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Martin M, Llorens-Cebria C, León-Román J, Perurena-Prieto J, Perez-Beltran V, Saumell S, Torres IB, Agraz I, Sellarès J, Ramos N, Bestard O, López M, Moreso F, Ariceta G, Soler MJ, Hernandez-Gonzalez M, Jacobs-Cachá C. Ex vivo C5b-9 Deposition Test to Monitor Complement Activity in Clinical and Subclinical Atypical Hemolytic Uremic Syndrome and in Transplantation-Associated Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:2227-2239. [PMID: 39081726 PMCID: PMC11284441 DOI: 10.1016/j.ekir.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a complement system (CS)-mediated ultrarare disease that manifests as thrombotic microangiopathy (TMA) with preferential small kidney vessels involvement. Transient CS activation is also observed in secondary TMA or in patients at risk of developing aHUS. There is no gold standard test to monitor disease activity; however, the ex vivo C5b-9 deposition test seems to be a good approach. Methods We assessed the C5b-9 deposition induced by serum samples of patients with aHUS (n = 8) and with TMA associated with kidney (n = 2), lung (n = 1) or hematopoietic stem cell (HSC) transplantation (HSCT, n = 2) during the acute phase of the disease or in remission. As control for transplant-associated TMA (TA-TMA), we analyzed samples of clinically stable kidney and HSC-transplanted patients without signs of TMA. In addition, we studied 1 child with genetic risk of aHUS during an acute infection. Results In the acute disease phase or in patients with disease activity despite C5 blockade, a significant increase of C5b-9 deposition was detected. In all patients with clinical response to C5 blockade but one, levels of C5b-9 deposition were within the normal range. Finally, we detected increased C5b-9 deposition levels in an asymptomatic child with genetic risk of aHUS when a concomitant otitis episode was ongoing. Conclusion The ex vivo C5b-9 deposition test is an auspicious tool to monitor CS activity in aHUS and TA-TMA. In addition, we demonstrate that the test may be useful to detect subclinical increase of CS activity, which expands the spectrum of patients that would benefit from a better CS activity assessment.
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Affiliation(s)
- Maria Martin
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carmen Llorens-Cebria
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan León-Román
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Janire Perurena-Prieto
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Víctor Perez-Beltran
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Silvia Saumell
- Hematology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irina B. Torres
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irene Agraz
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Joana Sellarès
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Natàlia Ramos
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Bestard
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Mercedes López
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francesc Moreso
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Gema Ariceta
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Universitat Autonoma Barcelona, Barcelona, Spain
| | - Maria José Soler
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Hernandez-Gonzalez
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Conxita Jacobs-Cachá
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Biochemistry Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
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Ávila A, Gavela E, Sancho A. Thrombotic Microangiopathy After Kidney Transplantation: An Underdiagnosed and Potentially Reversible Entity. Front Med (Lausanne) 2021; 8:642864. [PMID: 33898482 PMCID: PMC8063690 DOI: 10.3389/fmed.2021.642864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 01/25/2023] Open
Abstract
Thrombotic microangiopathy is a rare but serious complication that affects kidney transplant recipients. It appears in 0.8–14% of transplanted patients and negatively affects graft and patient survival. It can appear in a systemic form, with hemolytic microangiopathic anemia, thrombocytopenia, and renal failure, or in a localized form, with progressive renal failure, proteinuria, or arterial hypertension. Post-transplant thrombotic microangiopathy is classified as recurrent atypical hemolytic uremic syndrome or de novo thrombotic microangiopathy. De novo thrombotic microangiopathy accounts for the majority of cases. Distinguishing between the 2 conditions can be difficult, given there is an overlap between them. Complement overactivation is the cornerstone of all post-transplant thrombotic microangiopathies, and has been demonstrated in the context of organ procurement, ischemia-reperfusion phenomena, immunosuppressive drugs, antibody-mediated rejection, viral infections, and post-transplant relapse of antiphospholipid antibody syndrome. Although treatment of the causative agents is usually the first line of treatment, this approach might not be sufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve renal function. Complement blockade with eculizumab has been shown to be an effective therapy in post-transplant thrombotic microangiopathy, but it is necessary to define which patients can benefit from this therapy and when and how eculizumab should be used.
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Affiliation(s)
- Ana Ávila
- Nephrology Department, University Hospital Dr. Peset, Valencia, Spain
| | - Eva Gavela
- Nephrology Department, University Hospital Dr. Peset, Valencia, Spain
| | - Asunción Sancho
- Nephrology Department, University Hospital Dr. Peset, Valencia, Spain
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3
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Jarmoliński T, Rosa M, Puziewicz-Zmonarska A, Kałwak K. Short Course of Eculizumab May Be Effective in Dialysis-Dependent Transplantation-Associated Thrombotic Microangiopathy After Hematopoietic Stem Cell Transplantation: A Case Report. Transplant Proc 2020; 52:2544-2547. [PMID: 32917392 DOI: 10.1016/j.transproceed.2020.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (alloHSCT) could induce several complications. The most frequent viral infections and graft-vs-host disease (GvHD) sometimes lead to thrombotic microangiopathy (TMA). It is associated with significant morbidity and mortality with the risk of death reaching 90%. Effective prevention and treatment are not available to date. Recent attempts at using antibody against C5 have been made. CASE REPORT A 19-year-old girl with acute myeloid leukemia twice underwent alloHSCTs from her 10/10 HLA-matched sister. After the second HSCT severe acute steroid-resistant grade 4 GvHD occurred. Despite treatment with high doses of steroids, mycophenolate mofetil, biological therapy, and extracorporeal photopheresis, the patient developed TMA with acute kidney injury and the need for renal replacement therapy. The concentration of complement component 3 and activity of ADAMTS 13 were normal, and infection with Escherichia coli (E. coli) 0157H7 was excluded. Due to failure of all ordered therapies and severity of the condition, an attempt was taken to use eculizumab. Two 900-mg doses of eculizumab (Soliris) were administered at an interval of 2 weeks, which resulted in the improvement of renal function and amelioration of hemolysis and thrombocytopenia. Dialysis therapy was finished after 5 weeks, and then a third dose of the drug was administered. Eighteen months later, the patient is alive and well, with limited chronic GvHD. eGFR remains stable at 40 to 46 mL/min/1.73 m2, and mild hypertension requires treatment with angiotensin converting enzyme inhibitors and furosemide. CONCLUSION Even a short course of eculizumab can be sufficient in controlling the TMA after HSCT, provided that the TMA-triggering factors are well controlled.
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Affiliation(s)
- Tomasz Jarmoliński
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland; Department of Pediatrics and Pediatric Neurology, District Hospital, Gorzów Wielkopolski, Poland
| | - Monika Rosa
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Krzysztof Kałwak
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland.
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Atypical and secondary hemolytic uremic syndromes have a distinct presentation and no common genetic risk factors. Kidney Int 2019; 95:1443-1452. [DOI: 10.1016/j.kint.2019.01.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/01/2019] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
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Wijnsma KL, Duineveld C, Wetzels JFM, van de Kar NCAJ. Eculizumab in atypical hemolytic uremic syndrome: strategies toward restrictive use. Pediatr Nephrol 2019; 34:2261-2277. [PMID: 30402748 PMCID: PMC6794245 DOI: 10.1007/s00467-018-4091-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 12/19/2022]
Abstract
With the introduction of the complement C5-inhibitor eculizumab, a new era was entered for patients with atypical hemolytic uremic syndrome (aHUS). Eculizumab therapy very effectively reversed thrombotic microangiopathy and reduced mortality and morbidity. Initial guidelines suggested lifelong treatment and recommended prophylactic use of eculizumab in aHUS patients receiving a kidney transplant. However, there is little evidence to support lifelong therapy or prophylactic treatment in kidney transplant recipients. Worldwide, there is an ongoing debate regarding the optimal dose and duration of treatment, particularly in view of the high costs and potential side effects of eculizumab. An increasing but still limited number of case reports and small cohort studies suggest that a restrictive treatment regimen is feasible. We review the current literature and focus on the safety and efficacy of restrictive use of eculizumab. Our current treatment protocol is based on restrictive use of eculizumab. Prospective monitoring will provide more definite proof of the feasibility of such restrictive treatment.
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Affiliation(s)
- Kioa L. Wijnsma
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Caroline Duineveld
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands ,Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F. M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole C. A. J. van de Kar
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Abbas F, El Kossi M, Kim JJ, Sharma A, Halawa A. Thrombotic microangiopathy after renal transplantation: Current insights in de novo and recurrent disease. World J Transplant 2018; 8:122-141. [PMID: 30211021 PMCID: PMC6134269 DOI: 10.5500/wjt.v8.i5.122] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 06/26/2018] [Accepted: 07/10/2018] [Indexed: 02/05/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is one of the most devastating sequalae of kidney transplantation. A number of published articles have covered either de novo or recurrent TMA in an isolated manner. We have, hereby, in this article endeavored to address both types of TMA in a comparative mode. We appreciate that de novo TMA is more common and its prognosis is poorer than recurrent TMA; the latter has a genetic background, with mutations that impact disease behavior and, consequently, allograft and patient survival. Post-transplant TMA can occur as a recurrence of the disease involving the native kidney or as de novo disease with no evidence of previous involvement before transplant. While atypical hemolytic uremic syndrome is a rare disease that results from complement dysregulation with alternative pathway overactivity, de novo TMA is a heterogenous set of various etiologies and constitutes the vast majority of post-transplant TMA cases. Management of both diseases varies from simple maneuvers, e.g., plasmapheresis, drug withdrawal or dose modification, to lifelong complement blockade, which is rather costly. Careful donor selection and proper recipient preparation, including complete genetic screening, would be a pragmatic approach. Novel therapies, e.g., purified products of the deficient genes, though promising in theory, are not yet of proven value.
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Affiliation(s)
- Fedaey Abbas
- Nephrology Department, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Renal Unit, Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Jon Jin Kim
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Nottingham Children Hospital, Nottingham NG7 2UH, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Transplant Surgery, Royal Liverpool University Hospitals, Liverpool UK L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation Surgery, Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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Román E, Mendizábal S, Jarque I, de la Rubia J, Sempere A, Morales E, Praga M, Ávila A, Górriz JL. Secondary thrombotic microangiopathy and eculizumab: A reasonable therapeutic option. Nefrologia 2018; 37:478-491. [PMID: 28946961 DOI: 10.1016/j.nefro.2017.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 01/03/2017] [Accepted: 01/14/2017] [Indexed: 12/16/2022] Open
Abstract
Understanding the role of the complement system in the pathogenesis of atypical haemolytic uraemic syndrome and other thrombotic microangiopathies (TMA) has led to the use of anti-complement therapy with eculizumab in these diseases, in addition to its original use in patients with paroxysmal nocturnal haemoglobinuria andatypical haemolytic uraemic syndrome. Scientific evidence shows that both primary and secondary TMAs with underlying complement activation are closely related. For this reasons, control over the complement system is a therapeutic target. There are 2scenarios in which eculizumab is used in patients with TMA: primary or secondary TMA that is difficult to differentiate (including incomplete clinical presentations) and complement-mediated damage in various processes in which eculizumab proves to be efficacious. This review summarises the evidence on the role of the complement activation in the pathophysiology of secondary TMAs and the efficacy of anti-complement therapy in TMAs secondary to pregnancy, drugs, transplant, humoral rejection, systemic diseases and glomerulonephritis. Although experience is scarce, a good response to eculizumab has been reported in patients with severe secondary TMAs refractory to conventional treatment. Thus, the role of the anti-complement therapy as a new treatment option in these patients should be investigated.
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Affiliation(s)
- Elena Román
- Servicio de Nefrología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Santiago Mendizábal
- Servicio de Nefrología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Isidro Jarque
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario Dr. Peset, Valencia, España
| | - Amparo Sempere
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Enrique Morales
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Ana Ávila
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
| | - José Luis Górriz
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
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Tatapudi VS, Lonze BE, Wu M, Montgomery RA. Early Conversion from Tacrolimus to Belatacept in a Highly Sensitized Renal Allograft Recipient with Calcineurin Inhibitor-Induced de novo Post-Transplant Hemolytic Uremic Syndrome. Case Rep Nephrol Dial 2018; 8:10-19. [PMID: 29594146 PMCID: PMC5836164 DOI: 10.1159/000486158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/06/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Kidney transplantation is the first-line therapy for patients with end-stage renal disease since it offers greater long-term survival and improved quality of life when compared to dialysis. The advent of calcineurin inhibitor (CNI)-based maintenance immunosuppression has led to a clinically significant decline in the rate of acute rejection and better short-term graft survival rates. However, these gains have not translated into improvement in long-term graft survival. CNI-related nephrotoxicity and metabolic side effects are thought to be partly responsible for this. CASE PRESENTATION Here, we report the conversion of a highly sensitized renal transplant recipient with pretransplant donor-specific antibodies from tacrolimus to belatacept within 1 week of transplantation. This substitution was necessitated by the diagnosis of CNI-induced de novo post-transplant hemolytic uremic syndrome. CONCLUSION Belatacept is a novel costimulation blocker that is devoid of the nephrotoxic properties of CNIs and has been shown to positively impact long-term graft survival and preserve renal allograft function in low-immunologic-risk kidney transplant recipients. Data regarding its use in patients who are broadly sensitized to human leukocyte antigens are scarce, and the increased risk of rejection associated with belatacept has been a deterrent to more widespread use of this immunosuppressive agent. This case serves as an example of a highly sensitized patient that has been successfully converted to a belatacept-based CNI-free regimen.
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Affiliation(s)
- Vasishta S. Tatapudi
- aDepartment of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Bonnie E. Lonze
- bDepartment of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Ming Wu
- cDepartment of Pathology, New York University Langone Medical Center, New York, NY, USA
| | - Robert A. Montgomery
- bDepartment of Surgery, New York University Langone Medical Center, New York, NY, USA
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Garg N, Rennke HG, Pavlakis M, Zandi-Nejad K. De novo thrombotic microangiopathy after kidney transplantation. Transplant Rev (Orlando) 2017; 32:58-68. [PMID: 29157988 DOI: 10.1016/j.trre.2017.10.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 10/22/2017] [Accepted: 10/23/2017] [Indexed: 12/14/2022]
Abstract
Thrombotic microangiopathy (TMA) is a serious complication of transplantation that adversely affects kidney transplant recipient and allograft survival. Post-transplant TMA is usually classified into two categories: 1) recurrent TMA and 2) de novo TMA. Atypical hemolytic uremic syndrome (aHUS) resulting from dysregulation and over-activation of the alternate complement pathway is a rare disease but the most common diagnosis associated with recurrence in the allografts. De novo TMA, on the other hand, represents an overwhelming majority of the cases of post-transplant TMA and is a substantially more heterogeneous entity than recurrent aHUS. Here, we review the etio-pathogenesis, diagnosis and treatment options for de novo post-transplant TMA. It is usually in the setting of calcineurin inhibitor use, mammalian target of rapamycin inhibitor use, or antibody mediated rejection; recently genetic mutations in complement regulatory genes for Factor H and Factor I similar to those described in aHUS have been reported in up to a third of these patients. Systemic signs of TMA are frequently absent, and a renal allograft biopsy is often needed to establish the diagnosis. Although withdrawal of the offending agents is usually the first line of treatment and resolution of laboratory abnormalities has been documented with this approach in several case reports and case series, available retrospective data demonstrate lack of benefit in long-term graft outcomes. Co-stimulation blockage with belatacept provides an effective alternate immunosuppressive strategy for these patients. Anti-complement therapy with eculizumab is effective in some cases; further work is required to define which patients with TMA (with and without concomitant antibody-mediated rejection) would benefit from receiving this treatment, and what biomarkers can be used to identify them.
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Affiliation(s)
- Neetika Garg
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, United States.
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Martha Pavlakis
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, United States
| | - Kambiz Zandi-Nejad
- Department of Medicine, Nephrology Division, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, United States
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10
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Allinovi M, Cirami CL, Caroti L, Antognoli G, Farsetti S, Amato MP, Minetti EE. Thrombotic microangiopathy induced by interferon beta in patients with multiple sclerosis: three cases treated with eculizumab. Clin Kidney J 2017; 10:625-631. [PMID: 28980667 PMCID: PMC5622889 DOI: 10.1093/ckj/sfw143] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/22/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Interferon-beta (IFN-beta) is one of the most widely prescribed medications for relapsing-remitting multiple sclerosis (RRMS). IFN-related thrombotic microangiopathy (TMA) is a rare but severe complication, with a fulminant clinical onset and a possibly life-threatening outcome that may occur years after a well-tolerated treatment with IFN. Most patients evolve rapidly to advanced chronic kidney disease and eventually to renal failure. METHODS We performed a retrospective analysis of TMA cases diagnosed and managed in our Nephrology Department from 2010 to 2015, and performed a literature review of IFN-beta-induced TMA. RESULTS Three cases of TMA among patients treated with IFN-beta were identified who did not show any renal improvement following conventional therapy: IFN withdrawal and plasma exchange (PE, range 8-18) sessions. All of them responded favourably to eculizumab, with progressive clinical and renal improvement, allowing dialysis discontinuation, without recurrence of TMA during a long-term follow-up (range 1-5 years). CONCLUSIONS TMA is a recognized severe complication in RRMS patients treated with IFN-beta. Withdrawal of IFN and treatment with PE, steroids or rituximab did not improve the poor renal prognosis in our three patients and in all the previously described cases in the literature. In our experience, eculizumab had a strikingly favourable effect on renal recovery, suggesting a role of IFN-beta as a trigger in complement-mediated TMA. Neurologists and nephrologists should be vigilant to this complication to prevent possibly irreversible renal damage.
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Affiliation(s)
- Marco Allinovi
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | | | - Leonardo Caroti
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | | | - Silvia Farsetti
- Nephrology Unit, Careggi University Hospital, Florence, Italy
| | - Maria Pia Amato
- Department of NEUROFARBA, Section Neuroscience, University of Florence, Florence, Italy
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11
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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12
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Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C. Haemolytic uraemic syndrome. Lancet 2017; 390:681-696. [PMID: 28242109 DOI: 10.1016/s0140-6736(17)30062-4] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
Haemolytic uraemic syndrome is a form of thrombotic microangiopathy affecting predominantly the kidney and characterised by a triad of thrombocytopenia, mechanical haemolytic anaemia, and acute kidney injury. The term encompasses several disorders: shiga toxin-induced and pneumococcus-induced haemolytic uraemic syndrome, haemolytic uraemic syndrome associated with complement dysregulation or mutation of diacylglycerol kinase ɛ, haemolytic uraemic syndrome related to cobalamin C defect, and haemolytic uraemic syndrome secondary to a heterogeneous group of causes (infections, drugs, cancer, and systemic diseases). In the past two decades, experimental, genetic, and clinical studies have helped to decipher the pathophysiology of these various forms of haemolytic uraemic syndrome and undoubtedly improved diagnostic approaches. Moreover, a specific mechanism-based treatment has been made available for patients affected by atypical haemolytic uraemic syndrome due to complement dysregulation. Such treatment is, however, still absent for several other disease types, including shiga toxin-induced haemolytic uraemic syndrome.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, and INSERM UMR S1064, Nantes, France
| | - Julien Zuber
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology and Renal Transplantation, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, and INSERM UMR S1138, Complément et Maladies, Centre de Recherche des Cordeliers, Paris, France
| | - Chantal Loirat
- Assistance Publique-Hôpitaux de Paris, Department of Pediatric Nephrology, Hôpital Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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13
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Antibodies Against Complement Components: Relevance for the Antiphospholipid Syndrome-Biomarkers of the Disease and Biopharmaceuticals. Curr Rheumatol Rep 2017. [PMID: 28631067 DOI: 10.1007/s11926-017-0669-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Laboratory criterion for the diagnosis of antiphospholipid syndrome (APS) is the presence of antiphospholipid antibodies (aPL Abs). Complement system has a role in mediating aPL Abs-induced thrombosis in animal models. The importance of antibodies against complement components (potential biomarkers of APS) and the importance of antibodies with beneficial anti-complement effects in APS (as biopharmaceuticals) are reviewed. RECENT FINDINGS Antibodies against complement components described in APS patients, so far, are anti-C1q and anti-factor H Abs, although anti-factor B Abs and anti-C5a Abs were described in animal models of APS. Clinical studies in APS patients are limited to a small number of case reports. Studies that would confirm potential role of Abs against complement components (as potential biomarkers of APS) are lacking. Lack of randomized clinical trials (that would provide complete data for confirmation of beneficial effects of biopharmaceuticals in complement inhibition) in APS is alarming.
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Tatapudi VS, Montgomery RA. Pharmacologic Complement Inhibition in Clinical Transplantation. CURRENT TRANSPLANTATION REPORTS 2017; 4:91-100. [PMID: 29214126 PMCID: PMC5707230 DOI: 10.1007/s40472-017-0148-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review Over the past two decades, significant strides made in our understanding of the etiology of antibody-mediated rejection (AMR) in transplantation have put the complement system in the spotlight. Here, we review recent progress made in the field of pharmacologic complement inhibition in clinical transplantation and aim to understand the impact of this therapeutic approach on outcomes in transplant recipients. Recent Findings Encouraged by the success of agents targeting the complement cascade in disorders of unrestrained complement activation like paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), investigators are testing the safety and efficacy of pharmacologic complement blockade in mitigating allograft injury in conditions ranging from AMR to recurrent post-transplant aHUS, C3 glomerulopathies and antiphospholipid anti-body syndrome (APS). A recent prospective study demonstrated the efficacy of terminal complement inhibition with eculizumab in the prevention of acute AMR in human leukocyte antigen (HLA)-incompatible living donor renal transplant recipients. C1 esterase inhibitor (C1-INH) was well tolerated in two recent studies in the treatment of AMR and was associated with improved renal allograft function. Summary Pharmacologic complement inhibition is emerging as valuable therapeutic tool, especially in the management of highly sensitized renal transplant recipients. Novel and promising agents that target various elements in the complement cascade are in development. Graphical Abstractᅟ.
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Affiliation(s)
- Vasishta S Tatapudi
- Division of Nephrology, Department of Internal Medicine, NYU Langone Medical Center, New York, NY 10016 USA
| | - Robert A Montgomery
- NYU Langone Transplant Institute, 530 First Avenue, HCC 7A, New York, NY 10016 USA
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15
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Zwang NA, Ho B, Kanwar YS, Lewis B, Cusick M, Friedewald JJ, Gallon L. A case of atypical hemolytic uremic syndrome in a second renal transplant. J Nephrol 2017; 31:165-172. [PMID: 28224376 DOI: 10.1007/s40620-016-0373-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/22/2016] [Indexed: 01/29/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) has gained increased visibility over several years as an important cause of renal failure. Unfortunately, diagnosis is often difficult because individual courses can be highly variable depending the causative genetic mutations. Here we present the case of a patient with a failed renal allograft and acute failure of a second allograft who was ultimately diagnosed with aHUS. Interestingly, he developed early de novo donor specific antibodies (DSA) after the second renal transplant in context of likely recurrent aHUS. Terminal complement inhibition with eculizumab resulted in prompt improvement of renal allograft function.
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Affiliation(s)
- Nicholas A Zwang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA. .,McGaw Medical Center of Northwestern University, Chicago, USA. .,Northwestern Memorial Hospital/Arkes Family Pavilion Suite 1900, 676N. St. Clair, Chicago, IL, 60611, USA.
| | - Bing Ho
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Yashpal S Kanwar
- Department of Pathology, Northwestern Memorial Hospital, Chicago, USA
| | | | - Matthew Cusick
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - John J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA.,McGaw Medical Center of Northwestern University, Chicago, USA.,Department of Pathology, Northwestern Memorial Hospital, Chicago, USA.,Machaon Diagnostics, Oakland, CA, USA.,Northwestern Memorial Hospital/Arkes Family Pavilion Suite 1900, 676N. St. Clair, Chicago, IL, 60611, USA
| | - Lorenzo Gallon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, USA
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16
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Ibrahim H, Al Qurashi S, Abdullah M, Hajeer A, Alsaad KO, Al Sayyari A. Antibody-mediated rejection and aHUS in renal graft recipient. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1215014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Hafez Ibrahim
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia
| | - Salem Al Qurashi
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia
| | - Mubarak Abdullah
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia
| | - Ali Hajeer
- Department of Laboratory Medicine, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia
| | - Khaled O. Alsaad
- Department of Laboratory Medicine, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia
| | - Abdulla Al Sayyari
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia
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17
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Dhakal P, Giri S, Pathak R, Bhatt VR. Eculizumab in Transplant-Associated Thrombotic Microangiopathy. Clin Appl Thromb Hemost 2016; 23:175-180. [DOI: 10.1177/1076029615599439] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Introduction: Transplant-associated thrombotic microangiopathy (TA-TMA) is a rare entity with no standard of care and high mortality, despite the use of plasma exchange. Methods: Using specific search terms, all cases having TA-TMA treated with eculizumab and indexed in MEDLINE (English language only) by November 2014 were reviewed. Results: A total of 26 cases, 53% men, had a median age of 33 years (range 2-61). Transplant-associated thrombotic microangiopathy occurred after stem-cell transplant (35%) or solid-organ transplant (65%), frequently associated with the use of cyclosporine or tacrolimus (96%). A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS 13) level was always >10%. After TA-TMA diagnosis, the following drug adjustments were made: discontinuation of cyclosporine or tacrolimus in 45%, dose reduction in another 27%, continuation of the drugs in 23%, and switch from cyclosporine to tacrolimus in remaining 5%. Plasma exchange was performed in ∼43%. The median interval between transplant and initiation of eculizumab was 63 days (range 11-512). A median of 5.5 doses (range 2-21) of eculizumab was utilized with 92% response occurring after a median of 2 doses (range 1-18). At a median follow-up of 52 weeks (range 3-113), the survivors (92%) were doing well. Conclusion: Within the limits of this retrospective analysis, our study demonstrates that eculizumab use may result in high response rate and 1-year survival in patients with TA-TMA refractory to discontinuation of calcineurin inhibitor and plasma exchange.
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Affiliation(s)
- Prajwal Dhakal
- Department of Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Smith Giri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ranjan Pathak
- Department of Medicine, Reading Health System, West Reading, PA, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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18
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Viglietti D, Gosset C, Loupy A, Deville L, Verine J, Zeevi A, Glotz D, Lefaucheur C. C1 Inhibitor in Acute Antibody-Mediated Rejection Nonresponsive to Conventional Therapy in Kidney Transplant Recipients: A Pilot Study. Am J Transplant 2016; 16:1596-603. [PMID: 26693703 DOI: 10.1111/ajt.13663] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/08/2015] [Accepted: 11/27/2015] [Indexed: 02/06/2023]
Abstract
Complement inhibitors have not been thoroughly evaluated in the treatment of acute antibody-mediated rejection (ABMR). We performed a prospective, single-arm pilot study to investigate the potential effects and safety of C1 inhibitor (C1-INH) Berinert added to high-dose intravenous immunoglobulin (IVIG) for the treatment of acute ABMR that is nonresponsive to conventional therapy. Kidney recipients with nonresponsive active ABMR and acute allograft dysfunction were enrolled between April 2013 and July 2014 and received C1-INH and IVIG for 6 months (six patients). The primary end point was the change in eGFR at 6 months after inclusion (M+6). Secondary end points included the changes in histology and DSA characteristics and adverse events as evaluated at M+6. All patients showed an improvement in eGFR between inclusion and M+6: from 38.7 ± 17.9 to 45.2 ± 21.3 mL/min/1.73 m(2) (p = 0.0277). There was no change in histological features, except a decrease in the C4d deposition rate from 5/6 to 1/6 (p = 0.0455). There was a change in DSA C1q status from 6/6 to 1/6 positive (p = 0.0253). One deep venous thrombosis was observed. In a secondary analysis, C1-INH patients were compared with a similar historical control group (21 patients). C1-INH added to IVIG is safe and may improve allograft function in kidney recipients with nonresponsive acute ABMR.
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Affiliation(s)
- D Viglietti
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - C Gosset
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - A Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Kidney Transplantation, Necker Hospital, Assitance Publique - Hôpitaux de Paris, Paris, France
| | - L Deville
- Department of Pharmacy, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - J Verine
- Department of Pathology, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - A Zeevi
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - D Glotz
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - C Lefaucheur
- Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
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19
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Abstract
The biology of atypical hemolytic uremic syndrome has been shown to involve inability to limit activation of the alternative complement pathway, with subsequent damage to systemic endothelial beds and the vasculature, resulting in the prototypic findings of a thrombotic microangiopathy. Central to this process is the formation of the terminal membrane attack complex C5b-9. Recently, application of a monoclonal antibody that specifically binds to C5, eculizumab, became available to treat patients with atypical hemolytic uremic syndrome, replacing plasma exchange or infusion as primary therapy. This review focuses on the evidence, based on published clinical trials, case series, and case reports, on the efficacy and safety of this approach.
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Affiliation(s)
- Lilian M Pereira Palma
- Pediatric Nephrology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Craig B Langman
- The Feinberg School of Medicine, Northwestern University, and the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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20
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Juega-Mariño FJ, Sala N, López D, Cañas L, Bonet J, Lauzurica R. Late onset of de novo atypical hemolytic-uremic syndrome presented on a simultaneous pancreas and kidney transplant recipient successfully treated with eculizumab. Nefrologia 2016; 36:328-9. [PMID: 27012439 DOI: 10.1016/j.nefro.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 01/14/2016] [Accepted: 02/11/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Neus Sala
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Dolores López
- Servicio de Anatomía patológica, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Laura Cañas
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Josep Bonet
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ricardo Lauzurica
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
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21
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Off-label use of the expensive orphan drug eculizumab in France 2009-2013 and the impact of literature: focus on the transplantation field. Eur J Clin Pharmacol 2016; 72:737-46. [PMID: 26915814 DOI: 10.1007/s00228-016-2027-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/11/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE The orphan drug eculizumab (Soliris ®) is one of the most expensive in the world and based on expenditures is classed among the highest in France, a scenario suggestive of off-label use. Given its pharmacological properties, it is likely to be used in organ transplantation. Our purposes were to describe the consumption trends of eculizumab for off-label indications overall and in the organ transplantation field and to assess the impact of publications on the latter use. METHODS We carried out a temporal ecological study within the French national hospitalization database (PMSI). First, the trend of eculizumab consumption (2009-2013) was compared to our estimate of the maximum on-label consumption (overall and for transplantation). Second, we evaluated the impact of the publications supporting the effectiveness of eculizumab in the transplantation field on temporal trends of eculizumab consumption. RESULTS Eculizumab total consumption exceeded our estimate of the maximum on-label consumption since the end of 2011 and increased until the end of the study. The off-label consumption represented at least 50 % of the total consumption. The off-label consumption in organ transplantation also increased since 2011. The amount of publications grew through the study period, but overall, the evidence level remained low. Statistically, publications were neither associated with the drug consumption for transplantation in the long term nor in the short term. CONCLUSION Eculizumab started being notably used for off-label indications in France since the end of 2011, and this use increased until the end of the study. We found only low-level evidence concerning the off-label use of eculizumab in the transplantation field through the studied period.
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22
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Campistol JM, Arias M, Ariceta G, Blasco M, Espinosa L, Espinosa M, Grinyó JM, Macía M, Mendizábal S, Praga M, Román E, Torra R, Valdés F, Vilalta R, Rodríguez de Córdoba S. An update for atypical haemolytic uraemic syndrome: diagnosis and treatment. A consensus document. Nefrologia 2015; 35:421-47. [PMID: 26456110 DOI: 10.1016/j.nefro.2015.07.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a clinical entity defined as the triad of nonimmune haemolytic anaemia, thrombocytopenia, and acute renal failure, in which the underlying lesions are mediated by systemic thrombotic microangiopathy (TMA). Different causes can induce the TMA process that characterizes HUS. In this document we consider atypical HUS (aHUS) a sub-type of HUS in which the TMA phenomena are the consequence of the endotelial damage in the microvasculature of the kidneys and other organs due to a disregulation of the activity of the complement system. In recent years, a variety of aHUs-related mutations have been identified in genes of the the complement system, which can explain approximately 60% of the aHUS cases, and a number of mutations and polymorphisms have been functionally characterized. These findings have stablished that aHUS is a consequence of the insufficient regulation of the activiation of the complement on cell surfaces, leading to endotelial damage mediated by C5 and the complement terminal pathway. Eculizumab is a monoclonal antibody that inhibits the activation of C5 and blocks the generation of the pro-inflammatory molecule C5a and the formation of the cell membrane attack complex. In prospective studies in patients with aHUS, the use of Eculizumab has shown a fast and sustained interruption of the TMA process and it has been associated with significative long-term improvements in renal function, the interruption of plasma therapy and important reductions in the need of dialysis. According to the existing literature and the accumulated clinical experience, the Spanish aHUS Group published a consensus document with recommendations for the treatment of aHUs (Nefrologia 2013;33[1]:27-45). In the current online version of this document, we update the aetiological classification of TMAs, the pathophysiology of aHUS, its differential diagnosis and its therapeutic management.
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Affiliation(s)
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
| | - Miguel Blasco
- Servicio de Nefrología, Hospital Clínic, Barcelona, España
| | - Laura Espinosa
- Servicio de Nefrología Pediátrica, Hospital La Paz, Madrid, España
| | - Mario Espinosa
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, España
| | - Josep M Grinyó
- Servicio de Nefrología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Manuel Macía
- Servicio de Nefrología, Hospital Virgen de la Candelaria, Santa Cruz de Tenerife, España
| | | | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Elena Román
- Servicio de Nefrología Pediátrica, Hospital La Fe, Valencia, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Fundació Puigvert, Barcelona, España
| | - Francisco Valdés
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, España
| | - Ramón Vilalta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
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Elsallabi O, Bhatt VR, Dhakal P, Foster KW, Tendulkar KK. Hematopoietic Stem Cell Transplant-Associated Thrombotic Microangiopathy. Clin Appl Thromb Hemost 2015; 22:12-20. [PMID: 26239316 DOI: 10.1177/1076029615598221] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA) is a fatal, multifactorial disorder, which may present with thrombocytopenia, hemolysis, acute renal failure, mental status changes and involvement of other organs. The pathogenesis of TA-TMA is complex and includes multiple risk factors such as certain conditioning regimens, calcineurin inhibitors (CNIs), graft-versus-host disease (GVHD), human leukocyte antigen mismatch, and opportunistic infections. The end result of these insults is endothelial injury in the kidney and other organs. Recent studies also indicate a role of complement activation in tissue damage. The lack of sensitive and specific diagnostic tests for TA-TMA often results in delayed diagnosis. Biopsy is not always possible for diagnosis because of the risk of complications such as bleeding. Recently, an emerging role of renal-centered screening approach has been demonstrated, which utilize the monitoring of blood pressure, urine protein, serum lactate dehydrogenase and hemogram for early detection. Therapeutic options are limited, and plasma exchange plays a minor role. Withdrawal of offending agent such as CNIs and the use of rituximab can be effective in some patients. However, the current treatment strategy is suboptimal and associated with high mortality rate. Recently, eculizumab has been utilized in a few patients with good outcomes. Patients, who develop TA-TMA, are also at an increased risk of GVHD, infection, renal, cardiovascular, and other complications, which can contribute to high mortality. Better understanding of molecular pathogenesis, improvement in posttransplant management, leading to early diagnosis, and management of TA-TMA are required to improve outcomes of this fatal entity.
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Affiliation(s)
- Osama Elsallabi
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Prajwal Dhakal
- Department of Medicine, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Kirk W Foster
- Department of Pathology and Microbiology, Division of Renal Pathology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ketki K Tendulkar
- Department of Internal Medicine, Division of Nephrology, University of Nebraska Medical Center, Omaha, NE, USA
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24
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Antibody-Mediated Rejection in Pediatric Kidney Transplantation: Pathophysiology, Diagnosis, and Management. Drugs 2015; 75:455-72. [DOI: 10.1007/s40265-015-0369-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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25
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Kaplan BS, Ruebner RL, Spinale JM, Copelovitch L. Current treatment of atypical hemolytic uremic syndrome. Intractable Rare Dis Res 2014; 3:34-45. [PMID: 25343125 PMCID: PMC4204535 DOI: 10.5582/irdr.2014.01001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 02/17/2014] [Accepted: 02/23/2014] [Indexed: 12/25/2022] Open
Abstract
Tremendous advances have been made in understanding the pathogenesis of atypical Hemolytic Uremic Syndrome (aHUS), an extremely rare disease. Insights into the molecular biology of aHUS resulted in rapid advances in treatment with eculizumab (Soliris(®), Alexion Pharmaceuticals Inc.). Historically, aHUS was associated with very high rates of mortality and morbidity. Prior therapies included plasma therapy and/or liver transplantation. Although often life saving, these were imperfect and had many complications. We review the conditions included under the rubric of aHUS: S. pneumoniae HUS (SpHUS), inborn errors of metabolism, and disorders of complement regulation, emphasizing their differences and similarities. We focus on the clinical features, diagnosis, and pathogenesis, and treatment of aHUS that results from mutations in genes encoding alternative complement regulators, SpHUS and HUS associated with inborn errors of metabolism. Mutations in complement genes, or antibodies to their protein products, result in unregulated activity of the alternate complement pathway, endothelial injury, and thrombotic microangiopathy (TMA). Eculizumab is a humanized monoclonal antibody that inhibits the production of the terminal complement components C5a and the membrane attack complex (C5b-9) by binding to complement protein C5a. This blocks the proinflammatory and cytolytic effects of terminal complement activation. Eculizumab use has been reported in many case reports, and retrospective and prospective clinical trials in aHUS. There have been few serious side effects and no reports of tachphylaxis or drug resistance. The results are very encouraging and eculizumab is now recognized as the treatment of choice for aHUS.
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Affiliation(s)
- Bernard S. Kaplan
- Division of Pediatric Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, and The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Address correspondence to: Dr. Bernard S. Kaplan, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA. E-mail:
| | - Rebecca L. Ruebner
- Division of Pediatric Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, and The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joann M. Spinale
- Division of Pediatric Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, and The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lawrence Copelovitch
- Division of Pediatric Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, and The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ponticelli C, Moroni G, Glassock RJ. De novo glomerular diseases after renal transplantation. Clin J Am Soc Nephrol 2014; 9:1479-87. [PMID: 24700797 DOI: 10.2215/cjn.12571213] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Glomerular diseases developing in the kidney allograft are more often recurrences of the original disease affecting the native kidneys. However, in an undefined number of cases de novo, glomerular diseases unrelated to the original disease in the native kidneys can develop in the transplanted kidney. The clinical presentation and histologic features of de novo diseases are often similar to those features observed in patients with primary or secondary GN in the native kidneys. However, in transplanted kidneys, the glomerular, vascular, and tubulointerstitial changes are often intertwined with structural abnormalities already present at the time of transplant or caused by antibody- or cell-mediated allograft rejection, immunosuppressive drugs, or superimposed infection (most often of a viral nature). The pathophysiology of de novo glomerular diseases is quite variable. In rare cases of de novo minimal change disease, circulating factors increasing the glomerular permeability likely participate. Maladaptive hemodynamic changes and tissue fibrosis caused by calcineurin inhibitors or other factors may be involved in the pathogenesis of de novo FSGS. The exposure of cryptic podocyte antigens may favor the development of de novo membranous nephropathy. Many cases of de novo membranoproliferative GN are related to hepatitis C virus infection. Patients with Alport syndrome lacking antigenic epitopes in their glomerular basement membrane may develop antibodies against these glomerular basement membrane antigens expressed in the transplanted kidney. Infection may cause acute GN to have a heterogeneous clinical presentation and outcome. De novo pauci-immune GN in renal transplant is rare. Preexisting or acquired intolerance to glucose may, in the long term, cause diabetic nephropathy. The prognosis of de novo diseases depends on the type of GN, the severity of lesions caused by the alloimmune response, or the efficacy of immunosuppressive therapy. In most cases, the management of de novo glomerular diseases is empirical or elusive.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Humanitas Scientific Institute, Rozzano, Milan, Italy;
| | - Gabriella Moroni
- Division of Nephrology, Fondazione Ca' Granda Ospedale Maggiore Istituto Scientifico, Milan, Italy; and
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at the University of California at Los Angeles, Laguna Niguel, California
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Ghirardo G, Benetti E, Poli F, Vidal E, Della Vella M, Cozzi E, Murer L. Plasmapheresis-resistant acute humoral rejection successfully treated with anti-C5 antibody. Pediatr Transplant 2014; 18:E1-5. [PMID: 24266980 DOI: 10.1111/petr.12187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2013] [Indexed: 12/14/2022]
Abstract
Even if kidney graft survival has improved during the last decades, sensitized pediatric patients are an emerging problem. We describe a 17-yr-old male who lost his first graft due to chronic rejection becoming hyperimmunized (CDC PRA 99.61%). A desensitization protocol based on high-dose IVIG, PP, and two Mabthera(®) infusions was performed with minor response (CDC PRA post-desensitization 80%). One month after his second non-living transplant, he developed a biopsy-proven AMR; post-transplant immunological monitoring showed the presence of donor-specific anti-DQ5 antibodies (DSA, MFI 20.000). He received methylprednisolone pulses and 45 PP sessions without clinical response; eculizumab was then used to salvage a kidney undergoing severe PP-resistant rejection. A biopsy performed after the fourth eculizumab infusion showed complete resolution of AMR. Eculizumab infusions were then continued for the first year post-transplantation. Two yr after transplantation, graft function is stable. Anti-C5 therapy may represent an effective therapeutic option in pediatric patients with PP-resistant AMR.
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Affiliation(s)
- Giulia Ghirardo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Pediatrics, University Hospital of Padua, Padua, Italy
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28
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Hardinger KL, Brennan DC. Novel immunosuppressive agents in kidney transplantation. World J Transplant 2013; 3:68-77. [PMID: 24392311 PMCID: PMC3879526 DOI: 10.5500/wjt.v3.i4.68] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/26/2013] [Accepted: 10/16/2013] [Indexed: 02/05/2023] Open
Abstract
Excellent outcomes have been achieved in the field of renal transplantation. A significant reduction in acute rejection has been attained at many renal transplant centers using contemporary immunosuppressive, consisting of an induction agent, a calcineurin inhibitor, an antiproliferative agent plus or minus a corticosteroid. Despite improvements with these regimens, chronic allograft injury and adverse events still persist. The perfect immunosuppressive regimen would limit or eliminate calcineurin inhibitors and/or corticosteroid toxicity while providing enhanced allograft outcomes. Potential improvements to the calcineurin inhibitor class include a prolonged release tacrolimus formulation and voclosporin, a cyclosporine analog. Belatacept has shown promise as an agent to replace calcineurin inhibitors. A novel, fully-human anti-CD40 monoclonal antibody, ASKP1240, is currently enrolling patients in phase 2 trials with calcineurin minimization and avoidance regimens. Another future goal of transplant immunosuppression is effective and safe treatment of allograft rejection. Novel treatments for antibody mediated rejection include bortezomib and eculizumab. Several investigational agents are no longer being pursed in transplantation including the induction agents, efalizumab and alefacept, and maintenance agents, sotrastaurin and tofacitinib. The purpose of this review is to consolidate the published evidence of the effectiveness and safety of investigational immunosuppressive agents in renal transplant recipients.
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Reindl-Schwaighofer R, Oberbauer R. Blood disorders after kidney transplantation. Transplant Rev (Orlando) 2013; 28:63-75. [PMID: 24211181 DOI: 10.1016/j.trre.2013.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 09/21/2013] [Accepted: 10/01/2013] [Indexed: 02/07/2023]
Abstract
Post transplant anemia (PTA) is a common issue in kidney transplant recipients. Most importantly it is associated with an impaired allograft function. Other important factors associated with PTA are immunosuppressive drugs (MPA, AZA and SRL), iron deficiency, infections (Parvo B19), older donor age, rejection episodes, an increased inflammatory state, and erythropoietin hyporesponsiveness. As there are no adequately powered RCTs in the kidney transplant population on anemia treatment with ESA, we have to rely on what we know from the large RCTs in the CKD population. The recently published KDIGO guidelines do not recommend treatment with ESA if Hb is >10 g/dl. Repletion of iron stores is emphasized. Post transplant leukopenia (PTL) and thrombocytopenia (PTT) are frequent complications especially in the first six months after kidney transplantation. Myelosuppression caused by immunosuppressive agents (MPA, AZA, SRL, rATG), antimicrobial drugs (VGCV), and CMV infection is the predominant cause. There are no widely accepted guidelines on treatment strategies, but most often dose reduction or discontinuation of causative medication is done. Most clinicians tend to decrease MPA dose, but this is eventually associated with an increase in acute rejection episodes. VGCV dose reduction (preemptive treatment instead of CMV prophylaxis) may be a successful strategy. In severe cases G-CSF treatment is an important management option and seems to be safe.
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Affiliation(s)
| | - Rainer Oberbauer
- Department of Nephrology, KH Elisabethinen, Linz, Austria; Department of Nephrology, Medical University of Vienna, Vienna, Austria.
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Hamilton AJ, Lyons CBA, Goodship THJ, Bingham C. Prevalence in the General Population of a CFH Sequence Variant Associated with Atypical Haemolytic Uraemic Syndrome in an Extensive Family from Southwest England. NEPHRON EXTRA 2013; 3:86-90. [PMID: 24163689 PMCID: PMC3806708 DOI: 10.1159/000354667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Twenty-five members of a family from the county of Devon in England have been affected by atypical haemolytic uraemic syndrome (aHUS) associated with a CFH mutation (c.3643C>G; p.Arg1215Gly). A 65-year-old male was diagnosed with aHUS after losing a renal transplant to a thrombotic microangiopathy. Subsequent mutation screening revealed the same CFH mutation without him being knowingly related to the local kindred. We designed a study to investigate the prevalence of this mutation in the local area. In addition, we examined the diagnoses of pre-existing haemodialysis patients to determine whether other patients might unknowingly be at risk of carrying the same CFH mutation. METHODS The Exeter Ten Thousand (EXTEND) study aims to recruit 10,000 healthy volunteers over the age of 18 years living within 25 miles of Exeter in Devon. We genotyped DNA from 4,000 EXTEND subjects for CFH c.3643C>G; p.Arg1215Gly. We reviewed the diagnoses of 294 haemodialysis patients in the Devon area and genotyped 7 patients with either end-stage renal disease of unknown aetiology, malignant hypertension or renovascular disease. RESULTS CFH c.3643C>G; p.Arg1215Gly was not detected in any of the 7 haemodialysis patients or the 4,000 individuals within the EXTEND study. CONCLUSIONS We conclude that CFH c.3643C>G; p.Arg1215Gly is not endemic in Devon. This reinforces our existing practice of genotyping only patients with kidney disease and evidence of a thrombotic microangiopathy for this mutation. This is the first study looking at the prevalence of CFH mutations in the general population.
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Affiliation(s)
- Alexander J Hamilton
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Plymouth, UK ; Renal Unit, Royal Devon and Exeter Hospital, Exeter, Plymouth, UK
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31
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Barnett ANR, Asgari E, Chowdhury P, Sacks SH, Dorling A, Mamode N. The use of eculizumab in renal transplantation. Clin Transplant 2013; 27:E216-29. [DOI: 10.1111/ctr.12102] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2013] [Indexed: 01/02/2023]
Affiliation(s)
- A. Nicholas R. Barnett
- Renal and Transplant Department; Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust; London; UK
| | - Elham Asgari
- MRC Centre for Transplantation; King's College London; UK
| | - Paramit Chowdhury
- Renal and Transplant Department; Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust; London; UK
| | | | | | - Nizam Mamode
- Renal and Transplant Department; Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust; London; UK
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32
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McCaughan JA, O'Rourke DM, Courtney AE. The complement cascade in kidney disease: from sideline to center stage. Am J Kidney Dis 2013; 62:604-14. [PMID: 23489674 DOI: 10.1053/j.ajkd.2012.12.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/17/2012] [Indexed: 12/12/2022]
Abstract
Activation of the complement pathway is implicated in the pathogenesis of many kidney diseases. The pathologic and clinical features of these diseases are determined in part by the mechanism and location of complement activation within the kidney parenchyma. This review describes the physiology, action, and control of the complement cascade and explains the role of complement overactivation and dysregulation in kidney disease. There have been recent advances in the understanding of the effects of upregulation of the complement cascade after kidney transplantation. Complement plays an important role in initiating and propagating damage to transplanted kidneys in ischemia-reperfusion injury, antibody-mediated rejection, and cell-mediated rejection. Complement-targeting therapies presently are in development, and the first direct complement medication for kidney disease was licensed in 2011. The potential therapeutic targets for anticomplement drugs in kidney disease are described. Clinical and experimental studies are ongoing to identify further roles for complement-targeting therapy.
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Affiliation(s)
- Jennifer A McCaughan
- Nephrology Research Group, Queen's University, Belfast City Hospital, Belfast, Northern Ireland.
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33
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34
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Kaplan BS, Ruebner RL, Copelovitch L. Eculizumab treatment of atypical hemolytic uremic syndrome. Expert Opin Orphan Drugs 2012. [DOI: 10.1080/21678707.2013.750579] [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: 10/27/2022]
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35
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Zuber J, Le Quintrec M, Krid S, Bertoye C, Gueutin V, Lahoche A, Heyne N, Ardissino G, Chatelet V, Noël LH, Hourmant M, Niaudet P, Frémeaux-Bacchi V, Rondeau E, Legendre C, Loirat C. Eculizumab for atypical hemolytic uremic syndrome recurrence in renal transplantation. Am J Transplant 2012; 12:3337-54. [PMID: 22958221 DOI: 10.1111/j.1600-6143.2012.04252.x] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Eculizumab (anti-C5) has been sporadically reported as an efficient therapy for atypical hemolytic uremic syndrome (aHUS). However, the lack of series precludes any firm conclusion about the optimal use of anti-C5 for preventing or treating aHUS posttransplant aHUS recurrence. We thoroughly studied 22 renal transplant recipients with aHUS who received off-label therapy with anti-C5, including 12 cases, which have not been reported yet. Nine patients, all carrying a complement genetic abnormality associated with a high risk of aHUS recurrence, received prophylactic anti-C5 therapy to prevent posttransplant recurrence. Eight of them had a successful recurrence-free posttransplant course and achieved a satisfactory graft function, while the remaining patient experienced early arterial thrombosis of the graft. Thirteen renal transplant recipients were given anti-C5 for posttransplant aHUS recurrence. A complete reversal of aHUS activity was obtained in all of them. Importantly, the delay of anti-C5 initiation after the onset of the aHUS episode inversely correlated with the degree of renal function improvement. Three patients in whom anti-C5 was subsequently stopped experienced a relapse. Altogether these data suggest that long-term eculizumab is highly effective for preventing and treating posttransplant aHUS recurrence. Our study also indicates that anti-C5 should be promptly started if a recurrence occurs.
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Affiliation(s)
- J Zuber
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker; Université Paris Descartes, Sorbonne Paris Cité; Department of Renal Transplantation, Paris, France.
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36
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Abstract
In the past decade, a large body of evidence has accumulated in support of the critical role of dysregulation of the alternative complement pathway in atypical haemolytic uraemic syndrome (aHUS) and C3 glomerulopathies. These findings have paved the way for innovative therapeutic strategies based on complement blockade, and eculizumab, a monoclonal antibody targeting the human complement component 5, is now widely used to treat aHUS. In this article, we review 28 case reports and preliminary data from 37 patients enrolled in prospective trials of eculizumab treatment for episodes of aHUS involving either native or transplanted kidneys. Eculizumab may be considered as an optimal first-line therapy when the diagnosis of aHUS is unequivocal and this treatment has the potential to rescue renal function when administered early after onset of the disease. However, a number of important issues require further study, including the appropriate duration of treatment according to an individual's genetic background and medical history, the optimal strategy to prevent post-transplantation recurrence of aHUS and a cost-efficacy analysis. Data regarding the efficacy of eculizumab in the control of C3 glomerulopathies are more limited and less clear, but several observations suggest that eculizumab may act on the most inflammatory forms of this disorder.
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37
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Stewart ZA, Collins TE, Schlueter AJ, Raife TI, Holanda DG, Nair R, Reed AI, Thomas CP. Case report: Eculizumab rescue of severe accelerated antibody-mediated rejection after ABO-incompatible kidney transplant. Transplant Proc 2012. [PMID: 23195021 DOI: 10.1016/j.transproceed.2012.03.053] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
ABO-incompatible (ABOI) living donor kidney transplantation has become a well-accepted practice with standard protocols using perioperative antibody-depleting therapies to lower blood group titers to an acceptable threshold for transplantation. However, a subset of patients will experience accelerated antibody-mediated rejection (AMR) after ABOI kidney transplantation and require aggressive intervention to prevent allograft loss. Here in we report the successful use of terminal complement inhibition with eculizumab to rescue an ABOI kidney allograft with accelerated AMR refractory to salvage splenectomy and daily plasmapheresis. This case emphasizes the fact that, despite close postoperative surveillance and aggressive intervention, graft loss from accelerated AMR after ABOI kidney transplantation remains a very real risk. Eculizumab may offer a graft-saving therapeutic option for isolated cases of severe AMR after ABOI kidney transplantation refractory to standard treatment.
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Affiliation(s)
- Z A Stewart
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
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38
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Noone D, Al-Matrafi J, Tinckam K, Zipfel PF, Herzenberg AM, Thorner PS, Pluthero FG, Kahr WHA, Filler G, Hebert D, Harvey E, Licht C. Antibody mediated rejection associated with complement factor h-related protein 3/1 deficiency successfully treated with eculizumab. Am J Transplant 2012; 12:2546-53. [PMID: 22681773 DOI: 10.1111/j.1600-6143.2012.04124.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibody mediated rejection (AMR) activates the classical complement pathway and can be detrimental to graft survival. AMR can be accompanied by thrombotic microangiopathy (TMA). Eculizumab, a monoclonal C5 antibody prevents induction of the terminal complement cascade (TCC) and has recently emerged as a therapeutic option for AMR. We present a highly sensitized 13-year-old female with end-stage kidney disease secondary to spina bifida-associated reflux nephropathy, who developed severe steroid-, ATG- and plasmapheresis-resistant AMR with TMA 1 week post second kidney transplant despite previous desensitization therapy with immunoglobulin infusions. Eculizumab rescue therapy resulted in a dramatic improvement in biochemical (C3; creatinine) and hematological (platelets) parameters within 6 days. The patient was proven to be deficient in complement Factor H-related protein 3/1 (CFHR3/1), a plasma protein that regulates the complement cascade at the level of C5 conversion and has been involved in the pathogenesis of atypical hemolytic uremic syndrome caused by CFH autoantibodies (DEAP-HUS). CFHR1 deficiency may have worsened the severe clinical progression of AMR and possibly contributed to the development of donor-specific antibodies. Thus, screening for CFHR3/1 deficiency should be considered in patients with severe AMR associated with TMA.
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Affiliation(s)
- D Noone
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, ON, Canada
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Abstract
The complement system is an important part of the innate immune system. Complement plays a crucial role in the pathophysiology of many disorders. Despite the pivotal role of the complement system, an approved targeted inhibitor of a complement factor became available only recently. Eculizumab is a humanized monoclonal antibody that inhibits complement factor C5. It is a targeted, disease modifying, treatment of paroxysmal nocturnal hemoglobinuria (PNH). It was approved be the US FDA and the European Commission in 2007. In this review we will update the experience with eculizumab in PNH and discuss potential use of eculizumab in other disorders (e.g. cold agglutinin disease; atypical HUS) and new approaches to complement inhibition with drugs other than eculizumab.
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Affiliation(s)
- Hubert Schrezenmeier
- German Red Cross Blood Transfusion Service Baden-Württemberg-Hessia, Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, and University of Ulm, Helmholtzstraße 10, 89081 Ulm, Germany.
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