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Pryzdial ELG, Leatherdale A, Conway EM. Coagulation and complement: Key innate defense participants in a seamless web. Front Immunol 2022; 13:918775. [PMID: 36016942 PMCID: PMC9398469 DOI: 10.3389/fimmu.2022.918775] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/06/2022] [Indexed: 12/30/2022] Open
Abstract
In 1969, Dr. Oscar Ratnoff, a pioneer in delineating the mechanisms by which coagulation is activated and complement is regulated, wrote, “In the study of biological processes, the accumulation of information is often accelerated by a narrow point of view. The fastest way to investigate the body’s defenses against injury is to look individually at such isolated questions as how the blood clots or how complement works. We must constantly remind ourselves that such distinctions are man-made. In life, as in the legal cliché, the devices through which the body protects itself form a seamless web, unwrinkled by our artificialities.” Our aim in this review, is to highlight the critical molecular and cellular interactions between coagulation and complement, and how these two major component proteolytic pathways contribute to the seamless web of innate mechanisms that the body uses to protect itself from injury, invading pathogens and foreign surfaces.
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Affiliation(s)
- Edward L. G. Pryzdial
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, BC, Canada
- *Correspondence: Edward L. G. Pryzdial, ; Edward M. Conway,
| | - Alexander Leatherdale
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Edward M. Conway
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Medical Affairs and Innovation, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Edward L. G. Pryzdial, ; Edward M. Conway,
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2
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Smirnova TV, Kazaryan EE, Sheludchenko VM. [Retinal tomography features of thrombotic microangiopathy associated with atypical hemolytic-uremic syndrome]. Vestn Oftalmol 2022; 138:20-28. [PMID: 36004587 DOI: 10.17116/oftalma202213804120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate structural and morphological changes in the retina using optical coherence tomography (OCT) in patients with thrombotic microangiopathy (TMA) associated with atypical hemolytic-uremic syndrome (aHUS). MATERIAL AND METHODS The study analyzed OCT data of 14 patients (28 eyes) with an established diagnosis of aHUS including such indicators as central retinal thickness (CRT), thickness of the retinal nerve fiver layer (RNFL), ganglion cell layer (GCL), retinal pigment epithelium (RPE), etc. RESULTS Patients with aHUS were noted to have an increase in CRT, paracentral acute middle maculopathy in the form of a hyperreflective defect primarily of the inner nuclear layer of paracentral localization, as well as disorganization of the RPE, which was observed statistically significantly more often compared to healthy persons (p=0.0001, p=0.001 and p=0.009 respectively). In the subgroup with thrombotic retinopathy (6 people) a statistically significant increase in CRT and peripapillary RNFL was found (p=0.004 and p=0.001) compared to patients without thrombotic retinopathy, as well as the presence of paracentral acute middle maculopathy and transudative macular retinoschisis (p=0.0001 and p=0.004). A statistically significant thinning of the peripapillary RNFL was revealed (p=0.0001) in the subgroup with symptoms of Purtscher-like retinopathy (PLR) found retrospectively (4 people) compared to patients without retrospective PLR symptoms. A statistically significant decrease in CRT was revealed (p=0.018) in the subgroup of patients receiving systemic therapy with eculizumab (5 people) compared with patients not receiving this therapy. Statistically significant correlations were recorded between the studied OCT indicators, laboratory indicators, and the level of systolic blood pressure (p<0.05). CONCLUSION According to OCT, paracentral acute middle maculopathy is a biomarker of thrombotic retinopathy and the activity of systemic TMA associated with aHUS. Arterial hypertension is an additional aggravating factor in the development of paracentral acute middle maculopathy and transudative macular retinoschisis. Targeted therapy with eculizumab leads to an effective decrease in CRT, which is potentially associated with regression of ischemic edema. The outcome of PLR involves thinning of peripapillary RNFL.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
| | - E E Kazaryan
- Research Institute of Eye Diseases, Moscow, Russia
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3
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Stone JR. Diseases of small and medium-sized blood vessels. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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4
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Sheludchenko VM, Kozlovskaya NL, Budzinskaya MV, Krasnolutskaya EI, Durzhinskaya MH, Smirnova TV, Bondarenko TV. [The role of optical coherence tomography angiography in the assessment of retinal microcirculation in thrombotic microangiopathy associated with malignant arterial hypertension]. Vestn Oftalmol 2022; 138:177-185. [PMID: 36287153 DOI: 10.17116/oftalma2022138052177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
UNLABELLED Optical coherence tomography angiography (OCT-A) allows detailed assessment of the state of local blood flow in various systemic ischemic diseases, which include thrombotic microangiopathy (TMA) associated with malignant arterial hypertension (MAH). PURPOSE To evaluate retinal microcirculation using OCT-A imaging data in the group of patients with TMA associated with MAH. MATERIAL AND METHODS The study consisted of a qualitative and quantitative analysis of OCT-A data from 7 patients (14 eyes) with TMA associated with MAH and verified by renal biopsy. The control group included 7 healthy individuals (14 eyes). The following parameters were analyzed: area size of the foveal avascular zone FAZ, mm, vessel density (VD, %) and vessel skeleton density (VSD, %). The indicators were measured separately in the deep and superficial vascular plexuses and divided by localization into: the total density of the entire measured area, central density, density by quadrants (superior, inferior, nasal and temporal). All quadrants were subdivided into inner (corresponding to parafovea) and outer (corresponding to perifovea). RESULTS Local foci of vascular attenuation of the deep retinal capillary plexus, pathological tortuosity of blood vessels in the deep and superficial retinal capillary plexuses were found in 100% of study group patients. Per-quadrant analysis of OCT-A finding in the macular zone revealed a statistically significant decrease in VD of the deep retinal capillary plexus (p<0.05). A direct correlation was found between glomerular filtration rate and the VD index in the outer inferior (r=0.567; p=0.034) and inner temporal quadrants (r=0.613; p=0.020) of the deep retinal capillary plexus, as well as the level of hemoglobin in blood serum and VD in inner temporal quadrant of the deep vascular plexus (r=0.596; p=0.025). CONCLUSION Changes revealed with OCT-A are the symptoms of TMA in MAH patients spreading to the retinal microvasculature, mainly at the level of the deep retinal capillary plexus.
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Affiliation(s)
| | - N L Kozlovskaya
- City Clinical Hospital No. 20 named after A.K. Yeramishantsev, Moscow, Russia
- Peoples' Friendship University of Russia, Moscow, Russia
| | | | | | | | - T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
| | - T V Bondarenko
- City Clinical Hospital No. 20 named after A.K. Yeramishantsev, Moscow, Russia
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5
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Smirnova TV, Kozlovskaya NL, Sheludchenko VM. [Ocular manifestations of primary thrombotic microangiopathy]. Vestn Oftalmol 2021; 137:138-144. [PMID: 34726868 DOI: 10.17116/oftalma2021137051138] [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: 11/17/2022]
Abstract
The article reviews literature on ocular manifestations of primary thrombotic microangiopathy. Thrombotic microangiopathy is a clinical and morphological syndrome that characterizes a systemic disseminated lesion of the microcirculatory bed, it is a special type of vascular damage that combines thrombosis and inflammation of the vascular wall leading to occlusion of the vessel lumen, causing ischemic damage to various organs and tissues. The classic types of primary thrombotic microangiopathy are thrombotic thrombocytopenic purpura, shigatoxin-associated hemolytic uremic syndrome (STEC-HUS) and atypical hemolytic uremic syndrome. Thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome are characterized by ischemic damage to the visual organ as a result of suspected thrombotic microangiopathy in the microcirculatory bed of the eye. The clinical picture of ocular manifestations of these diseases is similar, however the damage to the eye in the form of ischemic Purtscher-like retinopathy is more characteristic of atypical hemolytic uremic syndrome, which may be due to chronic uncontrolled activation of the alternative complement pathway in this disorder. Timely initiation of systemic therapy of the underlying disease in most cases leads to complete restoration of visual functions. A thorough ophthalmological examination of patients with these diseases is required.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
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Dos Santos C, Paiva J, Romero ML, Agazzoni M, Kempfer AC, Rotondo S, Casinelli MM, Alberto MF, Sánchez‐Luceros A. Thrombotic microangiopathies: First report of 294 cases from a single institution experience in Argentina. EJHAEM 2021; 2:149-156. [PMID: 35845285 PMCID: PMC9175742 DOI: 10.1002/jha2.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 11/11/2022]
Abstract
Introduction Introduction: Thrombotic microangiopathies (TMAs) are rare disorders associated with fatal outcomes if left uncared for. However, healthcare problems in developing countries tend to limit medical assistance to patients. Methods Methods: We prospectively studied an Argentine cohort of 294 consecutive patients from 2013 to 2016. Patients’ subcategory classification relied on clinical symptoms and presence or absence of trigger events associated with TMA. Results Main suspected disorders were the primary TMAs known as thrombotic thrombocytopenic purpura (TTP) (n = 72/294, 24%) and atypical haemolytic uraemic syndrome (aHUS) (n = 94/294, 32%). In acute phase, demographic parameters for acquired TTP (aTTP) (n = 28) and aHUS (n = 47) showed that both groups were characterised by a young median age (37 and 25 years, respectively) and female predominance (60% and 86%). Median of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 activity was significantly lower in aTTP than in aHUS group (1.4% vs 83%) and was associated with a more severe thrombocytopenia (15 × 109 vs 53 × 109/L). Creatinine (Cr) and urea (Ur) were significantly increased in aHUS compared to aTTP subjects (Cr: 3.7 vs 0.7 mg/dL, Ur: 118 vs 33 mg/dL). Gastrointestinal and neurological symptoms were more frequent in aHUS and aTTP, respectively. Conclusion The first description of a TMA cohort in Argentina revealed similar clinical presentations to those of other countries.
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Affiliation(s)
- Célia Dos Santos
- Laboratory of Haemostasis and Thrombosis CONICET National Academy of Medicine Institute of Experimental Medicine Buenos Aires Argentina
| | - Juvenal Paiva
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - María Lucila Romero
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - Mara Agazzoni
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - Ana Catalina Kempfer
- Laboratory of Haemostasis and Thrombosis CONICET National Academy of Medicine Institute of Experimental Medicine Buenos Aires Argentina
| | - Sabrina Rotondo
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - María Marta Casinelli
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - María Fabiana Alberto
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
| | - Analía Sánchez‐Luceros
- Laboratory of Haemostasis and Thrombosis CONICET National Academy of Medicine Institute of Experimental Medicine Buenos Aires Argentina
- Department of Haemostasis and Thrombosis National Academy of Medicine Haematologic Research Institute “Mariano R. Castex” Buenos Aires Argentina
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Smirnova TV, Kozlovskaya NL, Sheludchenko VM, Budzinskaya MV. [Optical coherence tomography angiography in the diagnosis of retinal microangiopathy in atypical hemolytic-uremic syndrome (a case report)]. Vestn Oftalmol 2020; 136:226-234. [PMID: 32880144 DOI: 10.17116/oftalma2020136042226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The article describes a clinical case of acute macular neuroretinopathy and «chronic» paracentral acute middle maculopathy in a patient with atypical hemolytic-uremic syndrome - an orphan disease characterized by systemic thrombosis in the vessels of the microcirculatory bed due to chronic uncontrolled activation of the alternative complement pathway. Optical coherence tomography angiography data confirm the ischemic nature of the disease with localization in the deep vascular plexus of the retina in acute macular neuroretinopathy and in the superficial vascular plexus of the retina in «chronic» paracentral acute middle maculopathy. The use of modern diagnostic methods, including optical coherence tomography angiography, can help improve detection of the pathology and expand its understanding in severe microangiopathic syndromes, which include atypical hemolytic-uremic syndrome.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
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8
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Tsai HM. Atypical Hemolytic Uremic Syndrome: Beyond Hemolysis and Uremia. Am J Med 2019; 132:161-167. [PMID: 30145224 DOI: 10.1016/j.amjmed.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/08/2018] [Accepted: 08/11/2018] [Indexed: 12/20/2022]
Abstract
Atypical hemolytic uremic syndrome commonly presents with the triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal function impairment without an antecedent hemorrhagic diarrhea. Less known are extrarenal complications due to abnormal vascular permeability, although these are a major cause of morbidity and mortality for the patients. Furthermore, it is increasingly recognized that the disease may present with hypertension or renal function impairment with no or mild thrombocytopenia and microangiopathic hemolytic anemia. Awareness of the full spectrum of atypical hemolytic uremic syndrome may facilitate its diagnosis and treatment before serious complications or death occurs.
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Affiliation(s)
- Han-Mou Tsai
- Division of Hematology/Oncology, State University of New York Downstate Medical Center, Brooklyn, NY.
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9
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Smirnova TV, Sheludchenko VM, Kozlovskaya NL, Kazaryan EE, Andzhelova DV, Sherstneva LV, Velieva IA, Kuchieva AM, Akaeva MI. [Ocular thrombotic microangiopathy in atypical hemolytic-uremic syndrome (a clinical case study)]. Vestn Oftalmol 2018; 134:215-226. [PMID: 30499520 DOI: 10.17116/oftalma2018134051215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The article presents a clinical observation of ocular thrombotic microangiopathy in atypical hemolytic-uremic syndrome - a rare genetic disease characterized by systemic thrombosis caused by uncontrolled activation of alternative complement pathway. A typical manifestation of this ocular lesion in this disease is bilateral Purtscher-like retinopathy. Timely diagnostics of atypical hemolytic-uremic syndrome, including ophthalmologic examination, determines the early start of a highly effective pathogenetic therapy with complement inhibitor eculizumab.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - V M Sheludchenko
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - N L Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - E E Kazaryan
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - D V Andzhelova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - L V Sherstneva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - I A Velieva
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - A M Kuchieva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - M I Akaeva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
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Abstract
: Complement and coagulation are evolutionarily related proteolytic cascades in the blood that are critical for effecting an appropriate innate response to injury that limits bleeding and infection, while promoting healing. Although often viewed as distinct, it has long been recognized that cross-talk likely exists between these pathways. Only recently have molecular links been established. These are providing insights that are revealing opportunities for the development of novel therapeutic strategies to better treat a wide range of thrombotic, inflammatory, immune, infectious, and malignant diseases. In this brief review, the complex relationship between complement and coagulation is highlighted, underlining some of the newly uncovered interactions, in the hopes of stimulating innovative research that will yield improvements in patient outcomes.
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11
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Skulberg R, Cortellini S, Chan DL, Stanzani G, Jepson RE. Description of the Use of Plasma Exchange in Dogs With Cutaneous and Renal Glomerular Vasculopathy. Front Vet Sci 2018; 5:161. [PMID: 30073173 PMCID: PMC6060235 DOI: 10.3389/fvets.2018.00161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/26/2018] [Indexed: 01/26/2023] Open
Abstract
Cutaneous and renal glomerular vasculopathy (CRGV) is a rare disease affecting dogs, with a recent apparent increase in prevalence since 2012 in the UK. This disease is characterized by a vasculopathy affecting small vessels of the kidney and skin, leading to thrombotic microangiopathy. The underlying etiology remains unknown although clinicopathological and histological findings resemble features of certain forms of thrombotic microangiopathy in people, for which plasma exchange (PEX) is considered an important component of therapy. The objective of the present study is to describe the use of PEX as adjunctive treatment in dogs diagnosed with CRGV. A retrospective review of dogs diagnosed with CRGV between 2014 and 2016 treated with PEX was performed. Clinical records were reviewed and data relating to signalment, diagnostic tests and management strategies were summarized. Information and complications relating to PEX were recorded. Six dogs were diagnosed with CRGV (n = 2 ante-mortem, n = 4 post-mortem) and underwent PEX as part of their therapy. All dogs had cutaneous lesions and were azotemic with oliguria or anuria. All dogs underwent at least one PEX cycle; one dog had a single cycle PEX, three dogs two cycles PEX, and two dogs had one cycle PEX and one cycle of prolonged intermittent renal replacement treatment. Complications seen during PEX therapy included hypothermia (n = 4), tachycardia (n = 2), hypotension (n = 2), and hypocalcemia (n = 6). Two dogs survived to discharge, the remaining four dogs were euthanized. The positive outcome in two dogs treated with PEX despite the reported high mortality rate once acute kidney injury with oliguria/anuria occurs does not confirm success of this treatment. However, survival in two dogs that were initially oligoanuric highlights that further consideration and evaluation of PEX for this patient group is warranted for this specific disease. Additional studies are urgently needed to identify the underlying etiology of CRGV before more targeted therapies can be developed. Based on our findings, further evaluation of the role of PEX in this specific disease are warranted.
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Affiliation(s)
- Ragnhild Skulberg
- Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, United Kingdom
| | - Stefano Cortellini
- Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, United Kingdom
| | - Daniel L Chan
- Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, United Kingdom
| | - Giacomo Stanzani
- Division of Medicine, Bloomsbury Institute for Intensive Care Medicine, University College London, London, United Kingdom
| | - Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, United Kingdom
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Abstract
Atypical hemolytic uremic syndrome is a rare life-threatening disease of unregulated complement activation. Untreated, the prognosis is generally poor; more than one-half of patients die or develop end-stage renal disease within 1 year. Atypical hemolytic uremic syndrome is characterized by thrombotic microangiopathy with evidence of hemolysis, thrombocytopenia, and renal impairment. This systemic disease affects the kidneys, brain, heart, lungs, gastrointestinal tract, pancreas, and skin. Acquired and genetic abnormalities of complement regulation may be identified in approximately 70% of patients. Plasma therapy is generally ineffective. Eculizumab blocks terminal complement activation, prevents complement-mediated organ damage, and is currently recommended as front-line therapy.
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13
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Åkesson A, Zetterberg E, Klintman J. At the Cross Section of Thrombotic Microangiopathy and Atypical Hemolytic Uremic Syndrome: A Narrative Review of Differential Diagnostics and a Problematization of Nomenclature. Ther Apher Dial 2017; 21:304-319. [DOI: 10.1111/1744-9987.12535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Alexander Åkesson
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
| | - Eva Zetterberg
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
| | - Jenny Klintman
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
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Shen YM. Clinical evaluation of thrombotic microangiopathy: identification of patients with suspected atypical hemolytic uremic syndrome. Thromb J 2016; 14:19. [PMID: 27766045 PMCID: PMC5056489 DOI: 10.1186/s12959-016-0114-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare genetic disorder caused by defective complement regulation resulting in thrombotic microangiopathy (TMA). Patients can present as children or adults. The syndrome consists of hemolytic anemia with schistocytosis, thrombocytopenia, significant renal damage, and/or other organ system dysfunction(s). Patients with aHUS may succumb to the complications of the disease with the very first manifestation; surviving patients often suffer from progressive organ dysfunction with significant morbidity and mortality despite plasma infusion or plasma exchange. Eculizumab, a humanized monoclonal antibody to C5, was approved for treatment of aHUS in 2011. This is an expensive but highly effective therapy changing the lives and improving the outcome of patients with aHUS. Making timely and accurate diagnosis of aHUS can be life-saving if eculizumab treatment is begun promptly. Finding a genetic mutation in a complement regulatory protein is diagnostic with the appropriate clinical syndrome, but at least 30 % of patients do not have defined or reported mutations. Thus the diagnosis rests on the clinical acumen of the physician. However, the clinical manifestations of aHUS are shared by other etiologies of thrombotic microangiopathy. While laboratory finding of undetectable ADAMTS13 activity defines TTP, distinguishing aHUS from the other causes of TMA remains an art. In addition, aHUS can be unmasked by conditions with enhanced complement activation, such as systemic lupus erythematosus, pregnancy, malignant hypertension, and hematopoietic stem cell transplantation. Thus if TMA occurs in the setting of enhanced complement activation, one must consider aHUS as an underlying etiology, especially if treatment of the condition does not resolve the TMA.
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Affiliation(s)
- Yu-Min Shen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8852 USA
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Leinøe E, Nielsen OJ, Jønson L, Rossing M. Whole-exome sequencing of a patient with severe and complex hemostatic abnormalities reveals a possible contributing frameshift mutation in C3AR1. Cold Spring Harb Mol Case Stud 2016; 2:a000828. [PMID: 27551680 PMCID: PMC4990812 DOI: 10.1101/mcs.a000828] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The increasing availability of genome-wide analysis has made it possible to rapidly sequence the exome of patients with undiagnosed or unresolved medical conditions. Here, we present the case of a 64-yr-old male patient with schistocytes in the peripheral blood smear and a complex and life-threatening coagulation disorder causing recurrent venous thromboembolic events, severe thrombocytopenia, and subdural hematomas. Whole-exome sequencing revealed a frameshift mutation (C3AR1 c.355-356dup, p.Asp119Alafs*19) resulting in a premature stop codon in C3AR1 (Complement Component 3a Receptor 1). Based on this finding, atypical hemolytic uremic syndrome was suspected because of a genetic predisposition, and a targeted treatment regime with eculizumab was initiated. Life-threatening hemostatic abnormalities would most likely have persisted had it not been for the implementation of whole-exome sequencing in this particular clinical setting.
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Affiliation(s)
- Eva Leinøe
- Department of Hematology, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark
| | - Ove Juul Nielsen
- Department of Hematology, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark
| | - Lars Jønson
- Center for Genomic Medicine, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark
| | - Maria Rossing
- Center for Genomic Medicine, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark
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16
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From Gestational Hypertension and Preeclampsia to Atypical Hemolytic Uremic Syndrome. Obstet Gynecol 2016; 127:907-910. [DOI: 10.1097/aog.0000000000001340] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Chonat S, Chandrakasan S, Kalinyak KA, Ingala D, Gruppo R, Kalfa TA. Atypical haemolytic uraemic syndrome in a patient with sickle cell disease, successfully treated with eculizumab. Br J Haematol 2015; 175:744-747. [PMID: 27870017 DOI: 10.1111/bjh.13884] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Satheesh Chonat
- Division of Haematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shanmuganathan Chandrakasan
- Division of Haematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Karen Ann Kalinyak
- Division of Haematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David Ingala
- Division of Haematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ralph Gruppo
- Division of Haematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theodosia A Kalfa
- Division of Haematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Dusse LM, Alpoim PN, Silva JT, Rios DRA, Brandão AH, Cabral ACV. Revisiting HELLP syndrome. Clin Chim Acta 2015; 451:117-20. [PMID: 26525965 DOI: 10.1016/j.cca.2015.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 10/14/2015] [Accepted: 10/22/2015] [Indexed: 01/17/2023]
Abstract
HELLP syndrome was first described in 1982 by Weinstein et al. and the term HELLP refers to an acronym used to describe the clinical condition that leads to hemolysis, elevated liver enzymes and low platelets. The syndrome frequency varies from 0.5 to 0.9% pregnancies and manifests preferentially between the 27th and 37th week of gestation. Approximately 30% of cases occur after delivery. Although the etiopathogenesis of this syndrome remains unclear, histopathologic findings in the liver include intravascular fibrin deposits that presumably may lead to hepatic sinusoidal obstruction, intrahepatic vascular congestion, and increased intrahepatic pressure with ensuing hepatic necrosis, intraparenchymal and subcapsular hemorrhage, and eventually capsular rupture. Typical clinical symptoms of HELLP syndrome are pain in the right upper quadrant abdomen or epigastric pain, nausea and vomiting. However, this syndrome can present nonspecific symptoms and the diagnosis may be difficult to be established. Laboratory tests and imaging exams are essential for differential diagnosis with other clinical conditions. Treatment of HELLP syndrome with corticosteroids, targeting both lung maturation of the fetus is still an uncertain clinical value. In conclusion, three decades after the tireless efforts of Dr. Weinstein to characterize HELLP syndrome, it remains a challenge to the scientific community and several questions need to be answered for the benefit of pregnant women.
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Affiliation(s)
- Luci Maria Dusse
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil.
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Tsai HM. Does Anticomplement Therapy Have a Role in the Management of Malignant Hypertension? J Clin Hypertens (Greenwich) 2015; 18:359-60. [DOI: 10.1111/jch.12664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Throughout evolution, organisms have developed means to contain wounds by simultaneously limiting bleeding and eliminating pathogens and damaged host cells via the recruitment of innate defense mechanisms. Disease emerges when there is unchecked activation of innate immune and/or coagulation responses. A key component of innate immunity is the complement system. Concurrent excess activation of coagulation and complement - two major blood-borne proteolytic pathways - is evident in numerous diseases, including atherosclerosis, diabetes, venous thromboembolic disease, thrombotic microangiopathies, arthritis, cancer, and infectious diseases. Delineating the cross-talk between these two cascades will uncover novel therapeutic insights.
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Affiliation(s)
- E M Conway
- Centre for Blood Research, Life Sciences Institute, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
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Eculizumab therapy leads to rapid resolution of thrombocytopenia in atypical hemolytic uremic syndrome. Adv Hematol 2014; 2014:295323. [PMID: 25400666 PMCID: PMC4221969 DOI: 10.1155/2014/295323] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 10/05/2014] [Indexed: 11/17/2022] Open
Abstract
Eculizumab is highly effective in controlling complement activation in patients with the atypical hemolytic uremic syndrome (aHUS). However, the course of responses to the treatment is not well understood. We reviewed the responses to eculizumab therapy for aHUS. The results show that, in patients with aHUS, eculizumab therapy, when not accompanied with concurrent plasma exchange therapy, led to steady increase in the platelet count and improvement in extra-renal complications within 3 days. By day 7, the platelet count was normal in 15 of 17 cases. The resolution of hemolytic anemia and improvement in renal function were less predictable and were not apparent for weeks to months in two patients. The swift response in the platelet counts was only observed in one of five cases who received concurrent plasma exchange therapy and was not observed in a case of TMA due to gemcitabine/carboplatin. In summary, eculizumab leads to rapid increase in the platelet counts and resolution of extrarenal symptoms in patients with aHUS. Concurrent plasma exchange greatly impedes the response of aHUS to eculizumab therapy. Eculizumab is ineffective for gemcitabine/carboplatin associated TMA.
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