1
|
Wang C, Chen J, Han X, Sun M, Fang X, Zhai Y, Miao Q, Zhang Z, Tang X, Liu J, Shen Q, Xu H. Protein-losing enteropathy as a new phenotype in atypical hemolytic uremic syndrome caused by CD46 gene mutation. Pediatr Nephrol 2024:10.1007/s00467-024-06451-0. [PMID: 39097532 DOI: 10.1007/s00467-024-06451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a life-threatening thrombotic microangiopathy. Genetic defects in the alternative complement (AP) pathway have been identified in 60-70% of individuals. Eculizumab is recommended as a first-line therapy. METHODS We collected the clinical data of a pediatric patient with aHUS accompanied by protein-losing enteropathy (PLE). Genetic testing was performed. Related literature on aHUS combined with PLE was reviewed. RESULTS A 15-year-old Chinese girl was diagnosed with aHUS at 3.7 years of age and experienced five episodes; her symptoms completely resolved with plasma treatment. Severe gastrointestinal symptoms and hypoalbuminemia presented after the first episode, and PLE was diagnosed. A novel homozygous CD46 variant was identified, and FACS revealed significantly decreased CD46 expression. She presented at a recent relapse with persistent GI symptoms and headache and progressed to chronic kidney failure; peritoneal dialysis was initiated. Eculizumab was given 8 months after the last recurrence. Surprisingly, PLE was cured. Afterward, dialysis was discontinued, and eGFR recovered to 44.8 ml/min/1.73 m2. A review of the literature indicated that PLE with thrombosis was caused by CD55 variants via hyperactivation of the AP system. We report an aHUS patient with PLE caused by CD46 variants. Symptoms of both PLE and aHUS were significantly alleviated in our patient and patients with CD55 variants treated with eculizumab, indicating that PLE was a new symptom of aHUS in our patient with a CD46 variant. CONCLUSIONS Our case expands the phenotype of aHUS caused by a CD46 mutation and provides evidence of the efficacy of eculizumab after a long phase of chronic kidney failure.
Collapse
Affiliation(s)
- Chunyan Wang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xinli Han
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Manqing Sun
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xiaoyan Fang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Yihui Zhai
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Qianfan Miao
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Zhiqing Zhang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xiaoshan Tang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Jiaojiao Liu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
- National Key Laboratory of Kidney Diseases, Beijing, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China.
- National Key Laboratory of Kidney Diseases, Beijing, China.
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Cole MA, Ranjan N, Gerber GF, Pan XZ, Flores-Guerrero D, Chaturvedi S, Sperati CJ, McCrae KR, Brodsky RA. Complement Biosensors Identify a Classical Pathway Stimulus in Complement-Mediated Hemolytic Uremic Syndrome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.29.596475. [PMID: 38854038 PMCID: PMC11160691 DOI: 10.1101/2024.05.29.596475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Complement-mediated hemolytic uremic syndrome (CM-HUS) is a thrombotic microangiopathy characterized by germline variants or acquired antibodies to complement proteins and regulators. Building upon our prior experience with the modified Ham (mHam) assay for ex vivo diagnosis of complementopathies, we have developed an array of cell-based complement "biosensors'' by selective removal of complement regulatory proteins (CD55 and CD59, CD46, or a combination thereof) in an autonomously bioluminescent HEK293 cell line. These biosensors can be used as a sensitive method for diagnosing CM-HUS and monitoring therapeutic complement blockade. Using specific complement pathway inhibitors, this model identifies IgM-driven classical pathway stimulus during both acute disease and in many patients during clinical remission. This provides a potential explanation for ~50% of CM-HUS patients who lack an alternative pathway "driving" variant and suggests at least a subset of CM-HUS is characterized by a breakdown of IgM immunologic tolerance. Key Points CM-HUS has a CP stimulus driven by polyreactive IgM, addressing the mystery of why 40% of CM-HUS lack complement specific variantsComplement biosensors and the bioluminescent mHam can be used to aid in diagnosis of CM-HUS and monitor complement inhibitor therapy.
Collapse
|
5
|
Fung WWS, Chao ACW, Pang WF, Wong RSM, Chow KM, Szeto CC. An unusual case of adult-onset still's disease complicated with anti-complement factor H antibodies associated atypical haemolytic uraemic syndrome. BMC Nephrol 2024; 25:164. [PMID: 38745129 PMCID: PMC11094913 DOI: 10.1186/s12882-024-03548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/15/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Atypical haemolytic uremic syndrome (aHUS) is an uncommon form of thrombotic microangiopathy (TMA). However, it remains difficult to diagnose the disease early, given its non-specific and overlapping presentation to other conditions such as thrombotic thrombocytopenic purpura and typical HUS. It is also important to identify the underlying causes and to distinguish between primary (due to a genetic abnormality leading to a dysregulated alternative complement pathway) and secondary (often attributed by severe infection or inflammation) forms of the disease, as there is now effective treatment such as monoclonal antibodies against C5 for primary aHUS. However, primary aHUS with severe inflammation are often mistaken as a secondary HUS. We presented an unusual case of adult-onset Still's disease (AOSD) with macrophage activation syndrome (MAS), which is in fact associated with anti-complement factor H (anti-CFH) antibodies related aHUS. Although the aHUS may be triggered by the severe inflammation from the AOSD, the presence of anti-CFH antibodies suggests an underlying genetic defect in the alternative complement pathway, predisposing to primary aHUS. One should note that anti-CFH antibodies associated aHUS may not always associate with genetic predisposition to complement dysregulation and can be an autoimmune form of aHUS, highlighting the importance of genetic testing. CASE PRESENTATION A 42 years old man was admitted with suspected adult-onset Still's disease. Intravenous methylprednisolone was started but patient was complicated with acute encephalopathy and low platelet. ADAMTS13 test returned to be normal and concurrent aHUS was eventually suspected, 26 days after the initial thrombocytopenia was presented. Plasma exchange was started and patient eventually had 2 doses of eculizumab after funding was approved. Concurrent tocilizumab was also used to treat the adult-onset Still's disease with MAS. The patient was eventually stabilised and long-term tocilizumab maintenance treatment was planned instead of eculizumab following haematology review. Although the aHUS may be a secondary event to MAS according to haematology opinion and the genetic test came back negative for the five major aHUS gene, high titre of anti-CFH antibodies was detected (1242 AU/ml). CONCLUSION Our case highlighted the importance of prompt anti-CFH antibodies test and genetic testing for aHUS in patients with severe AOSD and features of TMA. Our case also emphasized testing for structural variants within the CFH and CFH-related proteins gene region, as part of the routine genetic analysis in patients with anti-CFH antibodies associated aHUS to improve diagnostic approaches.
Collapse
Affiliation(s)
- Winston Wing-Shing Fung
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China.
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China.
| | - Amelia Chien-Wei Chao
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Wing-Fai Pang
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Raymond Siu-Ming Wong
- Division of Haematology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Kai-Ming Chow
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Cheuk-Chun Szeto
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Li Ka Shing Institute of Health Sciences (LiHS), The Chinese University of Hong Kong, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| |
Collapse
|
6
|
Shojaei M, Mohammadvand N, Doğan T, Alkan C, Çetin Atalay R, Acar AC. An integrative framework for clinical diagnosis and knowledge discovery from exome sequencing data. Comput Biol Med 2024; 169:107810. [PMID: 38134749 DOI: 10.1016/j.compbiomed.2023.107810] [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: 03/28/2023] [Revised: 11/06/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023]
Abstract
Non-silent single nucleotide genetic variants, like nonsense changes and insertion-deletion variants, that affect protein function and length substantially are prevalent and are frequently misclassified. The low sensitivity and specificity of existing variant effect predictors for nonsense and indel variations restrict their use in clinical applications. We propose the Pathogenic Mutation Prediction (PMPred) method to predict the pathogenicity of single nucleotide variations, which impair protein function by prematurely terminating a protein's elongation during its synthesis. The prediction starts by monitoring functional effects (Gene Ontology annotation changes) of the change in sequence, using an existing ensemble machine learning model (UniGOPred). This, in turn, reveals the mutations that significantly deviate functionally from the wild-type sequence. We have identified novel harmful mutations in patient data and present them as motivating case studies. We also show that our method has increased sensitivity and specificity compared to state-of-the-art, especially in single nucleotide variations that produce large functional changes in the final protein. As further validation, we have done a comparative docking study on such a variation that is misclassified by existing methods and, using the altered binding affinities, show how PMPred can correctly predict the pathogenicity when other tools miss it. PMPred is freely accessible as a web service at https://pmpred.kansil.org/, and the related code is available at https://github.com/kansil/PMPred.
Collapse
Affiliation(s)
- Mona Shojaei
- Cancer Systems Biology Laboratory, Graduate School of Informatics, Middle East Technical University, Ankara 06800 Turkey
| | - Navid Mohammadvand
- Biological Data Science Lab, Dept. of Computer Engineering, Hacettepe University, Ankara 06800 Turkey
| | - Tunca Doğan
- Biological Data Science Lab, Dept. of Computer Engineering, Hacettepe University, Ankara 06800 Turkey; Dept. of Bioinformatics, Graduate School of Health Sciences, Hacettepe University, Ankara 06800 Turkey
| | - Can Alkan
- Department of Computer Engineering, Bilkent University, Ankara 06800 Turkey
| | - Rengül Çetin Atalay
- Department of Medicine, University of Chicago, Chicago, IL, USA; Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Avenue, MC6026, Chicago, IL, 60637, USA
| | - Aybar C Acar
- Cancer Systems Biology Laboratory, Graduate School of Informatics, Middle East Technical University, Ankara 06800 Turkey.
| |
Collapse
|
7
|
Acharya R, Clapp WL, Upadhyay K. Efficacy and Safety of Eculizumab in Enteroaggregative E. coli Associated Hemolytic Uremic Syndrome. Pediatr Rep 2024; 16:26-34. [PMID: 38251312 PMCID: PMC10801546 DOI: 10.3390/pediatric16010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) may present atypically without the full triad of classical HUS. Eculizumab has been shown to be efficacious in complement-mediated atypical HUS and some cases of Shiga-toxin (ST) associated HUS. We report the utility of eculizumab in enteroaggregative E. coli (EAEC) associated HUS. CASE SUMMARY A female toddler presented with hemolytic anemia, oliguric acute kidney injury (AKI) without thrombocytopenia, and peripheral schistocytes. The stool examination for ST was negative but positive for EAEC. She required several hemodialysis sessions and received one dosage of eculizumab with rapid reversal of AKI and hemolytic markers. A kidney biopsy revealed acute tubular injury and segmental glomerular basement membrane splitting. Genetic testing was negative for complement mutations or deficiencies. A follow-up six months later showed persistently normal renal function and hematological markers. CONCLUSION The clinical and histological manifestations of non-ST-associated diarrheal HUS and the role of eculizumab in this condition warrant future larger studies.
Collapse
Affiliation(s)
- Ratna Acharya
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Nemours Children’s Hospital, Orlando, FL 32827, USA;
| | - William L. 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
| |
Collapse
|
8
|
Pasari A, Balwani M, Gurjar P, Sejpal K, Bawankule C, Tolani P, Dubey S, Kashiv P, Bhawane A, Malde S, Gupta S. A Rare Case of Autoimmune Disorder as a Trigger for Atypical Hemolytic Uremic Syndrome. Cureus 2024; 16:e53126. [PMID: 38420105 PMCID: PMC10899531 DOI: 10.7759/cureus.53126] [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: 09/05/2023] [Accepted: 01/23/2024] [Indexed: 03/02/2024] Open
Abstract
Autoimmune diseases may act as a trigger for atypical hemolytic uremic syndrome (aHUS). Triggers for aHUS may include autoimmune diseases, infections, metabolic conditions, pregnancy, and transplants. aHUS-mediated injury to various organs, especially kidneys, can be life-threatening. Here, we present the case of a young female who had perinuclear antineutrophil cytoplasmic antibody (p-ANCA)-associated vasculitis and was diagnosed with aHUS. We consider underlying autoimmune p-ANCA-associated vasculitis as a trigger for aHUS in this case.
Collapse
Affiliation(s)
- Amit Pasari
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
- Department of Nephrology, Saraswati Kidney Care Center, Nagpur, IND
| | - Manish Balwani
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
- Department of Nephrology, Saraswati Kidney Care Center, Nagpur, IND
| | - Prasad Gurjar
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kapil Sejpal
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | | | - Priyanka Tolani
- Department of Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shubham Dubey
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pranjal Kashiv
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amol Bhawane
- Department of Nephrology, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Sunny Malde
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sushrut Gupta
- Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
9
|
Abstract
The complement cascade comprises soluble and cell surface proteins and is an important arm of the innate immune system. Once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammatory, vasoactive and metabolic responses. Although complement is crucial to host defence and homeostasis, its inappropriate or uncontrolled activation can also drive tissue injury. For example, the complement system has been known for more than 50 years to be activated by glomerular immune complexes and to contribute to autoimmune kidney disease. Notably, the latest research shows that complement is also activated in kidney diseases that are not traditionally thought of as immune-mediated, including haemolytic-uraemic syndrome, diabetic kidney disease and focal segmental glomerulosclerosis. Several complement-targeted drugs have been approved for the treatment of kidney disease, and additional anti-complement agents are being investigated in clinical trials. These drugs are categorically different from other immunosuppressive agents and target pathological processes that are not effectively inhibited by other classes of immunosuppressants. The development of these new drugs might therefore have considerable benefits in the treatment of kidney disease.
Collapse
Affiliation(s)
- Vojtech Petr
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua M Thurman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| |
Collapse
|
10
|
Heurich M, McCluskey G. Complement and coagulation crosstalk - Factor H in the spotlight. Immunobiology 2023; 228:152707. [PMID: 37633063 DOI: 10.1016/j.imbio.2023.152707] [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: 04/11/2023] [Revised: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 08/28/2023]
Abstract
The immune complement and the coagulation systems are blood-based proteolytic cascades that are activated by pathway-specific triggers, based on protein-protein interactions and enzymatic cleavage reactions. Activation of these systems is finely balanced and controlled through specific regulatory mechanisms. The complement and coagulation systems are generally viewed as distinct, but have common evolutionary origins, and several interactions between these homologous systems have been reported. This complement and coagulation crosstalk can affect activation, amplification and regulatory functions in both systems. In this review, we summarize the literature on coagulation factors contributing to complement alternative pathway activation and regulation and highlight molecular interactions of the complement alternative pathway regulator factor H with several coagulation factors. We propose a mechanism where factor H interactions with coagulation factors may contribute to both complement and coagulation activation and regulation within the haemostatic system and fibrin clot microenvironment and introduce the emerging role of factor H as a modulator of coagulation. Finally, we discuss the potential impact of these protein interactions in diseases associated with factor H dysregulation or deficiency as well as evidence of coagulation dysfunction.
Collapse
Affiliation(s)
- Meike Heurich
- School of Pharmacy and Pharmaceutical Sciences, College of Biomedical and Life Sciences, Cardiff University, United Kingdom.
| | - Geneviève McCluskey
- Université Paris-Saclay, INSERM, Hémostase, Inflammation, Thrombose HITH U1176, 94276 Le Kremlin-Bicêtre, France
| |
Collapse
|
11
|
Brocklebank V, Walsh PR, Smith-Jackson K, Hallam TM, Marchbank KJ, Wilson V, Bigirumurame T, Dutt T, Montgomery EK, Malina M, Wong EKS, Johnson S, Sheerin NS, Kavanagh D. Atypical hemolytic uremic syndrome in the era of terminal complement inhibition: an observational cohort study. Blood 2023; 142:1371-1386. [PMID: 37369098 PMCID: PMC10651868 DOI: 10.1182/blood.2022018833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 05/11/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
Historically, the majority of patients with complement-mediated atypical hemolytic uremic syndrome (CaHUS) progress to end-stage kidney disease (ESKD). Single-arm trials of eculizumab with a short follow-up suggested efficacy. We prove, for the first time to our knowledge, in a genotype matched CaHUS cohort that the 5-year cumulative estimate of ESKD-free survival improved from 39.5% in a control cohort to 85.5% in the eculizumab-treated cohort (hazard ratio, 4.95; 95% confidence interval [CI], 2.75-8.90; P = .000; number needed to treat, 2.17 [95% CI, 1.81-2.73]). The outcome of eculizumab treatment is associated with the underlying genotype. Lower serum creatinine, lower platelet count, lower blood pressure, and younger age at presentation as well as shorter time between presentation and the first dose of eculizumab were associated with estimated glomerular filtration rate >60 ml/min at 6 months in multivariate analysis. The rate of meningococcal infection in the treated cohort was 550 times greater than the background rate in the general population. The relapse rate upon eculizumab withdrawal was 1 per 9.5 person years for patients with a pathogenic mutation and 1 per 10.8 person years for those with a variant of uncertain significance. No relapses were recorded in 67.3 person years off eculizumab in those with no rare genetic variants. Eculizumab was restarted in 6 individuals with functioning kidneys in whom it had been stopped, with no individual progressing to ESKD. We demonstrated that biallelic pathogenic mutations in RNA-processing genes, including EXOSC3, encoding an essential part of the RNA exosome, cause eculizumab nonresponsive aHUS. Recessive HSD11B2 mutations causing apparent mineralocorticoid excess may also present with thrombotic microangiopathy.
Collapse
Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Patrick R. Walsh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kate Smith-Jackson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas M. Hallam
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kevin J. Marchbank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Theophile Bigirumurame
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tina Dutt
- Department of Haematology, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Emma K. Montgomery
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Edwin K. S. Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Neil S. Sheerin
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health and Care Research Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
12
|
Pande A, Kumar A, Krishnani H, Acharya S, Shukla S. Recent Advances in the Management of Microangiopathic Hemolytic Anemias (MAHA): A Narrative Review. Cureus 2023; 15:e47196. [PMID: 38021690 PMCID: PMC10653637 DOI: 10.7759/cureus.47196] [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: 08/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Red blood cells (RBCs) start to break down early in hemolytic anemia, which can be chronic or life-threatening. It should be considered while determining if normocytic or macrocytic anemia is present. Hemolysis in the reticuloendothelial system may happen intravascularly, extravascularly, or both. It accounts for a broad spectrum of laboratory and clinical situations, both physiological and pathological. Whenever the frequency of RBC breakdown is rapid enough to lower hemoglobin levels below the normal range, hemolytic anemia occurs. Microangiopathic hemolytic anemia (MAHA) is a term used to describe non-immune hemolysis induced by intravascular RBC fragmentation caused by substances in the tiny blood arteries that generate schistocytes in the peripheral circulation. Microvasculature abnormalities, such as small arterioles and capillaries, are usually involved. Furthermore, MAHA can also be brought on by intravascular devices like a prosthetic heart valve or assistive technologies. Poor deformity results in entrapment, phagocytosis, antibody-mediated elimination through phagocytosis or direct complement activation, fragmentation brought about by microthrombi or acute mechanical stress, oxidation, or spontaneous cellular death. Hemolysis may cause acute anemia, jaundice, hematuria, dyspnea, tiredness, tachycardia, and possibly hypotension. This article aims to synthesize existing research, identify therapeutic strategies, and provide insights into current and emerging approaches for managing this complex hematological disorder.
Collapse
Affiliation(s)
- Arundhati Pande
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhishek Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshil Krishnani
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Samarth Shukla
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
13
|
Hallam TM, Sharp SJ, Andreadi A, Kavanagh D. Complement factor I: Regulatory nexus, driver of immunopathology, and therapeutic. Immunobiology 2023; 228:152410. [PMID: 37478687 DOI: 10.1016/j.imbio.2023.152410] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 07/23/2023]
Abstract
Complement factor I (FI) is the nexus for classical, lectin and alternative pathway complement regulation. FI is an 88 kDa plasma protein that circulates in an inactive configuration until it forms a trimolecular complex with its cofactor and substrate whereupon a structural reorganization allows the catalytic triad to cleave its substrates, C3b and C4b. In keeping with its role as the master complement regulatory enzyme, deficiency has been linked to immunopathology. In the setting of complete FI deficiency, a consumptive C3 deficiency results in recurrent infections with encapsulated microorganisms. Aseptic cerebral inflammation and vasculitic presentations are also less commonly observed. Heterozygous mutations in the factor I gene (CFI) have been demonstrated to be enriched in atypical haemolytic uraemic syndrome, albeit with a very low penetrance. Haploinsufficiency of CFI has also been associated with decreased retinal thickness and is a strong risk factor for the development of age-related macular degeneration. Supplementation of FI using plasma purified or recombinant protein has long been postulated, however, technical difficulties prevented progression into clinical trials. It is only using gene therapy that CFI supplementation has reached the clinic with GT005 in phase I/II clinical trials for geographic atrophy.
Collapse
Affiliation(s)
- T M Hallam
- Gyroscope Therapeutics Limited, A Novartis Company, Rolling Stock Yard, London N7 9AS, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK
| | - S J Sharp
- Gyroscope Therapeutics Limited, A Novartis Company, Rolling Stock Yard, London N7 9AS, UK
| | - A Andreadi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK
| | - D Kavanagh
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK; NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne NE4 5PL, UK.
| |
Collapse
|
14
|
Banjongjit A, Kittanamongkolchai W, Kanjanabuch T. Complement Factor I Gene Variant in an Atypical Hemolytic Uremic Syndrome Triggered by Hypereosinophilia Syndrome. Nephron Clin Pract 2023; 147:701-706. [PMID: 37611541 DOI: 10.1159/000531879] [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: 11/16/2022] [Accepted: 06/29/2023] [Indexed: 08/25/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a condition characterized by acute kidney injury (AKI), thrombocytopenia, and microangiopathic hemolytic anemia secondary to complement pathway dysregulation. Several triggers have been identified as causing aHUS in genetically susceptible patients; however, hypereosinophilia syndrome (HES)-triggered aHUS has not been reported. In this article, we present a case of aHUS presented with generalized urticarial rashes and angioedema. The initial investigations revealed hypereosinophilia (maximal absolute eosinophil count of 6,840 cells/µL) with normal bone-marrow analyses; hence, idiopathic HES was diagnosed. During hospitalization, the patient developed convulsion, stuporous, and full-blown thrombotic microangiopathy (TMA), with AKI requiring temporary hemodialysis. A kidney biopsy confirmed the existence of renal TMA. Next-generation sequencing of the coding regions of aHUS-related genes was performed, revealing an underlying complement factor I (CFI) deficiency, a heterozygous variant p.P64L of CFI gene. The patient was successfully treated with high-dose steroids and extended duration of plasmapheresis.
Collapse
Affiliation(s)
- Athiphat Banjongjit
- Nephrology Unit, Department of Medicine, Vichaiyut Hospital, Bangkok, Thailand
| | - Wonngarm Kittanamongkolchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Mahachakri Sirindhorn Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Renal Immunology and Renal Transplant Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Yerigeri K, Kadatane S, Mongan K, Boyer O, Burke LLG, Sethi SK, Licht C, Raina R. Atypical Hemolytic-Uremic Syndrome: Genetic Basis, Clinical Manifestations, and a Multidisciplinary Approach to Management. J Multidiscip Healthc 2023; 16:2233-2249. [PMID: 37560408 PMCID: PMC10408684 DOI: 10.2147/jmdh.s245620] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy (TMA) defined by the triad of hemolytic anemia, thrombocytopenia, and acute kidney injury. Microthrombi develop in the glomerular capillaries secondary to endothelial damage and exert shear stress on red blood cells, consume platelets, and contribute to renal dysfunction and failure. Per current understanding of pathophysiology, HUS is classified into infectious, secondary, and atypical disease. The most common etiology is infectious sequelae of Shiga toxin-producing Escherichia coli (STEC); other causative organisms include shigella and salmonella. Secondary HUS arises from cancer, chemotherapy, solid organ and hematopoietic stem cell transplant, pregnancy, or autoimmune disorders. Primary atypical hemolytic-uremic syndrome (aHUS) is associated with genetic mutations in complement and complement regulatory proteins. Under physiologic conditions, complement regulators keep the alternative complement system continuously active at low levels. In times of inflammation, mutations in complement-related proteins lead to uncontrolled complement activity. The hyperactive inflammatory state leads to glomerular endothelial damage, activation of the coagulation cascade, and TMA findings. Atypical hemolytic-uremic syndrome is a rare disorder with a prevalence of 2.21 to 9.4 per million people aged 20 years or younger; children between the ages of 0 and 4 are most affected. Multidisciplinary health care is necessary for timely management of its extra-renal manifestations. These include vascular disease of the heart, brain, and skin, pulmonary hypertension and hemorrhage, and pregnancy complications. Adequate screening is required to monitor for sequelae. First-line treatment is the monoclonal antibody eculizumab, but several organ systems may require specialized interventions and coordination of care with sub-specialists.
Collapse
Affiliation(s)
- Keval Yerigeri
- Department of Internal Medicine-Pediatrics, Case Western Reserve University/The MetroHealth System, Cleveland, OH, USA
| | - Saurav Kadatane
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kai Mongan
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Olivia Boyer
- Department of Pediatric Nephrology, Dialysis and Transplantation, Necker-Enfants Malades Hospital, MARHEA reference Center, Imagine Institute, Paris Cité University, Paris, France
| | - Linda L G Burke
- aHUS Global Advocate with aHUS Alliance, Cape Elizabeth, ME, USA
| | - Sidharth Kumar Sethi
- Department of Pediatric Nephrology and Pediatric Renal Transplant Medicine, Kidney and Urology Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Rupesh Raina
- Division of Pediatric Nephrology, Akron Children’s Hospital, Akron, OH, USA
| |
Collapse
|
17
|
Connaughton DM, Bhai P, Isenring P, Mahdi M, Sadikovic B, Schenkel LC. Genotypic analysis of a large cohort of patients with suspected atypical hemolytic uremic syndrome. J Mol Med (Berl) 2023; 101:1029-1040. [PMID: 37466676 PMCID: PMC10400659 DOI: 10.1007/s00109-023-02341-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/20/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. Complement and coagulation gene variants have been associated with aHUS susceptibility. We assessed the diagnostic yield of a next-generation sequencing (NGS) panel in a large cohort of Canadian patients with suspected aHUS. Molecular testing was performed on peripheral blood DNA samples from 167 patients, collected between May 2019 and December 2021, using a clinically validated NGS pipeline. Coding exons with 20 base pairs of flanking intronic regions for 21 aHUS-associated or candidate genes were enriched using a custom hybridization protocol. All sequence and copy number variants were assessed and classified following American College of Medical Genetics guidelines. Molecular diagnostic results were reported for four variants in three individuals (1.8%). Twenty-seven variants of unknown significance were identified in 25 (15%) patients, and 34 unique variants in candidate genes were identified in 28 individuals. An illustrative patient case describing two genetic alterations in complement genes is presented, highlighting that variable expressivity and incomplete penetrance must be considered when interpreting genetic data in patients with complement-mediated disease, alongside the potential additive effects of genetic variants on aHUS pathophysiology. In this cohort of patients with suspected aHUS, using clinical pipelines for genetic testing and variant classification, pathogenic/likely pathogenic variants occurred in a very small percentage of patients. Our results highlight the ongoing challenges in variant classification following NGS panel testing in patients with suspected aHUS, alongside the need for clear testing guidance in the clinical setting. KEY MESSAGES: • Clinical molecular testing for disease associated genes in aHUS is challenging. • Challenges include patient selection criteria, test validation, and interpretation. • Most variants were of uncertain significance (31.7% of patients; VUS + candidates). • Their clinical significance may be elucidated as more evidence becomes available. • Low molecular diagnostic rate (1.8%), perhaps due to strict classification criteria. • Case study identified two likely pathogenic variants; one each in MCP/CD46 and CFI.
Collapse
Affiliation(s)
- Dervla M Connaughton
- Schulich School of Medicine & Dentistry, University of Western, London, ON, Canada
- Department of Medicine, Division of Nephrology, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada
| | - Pratibha Bhai
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre (LHSC), London, ON, Canada
| | - Paul Isenring
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | | | - Bekim Sadikovic
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre (LHSC), London, ON, Canada
- Pathology and Laboratory Medicine, Western University, London, ON, Canada
| | - Laila C Schenkel
- Molecular Genetics Laboratory, Molecular Diagnostics Division, London Health Sciences Centre (LHSC), London, ON, Canada.
- Pathology and Laboratory Medicine, Western University, London, ON, Canada.
| |
Collapse
|
18
|
Xu C, Wong V, Kurniawan A, Wilson S, Gopal B, Lawton PD. Eculizumab was safe and effective in the management of transplant-associated thrombotic microangiopathy in a heart transplant recipient with concurrent COVID-19 infection. Intern Med J 2023; 53:1506-1508. [PMID: 37599228 DOI: 10.1111/imj.16178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/27/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Chi Xu
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Renal Services, Western Health, Melbourne, Victoria, Australia
| | - Vincent Wong
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Department of Renal Services, Western Health, Melbourne, Victoria, Australia
| | | | - Scott Wilson
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Basu Gopal
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Paul D Lawton
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
- Menzies School of Health Research, Darwin, Northwest Territories, Australia
| |
Collapse
|
19
|
Wang Y, Al-Dakkak I, Garlo K, Ong ML, Tomazos I, Mahajerin A. Atypical Hemolytic Uremic Syndrome Treated With Ravulizumab or Eculizumab: A Claims-Based Evaluation of Health Care Resource Utilization and Clinical Outcomes in the United States. Kidney Med 2023; 5:100683. [PMID: 37415624 PMCID: PMC10319830 DOI: 10.1016/j.xkme.2023.100683] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Rationale and Objective Ravulizumab and eculizumab have shown efficacy for the treatment of atypical hemolytic uremic syndrome (aHUS), but real-world evidence for ravulizumab is limited owing to its more recent approval. This real-world database study examined outcomes for adult patients switching to ravulizumab from eculizumab and patients treated with individual treatments. Study Design A retrospective, observational study using the Clarivate Real World Database. Setting and Population US health-insurance billing data (January 2012 to March 2021) of patients aged 18 years or older with ≥1 diagnosis relevant to aHUS, ≥1 claim for treatment with eculizumab or ravulizumab, and no evidence of other indicated conditions. Exposures Treatment-switch (to ravulizumab after eculizumab), ravulizumab-only, and eculizumab-only cohorts were examined. Outcomes Clinical procedures, facility visits, health care costs, and clinical manifestations. Analytical Approach Paired-sample statistical testing compared the mean numbers of claims for each group 0-3 months before (preindex period) and 0-3 months and 3-6 months after (postindex period) the index date (point of initiation with a single treatment or treatment switch). Results In total, 322 patients met the eligibility criteria at 3-6 months postindex in the treatment-switch (n=65), ravulizumab-only (n=9), and eculizumab-only (n=248) cohorts. The proportions of patients with claims for key clinical procedures continued to be small after treatment switch and were small (0%-11%) across all cohorts at 3-6 months postindex. Inpatient visits were reduced in the postindex period across all cohorts. At 3-6 months after treatment switch, patients reported fewer claims for outpatient, private practice, and home visits and lower median health care costs. The proportions of patients with claims for clinical manifestations of aHUS were generally reduced in the postindex period compared with those of the preindex period. Limitations Low patient numbers receiving ravulizumab only. Conclusions The health-insurance claims data showed a reduced health care burden for US adult patients after treatment with ravulizumab or eculizumab for treatment of aHUS.
Collapse
Affiliation(s)
- Yan Wang
- Alexion, AstraZeneca Rare Disease, Boston, MA
| | | | | | - Moh-Lim Ong
- Alexion, AstraZeneca Rare Disease, Boston, MA
| | | | | |
Collapse
|
20
|
Kavanagh D, Greenbaum LA, Bagga A, Karki RG, Chen CW, Vasudevan S, Charney A, Dahlke M, Fakhouri F. Design and Rationale of the APPELHUS Phase 3 Open-Label Study of Factor B Inhibitor Iptacopan for Atypical Hemolytic Uremic Syndrome. Kidney Int Rep 2023; 8:1332-1341. [PMID: 37441479 PMCID: PMC10334406 DOI: 10.1016/j.ekir.2023.04.029] [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: 02/15/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a rare, progressive, and life-threatening form of thrombotic microangiopathy (TMA) which is caused by dysregulation of the alternative complement pathway (AP). Complement inhibition is an effective therapeutic strategy in aHUS, though current therapies require intravenous administration and increase the risk of infection by encapsulated organisms, including meningococcal infection. Further studies are required to define the optimal duration of existing therapies, and to identify new agents that are convenient for long-term administration. Iptacopan (LNP023) is an oral, first-in-class, highly potent, proximal AP inhibitor that specifically binds factor B (FB). In phase 2 studies of IgA nephropathy, paroxysmal nocturnal hemoglobinuria, and C3 glomerulopathy, iptacopan inhibited the AP, showed clinically relevant benefits, and was well tolerated. Iptacopan thus has the potential to become an effective and safe treatment for aHUS, with the convenience of oral administration. Methods Alternative Pathway Phase III to Evaluate LNP023 in aHUS (APPELHUS; NCT04889430) is a multicenter, single-arm, open-label, phase 3 study to evaluate the efficacy and safety of iptacopan in patients (N = 50) with primary complement-mediated aHUS naïve to complement inhibitor therapy (including anti-C5). Eligible patients must have evidence of TMA (platelet count <150 × 109/l, lactate dehydrogenase ≥1.5 × upper limit of normal, hemoglobin ≤ lower limit of normal, serum creatinine ≥ upper limit of normal) and will receive iptacopan 200 mg twice daily. The primary objective is to assess the proportion of patients achieving complete TMA response without the use of plasma exchange or infusion or anti-C5 antibody during 26 weeks of iptacopan treatment. Conclusion APPELHUS will determine if iptacopan is safe and efficacious in patients with aHUS.
Collapse
Affiliation(s)
- David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK, and Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Emory School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshri G. Karki
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, East Hanover, New Jersey, USA
| | - Chien-Wei Chen
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, East Hanover, New Jersey, USA
| | - Sajita Vasudevan
- Chief Medical Office and Patient Safety, Novartis Healthcare, Hyderabad, India
| | - Alan Charney
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, East Hanover, New Jersey, USA
| | - Marion Dahlke
- Clinical Development and Analytics Group, Cardiovascular, Renal and Metabolism Development Unit, Novartis Pharma, Basel, Switzerland
| | - Fadi Fakhouri
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| |
Collapse
|
21
|
Ariceta G. Pharmacological and clinical profile of ravulizumab 100 mg/mL formulation for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Expert Rev Clin Pharmacol 2023; 16:401-410. [PMID: 37128905 DOI: 10.1080/17512433.2023.2209317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are two rare and severe conditions caused by chronic complement (C') system dysregulation. Treatment with eculizumab, a recombinant, humanized monoclonal antibody against complement C5, changed the natural history of both diseases inducing remission and improving patient outcome. Ravulizumab, a new long-acting next-generation C5 inhibitor has been recently approved for treatment of PNH and aHUS. AREAS COVERED Main characteristics of ravulizumab are described: composition, dosing, efficacy and safety profile. Further, an overview of seminal studies and clinical trials using ravulizumab to treat PNH and aHUS in children and adults is detailed. Literature review was performed using the following key words: paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and ravulizumab. EXPERT OPINION Ravulizumab profile to treat PNH and aHUS is equivalent to eculizumab in efficacy and safety but allows extended dosing interval to every 4-8 weeks based on patient weight, and requires reduced infusion time. Less travels to infusion centers and medical visits and decreasing job and school absences, significantly increases patient and families' QoL, while reducing cost. Further infusion time is reduced Ravulizumab will possibly become the treatment of choice for patients with PNH and aHUS on chronic C5 inhibition.
Collapse
Affiliation(s)
- Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autonoma Barcelona, Spain
| |
Collapse
|
22
|
Tseng MH, Lin SH, Tsai JD, Wu MS, Tsai IJ, Chen YC, Chang MC, Chou WC, Chiou YH, Huang CC. Atypical hemolytic uremic syndrome: Consensus of diagnosis and treatment in Taiwan. J Formos Med Assoc 2023; 122:366-375. [PMID: 36323601 DOI: 10.1016/j.jfma.2022.10.006] [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: 07/05/2022] [Revised: 09/03/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, is a rare but life-threatening systemic disorder caused by the dysregulation of the complement pathway. Current advances in molecular analysis and pathogenesis have facilitated the establishment of diagnosis and development of effective complement blockade. Based on this recent consensus, we provide suggestions regarding the diagnosis and management of aHUS in Taiwan. The diagnosis of aHUS is made by the presence of TMA with normal ADAMTS13 activity without known secondary causes. Although only 60% of patients with aHUS have mutations in genes involving the compliment and coagulation systems, molecular analysis is suggestive for helping establish diagnosis, clarifying the underlying pathophysiology, guiding the treatment decision-making, predicting the prognosis, and deciding renal transplantation. Complement blockade, anti-C5 monoclonal antibody, is the first-line therapy for patients with aHUS. Plasma therapy should be considered for removing autoantibody in patients with atypical HUS caused by anti-CFH or complement inhibitor is unavailable.
Collapse
Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taipei, Taiwan
| | - Yeu-Chin Chen
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Chih Chang
- Division of Hematology/Oncology, Department of Internal Medicine, MacKay Children's Hospital, Taipei, Taiwan
| | - Wen-Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
| | - Chiu-Ching Huang
- Division of Nephrology and the Kidney Institute, Department of Internal Medicine, China Medical University and Hospital, Taichung, Taiwan.
| |
Collapse
|
23
|
Turner NA, Moake JL. Heat-inactivated Factor B inhibits alternative pathway fluid-phase activation and convertase formation on endothelial cell-secreted ultra-large von Willebrand factor strings. Sci Rep 2023; 13:5764. [PMID: 37031266 PMCID: PMC10082794 DOI: 10.1038/s41598-023-33007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 04/10/2023] Open
Abstract
Defective regulation of the alternative complement pathway (AP) causes excessive activation and promotes the inflammation and renal injury observed in atypical hemolytic-uremic syndrome (aHUS). The usefulness of heat-inactivated Factor B (HFB) in reducing AP activation was evaluated in: fluid-phase reactions, using purified complement proteins and Factor H (FH)-depleted serum; and in surface-activated reactions using human endothelial cells (ECs). C3a and Ba levels, measured by quantitative Western blots, determined the extent of fluid-phase activation. In reactions using C3, FB, and Factor D proteins, HFB addition (2.5-fold FB levels), reduced C3a levels by 60% and Ba levels by 45%. In reactions using FH-depleted serum (supplemented with FH at 12.5% normal levels), Ba levels were reduced by 40% with HFB added at 3.5-fold FB levels. The effectiveness of HFB in limiting AP convertase formation on activated surfaces was evaluated using stimulated ECs. Fluorescent microscopy was used to quantify endogenously released C3, FB, and C5 attached to EC-secreted ultra-large VWF strings. HFB addition reduced attachment of C3b by 2.7-fold, FB by 1.5-fold and C5 by fourfold. Our data indicate that HFB may be of therapeutic value in preventing AP-mediated generation of C3a and C5a, and the associated inflammation caused by an overactive AP.
Collapse
Affiliation(s)
- Nancy A Turner
- Department of Bioengineering, Rice University, Houston, TX, USA.
| | - Joel L Moake
- Department of Bioengineering, Rice University, Houston, TX, USA
| |
Collapse
|
24
|
Glover EK, Smith-Jackson K, Brocklebank V, Wilson V, Walsh PR, Montgomery EK, Wong EKS, Johnson S, Malina M, Kavanagh D, Sheerin NS. Assessing the Impact of Prophylactic Eculizumab on Renal Graft Survival in Atypical Hemolytic Uremic Syndrome. Transplantation 2023; 107:994-1003. [PMID: 36413152 PMCID: PMC10065821 DOI: 10.1097/tp.0000000000004355] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/22/2022] [Accepted: 08/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare cause of end-stage kidney disease and associated with poor outcomes after kidney transplantation from early disease recurrence. Prophylactic eculizumab treatment at the time of transplantation is used in selected patients with aHUS. We report a retrospective case note review describing transplant outcomes in patients with aHUS transplanted between 1978 and 2017, including those patients treated with eculizumab. METHODS The National Renal Complement Therapeutics Centre database identified 118 kidney transplants in 86 recipients who had a confirmed diagnosis of aHUS. Thirty-eight kidney transplants were performed in 38 recipients who received prophylactic eculizumab. The cohort not treated with eculizumab comprised 80 transplants in 60 recipients and was refined to produce a comparable cohort of 33 transplants in 32 medium and high-risk recipients implanted since 2002. Complement pathway genetic screening was performed. Graft survival was censored for graft function at last follow-up or patient death. Graft survival without eculizumab treatment is described by complement defect status and by Kidney Disease: Improving Global Outcomes risk stratification. RESULTS Prophylactic eculizumab treatment improved renal allograft survival ( P = 0.006) in medium and high-risk recipients with 1-y survival of 97% versus 64% in untreated patients. Our data supports the risk stratification advised by Kidney Disease: Improving Global Outcomes. CONCLUSIONS Prophylactic eculizumab treatment dramatically improves graft survival making transplantation a viable therapeutic option in aHUS.
Collapse
Affiliation(s)
- Emily K Glover
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Kate Smith-Jackson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Patrick R Walsh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Emma K Montgomery
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Edwin K S Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| |
Collapse
|
25
|
Mocanu A, Bogos RA, Lazaruc TI, Cianga AL, Lupu VV, Ioniuc I, Alecsa M, Lupu A, Ivanov AV, Miron IC, Starcea IM. Pitfalls of Thrombotic Microangiopathies in Children: Two Case Reports and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13071228. [PMID: 37046448 PMCID: PMC10093431 DOI: 10.3390/diagnostics13071228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
Thrombotic microangiopathy can present itself in the form of several clinical entities, representing a real challenge for diagnosis and treatment in pediatric practice. Our article aims to explore the evolution of two rare cases of pediatric thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) with extremely similar clinical pictures, which, coincidentally, presented at approximately the same time in our hospital. These cases and our literature review demonstrate the multiple facets of thrombotic microangiopathy, which can produce various determinations and salient manifestations even among the pediatric population. TTP and aHUS may represent genuine diagnostic pitfalls through the overlap of their clinical and biological findings, although they develop through fundamentally different mechanisms that require different therapeutic approaches. As a novelty, we underline that COVID-19 infection cannot be excluded as potential trigger for TTP and aHUS in our patients and we predict that other reports of such an association will follow, raising a complex question of COVID-19's implication in the occurrence and evolution of thrombotic microangiopathies. On this matter, we conducted literature research that resulted in 15 cases of COVID-19 pediatric infections associated with either TTP or aHUS. Taking into consideration the morbidity associated with TTP and aHUS, an elaborate differential diagnosis and prompt intervention are of the essence.
Collapse
Affiliation(s)
- Adriana Mocanu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Roxana Alexandra Bogos
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Tudor Ilie Lazaruc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Lavinia Cianga
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ileana Ioniuc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Mirabela Alecsa
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ancuta Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Viorica Ivanov
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ingrith Crenguta Miron
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| |
Collapse
|
26
|
Tawhari M, Alhamadh MS, Alhabeeb AY, Almudayfir Z, Radwi M. End-Stage Kidney Disease Resulting from Atypical Hemolytic Uremic Syndrome after Receiving AstraZeneca SARS-CoV-2 Vaccine: A Case Report. Vaccines (Basel) 2023; 11:vaccines11030679. [PMID: 36992263 DOI: 10.3390/vaccines11030679] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/12/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is classically described as a triad of nonimmune hemolytic anemia, thrombocytopenia, and acute kidney injury. Atypical HUS (aHUS) is a rare variant of the disease, and it accounts for 5–10% of the cases. It has a poor prognosis, with a mortality rate exceeding 25% and a more than 50% chance of progressing into end-stage kidney disease (ESKD). Genetic or acquired dysregulation of the alternative complement pathway is highly implicated in the pathogenesis of aHUS. Multiple triggers for aHUS have been described in the literature, including pregnancy, transplantation, vaccination, and viral infections. Herein, we report a case of a previously healthy 38-year-old male who developed microangiopathic hemolytic anemia and severe kidney impairment one week after receiving the first dose of AstraZeneca SARS-CoV-2 vaccine. A diagnosis of aHUS was made after excluding other causes of thrombotic microangiopathies. Treatment with plasma exchange, prednisone, and rituximab (375 mg/m2) once weekly for four doses resulted in improvement of his hematological parameters. However, he progressed to ESKD.
Collapse
Affiliation(s)
- Mohammed Tawhari
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh 11481, Saudi Arabia
- Department of Medicine, Division of Nephrology, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs, Riyadh 11426, Saudi Arabia
| | - Moustafa S Alhamadh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh 11481, Saudi Arabia
| | - Abdulrahman Yousef Alhabeeb
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh 11481, Saudi Arabia
| | - Ziyad Almudayfir
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Ministry of the National Guard Health Affairs, Riyadh 14611, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh 11481, Saudi Arabia
| | - Mansoor Radwi
- Department of Hematology, College of Medicine, University of Jeddah, Jeddah 23218, Saudi Arabia
| |
Collapse
|
27
|
Claes KJ, Geerts I, Lemahieu W, Wilmer A, Kuypers DRJ, Koshy P, Ombelet S. Atypical Hemolytic Uremic Syndrome Occurring After Receipt of mRNA-1273 COVID-19 Vaccine Booster: A Case Report. Am J Kidney Dis 2023; 81:364-367. [PMID: 36342000 PMCID: PMC9484133 DOI: 10.1053/j.ajkd.2022.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/22/2022] [Indexed: 02/08/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a subtype of thrombotic microangiopathy (TMA) characterized by a dysregulation of the alternative complement pathway. Here, we report a previously healthy 38-year-old woman in whom aHUS developed after a COVID-19 vaccine booster. One day after receipt of a booster dose of mRNA-1273 vaccine, she felt ill. Because of persistent headache, nausea, and general malaise, she went to her general practitioner, who referred her to the hospital after detecting hypertension and acute kidney injury. A diagnosis of TMA was made. Her treatment consisted of blood pressure control, hemodialysis, plasma exchange, and respiratory support. Kidney biopsy confirmed the diagnosis of acute TMA. The patient was referred for treatment with eculizumab, and kidney function improved after initiation of this therapy. Genetic analysis revealed a pathogenic C3 variant. SARS-CoV-2 infection as a trigger for complement activation and development of aHUS has been described previously. In addition, there is one reported case of aHUS occurring after receipt of the adenovirus-based COVID-19 vaccine ChAdOx1 nCoV-19, but, to our knowledge, this is the first case of aHUS occurring after a booster dose of an mRNA COVID-19 vaccine in a patient with an underlying pathogenic variant in complement C3. Given the time frame, we hypothesize that the vaccine probably was the trigger for development of aHUS in this patient.
Collapse
Affiliation(s)
- Kathleen J Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, UZ Leuven, Leuven, Belgium.
| | - Inge Geerts
- Departments of Laboratory Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Wim Lemahieu
- Department of Nephrology, Imelda Hospital, Bonheiden, Belgium
| | - Alexander Wilmer
- Department of Microbiology, Immunology and Transplantation, Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Medical Intensive Care Unit, UZ Leuven, Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, UZ Leuven, Leuven, Belgium
| | | | - Sara Ombelet
- Department of Nephrology, Imelda Hospital, Bonheiden, Belgium
| |
Collapse
|
28
|
Singhal J, Gupta RA, Sharma J. Delayed Hematological Remission Predicts Poor Renal Outcome in Children with Atypical Hemolytic Uremic Syndrome. Indian J Nephrol 2023; 33:108-113. [PMID: 37234434 PMCID: PMC10208542 DOI: 10.4103/ijn.ijn_484_21] [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: 11/24/2021] [Revised: 03/06/2022] [Accepted: 04/02/2022] [Indexed: 05/28/2023] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is hemolytic uremic syndrome (HUS) without a coexisting disease or specific infection. Eculizumab is the standard of care for children with aHUS. However, since it is not yet available in India, plasma therapy remains the treatment of choice in these patients. We studied the clinical profile of children with aHUS and the determinants associated with low estimated glomerular filtration rate (eGFR) on follow-up. Materials and Methods A retrospective chart review of children (1-18 years) with aHUS managed at a tertiary care center was done. Demographic details, clinical features, and investigations at presentation and on subsequent visits were noted. Details of treatment and duration of hospital stay were recorded. Results Of 26 children, boys outnumbered girls (2:1). The mean age at presentation was 80 ± 37.6 months. All children were hypertensive during the early phase of illness. Anti-factor H antibodies were elevated in 84% (22/26). Plasma therapy was initiated for 25 patients, and in 17 children, additionally immunosuppression was given. The median duration to achieve hematological remission was 17 days. As compared to children with normal eGFR, those with CKD stage 2 or more had significant delay in initiation of plasma therapy (4 vs. 14 days) and also took a longer time to achieve hematological remission (15 vs. 28 days). The prevalence of hypertension and proteinuria at the last follow-up was 63% and 27%, respectively. Conclusion Delayed initiation of plasma therapy and longer time to achieve hematological remission are associated with lower eGFR on follow-up. Long-term monitoring of hypertension and proteinuria is needed in these children.
Collapse
Affiliation(s)
- Jyoti Singhal
- Pediatric Renal Service, Renal Unit, KEM Hospital, Pune, Maharashtra, India
| | - Rashi A. Gupta
- Pediatric Renal Service, Renal Unit, KEM Hospital, Pune, Maharashtra, India
| | - Jyoti Sharma
- Pediatric Renal Service, Renal Unit, KEM Hospital, Pune, Maharashtra, India
| |
Collapse
|
29
|
Kolev M, Barbour T, Baver S, Francois C, Deschatelets P. With complements: C3 inhibition in the clinic. Immunol Rev 2023; 313:358-375. [PMID: 36161656 DOI: 10.1111/imr.13138] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
C3 is a key complement protein, located at the nexus of all complement activation pathways. Extracellular, tissue, cell-derived, and intracellular C3 plays critical roles in the immune response that is dysregulated in many diseases, making it an attractive therapeutic target. However, challenges such as very high concentration in blood, increased acute expression, and the elevated risk of infections have historically posed significant challenges in the development of C3-targeted therapeutics. This is further complicated because C3 activation fragments and their receptors trigger a complex network of downstream effects; therefore, a clear understanding of these is needed to provide context for a better understanding of the mechanism of action (MoA) of C3 inhibitors, such as pegcetacoplan. Because of C3's differential upstream position to C5 in the complement cascade, there are mechanistic differences between pegcetacoplan and eculizumab that determine their efficacy in patients with paroxysmal nocturnal hemoglobinuria. In this review, we compare the MoA of pegcetacoplan and eculizumab in paroxysmal nocturnal hemoglobinuria and discuss the complement-mediated disease that might be amenable to C3 inhibition. We further discuss the current state and outlook for C3-targeted therapeutics and provide our perspective on which diseases might be the next success stories in the C3 therapeutics journey.
Collapse
Affiliation(s)
- Martin Kolev
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | - Tara Barbour
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | - Scott Baver
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | | | | |
Collapse
|
30
|
Quinaux T, Tubail Z, Vrillon I, Sartelet H, Savenkoff B. Campylobacter Colitis as a Trigger for Atypical Hemolytic Uremic Syndrome: About One Case. Case Rep Nephrol Dial 2023; 13:113-119. [PMID: 37900922 PMCID: PMC10601843 DOI: 10.1159/000529941] [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: 05/01/2022] [Accepted: 02/20/2023] [Indexed: 10/31/2023] Open
Abstract
We present the case of a 17-year-old Caucasian male whose condition featured acute renal failure, anemia, and deep thrombocytopenia after five consecutive days of diarrhea. Campylobacter coli was identified in stool cultures and, although the direct role of this germ in the pathogenesis of hemolytic uremic syndrome (HUS) remains uncertain to this day, initial presentation was considered broadly consistent with typical HUS. However, the patient showed no signs of spontaneous recovery over time. While secondary investigations showed no abnormalities in ADAMTS13 activity or in the alternate pathway of complement, patient's condition deteriorated. Worsening kidney failure required emergency renal replacement therapy and was followed by cardiac involvement in the form of acute heart failure. Given this unfavorable development, blood samples were drawn to look for mutations in the alternate complement pathway, and eculizumab therapy was initiated without further delay, allowing prompt improvement of cardiac function and recovery of diuresis. Upon discharge, the patient still had to undergo intermittent dialysis, which would later be withdrawn. Genetic analysis ultimately confirmed the presence of a complement factor H mutation associated with a high risk of disease recurrence, indicating long-term continuation of eculizumab therapy.
Collapse
Affiliation(s)
- Thomas Quinaux
- Nephrology, dialysis and therapeutic apheresis department, Centre Hospitalier Régional Metz-Thionville, Metz, France
| | - Zead Tubail
- Nephrology, dialysis and therapeutic apheresis department, Centre Hospitalier Régional Metz-Thionville, Metz, France
| | - Isabelle Vrillon
- Pediatric nephrology, dialysis and transplantation department, Centre Hospitalier Régional Universitaire de Nancy - Hôpital Brabois Enfants, Nancy, France
| | - Hervé Sartelet
- Pathology department, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Benjamin Savenkoff
- Nephrology, dialysis and therapeutic apheresis department, Centre Hospitalier Régional Metz-Thionville, Metz, France
| |
Collapse
|
31
|
Matošević M, Kos I, Davidović M, Ban M, Matković H, Jakopčić I, Vuković Brinar I, Szilágyi Á, Csuka D, Sinkovits G, Prohászka Z, Vrljičak K, Lamot L. Hemolytic uremic syndrome in the setting of COVID-19 successfully treated with complement inhibition therapy: An instructive case report of a previously healthy toddler and review of literature. Front Pediatr 2023; 11:1092860. [PMID: 36873657 PMCID: PMC9975343 DOI: 10.3389/fped.2023.1092860] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION As the global pandemic continues, new complications of COVID-19 in pediatric population have turned up, one of them being hemolytic uremic syndrome (HUS), a complement-mediated thrombotic microangiopathy (CM-TMA) characterized by triad of thrombocytopenia, microangiopathic hemolytic anemia and acute kidney injury (AKI). With both multisystem inflammatory syndrome in children (MIS-C) and HUS sharing complement dysregulation as one of the key factors, the aim of this case report is to highlight differences between these two conditions and also emphasize the importance of complement blockade as a treatment modality. CASE REPORT We describe a 21-month-old toddler who initially presented with fever and confirmed COVID-19. His condition quickly deteriorated and he developed oliguria, accompanied with diarrhea, vomiting and oral intake intolerance. HUS was suspected, supported with compelling laboratory findings, including decreased platelets count and C3 levels, elevated LDH, urea, serum creatinine and sC5b-9 and presence of schistocytes in peripheral blood, negative fecal Shiga toxin and normal ADAMTS13 metalloprotease activity. The patient was given C5 complement blocker Ravulizumab and started to display rapid improvement. CONCLUSION Although reports of HUS in the setting of COVID-19 continue to pour in, the questions of exact mechanism and similarities to MIS-C remain. Our case for the first time accentuates the use of complement blockade as a valuable treatment option in this scenario. We sincerely believe that reporting on HUS as a complication of COVID-19 in children will give rise to improved diagnosis and treatment, as well as better understanding of both of these intricating diseases.
Collapse
Affiliation(s)
- Matija Matošević
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ivanka Kos
- Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Maša Davidović
- Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Maja Ban
- Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Hana Matković
- Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ivan Jakopčić
- Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ivana Vuković Brinar
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia.,Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Ágnes Szilágyi
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - György Sinkovits
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University- Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Kristina Vrljičak
- Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Lovro Lamot
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia.,Division of Nephrology, Dialysis and Transplantation, Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| |
Collapse
|
32
|
Smith-Jackson K, Harrison RA. Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events. Immunol Rev 2023; 313:298-319. [PMID: 36377667 PMCID: PMC10100418 DOI: 10.1111/imr.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.
Collapse
Affiliation(s)
- Kate Smith-Jackson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Faculty of Medical Science, Newcastle University, Newcastle-upon-Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | | |
Collapse
|
33
|
Patel DB, Farris AC, Hanna C, Hashim F. Concurrent acute kidney injury and pancreatitis in a female patient: Answers. Pediatr Nephrol 2023; 38:1047-1050. [PMID: 35758996 PMCID: PMC9243956 DOI: 10.1007/s00467-022-05665-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Darshan B Patel
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children's Medical Center, Temple, TX, USA
| | - Amanda C Farris
- Division of Pediatric Hospital Medicine, Baylor Scott & White McLane Children's Medical Center, Temple, TX, USA
| | - Christian Hanna
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Faris Hashim
- Division of Pediatric Nephrology, Baylor Scott & White McLane Children's Medical Center, Temple, TX, USA.
| |
Collapse
|
34
|
Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
Collapse
Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| |
Collapse
|
35
|
Peters K. Physiology and pathology of the C3 amplification cycle: A retrospective. Immunol Rev 2023; 313:217-224. [PMID: 36408746 PMCID: PMC10099761 DOI: 10.1111/imr.13165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The C3 "Tickover" hypothesis, a mechanism whereby the host maintains constant surveillance of potential invading pathogens, targeting them for elimination through amplified C3b generation and C3-dependent effector mechanisms, was proposed by the late Professor Peter Lachmann in 1973. This unique insight came from a combined understanding of the complement system as it was then defined and the nature of the disease process in rare complement deficiencies and complement-driven diseases. In this review, I give a personal perspective of how understanding of "Tickover" has developed in the subsequent 50 years, culminating in the introduction into the clinic of therapeutic agents designed to combat amplification-driven disease.
Collapse
|
36
|
Boyer O, Niaudet P. Hemolytic-Uremic Syndrome in Children. Pediatr Clin North Am 2022; 69:1181-1197. [PMID: 36880929 DOI: 10.1016/j.pcl.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hemolytic uremic syndrome is characterized by a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Most cases are caused by Shiga-toxin-producing bacteria, especially Escherichia coli. Transmission occurs through ground beef and unpasteurized milk. STEC-HUS is the main cause of acute renal failure in children. Management remains supportive. Immediate outcome is most often. Atypical HUS represents about 5% of cases, has a relapsing course with more than half of the patients progressing to end-stage kidney failure. Most cases are due to variants in complement regulators of the alternative pathway. Complement inhibitors, such as eculizumab, have considerably improved the prognosis.
Collapse
Affiliation(s)
- Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France; Néphrologie Pédiatrique, Hôpital Necker, 149 Rue de Sèvres, Paris 75015, France
| | - Patrick Niaudet
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France.
| |
Collapse
|
37
|
Yoshida Y, Nishi H. The role of the complement system in kidney glomerular capillary thrombosis. Front Immunol 2022; 13:981375. [PMID: 36189215 PMCID: PMC9515535 DOI: 10.3389/fimmu.2022.981375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
The complement system is part of the innate immune system. The crucial step in activating the complement system is the generation and regulation of C3 convertase complexes, which are needed to generate opsonins that promote phagocytosis, to generate C3a that regulates inflammation, and to initiate the lytic terminal pathway through the generation and activity of C5 convertases. A growing body of evidence has highlighted the interplay between the complement system, coagulation system, platelets, neutrophils, and endothelial cells. The kidneys are highly susceptible to complement-mediated injury in several genetic, infectious, and autoimmune diseases. Atypical hemolytic uremic syndrome (aHUS) and lupus nephritis (LN) are both characterized by thrombosis in the glomerular capillaries of the kidneys. In aHUS, congenital or acquired defects in complement regulators may trigger platelet aggregation and activation, resulting in the formation of platelet-rich thrombi in the kidneys. Because glomerular vasculopathy is usually noted with immunoglobulin and complement accumulation in LN, complement-mediated activation of tissue factors could partly explain the autoimmune mechanism of thrombosis. Thus, kidney glomerular capillary thrombosis is mediated by complement dysregulation and may also be associated with complement overactivation. Further investigation is required to clarify the interaction between these vascular components and develop specific therapeutic approaches.
Collapse
|
38
|
Thompson GL, Kavanagh D. Diagnosis and treatment of thrombotic microangiopathy. Int J Lab Hematol 2022; 44 Suppl 1:101-113. [PMID: 36074708 PMCID: PMC9544907 DOI: 10.1111/ijlh.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic haemolytic anaemia and end organ damage. TMAs have varying underlying pathophysiology and can therefore present with an array of clinical presentations. Renal involvement is common as the kidney is particularly susceptible to the endothelial damage and microvascular occlusion. TMAs require rapid assessment, diagnosis, and commencement of appropriate treatment due to the high morbidity and mortality associated with them. Ground-breaking research into the pathogenesis of TMAs over the past 20 years has driven the successful development of targeted therapeutics revolutionizing patient outcomes. This review outlines the clinical presentations, pathogenesis, diagnostic tests and treatments for TMAs.
Collapse
Affiliation(s)
- Gemma L Thompson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| |
Collapse
|
39
|
Lee FSW, Lee CY, Hung GY, Tseng MH, Wang HH, Yen HJ. Recurrent microangiopathic hemolysis after recovery from complement-mediated hemolytic uremia syndrome during chemotherapy for a CFH-mutated patient with T-lymphoblastic lymphoma. Int J Hematol 2022; 116:812-818. [PMID: 35790695 DOI: 10.1007/s12185-022-03409-6] [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: 01/15/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 11/25/2022]
Abstract
Complement-mediated hemolytic uremic syndrome (CM-HUS) following chemotherapy for pediatric acute lymphoid neoplasms has rarely been reported. We report the case of an 8-year-old boy with T-lymphoblastic lymphoma (T-LBL) who developed CM-HUS with complement factor H (CFH) mutations (S1191L, V1197A) during induction therapy. Safe administration of chemotherapy after CM-HUS recovery was challenging. By closely monitoring hemolytic and renal parameters during the 2-year treatment period, we observed four episodes of microangiopathic hemolytic anemia (MAHA) with hypocomplementemia and low haptoglobin but no renal dysfunction or thrombocytopenia. Here, we describe the MAHA and CM-HUS episodes in the hopes of elucidating the complex pathophysiology of disorders associated with CFH mutation.
Collapse
Affiliation(s)
- Fu-Shiuan Whitney Lee
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
| | - Chih-Ying Lee
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
- Department of Life Science, National Taiwan Normal University, Taipei, Taiwan, ROC
| | - Giun-Yi Hung
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
- Department of Life Science, National Taiwan Normal University, Taipei, Taiwan, ROC
| | - Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Hsin-Hui Wang
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
| | - Hsiu-Ju Yen
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC.
- Department of Life Science, National Taiwan Normal University, Taipei, Taiwan, ROC.
| |
Collapse
|
40
|
The Role of Complement in HSCT-TMA: Basic Science to Clinical Practice. Adv Ther 2022; 39:3896-3915. [PMID: 35781192 PMCID: PMC9402756 DOI: 10.1007/s12325-022-02184-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/06/2022] [Indexed: 12/05/2022]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a common complication occurring post-HSCT and is associated with substantial morbidity and mortality if not promptly identified and treated. Emerging evidence suggests a central role for the complement system in the pathogenesis of HSCT-TMA. The complement system has also been shown to interact with other pathways and processes including coagulation and inflammation, all of which are activated following HSCT. Three endothelial cell-damaging “hits” are required for HSCT-TMA genesis: a genetic predisposition or existing damage, an endothelial cell-damaging conditioning regimen, and additional damaging insults. Numerous risk factors for the development of HSCT-TMA have been identified (including primary diagnosis, graft type, and conditioning regimen) and validated lists of relatively simple diagnostic signs and symptoms exist, many utilizing routine clinical and laboratory assessments. Despite the relative ease with which HSCT-TMA can be screened for, it is often overlooked or masked by other common post-transplant conditions. Recent evidence that patients with HSCT-TMA may also concurrently present with these differential diagnoses only serve to further confound its identification and treatment. HSCT-TMA may be treated, or even prevented, by removing or ameliorating triggering “hits”, and recent studies have also shown substantial utility of complement-targeted therapies in this patient population. Further investigation into optimal management and treatment strategies is needed. Greater awareness of TMA post-HSCT is urgently needed to improve patient outcomes; the objective of this article is to clarify current understanding, explain underlying complement biology and provide simple tools to aid the early recognition, management, and monitoring of HSCT-TMA.
Collapse
|
41
|
The causes and consequences of paediatric kidney disease on adult nephrology care. Pediatr Nephrol 2022; 37:1245-1261. [PMID: 34389906 DOI: 10.1007/s00467-021-05182-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
Adult nephrologists often look after patients who have been diagnosed with kidney disease in childhood. This does present unique challenges to the adult nephrologist, who may be unfamiliar with the underlying cause of kidney disease as well as the complications of chronic kidney disease (CKD) that may have accumulated during childhood. This review discusses common causes of childhood CKD, in particular congenital anomalies of the kidney and urinary tract (CAKUT), autosomal dominant tubulointerstitial kidney disease (ADTKD), polycystic kidney disease, hereditary stone disease, nephrotic syndrome and atypical haemolytic uraemic syndrome. The long-term consequences of childhood CKD, such as the cardiovascular consequences, cognition and education as well as bone health, nutrition and growth are also discussed.
Collapse
|
42
|
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.
Collapse
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;
| |
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Ghazanfar H, Nawaz I, Allena N, Ashraf S, Saad M, Ali N. A Case of Atypical Hemolytic Uremic Syndrome in a Pregnant Patient. Cureus 2022; 14:e25096. [PMID: 35733482 PMCID: PMC9205294 DOI: 10.7759/cureus.25096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/05/2022] Open
|
45
|
Vitkauskaitė M, Vinikovas A, Miglinas M, Rimševičius L, Čerkauskaitė A, Mačionienė E, Ašakienė E. Complement inhibitor eculizumab in thrombotic microangiopathy: Single‐center case series. Clin Case Rep 2022; 10:e05573. [PMID: 35317070 PMCID: PMC8922540 DOI: 10.1002/ccr3.5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - Artūras Vinikovas
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Marius Miglinas
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Laurynas Rimševičius
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Agnė Čerkauskaitė
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Ernesta Mačionienė
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Eglė Ašakienė
- Faculty of MedicineVilnius UniversityVilniusLithuania
- Clinic of Gastroenterology, Nephro‐Urology and SurgeryFaculty of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| |
Collapse
|
46
|
A novel missense mutation in complement factor I predisposes patients to atypical hemolytic uremic syndrome: a case report. J Med Case Rep 2022; 16:101. [PMID: 35241161 PMCID: PMC8895779 DOI: 10.1186/s13256-022-03312-y] [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: 11/21/2019] [Accepted: 02/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome, also called the nondiarrheal form of hemolytic uremic syndrome, is a rare disease characterized by the triad of thrombocytopenia, Coomb’s test-negative microangiopathic hemolytic anemia, and acute renal failure. Approximately 60% of cases of atypical hemolytic uremic syndrome are associated with deficiencies of the complement regulatory protein, including mutations in complement factor H, complement factor I, or the membrane co-factor protein. Case presentation We report the case of a 26-year-old Asian man who presented with pulmonary infection, elevated blood pressure, microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. Renal biopsy revealed diffuse capillary fibrin deposition, endothelial swelling, and arteriole narrowing like “onion skinning” consistent with thrombotic microangiopathy. Bidirectional sequencing of CFH, CFHR5, CFHR1, CFI, DGKE, CFB, and MCP confirmed that the patient was heterozygous for a novel missense mutation, p.Cys67Phe, in CFI. This patient had rapid evolution to end-stage renal disease and needed renal replacement therapy. Plasma exchange seemed inefficacious in this patient. Conclusions This report confirms the importance of screening patients with atypical hemolytic uremic syndrome for mutations in genes involved in complement system to clarify the diagnosis and demonstrates the challenges in the management of these patients.
Collapse
|
47
|
Affiliation(s)
- C. John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
48
|
Daily ZH, Rizvi SS, Baez-Bonilla R. Atypical Hemolytic Uremic Syndrome in a Patient With Metastatic Peritoneal Serous Carcinoma: A Case Report. Cureus 2022; 14:e22624. [PMID: 35371768 PMCID: PMC8958130 DOI: 10.7759/cureus.22624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Atypical hemolytic uremic syndrome (HUS) is a part of a large category of diseases known as thrombotic microangiopathies that present with hemolytic anemia, thrombocytopenia, and target organ damage mostly characterized by acute kidney injury. It is a rare and challenging diagnosis due to the complex pathophysiology underlying the disease and its overlap with other conditions. We report the case of atypical hemolytic uremic syndrome in a 61-year-old female with a history of metastatic peritoneal serous carcinoma of the ovary presenting with anemia and acute renal failure.
Collapse
|
49
|
Cortes C, Desler C, Mazzoli A, Chen JY, Ferreira VP. The role of properdin and Factor H in disease. Adv Immunol 2022; 153:1-90. [PMID: 35469595 DOI: 10.1016/bs.ai.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The complement system consists of three pathways (alternative, classical, and lectin) that play a fundamental role in immunity and homeostasis. The multifunctional role of the complement system includes direct lysis of pathogens, tagging pathogens for phagocytosis, promotion of inflammatory responses to control infection, regulation of adaptive cellular immune responses, and removal of apoptotic/dead cells and immune complexes from circulation. A tight regulation of the complement system is essential to avoid unwanted complement-mediated damage to the host. This regulation is ensured by a set of proteins called complement regulatory proteins. Deficiencies or malfunction of these regulatory proteins may lead to pro-thrombotic hematological diseases, renal and ocular diseases, and autoimmune diseases, among others. This review focuses on the importance of two complement regulatory proteins of the alternative pathway, Factor H and properdin, and their role in human diseases with an emphasis on: (a) characterizing the main mechanism of action of Factor H and properdin in regulating the complement system and protecting the host from complement-mediated attack, (b) describing the dysregulation of the alternative pathway as a result of deficiencies, or mutations, in Factor H and properdin, (c) outlining the clinical findings, management and treatment of diseases associated with mutations and deficiencies in Factor H, and (d) defining the unwanted and inadequate functioning of properdin in disease, through a discussion of various experimental research findings utilizing in vitro, mouse and human models.
Collapse
Affiliation(s)
- Claudio Cortes
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, United States.
| | - Caroline Desler
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Amanda Mazzoli
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Jin Y Chen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States.
| |
Collapse
|
50
|
Kamel MH, Jaberi A, Gordon CE, Beck LH, Francis J. The Complement System in the Modern Era of Kidney Transplantation: Mechanisms of Injury and Targeted Therapies. Semin Nephrol 2022; 42:14-28. [DOI: 10.1016/j.semnephrol.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|