurence J. Economic Impact of Early-in-Hospital Diagnosis and Initiation of Eculizumab in Atypical Haemolytic Uraemic Syndrome. PHARMACOECONOMICS 2020; 38:307-313. [PMID: 31828738 PMCID: PMC7045788 DOI: 10.1007/s40273-019-00862-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Atypical haemolytic uraemic syndrome (aHUS) is a rare, potentially life-threatening condition caused by dysregulation of the complement pathway. Eculizumab is currently the only approved treatment for this disorder. OBJECTIVE Our objective was to investigate the impact of early administration of eculizumab on inpatient resource use and hospitalisation costs in 222 patients with aHUS. METHODS We conducted a retrospective analysis of the Premier Perspective® Hospital Database, including patients with a diagnosis of aHUS and evidence of eculizumab use for aHUS. Early initiation was defined as having received eculizumab within 7 days of admission, with late initiation defined as starting eculizumab on day 8 or later. This date represents the average time required to obtain a specific diagnostic test to discriminate aHUS from a similar haemolytic syndrome that requires a different treatment. Outcome measures were time from first eculizumab initiation to discharge, discharge status or death, days spent in the intensive care unit (ICU), readmission indicators, dialysis indicators, and total hospital costs. Time from first eculizumab initiation to discharge was analysed using a generalised linear model with a log link and an assumed underlying negative binomial distribution. Logistic regression models were used to test the statistical significance of early versus late initiation as a predictor of the occurrence of readmissions, dialysis, and death. Total hospital costs were analysed using a generalised linear model with a log link and an assumed underlying gamma distribution. RESULTS Before modelling, total length of stay and ICU duration were significantly longer for late initiators than for early initiators, and significantly more late initiators were readmitted within 90 days. Late initiation was associated with significantly higher hospital costs than early initiation. After multivariable analysis, late initiators were 3.2 times more likely to require dialysis. However, there was no significant association between early initiation and time to discharge, readmission, or death for any definition or early initiation after multivariable analysis. Estimated total hospital costs (year 2017 values) were $US103,557 in late initiators and $US85,776 in early initiators (p = 0.0024). CONCLUSION Initiation of eculizumab within 7 days of hospitalisation is associated with lower dialysis rates, less time in ICU, less plasmapheresis, and lower hospitalisation costs compared with late initiation.
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Affiliation(s)
- Michael Ryan
- CTI Clinical Trial and Consulting Services Inc., 100 E. RiverCenter Blvd, Covington, KY, 41011, USA.
| | | | - William Irish
- Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | | | | | - Jeffrey Laurence
- New York Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA
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Duineveld C, Steenbergen EJ, Bomback AS, van de Kar NCAJ, Wetzels JFM. Treatment-resistant nephrotic syndrome in dense deposit disease: complement-mediated glomerular capillary wall injury? Pediatr Nephrol 2020; 35:1791-1795. [PMID: 32447506 PMCID: PMC7384995 DOI: 10.1007/s00467-020-04600-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The C3 glomerulopathies (C3G) are recently defined glomerular diseases, attributed to abnormal complement regulation. Dense deposit disease (DDD) is part of the spectrum of C3G, characterized by electron-dense deposits in the lamina densa of the glomerular basement membrane. Patients with DDD present with hematuria, variable degrees of proteinuria, and kidney dysfunction. Kidney biopsies typically disclose proliferative and inflammatory patterns of injury. Treatment with glucocorticoids and mycophenolate mofetil has been shown to achieve remission of proteinuria in a significant proportion of C3G patients. CASE-DIAGNOSIS/TREATMENT We report two patients with persistent nephrotic syndrome while on immunosuppressive therapy. Repeat kidney biopsies disclosed massive C3 deposits with foot process effacement in the absence of proliferative or inflammatory lesions on light microscopy. CONCLUSION These cases, coupled with data from animal models of disease and the variable response to eculizumab in C3G patients, illustrate that two different pathways might be involved in the development of kidney injury in C3G: a C5-independent pathway leading to glomerular capillary wall injury and the development of proteinuria versus a C5-dependent pathway that causes proliferative glomerulonephritis and kidney dysfunction.
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Affiliation(s)
- Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, PO BOX 9101, 6500 HB, Nijmegen, Netherlands.
| | - Eric J. Steenbergen
- Department of Pathology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY USA
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jack F. M. Wetzels
- Department of Nephrology, Radboud University Medical Center, PO BOX 9101, 6500 HB Nijmegen, Netherlands
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Gulati S, Beurskens FJ, de Kreuk BJ, Roza M, Zheng B, DeOliveira RB, Shaughnessy J, Nowak NA, Taylor RP, Botto M, He X, Ingalls RR, Woodruff TM, Song WC, Schuurman J, Rice PA, Ram S. Complement alone drives efficacy of a chimeric antigonococcal monoclonal antibody. PLoS Biol 2019; 17:e3000323. [PMID: 31216278 PMCID: PMC6602280 DOI: 10.1371/journal.pbio.3000323] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 07/01/2019] [Accepted: 05/30/2019] [Indexed: 12/25/2022] Open
Abstract
Multidrug-resistant Neisseria gonorrhoeae is a global health problem. Monoclonal antibody (mAb) 2C7 recognizes a gonococcal lipooligosaccharide epitope that is expressed by >95% of clinical isolates and hastens gonococcal vaginal clearance in mice. Chimeric mAb 2C7 (human immunoglobulin G1 [IgG1]) with an E430G Fc modification that enhances Fc:Fc interactions and hexamerization following surface-target binding and increases complement activation (HexaBody technology) showed significantly greater C1q engagement and C4 and C3 deposition compared to mAb 2C7 with wild-type Fc. Greater complement activation by 2C7-E430G Fc translated to increased bactericidal activity in vitro and, consequently, enhanced efficacy in mice, compared with “Fc-unmodified” chimeric 2C7. Gonococci bind the complement inhibitors factor H (FH) and C4b-binding protein (C4BP) in a human-specific manner, which dampens antibody (Ab)-mediated complement-dependent killing. The variant 2C7-E430G Fc overcame the barrier posed by these inhibitors in human FH/C4BP transgenic mice, for which a single 1 μg intravenous dose cleared established infection. Chlamydia frequently coexists with and exacerbates gonorrhea; 2C7-E430G Fc also proved effective against gonorrhea in gonorrhea/chlamydia-coinfected mice. Complement activation alone was necessary and sufficient for 2C7 function, evidenced by the fact that (1) “complement-inactive” Fc modifications that engaged Fc gamma receptor (FcγR) rendered 2C7 ineffective, nonetheless; (2) 2C7 was nonfunctional in C1q−/− mice, when C5 function was blocked, or in C9−/− mice; and (3) 2C7 remained effective in neutrophil-depleted mice and in mice treated with PMX205, a C5a receptor (C5aR1) inhibitor. We highlight the importance of complement activation for antigonococcal Ab function in the genital tract. Elucidating the correlates of protection against gonorrhea will inform the development of Ab-based gonococcal vaccines and immunotherapeutics. A chimeric antibody that contains a "complement-enhancing" mutation in Fc (so-called HexaBody technology) shows increased bactericidal activity compared to antibody bearing wild-type Fc and may represent a promising immunotherapeutic approach against multidrug-resistant gonorrhea.
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Affiliation(s)
- Sunita Gulati
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | | | | | | | - Bo Zheng
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Rosane B. DeOliveira
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Jutamas Shaughnessy
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Nancy A. Nowak
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Ronald P. Taylor
- University of Virginia, Charlottesville, Virginia, United States of America
| | - Marina Botto
- Center for Complement and Inflammation Research, Imperial College, London, United Kingdom
| | - Xianbao He
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Robin R. Ingalls
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Trent M. Woodruff
- School of Biomedical Sciences, The University of Queensland, St. Lucia, Queensland, Brisbane, Australia
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
| | | | - Peter A. Rice
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- * E-mail: (SR); (FJB)
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Song D, Ueda Y, Bhuyan R, Mohammed I, Miwa T, Gullipali D, Kim H, Zhou L, Song Y, Schultz H, Bargoud A, Dunaief JL, Song WC. Complement Factor H Mutation W1206R Causes Retinal Thrombosis and Ischemic Retinopathy in Mice. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:826-838. [PMID: 30711487 DOI: 10.1016/j.ajpath.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 01/14/2023]
Abstract
Single-nucleotide polymorphisms and rare mutations in factor H (FH; official name, CFH) are associated with age-related macular degeneration and atypical hemolytic uremic syndrome, a form of thrombotic microangiopathy. Mice with the FH W1206R mutation (FHR/R) share features with human atypical hemolytic uremic syndrome. Herein, we report that FHR/R mice exhibited retinal vascular occlusion and ischemia. Retinal fluorescein angiography demonstrated delayed perfusion and vascular leakage in FHR/R mice. Optical coherence tomography imaging of FHR/R mice showed retinal degeneration, edema, and detachment. Histologic analysis of FHR/R mice revealed retinal thinning, vessel occlusion, as well as degeneration of photoreceptors and retinal pigment epithelium. Immunofluorescence showed albumin leakage from blood vessels into the neural retina, and electron microscopy demonstrated vascular endothelial cell irregularity with narrowing of retinal and choroidal vessels. Knockout of C6, a component of the membrane attack complex, prevented the aforementioned retinal phenotype in FHR/R mice, consistent with membrane attack complex-mediated pathogenesis. Pharmacologic blockade of C5 also rescued retinas of FHR/R mice. This FHR/R mouse strain represents a model for retinal vascular occlusive disorders and ischemic retinopathy. The results suggest complement dysregulation can contribute to retinal vascular occlusion and that an anti-C5 antibody might be helpful for C5-mediated thrombotic retinal diseases.
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Affiliation(s)
- Delu Song
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoshiyasu Ueda
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rupak Bhuyan
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Imran Mohammed
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Takashi Miwa
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Damodar Gullipali
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hangsoo Kim
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lin Zhou
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ying Song
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Schultz
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert Bargoud
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua L Dunaief
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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