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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024; 106:369-391. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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2
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Trujillo H, Huerta A, Alonso R, Serrano ML, Aguilar M, Morales E, Cavero T. Eculizumab as Salvage Treatment for Thrombotic Microangiopathy After Lung Transplantation. Clin Transplant 2024; 38:e15443. [PMID: 39207183 DOI: 10.1111/ctr.15443] [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: 04/02/2024] [Revised: 07/29/2024] [Accepted: 08/14/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a rare complication after lung transplantation (LT) that has seldom been characterized in detail. Recent evidence has linked TMA other than primary atypical hemolytic uremic syndrome (aHUS) with hyperactivation of the complement alternative pathway. The focus of this investigation was to analyze the treatment response with eculizumab in TMA after LT. METHODS Case series where we have studied 11 patients with TMA after LT from 2 Spanish tertiary healthcare centers. Clinical data and response rates to eculizumab are provided. RESULTS The main indication for lung transplant was chronic obstructive pulmonary disease (COPD) (36%) and most cases (82%) received bilateral LT. The median time to TMA diagnosis was 11.6 months (4.7-28.9) and the TMA trigger in the majority of cases (73%) was immunosuppressive drugs. Platelet and hemoglobin nadir were 58 × 103/µL (24-108) and 7.7 g/dL (7.1-7.9), respectively. All cases presented acute kidney injury (AKI) with a median creatinine of 4 mg/dL (3.2-4.8) and 54.5% required acute dialysis. Eculizumab was started after a median time of 8 days (6-14) with a median duration of 3 weeks (2-8). Complete TMA response was observed in 7 (63.6%) cases and hematologic response in 10 (90.9%). The time to hematologic and renal response was 23 days (13-29) and 28 days (14-46), respectively. CONCLUSIONS TMA after LT is infrequent but potentially devastating. Our findings suggest that short cycles of eculizumab may be effective for severe TMA after LT.
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Affiliation(s)
- Hernando Trujillo
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ana Huerta
- Nephrology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Rodrigo Alonso
- Pneumology Department, Lung Transplant Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Luisa Serrano
- Nephrology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Myriam Aguilar
- Pneumology Department, Lung Transplant Unit, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Enrique Morales
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Cavero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
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Schwotzer N, Fakhouri F, Martins PV, Delmas Y, Caillard S, Zuber J, Moranne O, Mesnard L, Frémeaux-Bacchi V, El-Sissy C. Hot Spot of Complement Factor I Rare Variant p.Ile357Met in Patients With Hemolytic Uremic Syndrome. Am J Kidney Dis 2024; 84:244-249. [PMID: 38423159 DOI: 10.1053/j.ajkd.2023.12.021] [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: 06/28/2023] [Revised: 11/21/2023] [Accepted: 12/23/2023] [Indexed: 03/02/2024]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare kidney disease due to a dysregulation of the complement alternative pathway. Complement factor I (CFI) negatively regulates the alternative pathway and CFI gene rare variants have been associated to aHUS with a low disease penetrance. We report 10 unrelated cases of HUS associated to a rare CFI variant, p.Ile357Met (c.1071T>G). All patients with isolated p.Ile357Met CFI missense variant were retrospectively identified among patients included between January 2007 and January 2022 in the French HUS Registry. We identified 10 unrelated patients (70% women; median age at HUS diagnosis, 36.5 years) who carry the same rare variant p.Ile357Met in the CFI gene. Seven patients (cases 1-7) presented with aHUS in the native kidney associated with malignant hypertension in 5 patients. None received a C5 inhibitor. Two of these cases occurred in the peripartum period with complete recovery of kidney function, while 5 of these patients reached kidney failure requiring replacement therapy (KFRT). Four patients with KFRT subsequently underwent kidney transplantation. Three later developed C3 glomerulopathy in their kidney graft, but none had aHUS recurrence. Three other patients (cases 8-10) experienced de novo thrombotic microangiopathy after kidney transplantation, precipitated by various triggers. The rare CFI variant p.Ile357Met appears to be a facilitating genetic factor for HUS and for some forms of secondary HUS.
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Affiliation(s)
- Nora Schwotzer
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Paula Vieira Martins
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France
| | - Yahsou Delmas
- Nephrology Department, CHU de Bordeaux Bordeaux, France
| | - Sophie Caillard
- Nephrology Department, Strasbourg University Hospital, Strasbourg, France
| | - Julien Zuber
- Department of Renal and Metabolic Diseases, Transplantation, and Clinical Immunology Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Olivier Moranne
- Department of Nephrology, Dialysis and Apheresis, Nîmes Hôpital Universitaire, Nîmes, France
| | - Laurent Mesnard
- Sorbonne Université, Paris, France; Nephrology Intensive Care Unit, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Véronique Frémeaux-Bacchi
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France; Inflammation, Complement and Cancer Team, Cordeliers Research Center, INSERM Unité Mixte de Recherche (UMR) S1138, Paris, France
| | - Carine El-Sissy
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France
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Licht C, Al-Dakkak I, Anokhina K, Isbel N, Frémeaux-Bacchi V, Gilbert RD, Greenbaum LA, Ariceta G, Ardissino G, Schaefer F, Rondeau E. Characterization of patients with aHUS and associated triggers or clinical conditions: A Global aHUS Registry analysis. Nephrology (Carlton) 2024; 29:519-527. [PMID: 38604995 DOI: 10.1111/nep.14304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/07/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Atypical haemolytic uremic syndrome (aHUS) is a rare form of thrombotic microangiopathy (TMA) associated with complement dysregulation; aHUS may be associated with other 'triggers' or 'clinical conditions'. This study aimed to characterize this patient population using data from the Global aHUS Registry, the largest collection of real-world data on patients with aHUS. METHODS Patients enrolled in the Global aHUS Registry between April 2012 and June 2021 and with recorded aHUS-associated triggers or clinical conditions prior/up to aHUS onset were analysed. aHUS was diagnosed by the treating physician. Data were classified by age at onset of aHUS (< or ≥18 years) and additionally by the presence/absence of identified pathogenic complement genetic variant(s) and/or anti-complement factor H (CFH) antibodies. Genetically/immunologically untested patients were excluded. RESULTS 1947 patients were enrolled in the Global aHUS Registry by June 2021, and 349 (17.9%) met inclusion criteria. 307/349 patients (88.0%) had a single associated trigger or clinical condition and were included in the primary analysis. Malignancy was most common (58/307, 18.9%), followed by pregnancy and acute infections (both 53/307, 17.3%). Patients with an associated trigger or clinical condition were generally more likely to be adults at aHUS onset. CONCLUSION Our analysis suggests that aHUS-associated triggers or clinical conditions may be organized into clinically relevant categories, and their presence does not exclude the concurrent presence of pathogenic complement genetic variants and/or anti-CFH antibodies. Considering a diagnosis of aHUS with associated triggers or clinical conditions in patients presenting with TMA may allow faster and more appropriate treatment.
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Affiliation(s)
- Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Imad Al-Dakkak
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | - Nicole Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Rodney D Gilbert
- Regional Paediatric Nephro-Urology Unit, Southampton Children's Hospital, Southampton, UK
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Gema Ariceta
- Department of Pediatric Nephrology, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Gianluigi Ardissino
- Centro per la Cura e lo Studio della Sindrome Emolitico-Uremica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Franz Schaefer
- Division of Pediatric Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Eric Rondeau
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France
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Uriol-Rivera MG, Andrade BL, Bonet AM, Mulet AO, Ruiz CB, Parraga LP, Lumbreras J, Rota JIA, Servalos MF, Balaguer JF, Ferreres LP, Valles MJP, Valero RMRDG, Sanchez ST, Martin AG, Garcia JR, Cobo CG, Ramis-Cabrer D. Risk factors of death or chronic renal replacement therapy requirements in patients with thrombotic microangiopathies without ADAMTS-13 deficiency. Eur J Haematol 2024. [PMID: 38955806 DOI: 10.1111/ejh.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 07/04/2024]
Abstract
Thrombotic microangiopathy (TMA), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and multisystem organ dysfunction, is a life-threatening disease. Patients with TMA who do not exhibit a severe ADAMTS-13 deficiency (defined as a disintegrin-like and metalloprotease with thrombospondin type 1 motif no. 13 activity ≥10%: TMA-13n) continue to experience elevated mortality rates. This study explores the prognostic indicators for augmented mortality risk or necessitating chronic renal replacement therapy (composite outcome: CO) in TMA-13n patients. We included 42 TMA-13n patients from January 2008 to May 2018. Median age of 41 years and 60% were female. At presentation, 62% required dialysis, and 57% warranted intensive care unit admission. CO was observed in 45% of patients, including a 9-patient mortality subset. Multivariate logistic regression revealed three independent prognostic factors for CO: early administration of eculizumab (median time from hospitalization to eculizumab initiation: 5 days, range 0-19 days; odds ratio [OR], 0.14; 95% confidence interval [CI], 0.02-0.94), presence of neuroradiological lesions (OR, 6.67; 95% CI, 1.12-39.80), and a PLASMIC score ≤4 (OR, 7.39; 95% CI, 1.18-46.11). In conclusion, TMA-13n patients exhibit a heightened risk of CO in the presence of low PLASMIC scores and neuroradiological lesions, while early eculizumab therapy was the only protective factor.
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Affiliation(s)
- Miguel G Uriol-Rivera
- Nephrology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Bernardo López Andrade
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Hematology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Antonio Mas Bonet
- Radiology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Aina Obrador Mulet
- Nephrology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Carmen Ballester Ruiz
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Hematology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Leonor Periañez Parraga
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Pharmacy Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Javier Lumbreras
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Pediatric Nephrology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - José Ignacio Ayestarán Rota
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Intensive Care Unit, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | | | - Joana Ferrer Balaguer
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Immunology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Lucio Pallares Ferreres
- Internal Medicine Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - María Jose Picado Valles
- Radiology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | | | - Susana Tarongi Sanchez
- Neurology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Ana Garcia Martin
- Neurology Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Juan Rodríguez Garcia
- Preventive Medicine Department, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Cristina Gomez Cobo
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
- Clinical Analysis, Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Daniel Ramis-Cabrer
- Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Hospital Universitario Son Espases, Palma de Mallorca, Balearic Islands, Spain
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Obata S, Hullekes F, Riella LV, Cravedi P. Recurrent complement-mediated Hemolytic uremic syndrome after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100857. [PMID: 38749097 DOI: 10.1016/j.trre.2024.100857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/16/2024]
Abstract
Hereditary forms of hemolytic uremic syndrome (HUS), formerly known as atypical HUS, typically involve mutations in genes encoding for components of the alternative pathway of complement, therefore they are often referred to as complement-mediated HUS (cHUS). This condition has a high risk of recurrence in the transplanted kidney, leading to accelerated graft loss. The availability of anti-complement component C5 antibody eculizumab has enabled successful transplantation with a notably reduced recurrence rate and improved prognosis. Open questions are related to the potential for complement inhibitor discontinuation, ideal timing of treatment withdrawal, and patient selection based on genetic abnormalities. Our review delves into the pathophysiology, classification, genetic predispositions, and management strategies for cHUS in the native and transplant kidneys.
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Affiliation(s)
- Shota Obata
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Frank Hullekes
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Paolo Cravedi
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Martin M, Llorens-Cebria C, León-Román J, Perurena-Prieto J, Perez-Beltran V, Saumell S, Torres IB, Agraz I, Sellarès J, Ramos N, Bestard O, López M, Moreso F, Ariceta G, Soler MJ, Hernandez-Gonzalez M, Jacobs-Cachá C. Ex vivo C5b-9 Deposition Test to Monitor Complement Activity in Clinical and Subclinical Atypical Hemolytic Uremic Syndrome and in Transplantation-Associated Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:2227-2239. [PMID: 39081726 PMCID: PMC11284441 DOI: 10.1016/j.ekir.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a complement system (CS)-mediated ultrarare disease that manifests as thrombotic microangiopathy (TMA) with preferential small kidney vessels involvement. Transient CS activation is also observed in secondary TMA or in patients at risk of developing aHUS. There is no gold standard test to monitor disease activity; however, the ex vivo C5b-9 deposition test seems to be a good approach. Methods We assessed the C5b-9 deposition induced by serum samples of patients with aHUS (n = 8) and with TMA associated with kidney (n = 2), lung (n = 1) or hematopoietic stem cell (HSC) transplantation (HSCT, n = 2) during the acute phase of the disease or in remission. As control for transplant-associated TMA (TA-TMA), we analyzed samples of clinically stable kidney and HSC-transplanted patients without signs of TMA. In addition, we studied 1 child with genetic risk of aHUS during an acute infection. Results In the acute disease phase or in patients with disease activity despite C5 blockade, a significant increase of C5b-9 deposition was detected. In all patients with clinical response to C5 blockade but one, levels of C5b-9 deposition were within the normal range. Finally, we detected increased C5b-9 deposition levels in an asymptomatic child with genetic risk of aHUS when a concomitant otitis episode was ongoing. Conclusion The ex vivo C5b-9 deposition test is an auspicious tool to monitor CS activity in aHUS and TA-TMA. In addition, we demonstrate that the test may be useful to detect subclinical increase of CS activity, which expands the spectrum of patients that would benefit from a better CS activity assessment.
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Affiliation(s)
- Maria Martin
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carmen Llorens-Cebria
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan León-Román
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Janire Perurena-Prieto
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Víctor Perez-Beltran
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Silvia Saumell
- Hematology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irina B. Torres
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irene Agraz
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Joana Sellarès
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Natàlia Ramos
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Bestard
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Mercedes López
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francesc Moreso
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Gema Ariceta
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Universitat Autonoma Barcelona, Barcelona, Spain
| | - Maria José Soler
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Hernandez-Gonzalez
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Conxita Jacobs-Cachá
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Biochemistry Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
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Sepúlveda Palamara RA, Modelli de Andrade LG, Fortunato RM, Gómez B, Nieto-Ríos JF. Clinical presentation and management of atypical hemolytic uremic syndrome in Latin America: a narrative review of the literature. Expert Rev Hematol 2024; 17:361-374. [PMID: 38841813 DOI: 10.1080/17474086.2024.2365169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/04/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Comprehensive information about atypical hemolytic uremic syndrome (aHUS) is relatively scarce outside of Europe and North America. This narrative review assembles available published data about the clinical presentation and management of aHUS in Latin America. AREAS COVERED A search conducted in February 2023 of the MEDLINE (from inception), Embase (from inception), and LILACS/IBECS (1950 to 2023) databases using search terms 'atypical hemolytic uremic syndrome' and 'Latin America' and their variations retrieved 51 records (full papers and conference abstracts) published in English, Spanish, or Portuguese. After de-duplication, manual screening of titles/abstracts and addition of author-known articles, 25 articles were included of which 17 (68%) are full papers. All articles were published during the years 2013-2022. Articles include cohort studies, a registry analysis, and case reports from Argentina, Brazil, Chile and Columbia. Overall, Latin American patients with aHUS present the classic epidemiological, clinical, and genetic characteristics associated with this condition as described in other world regions. Depending on the country and time of reporting, aHUS in Latin America was treated mainly with plasma therapy and/or eculizumab. Where reported, eculizumab substantially improved aHUS-related outcomes in almost all adult and pediatric patients. EXPERT OPINION Eculizumab has dramatically altered the natural course of aHUS, improving prognosis and patient outcomes. Addressing economic challenges and investing in healthcare infrastructure will be essential to implement strategies for timely detection and early treatment of aHUS in Latin America.
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Affiliation(s)
- R A Sepúlveda Palamara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - L G Modelli de Andrade
- Departamento de Clínica Médica, Universidade Estadual Paulista Júlio de Mesquita Filho, Faculdade de Medicina de Botucatu, Botucatu, Brazil
| | - R M Fortunato
- Renal Unit, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
- Department of Nephrology, German Hospital, Buenos Aires, Argentina
- Transplantation Department, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina
| | - B Gómez
- Departamento de Nefrología y Unidad de Trasplante del Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, México
| | - J F Nieto-Ríos
- Departamento de Nefrología y Trasplante Renal, Hospital Pablo Tobón Uribe y Universidad de Antioquia, Medellín, Colombia
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Maritati F, La Manna G, Comai G. Response to Letter to the Editor From Ville S. et al. About: "Eculizumab First" in the Management of Posttransplant Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:1933-1934. [PMID: 38899194 PMCID: PMC11184233 DOI: 10.1016/j.ekir.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Ville S, Drapeau L, Paraire J, Maanaoui M, Frimat M. Letter to the editor about: "Eculizumab First" in the Management of Posttransplant Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:1932. [PMID: 38899204 PMCID: PMC11184236 DOI: 10.1016/j.ekir.2024.02.1440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Simon Ville
- Institut de Transplantation Urologie Néphrologie, CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Leo Drapeau
- Institut de Transplantation Urologie Néphrologie, CHU Nantes, Nantes, France
| | - Jean Paraire
- Université de Lille, CHU Lille, Nephrology Department, Lille, France
| | - Mehdi Maanaoui
- Université de Lille, CHU Lille, Nephrology Department, Lille, France
| | - Marie Frimat
- Université de Lille, CHU Lille, Nephrology Department, Lille, France
- Université de Lille, Inserm, Institut Pasteur de Lille, U1167-RID-AGE, Lille, France
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Acharya R, Clapp W, Upadhyay K. Safety and Efficacy of Very Early Conversion to Belatacept in Pediatric Kidney Transplantation with Transplant-Associated Thrombotic Microangiopathy: Case Study and Review of Literature. Clin Pract 2024; 14:882-891. [PMID: 38804401 PMCID: PMC11130864 DOI: 10.3390/clinpract14030069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
The inhibition of co-stimulation during T-cell activation has been shown to provide effective immunosuppression in kidney transplantation (KT). Hence, the conversion from calcineurin inhibitor (CNI) to belatacept is emerging as a potential alternate maintenance immunosuppressive therapy in those with transplant-associated thrombotic microangiopathy (TA-TMA) or in the prevention of TA-TMA. We present a 17-year-old male who presented with biopsy-proven CNI-associated TA-TMA immediately post-KT. The administration of eculizumab led to the reversal of TMA. Tacrolimus was converted to belatacept with excellent efficacy and safety during a short-term follow-up of one year. Further larger controlled studies are required to demonstrate the efficacy of this approach in children who present with early-onset TMA post-KT.
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Affiliation(s)
- Ratna Acharya
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, FL 32827, USA
| | - William Clapp
- Division of Anatomic Pathology, Department of Pathology, University of Florida, Gainesville, FL 32610, USA
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
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12
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Maisons V, Duval A, Mesnard L, Frimat M, Fakhouri F, Grangé S, Servais A, Cartery C, Fauchier L, Coppo P, Titeca-Beauport D, Fage N, Delmas Y, Quérard AH, Seret G, Bobot M, Le Quintrec M, Ville S, von Tokarski F, Chauvet S, Wynckel A, Martins M, Schurder J, Barbet C, Sautenet B, Gatault P, Caillard S, Vuiblet V, Halimi JM. Assessment of epidemiology and outcomes of adult patients with kidney-limited thrombotic microangiopathies. Kidney Int 2024; 105:1100-1112. [PMID: 38431217 DOI: 10.1016/j.kint.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/31/2024] [Accepted: 02/12/2024] [Indexed: 03/05/2024]
Abstract
Thrombotic microangiopathies (TMA) are usually associated with hematological features (RH-TMA). The epidemiology of TMA limited to kidneys (RL-TMA) is unclear Therefore, patients with TMA and native kidney biopsies were identified during 2009-2022 in 20 French hospitals and results evaluated. RL-TMA was present in 341/757 (45%) patients and associated with lower creatinine levels (median 184 vs 346 μmol/L) than RH-TMA. RL-TMA resulted from virtually all identified causes, more frequently from anti-VEGF treatment and hematological malignancies but less frequently from shigatoxin-associated hemolytic uremic syndrome (HUS), systemic sclerosis, gemcitabine and bacterial infection, and even less frequently when three or more causes/triggers were combined (RL-TMA: 5%; RH-TMA: 12%). RL-TMA was associated with significantly lower major cardiovascular events (10% vs 20%), kidney replacement therapy (23% vs 43%) and death (12% vs 20%) than RH-TMA during follow-up (median 28 months). Atypical HUS (aHUS) was found in 326 patients (RL-TMA: 43%, RH-TMA: 44%). Among the 69 patients with proven complement-mediated aHUS, eculizumab (anti-C5 therapy) was used in 43 (62%) (RL-TMA: 35%; RH-TMA: 71%). Among the 257 other patients with aHUS, including 51% with RL-TMA, eculizumab was used in 29 but with unclear effects of this treatment. Thus, RL-TMA represents a very high proportion of patients with TMA and results from virtually all known causes of TMA and includes 25% of patients with complement-mediated aHUS. Adverse outcomes of RL-TMA are lower compared to RH-TMA but remain significant. Anti-C5 therapy was rarely used in RL-TMA, even in proven complement-mediated aHUS, and its effects remain to be assessed.
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Affiliation(s)
- Valentin Maisons
- Service de Néphrologie, CHU de Tours, Tours, France; U1246, INSERM, SPHERE, Université de Tours, Université de Nantes, Tours, Nantes, France
| | - Anna Duval
- Service de Néphrologie, CHU de Strasbourg, Strasbourg, France
| | | | - Marie Frimat
- Service de Néphrologie, CHU de Lille, Lille, France
| | - Fadi Fakhouri
- Service de Néphrologie, CHU Vaudois, Lausanne, Switzerland
| | | | - Aude Servais
- Service de Néphrologie, APHP Hopital Necker, Paris, France
| | - Claire Cartery
- Service de Néphrologie, CH de Valenciennes, Valenciennes, France
| | | | - Paul Coppo
- Service d'Hématologie, Centre de référence pour les microangiopathies thrombotiques (CNR-MAT), APHP Hopital Saint-Antoine, Paris, France
| | | | - Nicolas Fage
- Service de Néphrologie, Département de médecine intensive reanimation-médecine hyperbare, CHU d'Angers, Angers, France
| | - Yahsou Delmas
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | | | - Guillaume Seret
- Service de Néphrologie, Pole Santé Sud Echo Le Mans, Le Mans, France
| | - Mickaël Bobot
- Service de Néphrologie, CHU de Marseille; Aix, Marseille Université, INSERM 1263, INRAE 1260, C2VN, CERIMED, Marseille, France
| | | | - Simon Ville
- Service de Néphrologie, CHU de Nantes, Nantes, France
| | | | - Sophie Chauvet
- Service de Néphrologie, APHP Hopital Européen Georges Pompidou, Paris, France
| | | | - Manon Martins
- Service de Néphrologie, CHU de Rennes, Rennes, France
| | - Juliet Schurder
- Service de Néphrologie, CH de Saint-Malo, Saint-Malo, France
| | | | | | - Philippe Gatault
- Service de Néphrologie, CHU de Tours, U1327, INSERM, ISCHEMIA, Université de Tours, Tours, France
| | - Sophie Caillard
- U1246, INSERM, SPHERE, Université de Tours, Université de Nantes, Tours, Nantes, France
| | - Vincent Vuiblet
- Service de Pathologie, Institut d'Intelligence Artificielle en Santé, CHU de Reims et Université de Reims Champagne Ardenne, Reims, France
| | - Jean-Michel Halimi
- Service de Néphrologie, CHU de Tours, U1327, INSERM, ISCHEMIA, Université de Tours, Tours, France.
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Ardissino G, Cresseri D, Mancuso MC, Capone V, Porcaro L, Amico V, Tangredi M, Grovetti E, Griffini S, Castellano G, Montini G, Consonni D, Cugno M. Outcome of atypical hemolytic uremic syndrome: role of triggers and complement abnormalities in the response to C5 inhibition. J Nephrol 2024; 37:1017-1026. [PMID: 38280096 DOI: 10.1007/s40620-023-01873-9] [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: 08/10/2023] [Accepted: 12/26/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Atypical-hemolytic uremic syndrome (aHUS) is a rare thrombotic microangiopathy often due to uncontrolled complement activation, characterized by high risk of end-stage kidney disease (ESKD). Eculizumab has improved the outcome, however, its efficacy varies among patients and its discontinuation is debated. METHODS To identify characteristics associated with treatment response, we analyzed 244 aHUS patients referred to our center. Patients were classified according to the presence/absence of complement abnormalities and/or triggers at onset in 4 categories: (1) primary (complement abnormality without trigger), (2) secondary (trigger without complement abnormality), (3) combined (trigger and complement abnormality), (4) idiopathic (no trigger, no complement abnormality). Response to treatment was evaluated by comparing the response to eculizumab with that of conventional therapy. Short- and long-term outcomes were evaluated with the relapse rate after discontinuation of C5-inhibition. RESULTS Patients had a better outcome with eculizumab compared to conventional treatment, with a response rate of 81.9% vs 56.9%, p < 0.001 and a long-term cumulative incidence of ESKD of 5.8% vs 22.5% (hazard ratio 0.25, 95% confidence interval: 0.10-0.80). The excellent global response was driven by the primary and combined groups (89.8% vs 54.0% and 89.3% vs 54.2%, respectively). The relapse rate following discontinuation of the C5-inhibitor was as high as 66.7% in the primary group, 18.7% in the combined, and 0% in the secondary and idiopathic groups. CONCLUSIONS Our data show a better outcome in aHUS patients treated with C5-inhibition, particularly in the primary and combined forms, which have a high risk of relapse after discontinuation that is not observed in the secondary and idiopathic forms.
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Affiliation(s)
- Gianluigi Ardissino
- Center for HUS Prevention, Control and Management at the Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy.
| | - Donata Cresseri
- Center for HUS Prevention, Control and Management at the Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Cristina Mancuso
- Center for HUS Prevention, Control and Management at the Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Valentina Capone
- Center for HUS Prevention, Control and Management at the Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Luigi Porcaro
- Medical Genetics Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Amico
- Medical Genetics Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marianna Tangredi
- Center for HUS Prevention, Control and Management at the Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Grovetti
- Medicina Interna Dipartimento di Fisiopatologia Medico‑Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Samantha Griffini
- Medicina Interna Dipartimento di Fisiopatologia Medico‑Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giuseppe Castellano
- Center for HUS Prevention, Control and Management at the Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Medicina Interna Dipartimento di Fisiopatologia Medico‑Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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14
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Maritati F, Corradetti V, Bini C, Provenzano M, Cuna V, Busutti M, Tondolo F, Zappulo F, Vischini G, Iacovella F, Abenavoli C, Borelli G, Demetri M, Fabbrizio B, Radi G, Ravaioli M, Mele C, La Manna G, Comai G. "Eculizumab First" in the Management of Posttransplant Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:982-993. [PMID: 38765562 PMCID: PMC11101752 DOI: 10.1016/j.ekir.2024.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Posttransplant thrombotic microangiopathy (PT-TMA) is an uncommon event that characterizes approximately 3% to 14% of kidney transplants (KTs), and that is associated with a higher risk of delayed graft function and graft loss. PT-TMA occurs more frequently within the first 3 months after transplant and can be a manifestation of de novo disease or the recurrence of previous atypical hemolytic uremic syndrome (aHUS). Abnormalities in complement regulation genes could explain the increased susceptibility of some patients to PT-TMA. Eculizumab is a humanized monoclonal antibody that inhibits the formation of the membrane attack complex C5b-9. The aim of this study is to evaluate the efficacy of eculizumab as treatment for PT-TMA. Methods We retrospectively analyzed clinical records of 45 KT patients who received eculizumab immediately after the clinical diagnosis of PT-TMA. Results Kidney biopsy was performed in 91.1% of patients, and complement genetic study was performed in 64.4%. Of the kidney biopsies, 85.4% showed signs of TMA; genetic analysis revealed 1 pathogenetic variant, 2 variants of uncertain significance, 1 likely benign variant, 8 risk polymorphisms, and 27 risk haplotypes. After 2 weeks from the treatment starting, hemoglobin and platelets significantly increased. A remarkable improvement in kidney function was also observed. After 6 months, 28.8% of patients had a complete renal recovery whereas 44.4% had a partial recovery. Conclusion This is, to our knowledge, the largest series of KT patients with PT-TMA treated with eculizumab. These data suggest that eculizumab is associated with a normalization of hemolysis indices and an important and progressive improvement of graft function.
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Affiliation(s)
- Federica Maritati
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Vania Cuna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Busutti
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Fulvia Zappulo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Gisella Vischini
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Iacovella
- Nephrology and Dialysis Unit, Azienda USL della Romagna, Infermi Hospital, Rimini, Italy
| | - Chiara Abenavoli
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Greta Borelli
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Demetri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Benedetta Fabbrizio
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgia Radi
- Hepato-biliary Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Hepato-biliary Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Mele
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò Ranica, Bergamo, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
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15
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Cordero L, Cavero T, Gutiérrez E, Trujillo H, Sandino J, Auñón P, Rivero M, Morales E. Rational use of eculizumab in secondary atypical hemolytic uremic syndrome. Front Immunol 2024; 14:1310469. [PMID: 38274833 PMCID: PMC10808527 DOI: 10.3389/fimmu.2023.1310469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background Secondary atypical hemolytic uremic syndrome (secondary aHUS) is a heterogeneous group of thrombotic microangiopathies (TMA) associated with various underlying conditions. Unlike primary aHUS, there is still no hard evidence on the efficacy of complement blockade in secondary aHUS, since the two main series that investigated this subject showed discrepant results. Our work aims to reassess the efficacy of eculizumab in treating secondary aHUS. Methods Observational, retrospective, single-center study, in which we analyzed the hematological and renal evolution of 23 patients diagnosed with secondary aHUS who received treatment with eculizumab and compared them with a control cohort of 14 patients. Complete renal response was defined as the recovery of renal function before the event, partial renal response as a recovery of 50% of lost glomerular filtration rate, and hematological response as normalization of hemoglobin and platelets. Results We found no statistically significant differences in baseline characteristics or disease severity between both groups. After a median of 5 doses of eculizumab, the group of patients who received complement blockade presented a significant difference in renal response (complete in 52.3% of patients and partial in 23.8%) compared to the control cohort (complete response 14.3% and partial of 14.3%). Rates of hematological remission were similar in both groups (90.9% in the eculizumab cohort and 85.7% in the control cohort). Conclusion Early and short-term use of eculizumab in patients with secondary aHUS could be an effective and safe therapeutic option, assuring better renal recovery compared to patients who do not receive complement blockade.
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Affiliation(s)
- Lucía Cordero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Cavero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Eduardo Gutiérrez
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Hernando Trujillo
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Justo Sandino
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Auñón
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Rivero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Enrique Morales
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
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16
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Huerta A, Arjona E, Portoles J, Lopez-Sanchez P, Cavero T, Fernandez-Cusicanqui J, Blasco M, Cabello V, Calvo N, Diaz M, Herrero-Goñi M, Aguirre M, Elías S, Alcaide MP, Ramos N, Sellares J, Rodríguez de Córdoba S. On the relevance of thrombomodulin variants in atypical hemolytic uremic syndrome. Kidney Int 2023; 104:851-855. [PMID: 37567446 DOI: 10.1016/j.kint.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- Ana Huerta
- Nephrology Department. Hospital Puerta de Hierro-Majadahonda.IDIPHISA, Madrid, Spain; RedinRen Instituto de Salud Carlos III 16/009/009, Madrid, Spain.
| | - Emi Arjona
- Centro de Investigaciones Biológicas-Margarita Salas (CIB-MS), Madrid, Spain; Ciber de Enfermedades Raras (Ciberer), Madrid, Spain
| | - Jose Portoles
- Nephrology Department. Hospital Puerta de Hierro-Majadahonda.IDIPHISA, Madrid, Spain; RedinRen Instituto de Salud Carlos III 16/009/009, Madrid, Spain
| | - Paula Lopez-Sanchez
- Nephrology Department. Hospital Puerta de Hierro-Majadahonda.IDIPHISA, Madrid, Spain
| | - Teresa Cavero
- Nephrology Department, Hospital Universitario Doce de Octubre, Madrid, Spain
| | | | - Miquel Blasco
- Nephrology Department, Hospital Clinic, Barcelona, Spain
| | - Virginia Cabello
- Nephrology Department, Hospital Virgen del Rocio, Sevilla, Spain
| | | | | | | | - Mireia Aguirre
- Pediatric Nephrology Department, Hospital Cruces, Bizkaia, Spain
| | - Sandra Elías
- Nephrology Department, Hospital Ramon y Cajal, Madrid, Spain
| | | | - Natalia Ramos
- Nephrology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Joana Sellares
- Nephrology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas-Margarita Salas (CIB-MS), Madrid, Spain; Ciber de Enfermedades Raras (Ciberer), Madrid, Spain.
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17
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Turudic D, Pokrajac D, Tasic V, Kasumovic D, Prohaszka Z, Milosevic D. The Rationale of Complement Blockade of the MCP ggaac Haplotype following Atypical Hemolytic Uremic Syndrome of Three Southeastern European Countries with a Literature Review. Int J Mol Sci 2023; 24:13041. [PMID: 37685848 PMCID: PMC10487996 DOI: 10.3390/ijms241713041] [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: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023] Open
Abstract
We present eight cases of the homozygous MCPggaac haplotype, which is considered to increase the likelihood and severity of atypical hemolytic uremic syndrome (aHUS), especially in combination with additional risk aHUS mutations. Complement blockade (CBT) was applied at a median age of 92 months (IQR 36-252 months). The median number of relapses before CBT initiation (Eculizumab) was two. Relapses occurred within an average of 22.16 months (median 17.5, minimum 8 months, and maximum 48 months) from the first subsequent onset of the disease (6/8 patients). All cases were treated with PI/PEX, and rarely with renal replacement therapy (RRT). When complement blockade was applied, children had no further disease relapses. Children with MCPggaac haplotype with/without additional gene mutations can achieve remission through renal replacement therapy without an immediate need for complement blockade. If relapse of aHUS occurs soon after disease onset or relapses are repeated frequently, a permanent complement blockade is required. However, the duration of such a blockade remains uncertain. If complement inhibition is not applied within 4-5 relapses, proteinuria and chronic renal failure will eventually occur.
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Affiliation(s)
- Daniel Turudic
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia
| | - Danka Pokrajac
- Pediatric Clinic, Clinical Center, University of Sarajevo, Patriotske Lige 81, 71000 Sarajevo, Bosnia and Herzegovina;
| | - Velibor Tasic
- Medical Faculty Skopje, University Children’s Hospital, 1010 Skopje, North Macedonia;
| | - Dino Kasumovic
- Department of Nephrology and Dialysis, Dubrava University Hospital, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Zoltan Prohaszka
- Department of Internal Medicine and Hematology, Semmelweis University, 1085 Budapest, Hungary;
- Research Group for Immunology and Haematology, Eotvos Lorand Research Network (Office for Supported Research Groups), Semmelweis University, 1085 Budapest, Hungary
| | - Danko Milosevic
- Croatian Academy of Medical Sciences, Kaptol ul. 15, 10000 Zagreb, Croatia;
- Department of Pediatrics, Zabok General Hospital, and the Croatian Veterans Hospital, Bračak 8, 49210 Bračak, Croatia
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18
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Werion A, Storms P, Zizi Y, Beguin C, Bernards J, Cambier JF, Dahan K, Dierickx D, Godefroid N, Hilbert P, Lambert C, Levtchenko E, Meyskens T, Poiré X, van den Heuvel L, Claes KJ, Morelle J. Epidemiology, Outcomes, and Complement Gene Variants in Secondary Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2023; 18:881-891. [PMID: 37094330 PMCID: PMC10356144 DOI: 10.2215/cjn.0000000000000182] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The identification of complement defects as major drivers of primary atypical hemolytic uremic syndrome (HUS) has transformed the landscape of thrombotic microangiopathies (TMAs), leading to the development of targeted therapies and better patient outcomes. By contrast, little is known about the presentation, genetics, and outcomes of TMA associated with specific diseases or conditions, also referred to as secondary TMA. METHODS In this study, we assessed the relative incidence, clinical and genetic spectra, and long-term outcomes of secondary TMA versus other TMAs in consecutive patients hospitalized with a first episode of TMA from 2009 to 2019 at two European reference centers. RESULTS During the study period, 336 patients were hospitalized with a first episode of TMA. Etiologies included atypical HUS in 49 patients (15%), thrombotic thrombocytopenic purpura (TTP) in 29 (9%), shigatoxin-associated HUS in 70 (21%), and secondary TMA in 188 (56%). The main causes of secondary TMA were hematopoietic stem-cell transplantation ( n =56, 30%), solid-organ transplantation ( n =44, 23%), and malignant hypertension ( n =25, 13%). Rare variants in complement genes were identified in 32 of 49 patients (65%) with atypical HUS and eight of 64 patients (13%) with secondary TMA; pathogenic or likely pathogenic variants were found in 24 of 49 (49%) and two of 64 (3%) of them, respectively ( P < 0.001). After a median follow-up of 1157 days, death or kidney failure occurred in 14 (29%), eight (28%), five (7%), and 121 (64%) patients with atypical HUS, TTP, shigatoxin-associated HUS, and secondary TMA, respectively. Unadjusted and adjusted Cox regressions showed that patients with secondary TMA had the highest risk of death or kidney failure (unadjusted hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.85 to 6.07; P < 0.001; adjusted HR, 4.11; 95% CI, 2.00 to 8.46; P < 0.001; considering atypical HUS as reference). CONCLUSIONS Secondary TMAs represent the main cause of TMA and are independently associated with a high risk of death and progression to kidney failure.
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Affiliation(s)
- Alexis Werion
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pauline Storms
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Ysaline Zizi
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Claire Beguin
- Department of Medical Informatics and Statistics, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Jelle Bernards
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Nephrology, ZNA Middelheim, Antwerpen, Belgium
| | | | - Karin Dahan
- Institut de Pathologie et de Génétique, Gosselies, Belgium
| | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Nathalie Godefroid
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Pediatric Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | - Catherine Lambert
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Elena Levtchenko
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | - Xavier Poiré
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Lambert van den Heuvel
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kathleen J. Claes
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
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19
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Schwotzer N, Frémeaux-Bacchi V, Fakhouri F. Hemolytic Uremic Syndrome: A Question of Terminology. Clin J Am Soc Nephrol 2023; 18:831-833. [PMID: 37249504 PMCID: PMC10356109 DOI: 10.2215/cjn.0000000000000198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Nora Schwotzer
- Service of Nephrology and Hypertension, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, Paris, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
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20
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Donadelli R, Sinha A, Bagga A, Noris M, Remuzzi G. HUS and TTP: traversing the disease and the age spectrum. Semin Nephrol 2023; 43:151436. [PMID: 37949684 DOI: 10.1016/j.semnephrol.2023.151436] [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: 11/12/2023]
Abstract
Hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenia purpura (TTP) are rare diseases sharing a common pathological feature, thrombotic microangiopathy (TMA). TMA is characterized by microvascular thrombosis with consequent thrombocytopenia, microangiopathic hemolytic anemia and/or multiorgan dysfunction. In the past, the distinction between HUS and TTP was predominantly based on clinical grounds. However, clinical presentation of the two syndromes often overlaps and, the differential diagnosis is broad. Identification of underlying pathogenic mechanisms has enabled the classification of these syndromes on a molecular basis: typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS); atypical HUS or complement-mediated TMA (aHUS/CM-TMA) associated with genetic or acquired defects leading to dysregulation of the alternative pathway (AP) of complement; and TTP that results from a severe deficiency of the von Willebrand Factor (VWF)-cleaving protease, ADAMTS13. The etiology of TMA differs between pediatric and adult patients. Childhood TMA is chiefly caused by STEC-HUS, followed by CM-TMA and pneumococcal HUS (Sp-HUS). Rare conditions such as congenital TTP (cTTP), vitamin B12 metabolism defects, and coagulation disorders (diacylglycerol epsilon mutation) present as TMA chiefly in children under 2 years of age. In contrast secondary causes and acquired ADAMT13 deficiency are more common in adults. In adults, compared to children, diagnostic delays are more frequent due to the wide range of differential diagnoses. In this review we focus on the three major forms of TMA, STEC-HUS, aHUS and TTP, outlining the clinical presentation, diagnosis and management of the affected patients, to help highlight the salient features and the differences between adult and pediatric patients which are relevant for management.
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Affiliation(s)
- Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Aditi Sinha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy.
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21
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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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22
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Teoh CW, Riedl Khursigara M, Ortiz-Sandoval CG, Park JW, Li J, Bohorquez-Hernandez A, Bruno V, Bowen EE, Freeman SA, Robinson LA, Licht C. The loss of glycocalyx integrity impairs complement factor H binding and contributes to cyclosporine-induced endothelial cell injury. Front Med (Lausanne) 2023; 10:891513. [PMID: 36860338 PMCID: PMC9968885 DOI: 10.3389/fmed.2023.891513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 01/06/2023] [Indexed: 02/16/2023] Open
Abstract
Background Calcineurin inhibitors (CNIs) are associated with nephrotoxicity, endothelial cell dysfunction, and thrombotic microangiopathy (TMA). Evolving evidence suggests an important role for complement dysregulation in the pathogenesis of CNI-induced TMA. However, the exact mechanism(s) of CNI-induced TMA remain(s) unknown. Methods Using blood outgrowth endothelial cells (BOECs) from healthy donors, we evaluated the effects of cyclosporine on endothelial cell integrity. Specifically, we determined complement activation (C3c and C9) and regulation (CD46, CD55, CD59, and complement factor H [CFH] deposition) as these occurred on the endothelial cell surface membrane and glycocalyx. Results We found that exposing the endothelium to cyclosporine resulted in a dose- and time-dependent enhancement of complement deposition and cytotoxicity. We, therefore, employed flow cytometry, Western blotting/CFH cofactor assays, and immunofluorescence imaging to determine the expression of complement regulators and the functional activity and localization of CFH. Notably, while cyclosporine led to the upregulation of complement regulators CD46, CD55, and CD59 on the endothelial cell surface, it also diminished the endothelial cell glycocalyx through the shedding of heparan sulfate side chains. The weakened endothelial cell glycocalyx resulted in decreased CFH surface binding and surface cofactor activity. Conclusion Our findings confirm a role for complement in cyclosporine-induced endothelial injury and suggest that decreased glycocalyx density, induced by cyclosporine, is a mechanism that leads to complement alternative pathway dysregulation via decreased CFH surface binding and cofactor activity. This mechanism may apply to other secondary TMAs-in which a role for complement has so far not been recognized-and provide a potential therapeutic target and an important marker for patients on calcineurin inhibitors.
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Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada,Department of Paediatrics, University of Toronto, Toronto, ON, Canada,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Magdalena Riedl Khursigara
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada,Department of Paediatrics, University of Toronto, Toronto, ON, Canada,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Jee Woo Park
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jun Li
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Valentina Bruno
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada,Division of Paediatric Nephrology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Emily E. Bowen
- Bristol Renal, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Spencer A. Freeman
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada,Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Lisa A. Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada,Department of Paediatrics, University of Toronto, Toronto, ON, Canada,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada,Department of Paediatrics, University of Toronto, Toronto, ON, Canada,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada,*Correspondence: Christoph Licht ✉
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23
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Mazzierli T, Allegretta F, Maffini E, Allinovi M. Drug-induced thrombotic microangiopathy: An updated review of causative drugs, pathophysiology, and management. Front Pharmacol 2023; 13:1088031. [PMID: 36699080 PMCID: PMC9868185 DOI: 10.3389/fphar.2022.1088031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Drug-induced thrombotic microangiopathy (DITMA) represents 10%-13% of all thrombotic microangiopathy (TMA) cases and about 20%-30% of secondary TMAs, just behind pregnancy-related and infection-related forms. Although the list of drugs potentially involved as causative for TMA are rapidly increasing, the scientific literature on DITMA is quite scarce (mostly as individual case reports or little case series), leading to poor knowledge of pathophysiological mechanisms and clinical management. In this review, we focused on these critical aspects regarding DITMA. We provided an updated list of TMA-associated drugs that we selected from a scientific literature review, including only those drugs with a definite or probable causal association with TMA. The list of drugs is heterogeneous and could help physicians from several different areas to be familiar with DITMA. We describe the clinical features of DITMA, presenting the full spectrum of clinical manifestations, from systemic to kidney-limited forms. We also analyze the association between signs/symptoms (i.e., malignant hypertension, thrombocytopenia) and specific DITMA causative drugs (i.e., interferon, ticlopidine). We highlighted their multiple different pathophysiological mechanisms, being frequently classified as immune-mediated (idiosyncratic) and dose-related/toxic. In particular, to clarify the role of the complement system and genetic deregulation of the related genes, we conducted a revision of the scientific literature searching for DITMA cases who underwent renal biopsy and/or genetic analysis for complement genes. We identified a complement deposition in renal biopsies in half of the patients (37/66; 57%), with some drugs associated with major deposits (i.e., gemcitabine and ramucirumab), particularly in capillary vessels (24/27; 88%), and other with absent deposits (tyrosine kinase inhibitors and intraocular anti-VEGF). We also found out that, differently from other secondary TMAs (such as pregnancy-related-TMA and malignant hypertension TMA), complement genetic pathological mutations are rarely involved in DITMA (2/122, 1.6%). These data suggest a variable non-genetic complement hyperactivation in DITMA, which probably depends on the causative drug involved. Finally, based on recent literature data, we proposed a treatment approach for DITMA, highlighting the importance of drug withdrawal and the role of therapeutic plasma-exchange (TPE), rituximab, and anti-complementary therapy.
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Affiliation(s)
- Tommaso Mazzierli
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy,Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Federica Allegretta
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy,Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Enrico Maffini
- Department of Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy,Correspondence: Marco Allinovi,
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24
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Yamaguchi M, Mizuno M, Kitamura F, Iwagaitsu S, Nobata H, Kinashi H, Banno S, Asai A, Ishimoto T, Katsuno T, Ito Y. Case report: Thrombotic microangiopathy concomitant with macrophage activation syndrome in systemic lupus erythematosus refractory to conventional treatment successfully treated with eculizumab. Front Med (Lausanne) 2023; 9:1097528. [PMID: 36698804 PMCID: PMC9868404 DOI: 10.3389/fmed.2022.1097528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). Macrophage activation syndrome (MAS) is also a rare, life-threatening hyperinflammatory condition that is comorbid with SLE. However, the association between TMA and MAS in patients with SLE has rarely been assessed, and the difficulty of diagnosing these conditions remains prevalent. The efficacy of eculizumab has been reported for SLE patients whose conditions are complicated with TMA. However, no study has investigated the therapeutic efficacy of eculizumab for TMA concomitant with SLE-associated MAS. Herein, we report the first case of TMA concomitant with SLE-associated MAS that was initially refractory to conventional immunosuppressive therapy but showed remarkable recovery after eculizumab treatment. Furthermore, we evaluated serum syndecan-1 and hyaluronan levels, which are biomarkers of endothelial damage. We found that these levels decreased after the administration of eculizumab, suggesting that TMA was the main pathology of the patient. This case illustrates that it is important to appropriately assess the possibility of TMA during the course of SLE-associated MAS and consider the use of eculizumab as necessary.
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Affiliation(s)
- Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Masashi Mizuno
- Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumiya Kitamura
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Akimasa Asai
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan,Department of Nephrology and Rheumatology, Aichi Medical University Medical Center, Okazaki, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan,*Correspondence: Yasuhiko Ito,
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25
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Pharmacological Management of Atypical Hemolytic Uremic Syndrome in Pediatric Patients: Current and Future. Paediatr Drugs 2023; 25:193-202. [PMID: 36637720 PMCID: PMC9839393 DOI: 10.1007/s40272-022-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
Atypical hemolytic uremic syndrome is a thrombotic microangiopathy characterized by hemolysis, thrombocytopenia, and acute kidney injury, usually caused by alternative complement system overactivation due to pathogenic genetic variants or antibodies to components or regulatory factors in this pathway. Previously, a lack of effective treatment for this condition was associated with mortality, end-stage kidney disease, and the risk of disease recurrence after kidney transplantation. Plasma therapy has been used for atypical hemolytic uremic syndrome treatment with inconsistent results. Complement-blocking treatment changed the outcome and prognosis of patients with atypical hemolytic uremic syndrome. Early administration of eculizumab, a monoclonal C5 antibody, leads to improvements in hematologic, kidney, and systemic manifestations in patients with atypical hemolytic uremic syndrome, even with apparent dialysis dependency. Pre- and post-transplant use of eculizumab is effective in the prevention of atypical hemolytic uremic syndrome recurrence. Evidence on eculizumab use in secondary hemolytic uremic syndrome cases is controversial. Recent data favor the restrictive use of eculizumab in carefully selected atypical hemolytic uremic syndrome cases, but close monitoring for relapse after drug discontinuation is emphasized. Prophylaxis for meningococcal infection is important. The long-acting C5 monoclonal antibody ravulizumab is now approved for atypical hemolytic uremic syndrome treatment, enabling a reduction in the dosing frequency and improving the quality of life in patients with atypical hemolytic uremic syndrome. New strategies for additional and novel complement blockage medications in atypical hemolytic uremic syndrome are under investigation.
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26
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Rodríguez de Córdoba S. Genetic variability shapes the alternative pathway complement activity and predisposition to complement-related diseases. Immunol Rev 2023; 313:71-90. [PMID: 36089777 PMCID: PMC10086816 DOI: 10.1111/imr.13131] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The implementation of next-generation sequencing technologies has provided a sharp picture of the genetic variability in the components and regulators of the alternative pathway (AP) of the complement system and has revealed the association of many AP variants with different rare and common diseases. An important finding that has emerged from these analyses is that each of these complement-related diseases associate with genetic variants altering specific aspects of the activation and regulation of the AP. These genotype-phenotype correlations have provided valuable insights into their pathogenic mechanisms with important diagnostic and therapeutic implications. While genetic variants in coding regions and structural variants are reasonably well characterized and occasionally have been instrumental to uncover unknown features of the complement proteins, data about complement expressed quantitative trait loci are still very limited. A crucial task for future studies will be to identify these quantitative variations and to determine their impact in the overall activity of the AP. This is fundamental as it is now clear that the consequences of genetic variants in the AP are additive and that susceptibility or resistance to disease is the result of specific combinations of genetic variants in different complement components and regulators ("complotypes").
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27
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Rare Presentation of Atypical Hemolytic Uremic Syndrome in a Child With Acute Lymphocytic Leukemia and Pancreatitis. J Pediatr Hematol Oncol 2022; 44:412-414. [PMID: 35180765 DOI: 10.1097/mph.0000000000002409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is associated with significant mortality and morbidity, including acute renal injury, anemia and thrombocytopenia. Rare cases of aHUS in a child with acute leukemia before diagnosis or during chemotherapy have been reported. We report a pediatric case of B-cell acute lymphoblastic leukemia complicated by pancreatitis with concomitant aHUS following induction chemotherapy.
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Cavero T, Auñón P, Caravaca-Fontán F, Trujillo H, Arjona E, Morales E, Guillén E, Blasco M, Rabasco C, Espinosa M, Blanco M, Rodríguez-Magariños C, Cao M, Ávila A, Huerta A, Rubio E, Cabello V, Barros X, Goicoechea de Jorge E, Rodríguez de Córdoba S, Praga M. Thrombotic microangiopathy in patients with malignant hypertension. Nephrol Dial Transplant 2022; 38:1217-1226. [PMID: 36002030 DOI: 10.1093/ndt/gfac248] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a complication of malignant hypertension (mHTN) attributed to the high levels of blood pressure (BP). However, no studies have investigated in patients with mHTN of different etiologies whether the presence of TMA is associated with specific causes of mHTN. METHODS We investigate the presence of TMA (microangiopathic hemolytic anemia and thrombocytopenia) in a large and well characterized cohort of 199 patients with mHTN of different etiologies (primary HTN 44%, glomerular diseases 16.6%, primary atypical hemolytic uremic syndrome (aHUS) 13.1%, renovascular HTN 9.5%, drug-related HTN 7%, systemic diseases 5.5%, endocrine diseases 4.5%). Outcomes of the study were kidney recovery and kidney failure. RESULTS Patients with TMA (40 cases, 20.1%) were younger, had a lower proportion of males, lower BP levels and worse kidney function at presentation. Their underlying diseases were primary aHUS (60%), drug-related mHTN (15%), glomerular diseases (all of them IgA nephropathy) (10%), systemic diseases (10%) and primary HTN (5%). The presence of TMA was 92.3% in primary aHUS, 42.9% in drug-related HTN, 36.4% in systemic diseases, 12.1% in glomerular diseases and 2.3% in primary HTN. No patient with renovascular HTN or mHTN caused by endocrine diseases developed TMA, despite BP levels as severe as patients with TMA. A higher proportion of TMA patients developed kidney failure as compared to patients without TMA (56.4% versus 38.9%, respectively). CONCLUSIONS The presence of TMA in patients with mHTN should guide the diagnosis towards primary aHUS, drug-related mHTN, some systemic diseases and IgA nephropathy, while it is exceptional in other causes of mHTN.
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Affiliation(s)
- Teresa Cavero
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Auñón
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Caravaca-Fontán
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Emi Arjona
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Elena Guillén
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Marta Blanco
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | - Mercedes Cao
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Ana Ávila
- Department of Nephrology, Hospital Universitario Dr Peset, Valencia, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Esther Rubio
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitario Dr Josep Trueta, Gerona, Spain
| | - Elena Goicoechea de Jorge
- Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Complutense University, Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Manuel Praga
- Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
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Decaestecker A, Hamroun A, Provot F, Rondeau E, Faguer S, Sallee M, Titeca-Beauport D, Rebibou JM, Forestier A, Azar R, Deltombe C, Wynckel A, Grange S, Bacchi VF, Cartery C. Retrospective study of 59 cases of cancer-associated thrombotic microangiopathy: presentation and treatment characteristics. Nephrol Dial Transplant 2022; 38:913-921. [PMID: 35791491 DOI: 10.1093/ndt/gfac213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cancer-associated thrombotic microangiopathy (TMA) is a rare disease, with a poor prognosis. The classical treatment is urgent chemotherapy. Few data are available on the efficacy of plasma exchange (PE) and eculizumab in these patients.
Methods
Cases of cancer-related TMA treated between January 2008 and December 2019 in 12 French treatment centres were retrospectively analysed, excluding cases associated with chemotherapy and stem cell transplantation. Patients were divided into four groups depending on the treatment received: none, PE therapy alone, chemotherapy, with or without PE therapy, or eculizumab, with or without chemotherapy and PE therapy.
Results
The data of 59 patients with cancer-associated TMA were analysed. Twenty of these cases were related to a cancer recurrence. The cancer was metastatic in 90% of cases (53/59). Bone marrow invasion was observed in 20/41 biopsies. Some laboratory results, including DIC, high ferritin and CRP, were suggestive of cancer. None of the 16 patients whose alternative complement pathway was assessed had abnormal levels of protein expression or activity. The median survival time was 27 days. Chemotherapy was significantly associated with improved survival, with a 30-day survival rate of 85% (17/20) among patients who received PE and chemotherapy, versus 20% (3/15) among patients who received PE alone. Patients treated with eculizumab in addition to chemotherapy and PE therapy did not have longer overall survival or higher haematological remission rates than those treated with chemotherapy and PE therapy alone. Renal remission rates were non-significantly higher, and times to remission non-significantly shorter, in the eculizumab group.
Conclusions
Nephrologists and oncologists should make themselves aware of cancer diagnoses in patients with TMA and bone marrow biopsies should be performed systematically in these cases. All 59 patients had poor survival outcomes, but patients treated with urgent initiation of chemotherapy survived significantly longer than those who were not.
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Affiliation(s)
- Antoine Decaestecker
- Service de Néphrologie, Centre Hospitalier de Valenciennes , Valenciennes , France
| | - Aghilès Hamroun
- Service de Néphrologie, Centre Hospitalo-Universitaire de Lille , Lille , France
| | - François Provot
- Service de Néphrologie, Centre Hospitalo-Universitaire de Lille , Lille , France
| | - Eric Rondeau
- Service d'Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon , Assistance Publique des Hôpitaux de Paris, Paris , France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'organes, Hôpital Rangueil, Intensive Care Unit, Centre Hospitalo-Universitaire de Toulouse , Toulouse , France
| | - Marion Sallee
- Service de Néphrologie et Transplantation Rénale, Hôpital de la Conception, Centre Hospitalo-Universitaire de Marseille , Marseille , France
| | - Dimitri Titeca-Beauport
- Service de Néphrologie et Transplantation rénale, Centre Hospitalo-Universitaire d'Amiens , Amiens , France
| | - Jean Michel Rebibou
- Service de Néphrologie, Centre Hospitalo-Universitaire de Dijon , Dijon , France
| | | | - Raymond Azar
- Service de Néphrologie et Dialyse, Centre Hospitalier de Dunkerque , Dunkerque , France
| | - Clément Deltombe
- Service de Néphrologie et Immunologie clinique, Hotel Dieu, Centre Hospitalo-Universitaire de Nantes , Nantes , France
| | - Alain Wynckel
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalo-Universitaire de Reims , Reims , France
| | - Steven Grange
- Service de Néphrologie et Tansplantation rénale, Centre Hospitalo-Universitaire de Rouen , Rouen , France
| | - Veronique Fremeaux Bacchi
- Laboratoire d'Immunologie biologique, HEGP Hôpital Européen Georges Pompidou, Centre Hospitalo-Universitaire Paris Ouest , Paris , France
| | - Claire Cartery
- Service de Néphrologie, Centre Hospitalier de Valenciennes , Valenciennes , France
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30
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Fernandez-Ruiz R, Belmont HM. The role of anticomplement therapy in lupus nephritis. Transl Res 2022; 245:1-17. [PMID: 35158097 DOI: 10.1016/j.trsl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
The complement system plays crucial roles in homeostasis and host defense against microbes. Deficiency of early complement cascade components has been associated with increased susceptibility to systemic lupus erythematosus (SLE), whereas excessive complement consumption is a hallmark of this disease. Although enhanced classical pathway activation by immune complexes was initially thought to be the main contributor to lupus nephritis (LN) pathogenesis, an increasing body of evidence has suggested the alternative and the lectin pathways are also involved. Therapeutic agents targeting complement activation have been used in LN patients and clinical trials are ongoing. We review the mechanisms by which complement system dysregulation contributes to renal injury in SLE and summarize the latest evidence on the use of anticomplement agents to manage this condition.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, NYU Grossman School of Medicine, New York, New York
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31
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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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32
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Kovala M, Seppälä M, Kaartinen K, Meri S, Honkanen E, Räisänen-Sokolowski A. Vascular Occlusion in Kidney Biopsy Is Characteristic of Clinically Manifesting Thrombotic Microangiopathy. J Clin Med 2022; 11:jcm11113124. [PMID: 35683519 PMCID: PMC9181253 DOI: 10.3390/jcm11113124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) can sometimes manifest only histologically. Our aim was to retrospectively compare biopsy-proven adult TMA patients showing only histological (h-TMA) or both histological and clinical (c-TMA) TMA in 2006–2017. All native kidney biopsies with TMA were included. Biopsies were re-evaluated by light and electron microscopy, and immunofluorescence. Clinical characteristics, laboratory variables, and treatments were recorded from the electronic medical database. Patients were categorized into h-TMA and c-TMA and these groups were compared. In total, 30 biopsy-proven cases among 7943 kidney biopsies were identified and, of these, 15 had h-TMA and 15 c-TMA. Mean follow-up was 6.3 y, and 73.3% had secondary hemolytic uremic syndrome (HUS) and the rest were atypical HUS. Patient characteristics, treatments, and kidney, and patient survival in the groups were similar. Statistically significant differences were found in histological variables. Vascular myxoid swelling and vascular onion-skinning were almost exclusively detected in c-TMA and, thus, vascular occlusive changes indicate clinically apparent rather than merely histological TMA. In addition, regardless of clinical presentation, kidney and patient survival times were similar in the patient groups highlighting the importance of a kidney biopsy in the case of any kidney-related symptoms.
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Affiliation(s)
- Marja Kovala
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
- Correspondence:
| | - Minna Seppälä
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Kati Kaartinen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Seppo Meri
- Department of Bacteriology and Immunology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
| | - Eero Honkanen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Anne Räisänen-Sokolowski
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
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33
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Patriquin CJ, Pavenski K, Garland J, Girard LP, Isenring P. Complement-Amplifying Conditions in Atypical Hemolytic Uremic Syndrome: A Canadian Case Series. Can J Kidney Health Dis 2022; 9:20543581221100288. [PMID: 35615072 PMCID: PMC9125052 DOI: 10.1177/20543581221100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022] Open
Abstract
Rationale Thrombotic microangiopathies (TMAs) are systemic disorders that often affect the kidneys and encompass a heterogeneous group of conditions, including atypical hemolytic uremic syndrome (aHUS). The complement pathway is thought to play a crucial role in the pathogenesis of aHUS, and a favorable response can be obtained through complement C5 inhibition. There is emerging evidence to suggest that the same is also true for several other forms of TMA. Objective The purpose of this series is to report cases of aHUS in which both an innate defect of the alternative complement pathway and a complement-amplifying condition were suspected. Methods This case series describes 8 patients who were managed in Canadian tertiary centers for aHUS and who presented initially with complement-amplifying conditions. Results In all cases, aHUS was associated with organ dysfunction and in some, with an innate defect of the alternative complement pathway. The complement-amplifying conditions identified were diverse including immune disorders, pregnancy, and a Shiga toxin infection. Patients improved rapidly when treated with eculizumab or plasma exchange. Conclusions These observations illustrate the seriousness of secondary aHUS. They also add to existing lines of evidence that the complement pathway is potentially involved in this condition and that it should be considered as a therapeutic target of interest under such circumstances.
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Affiliation(s)
| | - Katerina Pavenski
- St. Michael’s Hospital, Unity Health Toronto, University of Toronto, ON, Canada
| | - Jocelyn Garland
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | | | - Paul Isenring
- Nephrology Research Group, Department of Medicine, L’Hôtel-Dieu de Québec Institution, Laval University, Québec, QC, Canada
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Kitamura F, Yamaguchi M, Nishimura M, Katsuno T, Ito M, Sugiyama H, Iwagaitsu S, Nobata H, Kinashi H, Ishimoto T, Banno S, Ito Y. Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis Complicated by Thrombotic Microangiopathy with Posterior Reversible Encephalopathy Syndrome Successfully Treated with Eculizumab: A Case Report. Mod Rheumatol Case Rep 2022; 6:254-259. [PMID: 35425980 DOI: 10.1093/mrcr/rxac029] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/07/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022]
Abstract
Thrombotic microangiopathy is characterised by endothelial cell injury, intravascular platelet-fibrin thrombi, and vascular damage, leading to acute kidney injury, thrombocytopenia, and microangiopathic haemolytic anaemia. Among the autoimmune diseases related to thrombotic microangiopathy, anti-neutrophil cytoplasmic antibody-associated vasculitis-related thrombotic microangiopathy cases have been rarely reported; therefore, the optimal treatment for associated vasculitis-related thrombotic microangiopathy remains unknown. An 84-year-old woman without significant medical history presented with a 1-month history of general fatigue, fever, and deteriorating bilateral leg numbness and was admitted to our hospital. She had elevated myeloperoxidase anti-neutrophil cytoplasmic antibody levels, polyneuropathy, and rapid progressive glomerulonephritis because of pauci-immune crescentic glomerulonephritis, as revealed by a kidney biopsy. Accordingly, we diagnosed her with microscopic polyangiitis. After administering methylprednisolone pulse therapy, rituximab, and intravenous immunoglobulin, the patient's mental state deteriorated, presenting signs of thrombotic microangiopathy with posterior reversible encephalopathy syndrome. Intermittent haemodialysis and plasma exchange were initiated; however, her condition was not improved, and eculizumab administration was initiated thereafter. The patient's symptoms showed a remarkable response to eculizumab; thrombotic microangiopathy findings, kidney function, and neurological symptoms improved after only two doses of eculizumab, and she achieved sustained remission. The extremely effective course of eculizumab treatment indicated that overt complement activation affected the development of thrombotic microangiopathy. Anti-neutrophil cytoplasmic antibody-associated vasculitis-related thrombotic microangiopathy may be mediated by complement activation, and prompt induction of eculizumab therapy may be a superior strategy to prevent organ damage. Further studies should elucidate the role of complement activation in associated vasculitis-related thrombotic microangiopathy and the efficacy of eculizumab treatment.
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Affiliation(s)
- Fumiya Kitamura
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Minori Nishimura
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takayuki Katsuno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Mayumi Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hirokazu Sugiyama
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Shiho Iwagaitsu
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Shogo Banno
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Aichi, Japan
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Werion A, Rondeau E. Application of C5 inhibitors in glomerular diseases in 2021. Kidney Res Clin Pract 2022; 41:412-421. [PMID: 35354244 PMCID: PMC9346396 DOI: 10.23876/j.krcp.21.248] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 11/04/2022] Open
Abstract
The complement pathway is an essential mechanism in innate immunity, but it is also involved in multiple pathologies. For kidney diseases, strong evidence of a dysregulation in the alternative pathway in atypical hemolytic uremic syndrome (aHUS) led to the use of eculizumab, the first anti-C5 inhibitor available in clinical practice. Intensive fundamental research resulted in the development of subsequent new drugs, such as long-acting C5 inhibitors, oral medications, or antagonists of C5aR, the receptor for C5a. New data in the domain of C5-inhibition in glomerular diseases are still limited and mainly focus on 1) the efficacy of ravulizumab, a long-acting C5 inhibitor in aHUS, and 2) the use of avacopan, a C5aR antagonist, in antineutrophil cytoplasmic antibody vasculitis. Several new studies ongoing or planned for the next few years will evaluate the efficacy of C5 inhibition in secondary thrombotic microangiopathy, C3 glomerulopathy, membranous nephropathy, or immunoglobulin A nephropathy.
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Affiliation(s)
- Alexis Werion
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
- Correspondence: Eric Rondeau Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Rue de la Chine 4, 75020 Paris, France. E-mail:
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36
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Prével R, Delmas Y, Guillotin V, Gruson D, Rivière E. Complement Blockade Is a Promising Therapeutic Approach in a Subset of Critically Ill Adult Patients with Complement-Mediated Hemolytic Uremic Syndromes. J Clin Med 2022; 11:jcm11030790. [PMID: 35160242 PMCID: PMC8837052 DOI: 10.3390/jcm11030790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) gathers consumptive thrombocytopenia, mechanical haemolytic anemia, and organ damage. Hemolytic uremic syndromes (HUS) are historically classified as primary or secondary to another disease once thrombotic thrombocytopenic purpura (TTP), Shiga-toxin HUS, and cobalamin C-related HUS have been ruled out. Complement genetics studies reinforced the link between complement dysregulation and primary HUS, contributing to reclassifying some pregnancy- and/or post-partum-associated HUS and to revealing complement involvement in severe and/or refractory hypertensive emergencies. By contrast, no firm evidence allows a plausible association to be drawn between complement dysregulation and Shiga-toxin HUS or other secondary HUS. Nevertheless, rare complement gene variants are prevalent in healthy individuals, thus providing an indication that an investigation into complement dysregulation should be carefully balanced and that the results should be cautiously interpreted with the help of a trained geneticist. Several authors have suggested reclassifying HUS in two entities, regardless of they are complement-mediated or not, since the use of eculizumab, an anti-C5 antibody, dramatically lowers the proportion of patients who die or suffer from end-stage renal disease within the year following diagnosis. Safety and the ideal timing of eculizumab discontinuation is currently under investigation, and the long-term consequences of HUS should be closely monitored over time once patients exit emergency departments.
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Affiliation(s)
- Renaud Prével
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-(0)5-56-79-55-17; Fax: +33-(0)5-56-79-54-18
| | - Yahsou Delmas
- CHU Bordeaux, Nephrology Transplantation Dialysis Apheresis Unit, F-33076 Bordeaux, France;
| | - Vivien Guillotin
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
| | - Etienne Rivière
- CHU Bordeaux, Internal Medicine Department, F-33000 Bordeaux, France;
- University Bordeaux, Biology of Cardiovascular Diseases, InsermU1034, F-33604 Pessac, France
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37
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Filippone EJ, Newman ED, Li L, Gulati R, Farber JL. Thrombotic Microangiopathy, an Unusual Form of Monoclonal Gammopathy of Renal Significance: Report of 3 Cases and Literature Review. Front Immunol 2021; 12:780107. [PMID: 34858436 PMCID: PMC8631422 DOI: 10.3389/fimmu.2021.780107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/22/2021] [Indexed: 12/25/2022] Open
Abstract
Monoclonal gammopathies result from neoplastic clones of the B-cell lineage and may cause kidney disease by various mechanisms. When the underlying clone does not meet criteria for a malignancy requiring treatment, the paraprotein is called a monoclonal gammopathy of renal significance (MGRS). One rarely reported kidney lesion associated with benign paraproteins is thrombotic microangiopathy (TMA), provisionally considered as a combination signifying MGRS. Such cases may lack systemic features of TMA, such as a microangiopathic hemolytic anemia, and the disease may be kidney limited. There is no direct deposition of the paraprotein in the kidney, and the presumed mechanism is disordered complement regulation. We report three cases of kidney limited TMA associated with benign paraproteins that had no other detectable cause for the TMA, representing cases of MGRS. Two of the cases are receiving clone directed therapy, and none are receiving eculizumab. We discuss in detail the pathophysiological basis for this possible association. Our approach to therapy involves first ruling out other causes of TMA as well as an underlying B-cell malignancy that would necessitate direct treatment. Otherwise, clone directed therapy should be considered. If refractory to such therapy or the disease is severe and multisystemic, C5 inhibition (eculizumab or ravulizumab) may be indicated as well.
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Affiliation(s)
- Edward J Filippone
- Divsion of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Eric D Newman
- Divsion of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Li Li
- Department of Pathology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Rakesh Gulati
- Divsion of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - John L Farber
- Department of Pathology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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Haydock L, Garneau AP, Tremblay L, Yen HY, Gao H, Harrisson R, Isenring P. Genetic abnormalities in biopsy-proven, adult-onset hemolytic uremic syndrome and C3 glomerulopathy. J Mol Med (Berl) 2021; 100:269-284. [PMID: 34714369 PMCID: PMC8770394 DOI: 10.1007/s00109-021-02102-1] [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] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/25/2022]
Abstract
Abstract Atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy (C3G) have been linked to mutations in many of the proteins that are involved in alternative complement pathway activation. Age and etiology confounded, the prevalence of such mutations has been reported to be over 30 to 50% in these diseases. However, the cohorts studied included many children or individuals with a familial history of complement-related disorders and genetic tests were usually limited to exome sequencing of known causative or risk-associated genes. In this study, a retrospective adult cohort of 35 patients with biopsy-proven thrombotic microangiopathy (the largest in Canada) and 10 patients with C3 glomerulopathy was tested through an extended exome panel to identify causative defects in associated or candidate genes including those of the alternative and terminal complement pathways. A variant of unknown significance was also analyzed for pathogenicity through in vitro studies. To our surprise, the prevalence of known causative or risk-associated variants in either of these cohorts was found to be less than ~ 15% overall. However, the panel used and analyses carried out allowed to identify novel variants of potential clinical significance and a number of candidate genes. The prevalence of known genetic defects in adult-onset aHUS and C3G is thus probably much lower than 30 to 50%. Our results also point towards the importance of investigating diseases of the alternative complement pathway through extended exome panels and in vitro analyses. Key messages The alternative complement pathway plays a major role in the pathogenesis of hemolytic uremic syndrome and C3 glomerulopathy. Based on previous studies, both disorders have been commonly linked to variants in the various intermediates that sustain or regulate this pathway. The prevalence of such mutations in the adult-onset and sporadic forms of these diseases is probably much lower than expected based on larger series. The sporadic forms of complementopathies are likely to involve additional genes that are yet to be uncovered.
Supplementary information The online version contains supplementary material available at 10.1007/s00109-021-02102-1.
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Affiliation(s)
- Ludwig Haydock
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada
| | - Alexandre P Garneau
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada.,Cardiometabolic Axis, School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montréal, 900, rue Saint-Denis, Montreal, QC, H2X 0A9, Canada
| | - Laurence Tremblay
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada
| | - Hai-Yun Yen
- Fulgent Genetics, Temple City, CA, 91780, USA
| | - Hanlin Gao
- Fulgent Genetics, Temple City, CA, 91780, USA
| | - Raphaël Harrisson
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada
| | - Paul Isenring
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada.
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Thrombotic microangiopathy triggered by podocytopathy. Clin Nephrol Case Stud 2021; 9:110-116. [PMID: 34646728 PMCID: PMC8507413 DOI: 10.5414/cncs110534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare group of diseases characterized by microangiopathic hemolytic anemia, thrombocytopenia, and target organ damage. It can be divided into primary and secondary TMA. Herein we report a case of TMA associated to a primary glomerular disease. We report the case of a 31-year-old Black male from Cape Verde admitted in March 2018 with nephrotic syndrome and upper gastrointestinal bleeding, the latter due to severe erythematous gastritis. He was discharged after clinical stabilization. The patient came to Portugal 8 months later. On admission, he presented with rapid deterioration of kidney function and hyperkalemia. The etiologic study revealed microangiopathic hemolytic anemia, nephrotic syndrome and microscopic hematuria. Immunologic study and viral serology were negative. ADAMTS13 activity and inhibitor testing were within normal range, genetic complement evaluation showed CFH-H3 in homozygosity, functional complement studies revealed decreased function of alternative pathway. Kidney biopsy was consistent with the diagnosis of TMA, and electron microscopy was compatible with minimal change disease. Patient underwent plasmapheresis with resolution of hemolysis, fluid overload and recovery of renal function. Two months later, he presented with nephrotic syndrome and started prednisolone with remission. Six months later, the nephrotic syndrome relapsed, and it became steroid-, MMF-, and rituximab-resistant. Tacrolimus was initiated, achieving partial remission. Atypical hemolytic uremic syndrome is an uncommon disease and is rarely reported as secondary to glomerular diseases. This case showcases the challenges regarding treatment options in a resistant glomerulopathy and the implications of therapeutic choices and kidney outcomes with the coexisting TMA.
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Sandino-Pérez J, Gutiérrez E, Caravaca-Fontán F, Morales E, Aubert-Girbal L, Delgado-Lillo R, Praga M. Haemolytic uraemic syndrome associated with pancreatitis: report of four cases and review of the literature. Clin Kidney J 2021; 14:1946-1952. [PMID: 34345418 PMCID: PMC8323133 DOI: 10.1093/ckj/sfaa245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/19/2020] [Indexed: 01/05/2023] Open
Abstract
Background The incidence of acute kidney injury (AKI) in patients with acute pancreatitis ranges from 15% to 40% and is associated with poor prognosis. Haemolytic uraemic syndrome (HUS) in the setting of acute pancreatitis is an uncommon association with fewer than 30 cases reported in the literature. Methods A retrospective review of the clinical records at our institution between January 1981 and December 2019 was carried out to identify patients with acute pancreatitis and HUS. Additionally, a literature review was conducted on this topic. The aims of the study were to describe the clinical course and outcomes of patients affected by this condition. Results Four cases of HUS following an acute pancreatitis were identified. The mean (±SD) age of the study group was 30 ± 6 years, all of which were males. Excessive alcohol consumption was the main cause of acute pancreatitis in all four patients. HUS with progressive AKI developed in a median interval of 2 days from the onset of pancreatitis (range 1-3 days). All patients required kidney replacement therapy during the course of follow-up. A kidney biopsy was performed in two patients, showing typical thrombotic microangiopathic features. One case was treated with eculizumab, whereas the rest were treated with supportive care and/or plasma exchange. A normalization of haematological parameters and complete recovery of kidney function were observed in all patients at last follow-up, although this improvement was significantly faster in the patient treated with eculizumab. Conclusions HUS may infrequently develop in patients with acute pancreatitis. An early identification of this complication is mandatory, and complement blockade with eculizumab may be associated with a faster kidney function recovery.
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Affiliation(s)
| | | | | | - Enrique Morales
- Department of Nephrology, Hospital Universitario, Madrid, Spain
| | | | | | - Manuel Praga
- Department of Nephrology, Hospital Universitario, Madrid, Spain
- Department of Nephrology, Instituto de Investigación Hospital Universitario, Madrid, Spain
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Fakhouri F, Frémeaux-Bacchi V. Thrombotic microangiopathy in aHUS and beyond: clinical clues from complement genetics. Nat Rev Nephrol 2021; 17:543-553. [PMID: 33953366 DOI: 10.1038/s41581-021-00424-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/02/2023]
Abstract
Studies of complement genetics have changed the landscape of thrombotic microangiopathies (TMAs), particularly atypical haemolytic uraemic syndrome (aHUS). Knowledge of complement genetics paved the way for the design of the first specific treatment for aHUS, eculizumab, and is increasingly being used to aid decisions regarding discontinuation of anti-complement treatment in this setting. Complement genetic studies have also been used to investigate the pathogenic mechanisms that underlie other forms of HUS and provided evidence that contributed to the reclassification of pregnancy- and postpartum-associated HUS within the spectrum of complement-mediated aHUS. By contrast, complement genetics has not provided definite evidence of a link between constitutional complement dysregulation and secondary forms of HUS. Therefore, the available data do not support systematic testing of complement genes in patients with typical HUS or secondary HUS. The potential relevance of complement genetics for distinguishing the underlying mechanisms of malignant hypertension-associated TMA should be assessed with caution owing to the overlap between aHUS and other causes of malignant hypertension. In all cases, the interpretation of complement genetics results remains complex, as even complement-mediated aHUS is not a classical monogenic disease. Such interpretation requires the input of trained geneticists and experts who have a comprehensive view of complement biology.
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Affiliation(s)
- Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Immunologie, Paris, France
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Grall M, Daviet F, Chiche NJ, Provot F, Presne C, Coindre JP, Pouteil-Noble C, Karras A, Guerrot D, François A, Benhamou Y, Veyradier A, Frémeaux-Bacchi V, Coppo P, Grangé S. Eculizumab in gemcitabine-induced thrombotic microangiopathy: experience of the French thrombotic microangiopathies reference centre. BMC Nephrol 2021; 22:267. [PMID: 34284729 PMCID: PMC8293501 DOI: 10.1186/s12882-021-02470-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gemcitabine is a broadly prescribed chemotherapy, the use of which can be limited by renal adverse events, including thrombotic microangiopathy (TMA). METHODS This study evaluated the efficacy of eculizumab, a monoclonal antibody targeting the terminal complement pathway, in patients with gemcitabine-induced TMA (G-TMA). We conducted an observational, retrospective, multicenter study in 5 French centres, between 2011 and 2016. RESULTS Twelve patients with a G-TMA treated by eculizumab were included. The main characteristics were acute renal failure (100%), including stage 3 acute kidney injury (AKI, 58%) and renal replacement therapy (17%), hypertension (92%) and diffuse oedema (83%). Eculizumab was started after a median of 15 days (range 4-44) following TMA diagnosis. A median of 4 injections of eculizumab was performed (range 2-22). Complete hematological remission was achieved in 10 patients (83%) and blood transfusion significantly decreased after only one injection of eculizumab (median of 3 packed red blood cells (range 0-10) before treatment vs 0 (range 0-1) after one injection, P < 0.001). Two patients recovered completely renal function (17%), and 8 achieved a partial remission (67%). Compared to a control group of G-TMA without use of eculizumab, renal outcome was more favourable. At the end of the follow up, median eGFR was 45 vs 33 ml/min/1.73m2 respectively in the eculizumab group and in the control group. CONCLUSIONS These results suggest that eculizumab is efficient on haemolysis and reduces transfusion requirement in G-TMA. Moreover, eculizumab may improve renal function recovery.
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Affiliation(s)
- Maximilien Grall
- Medical Intensive Care Unit, Rouen University Hospital, 37 boulevard Gambetta, 76031, Rouen Cedex, France
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
| | - Florence Daviet
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Conception University Hospital, APHM, Marseille, France
| | - Noémie Jourde Chiche
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Conception University Hospital, APHM, Marseille, France
| | - François Provot
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Lille University Hospital, Lille, France
| | - Claire Presne
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Amiens University Hospital, Amiens, France
| | - Jean-Philippe Coindre
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Le Mans General Hospital, Le Mans, France
| | - Claire Pouteil-Noble
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, E. Herriot Hospital, Lyon I university, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Georges Pompidou Hospital, APHP, Paris, France
| | | | - Arnaud François
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Ygal Benhamou
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Internal Medicine, Rouen University Hospital, Rouen, France
| | - Agnès Veyradier
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Biological Hematology, Lariboisière University Hospital, APHP, Paris, France
| | - Véronique Frémeaux-Bacchi
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of immunology, Georges Pompidou Hospital, APHP, Paris, France
| | - Paul Coppo
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Hematology, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
| | - Steven Grangé
- Medical Intensive Care Unit, Rouen University Hospital, 37 boulevard Gambetta, 76031, Rouen Cedex, France.
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France.
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Tavasoli A, Zafaranloo N, Hoseini R, Otukesh H, Nakhaiee S. Frequency of neurological involvement in patients with/without diarrhea hemolytic uremic syndrome: A Systematic review and meta-analysis. Med J Islam Repub Iran 2021; 35:91. [PMID: 34956937 PMCID: PMC8683803 DOI: 10.47176/mjiri.35.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Diarrhea-associated-hemolytic-uremic-syndrome (D+HUS) is a common from of HUS. Central-nervous-system (CNS) involvement is one of the most common extrarenal organ involvements in children with D+HUS. This systematic review and meta-analysis aim to recognize the frequency of neurological complications in pts with HUS. Methods: Databases of PubMed, Embase, and Web of Science were searched systematically to find the papers on neurological involvement in HUS pts. Two researchers independently assessed the papers' quality and extracted data. CMA v. 2.2.064. was used for data analysis. Heterogeneity was evaluated using the I-squared (I2) test, and a fixed/random-effects model was used when appropriate. Results: In this review, 21 studies including 2,189 participants with a median age between 1.3-40-year-old, entered the meta-analysis. The meta-analysis in D+HUS patients indicated 27.0% with neurological complications (95% CI, 22.0%-32.6%), 25.5% of symptoms weren't categorized (95% CI, 15.9%-38.3%), 20.8% of them developed the seizures (95% CI, 2.3%-74.4%). In D-HUS pts, 20.8% of them were presented neurological symptoms (95% CI, 17.9%-24.0%), of which 29.0% weren't categorized (95% CI, 19.2%-41.2%), 17.5% of pts got into coma (95% CI, 9.6%-29.7%), 5.6 % showed hemiparesis (95% CI, 2.8%-10.9%), 17.2% experienced lethargy (95% CI, 5.2%-44.1%), 30.5% developed the seizures (95% CI, 18.2%-46.2%), 7.4% manifested speech abnormalities (95% CI, 0.2%-7.22%), 6.4% of D-HUS pts presented visual-disturbances (95% CI, 3.4%-11.6%). Conclusion: This systematic review and meta-analysis indicated more than one-fourth of both D+HUS and D-HUS patients were presented with neurological symptoms, and the most prevalent symptoms were seizures, which can lead to an epilepsy sequel.
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Affiliation(s)
- Azita Tavasoli
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Nazanin Zafaranloo
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Rozita Hoseini
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Hasan Otukesh
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Shahrbanoo Nakhaiee
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
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The Syndromes of Thrombotic Microangiopathy: A Critical Appraisal on Complement Dysregulation. J Clin Med 2021; 10:jcm10143034. [PMID: 34300201 PMCID: PMC8307963 DOI: 10.3390/jcm10143034] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 01/12/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare and potentially life-threatening condition that can be caused by a heterogeneous group of diseases, often affecting the brain and kidneys. TMAs should be classified according to etiology to indicate targets for treatment. Complement dysregulation is an important cause of TMA that defines cases not related to coexisting conditions, that is, primary atypical hemolytic uremic syndrome (HUS). Ever since the approval of therapeutic complement inhibition, the approach of TMA has focused on the recognition of primary atypical HUS. Recent advances, however, demonstrated the pivotal role of complement dysregulation in specific subtypes of patients considered to have secondary atypical HUS. This is particularly the case in patients presenting with coexisting hypertensive emergency, pregnancy, and kidney transplantation, shifting the paradigm of disease. In contrast, complement dysregulation is uncommon in patients with other coexisting conditions, such as bacterial infection, drug use, cancer, and autoimmunity, among other disorders. In this review, we performed a critical appraisal on complement dysregulation and the use of therapeutic complement inhibition in TMAs associated with coexisting conditions and outline a pragmatic approach to diagnosis and treatment. For future studies, we advocate the term complement-mediated TMA as opposed to the traditional atypical HUS-type classification.
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Menne J. Is ravulizumab the new treatment of choice for atypical hemolytic uremic syndrome (aHUS)? Kidney Int 2021; 97:1106-1108. [PMID: 32444092 DOI: 10.1016/j.kint.2020.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/25/2022]
Abstract
Ravulizumab, a new long-acting C5 inhibitor, recently received FDA approval for the treatment of aHUS. Rates of complete thrombotic microangiopathy response were similar to those observed in major eculizumab trials; however, fewer patients in the ravulizumab study were able to stop dialysis, probably due to differences in the study populations. Until additional data/analyses are available, eculizumab remains the drug of choice for an acute aHUS episode, whereas ravulizumab has several advantages in maintenance treatment.
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Affiliation(s)
- Jan Menne
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany.
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Hemolytic uremic syndrome and kidney transplantation in uncontrolled donation after circulatory death (DCD): A two-case report. Clin Nephrol Case Stud 2021; 9:59-66. [PMID: 34084691 PMCID: PMC8170123 DOI: 10.5414/cncs110434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/11/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Hemolytic uremic syndrome (HUS) is a rare disease characterized by microangiopathic hemolysis, thrombocytopenia, and renal involvement. Complement-mediated atypical HUS (aHUS) is a result of genetic defects in the alternative complement pathway components or regulators. The introduction of eculizumab has improved renal and overall survival of aHUS patients. Nowadays, given organ shortage, it is necessary to consider kidney transplantation (KT) even in protocols with a high risk of HUS recurrence, such as from donation after circulatory death (DCD) donors. Here, we describe two patients with HUS who underwent a KT from an uncontrolled DCD (uDCD). Case summary: The first patient, affected by aHUS due to a heterozygous deletion in CFHR3-CFHR1 and a novel heterozygous variant in CFHR5 gene, underwent a KT with eculizumab prophylaxis. The patient did not experience a post-transplant aHUS recurrence. The second patient, who experienced an HUS episode characterized by a hypertensive crisis and with no underlying mutations in complement system genes, underwent a KT without eculizumab prophylaxis. At day 5, anti-complement treatment commenced due to hematological signs of thrombotic microangiopathy (TMA). After the introduction of eculizumab, we observed a stabilization of kidney function and hematological remission. Conclusion: We present herein two different patients with HUS who both underwent successful KT from uDCD donation under the umbrella of eculizumab therapy. Taking into account the importance of increasing the number of organs available for transplantation, uDCD could represent an additional resource in this subset of HUS patients.
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Sánchez-Moreno A, de la Cerda F, Rodríguez-Barba A, Fijo J, Bedoya R, Arjona E, de Córdoba SR. Is the atypical hemolytic uremic syndrome risk polymorphism in Membrane Cofactor Protein MCPggaac relevant in kidney transplantation? A case report. Pediatr Transplant 2021; 25:e13903. [PMID: 33217135 DOI: 10.1111/petr.13903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/08/2020] [Accepted: 10/06/2020] [Indexed: 12/26/2022]
Abstract
aHUS is a rare disease characterized by episodes of TMA that frequently progresses to CKD and often recurs after KT. The most frequent cause of aHUS is defective regulation of complement activation because of genetic anomalies. Eculizumab interrupts the process of TMA and improves renal function. We describe one female patient with aHUS who debuted in 2005 at 3-mo-old with extrarenal manifestations and progressed to end-stage kidney disease (ESKD) within a year. Her family history included several affected members with similar bad outcomes. Our patient carries a strong aHUS genetic predisposition consisting in a pathogenic gain-of-function mutation in complement factor B concurrent with the MCP aHUS risk haplotype MCPggaac. She received a kidney transplant in 2011 without eculizumab prophylaxis. The graft, which was negative for the MCPggaac risk haplotype, had an unexpected excellent evolution without aHUS recurrence. Different retrospective studies have shown that the risk of aHUS recurrence after KT correlates well with the genetic load of aHUS risk factors. Knowing important contribution of the MCPggaac risk haplotype to the risk of developing aHUS in Factor B mutations carriers, we speculate whether the absence of this polymorphism in the graft that our patient received may have decreased the risk of aHUS recurrence after KT.
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Affiliation(s)
- Ana Sánchez-Moreno
- Pediatric Nephrology Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Julia Fijo
- Pediatric Nephrology Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rafael Bedoya
- Pediatric Nephrology Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Emilia Arjona
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Enfermedades Raras, Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Enfermedades Raras, Madrid, Spain
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Perrier Q, Noble J, Grangé S, Bedouch P, Tetaz R, Rostaing L. Atypical Evolution of Secondary Hemolytic Uremic Syndrome Defined as Paraneoplastic Syndrome under Eculizumab and Palbociclib Therapies. Case Rep Oncol 2021; 14:676-680. [PMID: 33976652 PMCID: PMC8077600 DOI: 10.1159/000514982] [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] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 01/01/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is most of the time caused by thrombotic thrombocytopenic purpura or hemolytic uremic syndrome. A 60-year-old female was diagnosed in 2014 with mammary breast adenocarcinoma treated by several-line therapy: mastectomy, docetaxel, cyclophosphamide, radiotherapy, doxorubicine, and capecitabine. By mid-November, the patient was admitted to the hospital with regenerative, mechanical, and hemolytic anemia, schistocytes at 3%, and thrombopenia (99 G/L), associated with high blood transfusion requirement. After 9 sessions of plasmapheresis, there was no significant improvement in the biological parameters, nor after 2 cycles of paclitaxel. The patient was then treated with eculizumab during 4 weeks, with a slight reduction in blood requirement, and simultaneously with palbociclib. Since being treated with palpociclib, she had a great reduction in blood requirement and a good clinical condition. To conclude, we reported an initial moderate improvement of paraneoplasm-related TMA syndrome under eculizumab therapy with a slight reduction in red blood cell requirement; however, palbociclib therapy achieved a very good response with a dramatic reduction in red blood cell requirement.
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Affiliation(s)
- Quentin Perrier
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Steven Grangé
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France.,Centre de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France
| | - Pierrick Bedouch
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France.,Grenoble Alpes University, Grenoble, France.,Grenoble Alpes University, CNRS TIMC-IMAG, UMR 5525, Grenoble, France
| | - Rachel Tetaz
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France.,Grenoble Alpes University, Grenoble, France
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Werion A, Rondeau E. C5 Inhibition in Secondary Thrombotic Microangiopathies: A Yet Unresolved Question. Kidney Int Rep 2021; 6:878-880. [PMID: 33939775 PMCID: PMC8071650 DOI: 10.1016/j.ekir.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Alexis Werion
- Intensive Care Nephrology and Transplantation Department, SINRA, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, SINRA, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
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50
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Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group. Blood 2021; 136:2103-2117. [PMID: 32808006 DOI: 10.1182/blood.2020005221] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022] Open
Abstract
Pregnancy and postpartum are high-risk periods for different forms of thrombotic microangiopathy (TMA). However, the management of pregnancy-associated TMA remains ill defined. This report, by an international multidisciplinary working group of obstetricians, nephrologists, hematologists, intensivists, neonatologists, and complement biologists, summarizes the current knowledge of these potentially severe disorders and proposes a practical clinical approach to diagnose and manage an episode of pregnancy-associated TMA. This approach takes into account the timing of TMA in pregnancy or postpartum, coexisting symptoms, first-line laboratory workup, and probability-based assessment of possible causes of pregnancy-associated TMA. Its aims are: to rule thrombotic thrombocytopenic purpura (TTP) in or out, with urgency, using ADAMTS13 activity testing; to consider alternative disorders with features of TMA (preeclampsia/eclampsia; hemolysis elevated liver enzymes low platelets syndrome; antiphospholipid syndrome); or, ultimately, to diagnose complement-mediated atypical hemolytic uremic syndrome (aHUS; a diagnosis of exclusion). Although they are rare, diagnosing TTP and aHUS associated with pregnancy, and postpartum, is paramount as both require urgent specific treatment.
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