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Schumann A, Schultheiss UT, Ferreira CR, Blau N. Clinical and biochemical footprints of inherited metabolic diseases. XIV. Metabolic kidney diseases. Mol Genet Metab 2023; 140:107683. [PMID: 37597335 DOI: 10.1016/j.ymgme.2023.107683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023]
Abstract
Kidney disease is a global health burden with high morbidity and mortality. Causes of kidney disease are numerous, extending from common disease groups like diabetes and arterial hypertension to rare conditions including inherited metabolic diseases (IMDs). Given its unique anatomy and function, the kidney is a target organ in about 10% of known IMDs, emphasizing the relevant contribution of IMDs to kidney disease. The pattern of injury affects all segments of the nephron including glomerular disease, proximal and distal tubular damage, kidney cyst formation, built-up of nephrocalcinosis and stones as well as severe malformations. We revised and updated the list of known metabolic etiologies associated with kidney involvement and found 190 relevant IMDs. This represents the 14th of a series of educational articles providing a comprehensive and revised list of metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Anke Schumann
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Ulla T Schultheiss
- Department of Medicine IV, Nephrology and Primary Care, Faculty of Medicine, and Medical Center, University of Freiburg, Institute of Genetic Epidemiology, Freiburg, Germany.
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, USA.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
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Khandelwal P, Thangaraju S, Krishnamurthy S, Ohri A, Pais P, Mathew G, Sharma J, Sharma A, Hari P, Sinha A, Singh G, Bagga A. Clinical features and outcomes of patients with diacylglycerol kinase epsilon nephropathy: a nationwide experience. Pediatr Nephrol 2023; 38:3009-3016. [PMID: 36988693 DOI: 10.1007/s00467-023-05939-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/05/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is usually caused due to dysregulation of the alternative complement pathway. Rarely, thrombotic microangiopathy is caused by non-complement mediated mutations in diacylglycerol kinase epsilon (DGKE); information about therapy and outcome of these patients is limited. METHODS Medical records of patients, younger than 18 years, diagnosed with TMA and variants in DGKE were reviewed to include 12 patients from seven centers. Genetic studies included targeted exome sequencing and multiplex-ligation dependent probe amplification of CFH-CFHR5. RESULTS Patients presented at a median age of 11 (7.5, 12.3) months; all were younger than 2 years. All patients had an infectious prodrome; enteroinvasive, enteropathogenic, and enterotoxigenic Escherichia coli were detected in two patients with diarrhea. Chief features included those of microangiopathic hemolysis (n = 11), microscopic hematuria (n = 10), nephrotic range proteinuria (n = 10), hypoalbuminemia (n = 6), elevated total cholesterol (n = 6), and hypocomplementemia (n = 4). Histopathology showed thrombotic microangiopathy (n = 4), overlapping with membranoproliferative pattern of injury (n = 1). At median 3.3 years of follow-up, significant hypertension and/or proteinuria (40%), relapses (66.7%), and death or progression to CKD (60%) were common. Genetic sequencing showed 13 homozygous and compound heterozygous variants (7 pathogenic, 3 likely pathogenic) located throughout DGKE; 11 variants were novel. CONCLUSIONS This case series highlights the need to suspect DGKE nephropathy in young patients with TMA, especially those with severe proteinuria. Medium-term outcomes are unsatisfactory with risk of relapses, progressive kidney failure, and death. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Priyanka Khandelwal
- Department of Pediatrics, Division of Nephrology, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sharan Thangaraju
- Department of Pediatrics, Division of Nephrology, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sriram Krishnamurthy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Alpana Ohri
- Department of Pediatrics, Bai Jerbai Wadia Hospital and Institute of Child Health, Mumbai, India
| | - Priya Pais
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Georgie Mathew
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Jyoti Sharma
- Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Aditi Sharma
- Department of Pediatrics, Army Hospital Research and Referral, New Delhi, India
| | - Pankaj Hari
- Department of Pediatrics, Division of Nephrology, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Aditi Sinha
- Department of Pediatrics, Division of Nephrology, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Geetika Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Department of Pediatrics, Division of Nephrology, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Dai X, Ma Y, Lin Q, Tang H, Chen R, Zhu Y, Shen Y, Cui N, Hong Z, Li Y, Li X. Clinical features and management of atypical hemolytic uremic syndrome patient with DGKE gene variants: a case report. Front Pediatr 2023; 11:1162974. [PMID: 37456562 PMCID: PMC10340117 DOI: 10.3389/fped.2023.1162974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) with diacylglycerol kinase epsilon (DGKE) gene variant is a rare variant of thrombotic microangiopathy (TMA). The information on the clinical features, management and long-term outcomes of DGKE-aHUS patients have not yet been fully elucidated. The aim of this study was to report a novel variant of the DGKE gene in a Chinese population with aHUS. Case presentation The present work reports a 7-month-old boy with aHUS, possibly triggered by gastrointestinal infection, without complement activation, with little response to plasma therapy and nephroprotective measures. The patient died during the 8th week of his hospital stay. The causes of death were intracranial hemorrhage and multiorgan dysfunction. Comprehensive WES of peripheral blood-derived DNA revealed two heterozygous variations in the DGKE exon region: NM_003647.2, c.610dup, p.Thr204Asnfs*4 and deletion of exons 4-6. Conclusions This case suggest that atypical HUS with DGKE gene variant has a poor prognosis with a high mortality rate, which typically manifests in the first year of life and presents as a systemic disease with early-onset HUS with rapidly worsening renal function and chronic proteinuria. There is no specific treatment for DGKE-aHUS. There have an uncertain benefit of plasma therapy for DGKE-aHUS patients. The literature demonstrated that anti-complement therapy showed benefits for DGKE-aHUS with complement activation and autoantibodies during the overt TMA presentation but did not prevent TMA relapses. Early diagnosis and treatment may prevent complications and improve prognosis.
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Affiliation(s)
- Xiaomei Dai
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Yu Ma
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou, China
| | - Qiang Lin
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Hanyun Tang
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Ruyue Chen
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Yun Zhu
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Yunyan Shen
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Ningxun Cui
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Zhongqin Hong
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Yanhong Li
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaozhong Li
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
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ter Avest M, Steenbreker H, Bouwmeester RN, Duineveld C, Wijnsma KL, van den Heuvel LP, Langemeijer SM, Wetzels JF, van de Kar NC, ter Heine R. Proteinuria and Exposure to Eculizumab in Atypical Hemolytic Uremic Syndrome. Clin J Am Soc Nephrol 2023; 18:759-766. [PMID: 36913245 PMCID: PMC10278783 DOI: 10.2215/cjn.0000000000000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/28/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Eculizumab is a monoclonal antibody for the treatment of atypical hemolytic uremic syndrome (aHUS). Kidney damage, a common condition in patients with aHUS, may result in proteinuria. Because proteinuria may affect the pharmacokinetics of therapeutic proteins such as eculizumab, the aim of our study was to investigate the effect of proteinuria on eculizumab pharmacokinetics. METHODS This study was an ancillary study of a previously performed pharmacokinetic-pharmacodynamic study of eculizumab in aHUS. Proteinuria, measured as urinary protein-creatinine ratios (UPCR), was investigated as covariate for eculizumab clearance. Thereafter, we evaluated the effect of proteinuria on the exposure to eculizumab in a simulation study for the initial phase and for a 2-weekly and 3-weekly interval in the maintenance phase. RESULTS The addition of UPCR as a linear covariate on clearance to our base model resulted in a statistically improved fit ( P < 0.001) and reduction of unexplained variability in clearance. From our data, we predicted that in the initial phase, 16% of the adult patients with severe proteinuria (UPCR >3.1 g/g) will have inadequate complement inhibition (classical pathway activity >10%) on day 7 of treatment, compared with 3% of the adult patients without proteinuria. None of the pediatric patients will have inadequate complement inhibition at day 7 of treatment. For the 2- and 3-weekly dosing intervals, we predicted that, respectively, 18% and 49% of the adult patients and, respectively, 19% and 57% of the pediatric patients with persistent severe proteinuria will have inadequate complement inhibition, compared with, respectively, 2% and 13% of the adult patients and, respectively, 4% and 22% of the pediatric patients without proteinuria. CONCLUSIONS Severe proteinuria is associated with a higher risk of underexposure to eculizumab. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER CUREiHUS, Dutch Trial Register, NTR5988/NL5833.
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Affiliation(s)
- Mendy ter Avest
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hilbert Steenbreker
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Romy N. Bouwmeester
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kioa L. Wijnsma
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lambertus P.W.J. van den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, 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
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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A Life-Threating Postpartum Atypical Hemolytic-Uremic Syndrome with Multiorgan Involvement. J Clin Med 2022; 11:jcm11236957. [PMID: 36498532 PMCID: PMC9738905 DOI: 10.3390/jcm11236957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Atypical Hemolytic Uremic Syndrome is a very rare condition that can be triggered in predisposed patients. It can remain undiagnosed and can result in a life-threatening event or permanent renal failure. We report a case of a 36-year-old pregnant woman who developed atypical hemolytic uremic syndrome postpartum. She underwent an emergency caesarean section due to abruptio placenta, and she developed biochemical alterations suggestive of a thrombotic microangiopathy. Due to worsening of renal function after plasma exchange therapy, we decided to start therapy with eculizumab. Therapy was carried out with a weekly dose of 900 mg IV for five weeks. An improvement of clinical and biochemical parameters was rapidly observed, and her renal function completely recovered. The therapy was continued for six months, with a dose of 1200 mg of eculizumab every two weeks. One year after discontinuation of the therapy, her blood pressure and renal function were still normal. Our case confirms that it is important to promptly identify a pregnancy-related thrombotic microangiopathy and that early therapy can be life-saving for the patient and can preserve renal function, avoiding dialysis.
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Berthaud R, Heidet L, Oualha M, Brat R, Talmud D, Garaix F, Rabant M, Frémeaux-Bacchi V, Antignac C, Boyer O, Dorval G. Atypical severe early-onset nephrotic syndrome: Answers. Pediatr Nephrol 2022; 37:2637-2642. [PMID: 35507148 DOI: 10.1007/s00467-022-05537-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Romain Berthaud
- APHP, Service de Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Universitaire Necker-Enfants Malades, Université Paris Cité, 75015, Paris, France.
| | - Laurence Heidet
- APHP, Service de Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Universitaire Necker-Enfants Malades, 75015, Paris, France
| | - Mehdi Oualha
- APHP, Service de Réanimation, Surveillance Continue Médico-Chirurgicales Et SMUR Pédiatriques, Hôpital Universitaire Necker-Enfants Malades, 75015, Paris, France
| | - Roselyne Brat
- Service de Réanimation Et Médecine Néonatales, Centre Hospitalier Régional d'Orléans, 45000, Orléans, France
| | - Déborah Talmud
- Département de Pédiatrie, Centre Hospitalier Régional d'Orléans, 45000, Orléans, France
| | - Florentine Garaix
- Service de Pédiatrie Multidisciplinaire, Hôpital de La Timone, Marseille, France
| | - Marion Rabant
- APHP, Service d'Anatomie Pathologique, Hôpital Universitaire Necker-Enfants Malades, 75015, Paris, France
| | | | - Corinne Antignac
- APHP, Service de Génétique Moléculaire, Centre de Référence MARHEA, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, 75015, Paris, France
| | - Olivia Boyer
- APHP, Service de Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, 75015, Paris, France
| | - Guillaume Dorval
- APHP, Service de Génétique Moléculaire, Centre de Référence MARHEA, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, 75015, Paris, France
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Massicotte-Azarniouch D, Kotzen E, Todd S, Hu Y, Hogan SL, Jain K. Kidney thrombotic microangiopathy in lupus nephritis: Impact on treatment and prognosis. Lupus 2022; 31:1175-1185. [PMID: 35650019 PMCID: PMC9449430 DOI: 10.1177/09612033221106301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction Lupus nephritis (LN) may present with thrombotic microangiopathy (TMA) on
kidney biopsy, the impact of which on outcomes is unclear. This study
examined the prognostic importance of LN with TMA on kidney biopsy,
including response to therapy and long-term outcomes. Methods We conducted a single-center, retrospective study of all cases of LN with
concomitant TMA on kidney biopsy in the Glomerular Disease Collaborative
Network database. Controls were individuals with LN without TMA matched to
cases based on demographic and clinical variables. Outcomes were remission
at 6- and 12-months, end-stage kidney disease (ESKD) and death. Logistic
regression and Cox proportional hazards models were used to ascertain the
risks for outcomes, with adjustment for serum creatinine and
proteinuria. Results There were 17 cases and 28 controls. Cases had higher creatinine, higher
proteinuria and greater chronicity on biopsy at baseline compared to
controls. The rates of remission at 6-months and 12-months were similar
between cases and controls (6-months 53.9% vs 46.4%, adjusted OR 2.54, 95%
CI 0.48, 13.37; 12-months 53.9% vs 50.0%, adjusted OR 2.95, 95% CI 0.44,
19.78). Cases were at greater risk for ESKD in univariate analysis (HR 3.77;
95% CI 1.24, 11.41) but not when adjusting for serum creatinine and
proteinuria (HR 2.20; 95% CI 0.63, 7.71). There was no significant
difference in the risk of death between cases and controls. Conclusion Lupus nephritis with renal TMA likely responds to therapy similarly to those
without TMA; risk for ESKD is not significantly increased, although the
influence of renal function and proteinuria in larger samples is needed.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth Kotzen
- Division of Nephrology and Hypertension, Department of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah Todd
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yichun Hu
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Koyal Jain
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Wang Z, Zhou Z, Zhang Y, Zuo F, Du J, Wang M, Hu M, Sun Y, Wang X, Liu M, Zhang Y, Tang W, Yi F. Diacylglycerol kinase epsilon protects against renal ischemia/reperfusion injury in mice through Krüppel-like factor 15/klotho pathway. Ren Fail 2022; 44:902-913. [PMID: 35616094 PMCID: PMC9154760 DOI: 10.1080/0886022x.2022.2079524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Although recent studies have indicated that mutations in the gene encoding diacylglycerol kinase epsilon (DGKE) result in some proteinuria related hereditary kidney diseases, the DGKE expression pattern in the kidney and its contribution to acute kidney injury (AKI) remain unknown. Therefore, the present study was designed to detect the role of DGKE in mice with AKI. DGKE expression was time-dependently altered in the kidneys of mice with renal ischemia/reperfusion injury (IRI). Compared with wild-type (WT) mice, DGKE- overexpressing mice (Rosa26-Dgke+/+) exhibited protective effects against renal IRI, including reduced serum creatinine, blood urea concentration, tubular cell death and inflammatory responses as well as improved morphological injuries. Consistently, in vitro, DGKE overexpression in human renal proximal tubule (HK-2) cells also protected against oxygen-glucose deprivation (OGD)/reoxygenation-induced cell death. Mechanistically, DGKE regulated Klotho expression, at least partly via the transcription factor Krüppel-like factor (KLF) 15. Moreover, a significant reduction in DGKE was also found in kidneys from patients with ischemia-associated acute tubular necrosis (ATN). Collectively, our studies demonstrate that DGKE protects against AKI in mice at least partly through KLF15/Klotho signaling pathway, indicating that DGKE may present an innovative therapeutic strategy for treating patients with AKI.
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Affiliation(s)
- Ziying Wang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Zhuanli Zhou
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Yanan Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Fuwen Zuo
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Junyao Du
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Mingwei Wang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Muchen Hu
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Yu Sun
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Xiaojie Wang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Min Liu
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Yan Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Wei Tang
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Fan Yi
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
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Martin SM, Balestracci A, Puyol I, Toledo I, Cao G, Arizeta G. Uncommon Presentation of Atypical Hemolytic Uremic Syndrome: A Case Report. Indian J Nephrol 2021; 31:478-481. [PMID: 34880559 PMCID: PMC8597788 DOI: 10.4103/ijn.ijn_271_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/30/2020] [Accepted: 09/26/2020] [Indexed: 11/04/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare disease characterized by microangiopathic hemolytic anemia, thrombocytopenia and renal damage. Its presentation as nephrotic syndrome (NS) during first year of life is uncommon; we describe a child with clinical and laboratory findings of NS whose renal biopsy revealed thrombotic microangiopathy (TMA). A previously healthy 4-month-old male was admitted with severe dehydration, diarrhea and anuria. Laboratory results showed electrolyte disturbances, increased serum creatinine, anemia without schistocytes, thrombocytosis, normal lactic dehydrogenase (LDH) levels, hypoalbuminemia hypercholesterolemia and decreased C3 levels. After rehydration hematuria and massive proteinuria were also documented and an initial diagnosis of NS of the first year was established. Studies seeking for infectious agents were negative. During hospitalization he continued to be oligo-anuric needing dialysis and a renal biopsy was performed, which showed TMA findings. We here considered the diagnosis of aHUS and started plasma infusions as a bridge until starting eculizumab. After two infusions urine output improved leading to discontinuation dialysis. The diagnoses of STEC infection and thrombocytopenic thrombotic purpura were ruled out. Factor B, H, I and properdin levels were normal. Antibodies against CFH negative were negative. Screening for genes causative of aHUS detected a heterozygous variant in CFHR3 of uncertain significance. On day 20, treatment was switched to eculizumab, which induced a progressive remission of the NS. This case outlines the need for a heightened diagnosis suspicion of this already rare disease since early initiation of eculizumab therapy improves its prognosis.
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Affiliation(s)
- Sandra M Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Barcelona, España, Argentina
| | - Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Barcelona, España, Argentina
| | - Iris Puyol
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Barcelona, España, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Barcelona, España, Argentina
| | - Gabriel Cao
- Division of Pathology, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gema Arizeta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universidad Autónoma de Barcelona, Passeig de la Vall d'Hebron 119, Barcelona, España, Argentina
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IgA nephropathy and atypical hemolytic uremic syndrome: a case series and a literature review. J Nephrol 2021; 35:1091-1100. [PMID: 34757577 DOI: 10.1007/s40620-021-01189-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) has been anecdotally reported in association with atypical hemolytic uremic syndrome (aHUS). The association likely portends poor renal outcome, and the possible relationship with complement overactivation has yet to be elucidated. We evaluated a series of IgAN patients with aHUS and reviewed the available literature. METHODS Adult patients who received a diagnosis of IgAN and developed aHUS between January 2009 and December 2019 were included in this retrospective review. RESULTS We identified six IgAN-aHUS patients, all of whom developed end-stage kidney disease. At aHUS presentation all patients had decreased serum C3 levels. Predisposing pathogenetic variants and risk haplotypes for aHUS in CFH gene heterozygosity were documented in four out of six patients. Anti-CFH antibodies were found to be negative in the five tested patients. In the literature we identified 21 case reports involving aHUS-IgAN and six retrospective studies evaluating the presence of TMA at the time of renal biopsy. Hypertension, severe proteinuria, reduced sC3 and a worse renal prognosis were the common features of most cases. CONCLUSION Our case series and literature review show that the onset of either aHUS or renal TMA in the course of IgAN are associated with very poor renal outcome. Activation of the alternative pathway revealed by consumption of serum C3 seems to play a major role. Our hypothesis is that the presence of a predisposing factor (e.g. dysregualtion of complement alternative pathway and/or other intrarenal precipitating factors) might be at the heart of aHUS-IgAN pathophysiology.
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Thrombotic microangiopathy triggered by podocytopathy. Clin Nephrol Case Stud 2021; 9:110-116. [PMID: 34646728 PMCID: PMC8507413 DOI: 10.5414/cncs110534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare group of diseases characterized by microangiopathic hemolytic anemia, thrombocytopenia, and target organ damage. It can be divided into primary and secondary TMA. Herein we report a case of TMA associated to a primary glomerular disease. We report the case of a 31-year-old Black male from Cape Verde admitted in March 2018 with nephrotic syndrome and upper gastrointestinal bleeding, the latter due to severe erythematous gastritis. He was discharged after clinical stabilization. The patient came to Portugal 8 months later. On admission, he presented with rapid deterioration of kidney function and hyperkalemia. The etiologic study revealed microangiopathic hemolytic anemia, nephrotic syndrome and microscopic hematuria. Immunologic study and viral serology were negative. ADAMTS13 activity and inhibitor testing were within normal range, genetic complement evaluation showed CFH-H3 in homozygosity, functional complement studies revealed decreased function of alternative pathway. Kidney biopsy was consistent with the diagnosis of TMA, and electron microscopy was compatible with minimal change disease. Patient underwent plasmapheresis with resolution of hemolysis, fluid overload and recovery of renal function. Two months later, he presented with nephrotic syndrome and started prednisolone with remission. Six months later, the nephrotic syndrome relapsed, and it became steroid-, MMF-, and rituximab-resistant. Tacrolimus was initiated, achieving partial remission. Atypical hemolytic uremic syndrome is an uncommon disease and is rarely reported as secondary to glomerular diseases. This case showcases the challenges regarding treatment options in a resistant glomerulopathy and the implications of therapeutic choices and kidney outcomes with the coexisting TMA.
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12
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Rosa-Guerrero P, Leiva-Cepas F, Agüera-Morales M, Navarro-Cabello MD, Rodríguez-Benot A, Torres-De-Rueda A. First Report in the Literature of Biopsy-Proven Noncollapsing Focal Segmental Glomerulosclerosis Relapse in a Second Renal Transplant Presenting With Thrombotic Microangiopathy: A Case Report. Transplant Proc 2021; 53:2747-2750. [PMID: 34627595 DOI: 10.1016/j.transproceed.2021.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
Primary focal segmental glomerulosclerosis (FSGS) is a podocytopathy with an irregular response to immunosuppressive therapies. FSGS relapse occurs in 30% to 80% of kidney grafts, and poor survival outcomes include large proteinuria and the nephrotic syndrome's cardinal clinical features. Thrombotic microangiopathy (TMA) is caused by endothelial injury due to complement dysregulation including acute kidney injury, proteinuria, and severe hypertension common renal presentations. Both pathologies have well-described genetic forms, but their relationship remains uncertain. FSGS lesions can be found in kidney biopsy specimens in patients with TMA, and TMA has been reported in patients with collapsing glomerulopathy. However, this combination has not been clearly described in renal transplant recipients. We present the case of a 22-year-old man who received his second kidney allograft and developed an early graft disfunction with nephrotic syndrome and clinical TMA. His background was remarkable for primary, biopsy-confirmed FSGS in childhood, and he started hemodialysis in 2006 and received a living donor kidney graft the same year. He presented with a FSGS relapse with malignant hypertension and seizures in the first posttransplant month and had an irregular response to plasma exchange and rituximab, and dialysis was reinitiated 10 years later. A total of 3 biopsies were performed after his second kidney transplant showing the evolution of a FSGS relapse with histologic and clinical TMA in the absence of identified genetic mutations. Partial responses to treatments with plasma exchange, eculizumab, and rituximab were obtained, but the allograft was lost after 26 months. This case is the first report of concomitant FSGS and TMA in a renal transplant recipient.
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Affiliation(s)
- Pedro Rosa-Guerrero
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain.
| | - Fernando Leiva-Cepas
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Pathology, Reina Sofía University Hospital, Córdoba, Spain
| | - Marisa Agüera-Morales
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| | - María Dolores Navarro-Cabello
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| | - Alberto Rodríguez-Benot
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain
| | - Alvaro Torres-De-Rueda
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Cordoba, Córdoba, Spain; Department of Nephrology, Reina Sofía University Hospital, Córdoba, Spain; Asociación Medicina e Investigación (AMI), Córdoba, Spain
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13
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Su CF, Liao HT, Tsai CY. WT1 gene mutations in systemic lupus erythematosus with atypical haemolytic uremic syndrome. Rheumatology (Oxford) 2021; 60:e81-e82. [PMID: 32893307 DOI: 10.1093/rheumatology/keaa474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Chin-Fang Su
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsien-Tzung Liao
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chang-Youh Tsai
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang-Ming University, Taipei, Taiwan
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14
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Hu YF, Tan Y, Yu XJ, Wang H, Wang SX, Yu F, Zhao MH. Podocyte Involvement in Renal Thrombotic Microangiopathy: A Clinicopathological Study. Am J Nephrol 2020; 51:752-760. [PMID: 32862175 DOI: 10.1159/000510141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The current study aimed to evaluate the associations between podocyte injury and clinicopathological features in renal thrombotic microangiopathy (TMA) based on a Chinese cohort, which might be underscored in this disease. METHODS The clinical, laboratory, and renal histopathological data of patients with renal biopsy-proven TMA from 2000 to 2015 in our institute were collected. Foot process effacement (FPE) was quantified by foot process width (FPW) by electron microscopy. Podocytes in the renal specimens were also detected by stainings for podocyte-specific markers, including Wilms tumor 1 (WT-1), synaptopodin, and podocalyxin. The associations between FPW and clinico-histopathological data were further analyzed. A composite end-point was defined by all-cause death or end-stage renal disease to address the predictive value of FPW. RESULTS Sixty-three patients with renal biopsy-proven TMA were enrolled. The FPW of renal TMA patients was 1,090 ± 637 nm (range, 572-4,748 nm), which was significantly higher than the normal range in our center (p = 0.005). By immunohistochemistry and immunofluorescence assays, we found decreased expressions of synaptopodin, podocalyxin, and WT-1 and continued stainings of WT-1 in some podocytes without detectable synaptopodin stainings in the areas of sclerotic tufts and cellular crescents. The FPW value was correlated with the serum albumin concentration (rs = -0.281, p = 0.026), proteinuria amount (rs = 0.255, p = 0.047), serum creatinine levels (rs = 0.339, p = 0.007), and eGFR (rs = -0.335, p = 0.007). According to ROC curve analysis, the optimal cutoff level of FPW for predicting the composite end-point was 869 nm. In patients with FPW ≥ 869 nm, FPW levels were further correlated with the severity of mesangiolysis (rs = 0.351, p = 0.033) and glomerulosclerosis (rs = 0.369, p = 0.025) in pathological evaluations. Patients without clinical remission also had higher FPW than those with remission (1,240 ± 793 vs. 925 ± 344 nm, p = 0.013). The multivariate Cox hazard model showed that FPW ≥ 869 nm was an independent risk factor for the composite end-point (hazard ratio: 3.64, 95% CI: 1.37-9.66, p = 0.009). CONCLUSION The podocyte injury was prevalent and the FPW levels were closely associated with clinicopathological features, especially prognosis, in renal TMA patients.
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Affiliation(s)
- Yi-Fang Hu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Department of Electron Microscopy, Peking University First Hospital, Beijing, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Department of Electron Microscopy, Peking University First Hospital, Beijing, China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,
- Institute of Nephrology, Peking University, Beijing, China,
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China,
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China,
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China,
- Department of Nephrology, Peking University International Hospital, Beijing, China,
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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15
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Gholizad-Kolveiri S, Hooman N, Alizadeh R, Hoseini R, Otukesh H, Talebi S, Akouchekian M. Whole exome sequencing revealed a novel homozygous variant in the DGKE catalytic domain: a case report of familial hemolytic uremic syndrome. BMC MEDICAL GENETICS 2020; 21:169. [PMID: 32838746 PMCID: PMC7446132 DOI: 10.1186/s12881-020-01097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 07/28/2020] [Indexed: 11/13/2022]
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by microangiopathic hemolytic anemia caused by small vessel thrombosis, thrombocytopenia, and renal failure. The common cause of aHUS is a dysregulation in the alternative complement pathway. Mutations in none complement genes such as diacylglycerol kinase epsilon (DGKE) can also result in this syndrome. Case presentation Here, we report on a 19-year-old female with the clinical diagnosis of aHUS, who has unaffected consanguineous parents and an older sibling who was deceased from aHUS when she was seven months old. We performed whole exome sequencing (WES) followed by evaluation of detected variants for functional significance, using several online prediction tools. Next, in order to confirm the detected pathogenic variant in proband and segregation analysis in her family, Sanger sequencing was done. The novel variant was analyzed in terms of its impact on the protein 3-dimensional structure by computational structural modeling. The results revealed that the proband carried a novel homozygous missense variant in DGKE located in exon 6 of the gene (NM_003647.3, c.942C > G [p.Asn314Lys]), and in silico analysis anticipated it as damaging. Protein computational study confirmed the influence of potential pathogenic variant on structural stability and protein function. Conclusion We suggest that some variations in the catalytic domain of DGKE like p.Asn314Lys which can cause alterations in secondary and 3-D structure of protein, might lead to aHUS.
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Affiliation(s)
- Soraya Gholizad-Kolveiri
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran
| | - Nakysa Hooman
- Department of Pediatric Nephrology, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Alizadeh
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran
| | - Rozita Hoseini
- Department of Pediatric Nephrology, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Otukesh
- Department of Pediatric Nephrology, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Talebi
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran.
| | - Mansoureh Akouchekian
- Department of Medical Genetics and Molecular Biology, school of medicine, Iran University of Medical Sciences, P.O.Box: 1449614525, Tehran, Iran.
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16
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Matsuoka D, Noda S, Kamiya M, Hidaka Y, Shimojo H, Yamada Y, Miyamoto T, Nozu K, Iijima K, Tsukaguchi H. Immune-complex glomerulonephritis with a membranoproliferative pattern in Frasier syndrome: a case report and review of the literature. BMC Nephrol 2020; 21:362. [PMID: 32838737 PMCID: PMC7446187 DOI: 10.1186/s12882-020-02007-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background Mutations in the Wilms tumor 1 gene cause a spectrum of podocytopathy ranging from diffuse mesangial sclerosis to focal segmental glomerulosclerosis. In a considerable fraction of patients with Wilms tumor 1 mutations, the distinctive histology of immune-complex-type glomerulonephritis has been reported. However, the clinical relevance and etiologic mechanisms remain unknown. Case presentation A 5-year-old child presented with steroid-resistant nephrotic range proteinuria. Initial renal biopsy revealed predominant diffuse mesangial proliferation with a double-contour and coexisting milder changes of focal segmental glomerulosclerosis. Immunofluorescence and electron microscopy revealed a full-house-pattern deposition of immune complexes in the subendothelial and paramesangial areas. Serial biopsies at 6 and 8 years of age revealed that more remarkable changes of focal segmental glomerulosclerosis had developed on top of the initial proliferative glomerulonephritis. Identification of a de novo Wilms tumor 1 splice donor-site mutation in intron 9 (NM_024426.6:c.1447 + 4C > T) and 46,XY-gonadal dysgenesis led to the diagnosis of Frasier syndrome. Conclusions Our findings, together with those of others, point to the importance of heterogeneity in clinicopathological phenotypes caused by Wilms tumor 1 mutations and suggest that immune-complex-mediated membranoproliferative glomerulopathy should be considered as a histological variant.
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Affiliation(s)
- Daisuke Matsuoka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shunsuke Noda
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Pediatrics, Nagano Red Cross Hospital, Nagano, Japan
| | - Motoko Kamiya
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan.,Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Yoshihiko Hidaka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | | | - Yasushi Yamada
- Department of Obstetrics and Gynecology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsutomu Miyamoto
- Department of Obstetrics and Gynecology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyasu Tsukaguchi
- Second Department of Internal Medicine, Division of Nephrology, Kansai Medical University, 2-5-1 Shinmachi Hirakata, Osaka, 573-1191, Japan.
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17
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Caravaca-Fontán F, Díaz-Encarnación MM, Lucientes L, Cavero T, Cabello V, Ariceta G, Quintana LF, Marco H, Barros X, Ramos N, Rodríguez-Mendiola N, Cruz S, Fernández-Juárez G, Rodríguez A, Pérez de José A, Rabasco C, Rodado R, Fernández L, Pérez Gómez V, Ávila AI, Bravo L, Lumbreras J, Allende N, Sanchez de la Nieta MD, Rodríguez E, Olea T, Melgosa M, Huerta A, Miquel R, Mon C, Fraga G, de Lorenzo A, Draibe J, Cano-Megías M, González F, Shabaka A, López-Rubio ME, Fenollosa MÁ, Martín-Penagos L, Da Silva I, Alonso Titos J, Rodríguez de Córdoba S, Goicoechea de Jorge E, Praga M. Mycophenolate Mofetil in C3 Glomerulopathy and Pathogenic Drivers of the Disease. Clin J Am Soc Nephrol 2020; 15:1287-1298. [PMID: 32816888 PMCID: PMC7480558 DOI: 10.2215/cjn.15241219] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 05/26/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES C3 glomerulopathy is a complement-mediated disease arising from abnormalities in complement genes and/or antibodies against complement components. Previous studies showed that treatment with corticosteroids plus mycophenolate mofetil (MMF) was associated with improved outcomes, although the genetic profile of these patients was not systematically analyzed. This study aims to analyze the main determinants of disease progression and response to this therapeutic regimen. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective, multicenter, observational cohort study in 35 nephrology departments belonging to the Spanish Group for the Study of Glomerular Diseases. Patients diagnosed with C3 glomerulopathy (n=81) or dense deposit disease (n=16) between January 1995 and March 2018 were enrolled. Multivariable and propensity score matching analyses were used to evaluate the association of clinical and genetic factors with response to treatment with corticosteroids and MMF as measured by proportion of patients with disease remission and kidney survival (status free of kidney failure). RESULTS The study group comprised 97 patients (84% C3 glomerulopathy, 16% dense deposit disease). Forty-two patients were treated with corticosteroids plus MMF, and this treatment was associated with a higher rate of remission and lower probability of kidney failure (79% and 14%, respectively) compared with patients treated with other immunosuppressives (24% and 59%, respectively), or ecluzimab (33% and 67%, respectively), or conservative management (18% and 65%, respectively). The therapeutic superiority of corticosteroids plus MMF was observed both in patients with complement abnormalities and with autoantibodies. However, patients with pathogenic variants in complement genes only achieved partial remission, whereas complete remissions were common among patients with autoantibody-mediated forms. The main determinant of no remission was baseline proteinuria. Relapses occurred after treatment discontinuation in 33% of the patients who had achieved remission with corticosteroids plus MMF, and a longer treatment length of MMF was associated with a lower risk of relapse. CONCLUSIONS The beneficial response to corticosteroids plus MMF treatment in C3 glomerulopathy appears independent of the pathogenic drivers analyzed in this study.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Laura Lucientes
- Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Teresa Cavero
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Universitat de Barcelona,Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR); Institut d'Investigacions Biomediques August Pi I Sunyer, Barcelona, Spain
| | - Helena Marco
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitario Doctor Josep Trueta, Gerona, Spain
| | - Natalia Ramos
- Department of Nephrology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Sonia Cruz
- Department of Nephrology, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - Gema Fernández-Juárez
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Adela Rodríguez
- Department of Pediatric Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Pérez de José
- Department of Nephrology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Raquel Rodado
- Department of Nephrology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Loreto Fernández
- Department of Nephrology, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Vanessa Pérez Gómez
- Department of Nephrology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Ana I Ávila
- Department of Nephrology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Luis Bravo
- Department of Nephrology, Hospital Universitario A Coruña, La Coruña, Spain
| | - Javier Lumbreras
- Pediatric Nephrology Unit, Hospital Universitario Son Espases, Balearic Islands Health Research Institute, Palma de Mallorca, Spain
| | - Natalia Allende
- Department of Nephrology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Eva Rodríguez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Teresa Olea
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Marta Melgosa
- Department of Pediatric Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Rosa Miquel
- Department of Nephrology, Hospital Universitario Canarias, Tenerife, Spain
| | - Carmen Mon
- Department of Nephrology, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Gloria Fraga
- Department of Pediatric Nephrology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto de Lorenzo
- Department of Nephrology, Hospital Universitario de Getafe, Madrid, Spain
| | - Juliana Draibe
- Department of Nephrology, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Marta Cano-Megías
- Department of Nephrology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Fayna González
- Department of Nephrology, Hospital Doctor Negrín, Gran Canaria, Spain
| | - Amir Shabaka
- Department of Nephrology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | - Luis Martín-Penagos
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Iara Da Silva
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | - Juana Alonso Titos
- Department of Nephrology, Hospital Regional Universitario Carlos Haya, Málaga, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Madrid and Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Elena Goicoechea de Jorge
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain.,Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Madrid and Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain .,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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18
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Mühlig AK, Keir LS, Abt JC, Heidelbach HS, Horton R, Welsh GI, Meyer-Schwesinger C, Licht C, Coward RJ, Fester L, Saleem MA, Oh J. Podocytes Produce and Secrete Functional Complement C3 and Complement Factor H. Front Immunol 2020; 11:1833. [PMID: 32922395 PMCID: PMC7457071 DOI: 10.3389/fimmu.2020.01833] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/08/2020] [Indexed: 12/20/2022] Open
Abstract
Podocytes are an important part of the glomerular filtration barrier and the key player in the development of proteinuria, which is an early feature of complement mediated renal diseases. Complement factors are mainly liver-born and present in circulation. Nevertheless, there is a growing body of evidence for additional sites of complement protein synthesis, including various cell types in the kidney. We hypothesized that podocytes are able to produce complement components and contribute to the local balance of complement activation and regulation. To investigate the relevant balance between inhibiting and activating sides, our studies focused on complement factor H (CFH), an important complement regulator, and on C3, the early key component for complement activation. We characterized human cultured podocytes for the expression and secretion of activating and regulating complement factors, and analyzed the secretion pathway and functional activity. We studied glomerular CFH and C3 expression in puromycin aminonucleoside (PAN) -treated rats, a model for proteinuria, and the physiological mRNA-expression of both factors in murine kidneys. We found, that C3 and CFH were expressed in cultured podocytes and expression levels differed from those in cultivated glomerular endothelial cells. The process of secretion in podocytes was stimulated with interferon gamma and located in the Golgi apparatus. Cultured podocytes could initiate the complement cascade by the splitting of C3, which can be shown by the generation of C3a, a functional C3 split product. C3 contributed to external complement activation. Podocyte-secreted CFH, in conjunction with factor I, was able to split C3b. Podocytes derived from a patient with a CFH mutation displayed impaired cell surface complement regulation. CFH and C3 were synthesized in podocytes of healthy C57Bl/6-mice and were upregulated in podocytes of PAN treated rats. These data show that podocytes produce functionally active complement components, and could therefore influence the local glomerular complement activation and regulation. This modulating effect should therefore be considered in all diseases where glomerular complement activation occurs. Furthermore, our data indicate a potential novel role of podocytes in the innate immune system.
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Affiliation(s)
- Anne K. Mühlig
- University Children's Research@Kinder-UKE, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lindsay S. Keir
- Bristol Renal and Children's Renal Unit, University of Bristol, Bristol, United Kingdom
| | - Jana C. Abt
- Department of Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannah S. Heidelbach
- Department of Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rachel Horton
- Bristol Renal and Children's Renal Unit, University of Bristol, Bristol, United Kingdom
| | - Gavin I. Welsh
- Bristol Renal and Children's Renal Unit, University of Bristol, Bristol, United Kingdom
| | - Catherine Meyer-Schwesinger
- Center of Experimental Medicine, Institute of Cellular and Integrative Physiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Licht
- Division of Pediatric Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Richard J. Coward
- Bristol Renal and Children's Renal Unit, University of Bristol, Bristol, United Kingdom
| | - Lars Fester
- Department of Neuroanatomy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute for Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Moin A. Saleem
- Bristol Renal and Children's Renal Unit, University of Bristol, Bristol, United Kingdom
| | - Jun Oh
- University Children's Research@Kinder-UKE, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Pediatric Nephrology, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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19
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Bezdíčka M, Pavlíček P, Bláhová K, Háček J, Zieg J. Various phenotypes of disease associated with mutated DGKE gene. Eur J Med Genet 2020; 63:103953. [PMID: 32413569 DOI: 10.1016/j.ejmg.2020.103953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/31/2020] [Accepted: 05/09/2020] [Indexed: 01/22/2023]
Abstract
Atypical haemolytic uraemic syndrome and steroid-resistant nephrotic syndrome are highly rare kidney diseases that can occur in childhood. In some cases, genetic variants may trigger these conditions, although in atypical haemolytic uraemic syndrome they mostly confer only a predisposition to the disease. Most variants causing atypical haemolytic uraemic syndrome were identified in genes encoding proteins regulating the complement pathway; on the other hand, there are approximately 58 genes encoding distinct proteins primarily causing steroid-resistant nephrotic syndrome. We present a child with steroid-resistant nephrotic syndrome and a confirmed homozygous c.966G > A, p.Trp322Ter pathogenic variant in DGKE. This variant was also found in compound with a novel DGKE heterozygous deletion c.171delG, p.Ser58Alafs*111 in a patient from our paediatric cohort with atypical haemolytic uraemic syndrome. Both cases presented with hypertension, nephrotic proteinuria and severe acute kidney injury followed by renal recovery; however, their renal histology was different. In this paper, we deal with the clinical course of children with disrupted DGKE, including the steroid-resistant nephrotic syndrome and atypical haemolytic uraemic syndrome overlap.
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Affiliation(s)
- Martin Bezdíčka
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Petr Pavlíček
- Department of Anaesthesiology and Intensive Care, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Květa Bláhová
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Jaromír Háček
- Department of Pathology and Molecular Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - Jakub Zieg
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06, Prague 5, Czech Republic.
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20
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Cheng C, Chen L, Wen S, Lin Z, Jiang X. Case Report: Denys-Drash Syndrome With WT1 Causative Variant Presenting as Atypical Hemolytic Uremic Syndrome. Front Pediatr 2020; 8:605889. [PMID: 33392118 PMCID: PMC7775732 DOI: 10.3389/fped.2020.605889] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/03/2020] [Indexed: 01/04/2023] Open
Abstract
The WT1 variant is confirmed to be pathogenic for Denys-Drash syndrome (DDS), a rare disorder characterized by early-onset nephrotic syndrome and renal failure, pseudo-hermaphroditism, and a high risk of Wilms' tumor. Several cases of DDS presenting with atypical hemolytic uremic syndrome (aHUS) have been reported. Here we report the case of a 2-year-old child who was diagnosed with WT1 missense variant, associated with DDS and initial presentation of aHUS. Complement factor H autoantibodies were negative. Complement regulatory system-related gene variants were not found, but a de novo heterozygous c.754G>A missense variant in exon 9 of WT1 gene was detected, resulting in a p. Asp252Asn substitution, by next-generation sequencing. The patient was a female morphologically but proved to be a genetic male because of karyotype 46, XY with normally developed female external genitalia. Bilateral nephrectomy and renal transplantation were performed 1 year later, and there was no recurrence of aHUS at 10 months after transplantation.
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Affiliation(s)
- Cheng Cheng
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lizhi Chen
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sijia Wen
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhilang Lin
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoyun Jiang
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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21
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Berger BE. Atypical hemolytic uremic syndrome: a syndrome in need of clarity. Clin Kidney J 2019; 12:338-347. [PMID: 31198222 PMCID: PMC6543964 DOI: 10.1093/ckj/sfy066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Indexed: 12/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) originally understood to be limited to renal and hematopoietic involvement. Whereas aberrations in complement regulatory proteins (CRPs), C3 or complement factor B (CFB) are detected in ∼60% of patients, a complement-derived pathogenesis that reflects dysregulation of the alternative pathway (AP) of complement activation is present in ∼90% of patients. aHUS remains a diagnosis of exclusion. The discovery of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) and its utility in the diagnosis of thrombotic thrombocytopenic purpura (TTP) has resulted in the appreciation that cases of aHUS have been inappropriately diagnosed as TTP. Thus there has been an evolving appreciation of clinical manifestations of aHUS that renders the appellation aHUS misleading. This article will review the pathogenesis and the evolving clinical presentations of aHUS, present a hypothesis that there can be a phenotypic expression of aHUS due to a complement storm in a disorder where direct endothelial damage occurs and discuss future areas of research to more clearly define the clinical spectrum and management of aHUS.
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Affiliation(s)
- Bruce E Berger
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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22
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Neave L, Gale DP, Cheesman S, Shah R, Scully M. Atypical haemolytic uraemic syndrome in the eculizumab era: presentation, response to treatment and evaluation of an eculizumab withdrawal strategy. Br J Haematol 2019; 186:113-124. [PMID: 30916388 DOI: 10.1111/bjh.15899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/05/2019] [Indexed: 12/11/2022]
Abstract
The complement inhibitor, eculizumab, has revolutionised the management of atypical haemolytic uraemic syndrome (aHUS), although the optimum treatment duration is debated. Twenty-two cases of acute aHUS managed with eculizumab were retrospectively reviewed, including outcomes after eculizumab withdrawal. Although 41% had an associated complement genetic abnormality, mutation status did not affect severity of clinical presentation. Sixty-four percent required renal replacement acutely, with a high incidence of nephrotic range proteinuria (47%). Eculizumab followed a median of 6 days of plasma exchange. After a median duration of therapy of 11 weeks (range 1-227), haematological recovery was seen in 100%, while 81% achieved at least partial renal recovery (median increase in estimated glomerular filtration rate (eGFR) 49 ml/min/1·73 m2 ). At median duration of follow-up of 85 weeks (range 4-255), 54·5% had eGFR ≥ 60 ml/min/1·73 m2 , 27% had CKD, 14% were on dialysis, and 4·5% had died. Eculizumab was withdrawn in 59% (13/22) cases following complete haematological and renal recovery. Three of these 13 patients (23%) subsequently relapsed, with defined triggers in 2/3, but all made a full recovery with rapid resumption of eculizumab. There was a significant association between higher presenting creatinine and poorer renal outcomes. A strategy of eculizumab withdrawal in selected cases is both safe and cost effective.
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Affiliation(s)
- Lucy Neave
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Daniel P Gale
- UCL Centre for Nephrology, University College London, London, UK
| | - Simon Cheesman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Raakhee Shah
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie Scully
- Department of Haematology, UCLH, Cardiometabolic programme- NIHR UCLH/UCL BRC, London, UK
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23
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Ueda Y, Miwa T, Ito D, Kim H, Sato S, Gullipalli D, Zhou L, Golla M, Song D, Dunaief JL, Palmer MB, Song WC. Differential contribution of C5aR and C5b-9 pathways to renal thrombic microangiopathy and macrovascular thrombosis in mice carrying an atypical hemolytic syndrome-related factor H mutation. Kidney Int 2019; 96:67-79. [PMID: 30910380 PMCID: PMC10084839 DOI: 10.1016/j.kint.2019.01.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 01/24/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a form of thrombotic microangiopathy (TMA) caused by dysregulated complement activation. Clinically, aHUS is effectively treated by an anti-C5 monoclonal antibody (mAb) but whether the disease is mediated by the C5a receptor (C5aR) or C5b-9 pathway, or both, is unknown. Here we address this in a factor H mutant mouse (FHR/R) which developed complement-mediated TMA as well as macrovascular thrombosis caused by an aHUS-related factor H point mutation (mouse W1206R, corresponding to human W1183R). C5 deficiency and anti-C5 mAb treatment blocked all disease manifestations in FHR/R mice. C5aR1 gene deficiency prevented macrovascular thrombosis in various organs but did not improve survival or reduce renal TMA. Conversely, C6 or C9 deficiency significantly improved survival and markedly diminished renal TMA but did not prevent macrovascular thrombosis. Interestingly, as they aged both FHR/R C6-/- and FHR/R C9-/- mice developed glomerular disease reminiscent of C3 glomerulonephritis. Thus, C5aR and C5b-9 pathways drove different aspects of disease in FHR/R mice with the C5aR pathway being responsible for macrovascular thrombosis and chronic inflammatory injury while the C5b-9 pathway caused renal TMA. Our data provide new understanding of the pathogenesis of complement-mediated TMA and macrovascular thrombosis in FHR/R mice and suggest that C5 blockade is more effective for the treatment of aHUS than selectively targeting the C5aR or C5b-9 pathway alone.
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Affiliation(s)
- Yoshiyasu Ueda
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Takashi Miwa
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daisuke Ito
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hangsoo Kim
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sayaka Sato
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Damodar Gullipalli
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lin Zhou
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Madhu Golla
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Delu Song
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua L Dunaief
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew B Palmer
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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24
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Rubio-Navarro A, Sanchez-Niño MD, Guerrero-Hue M, García-Caballero C, Gutiérrez E, Yuste C, Sevillano Á, Praga M, Egea J, Román E, Cannata P, Ortega R, Cortegano I, de Andrés B, Gaspar ML, Cadenas S, Ortiz A, Egido J, Moreno JA. Podocytes are new cellular targets of haemoglobin-mediated renal damage. J Pathol 2018; 244:296-310. [PMID: 29205354 DOI: 10.1002/path.5011] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/27/2017] [Accepted: 11/21/2017] [Indexed: 01/02/2023]
Abstract
Recurrent and massive intravascular haemolysis induces proteinuria, glomerulosclerosis, and progressive impairment of renal function, suggesting podocyte injury. However, the effects of haemoglobin (Hb) on podocytes remain unexplored. Our results show that cultured human podocytes or podocytes isolated from murine glomeruli bound and endocytosed Hb through the megalin-cubilin receptor system, thus resulting in increased intracellular Hb catabolism, oxidative stress, activation of the intrinsic apoptosis pathway, and altered podocyte morphology, with decreased expression of the slit diaphragm proteins nephrin and synaptopodin. Hb uptake activated nuclear factor erythroid-2-related factor 2 (Nrf2) and induced expression of the Nrf2-related antioxidant proteins haem oxygenase-1 (HO-1) and ferritin. Nrf2 activation and Hb staining was observed in podocytes of mice with intravascular haemolysis. These mice developed proteinuria and showed podocyte injury, characterized by foot process effacement, decreased synaptopodin and nephrin expression, and podocyte apoptosis. These pathological effects were enhanced in Nrf2-deficient mice, whereas Nrf2 activation with sulphoraphane protected podocytes against Hb toxicity both in vivo and in vitro. Supporting the translational significance of our findings, we observed podocyte damage and podocytes stained for Hb, HO-1, ferritin and phosphorylated Nrf2 in renal sections and urinary sediments of patients with massive intravascular haemolysis, such as atypical haemolytic uraemic syndrome and paroxysmal nocturnal haemoglobinuria. In conclusion, podocytes take up Hb both in vitro and during intravascular haemolysis, promoting oxidative stress, podocyte dysfunction, and apoptosis. Nrf2 may be a potential therapeutic target to prevent loss of renal function in patients with intravascular haemolysis. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Alfonso Rubio-Navarro
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Maria Dolores Sanchez-Niño
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain.,Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Melania Guerrero-Hue
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Cristina García-Caballero
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Eduardo Gutiérrez
- Red de Investigación Renal (REDINREN), Madrid, Spain.,Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Claudia Yuste
- Red de Investigación Renal (REDINREN), Madrid, Spain.,Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Ángel Sevillano
- Red de Investigación Renal (REDINREN), Madrid, Spain.,Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Red de Investigación Renal (REDINREN), Madrid, Spain.,Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Javier Egea
- Instituto de Investigación Sanitaria-Hospital Universitario de la Princesa, Madrid, Spain.,Instituto Teófilo Hernando, Department of Pharmacology and Therapeutics, Medicine Faculty, Autónoma University, Madrid, Spain
| | - Elena Román
- Paediatric Nephrology Department, La Fe Hospital, Valencia, Spain
| | - Pablo Cannata
- Red de Investigación Renal (REDINREN), Madrid, Spain.,Pathology Department, Fundación Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Rosa Ortega
- Pathology Department, Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Isabel Cortegano
- Immunology Department, Centro Nacional de Microbiología, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Belén de Andrés
- Immunology Department, Centro Nacional de Microbiología, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - María Luisa Gaspar
- Immunology Department, Centro Nacional de Microbiología, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Susana Cadenas
- Centro de Biología Molecular 'Severo Ochoa' and Molecular Biology Department, Autónoma University, Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Alberto Ortiz
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain.,Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Jesús Egido
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain.,Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
| | - Juan Antonio Moreno
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
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25
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Guerrero-Hue M, Rubio-Navarro A, Sevillano Á, Yuste C, Gutiérrez E, Palomino-Antolín A, Román E, Praga M, Egido J, Moreno JA. Efectos adversos de la acumulación renal de hemoproteínas. Nuevas herramientas terapéuticas. Nefrologia 2018; 38:13-26. [DOI: 10.1016/j.nefro.2017.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/21/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022] Open
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26
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Bowen EE, Coward RJ. Advances in our understanding of the pathogenesis of hemolytic uremic syndromes. Am J Physiol Renal Physiol 2017; 314:F454-F461. [PMID: 29167171 DOI: 10.1152/ajprenal.00376.2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is major global health care issue as it is the leading cause of acute kidney injury in children. It is a triad of acute kidney injury, microangiopathic hemolytic anemia, and thrombocytopenia. In recent years, major advances in our understanding of complement-driven inherited rare forms of HUS have been achieved. However, in children 90% of cases of HUS are associated with a Shiga toxin-producing enteric pathogen. The precise pathological mechanisms in this setting are yet to be elucidated. The purpose of this review is to discuss advances in our understanding of the pathophysiology underlying HUS and identify the key questions yet to be answered by the scientific community.
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Affiliation(s)
- E E Bowen
- Academic Renal Unit, School of Clinical Sciences, University of Bristol , Bristol , United Kingdom
| | - R J Coward
- Academic Renal Unit, School of Clinical Sciences, University of Bristol , Bristol , United Kingdom
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27
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Azukaitis K, Simkova E, Majid MA, Galiano M, Benz K, Amann K, Bockmeyer C, Gajjar R, Meyers KE, Cheong HI, Lange-Sperandio B, Jungraithmayr T, Frémeaux-Bacchi V, Bergmann C, Bereczki C, Miklaszewska M, Csuka D, Prohászka Z, Killen P, Gipson P, Sampson MG, Lemaire M, Schaefer F. The Phenotypic Spectrum of Nephropathies Associated with Mutations in Diacylglycerol Kinase ε. J Am Soc Nephrol 2017; 28:3066-3075. [PMID: 28526779 PMCID: PMC5619969 DOI: 10.1681/asn.2017010031] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/16/2017] [Indexed: 01/01/2023] Open
Abstract
The recent discovery of mutations in the gene encoding diacylglycerol kinase ε (DGKE) identified a novel pathophysiologic mechanism leading to HUS and/or MPGN. We report ten new patients from eight unrelated kindreds with DGKE nephropathy. We combined these cases with all previously published cases to characterize the phenotypic spectrum and outcomes of this new disease entity. Most patients presented with HUS accompanied by proteinuria, whereas a subset of patients exhibited clinical and histologic patterns of MPGN without TMA. We also report the first two patients with clinical and histologic HUS/MPGN overlap. DGKE-HUS typically manifested in the first year of life but was not exclusively limited to infancy, and viral triggers frequently preceded HUS episodes. We observed signs of complement activation in some patients with DGKE-HUS, but the role of complement activation remains unclear. Most patients developed a slowly progressive proteinuric nephropathy: 80% of patients did not have ESRD within 10 years of diagnosis. Many patients experienced HUS remission without specific treatment, and a few patients experienced HUS recurrence despite complete suppression of the complement pathway. Five patients received renal allografts, with no post-transplant recurrence reported. In conclusion, we did not observe a clear genotype-phenotype correlation in patients with DGKE nephropathy, suggesting additional factors mediating phenotypic heterogeneity. Furthermore, the benefits of anti-complement therapy are questionable but renal transplant may be a feasible option in the treatment of patients with this condition.
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Affiliation(s)
- Karolis Azukaitis
- Clinic of Pediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania;
| | - Eva Simkova
- Pediatric Nephrology Department, Dubai Hospital, Dubai, United Arab Emirates
| | | | | | - Kerstin Benz
- Departments of Pediatrics and Adolescent Medicine, and
| | - Kerstin Amann
- Nephropathology, Institute of Pathology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Clemens Bockmeyer
- Nephropathology, Institute of Pathology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Radha Gajjar
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin E Meyers
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hae Il Cheong
- Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Bärbel Lange-Sperandio
- Division of Pediatric Nephrology, Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | | | - Véronique Frémeaux-Bacchi
- Department of Immunology, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- Unité Mixte de Recherche en Santé 872, Centre de Recherche des Cordeliers, Paris, France
| | | | - Csaba Bereczki
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Monika Miklaszewska
- Department of Pediatric Nephrology, Jagiellonian University Medical College, Cracow, Poland
| | - Dorottya Csuka
- Third Department of Internal Medicine, Research Laboratory and George Füst Complement Diagnostic Laboratory, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- Third Department of Internal Medicine, Research Laboratory and George Füst Complement Diagnostic Laboratory, Semmelweis University, Budapest, Hungary
| | | | - Patrick Gipson
- Nephrology Division, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew G Sampson
- Nephrology Division, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Mathieu Lemaire
- Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Canada
- Department of Biochemistry, Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; and
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, Heidelberg University, Heidelberg, Germany
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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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Alge JL, Wenderfer SE, Hicks J, Bekheirnia MR, Schady DA, Kain JS, Braun MC. Hemolytic uremic syndrome as the presenting manifestation of WT1 mutation and Denys-Drash syndrome: a case report. BMC Nephrol 2017; 18:243. [PMID: 28720077 PMCID: PMC5516385 DOI: 10.1186/s12882-017-0643-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 06/27/2017] [Indexed: 11/30/2022] Open
Abstract
Background Hemolytic uremic syndrome (HUS) can occur as a primary process due to mutations in complement genes or secondary to another underlying disease. HUS sometimes occurs in the setting of glomerular diseases, and it has been described in association with Denys-Drash syndrome (DDS), which is characterized by the triad of abnormal genitourinary development; a pathognomonic glomerulopathy, diffuse mesangial sclerosis; and the development of Wilms tumor. Case presentation We report the case of a 46, XX female infant who presented with HUS and biopsy-proven thrombotic microangiopathy. Next generation sequencing of genes with known mutations causative of atypical HUS found that she was homozygous for the Complement Factor H H3 haplotype and heterozygous for a variant of unknown significance in the DGKE gene. Whole exome sequencing identified a de novo heterozygous WT1 c.1384C > T; p.R394W mutation, which is classically associated with Denys-Drash syndrome (DDS). At the time of bilateral nephrectomy five months after her initial biopsy, she had diffuse mesangial sclerosis, typical of Denys-Drash syndrome, without evidence of thrombotic microangiopathy. Conclusion This unique case highlights HUS as a rare but important manifestation of WT1 mutation and provides new insight into the genetics underlying this association.
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Affiliation(s)
- Joseph L Alge
- Baylor College of Medicine, Department of Pediatrics, Pediatrician-Scientist Training and Development Program, Houston, TX, USA.
| | - Scott E Wenderfer
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | - John Hicks
- Baylor College of Medicine, Department of Pathology and Immunology, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | - Mir Reza Bekheirnia
- Baylor College of Medicine, Department of Molecular and Human Genetics, Houston, 77030, USA
| | - Deborah A Schady
- Baylor College of Medicine, Department of Pathology and Immunology, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | | | - Michael C Braun
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
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Azoulay E, Knoebl P, Garnacho-Montero J, Rusinova K, Galstian G, Eggimann P, Abroug F, Benoit D, von Bergwelt-Baildon M, Wendon J, Scully M. Expert Statements on the Standard of Care in Critically Ill Adult Patients With Atypical Hemolytic Uremic Syndrome. Chest 2017; 152:424-434. [PMID: 28442312 DOI: 10.1016/j.chest.2017.03.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/01/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022] Open
Abstract
A typical hemolytic uremic syndrome (aHUS) presents similarly to thrombotic thrombocytopenic purpura (TTP) and other causes or conditions with thrombotic microangiopathy (TMA), such as disseminated intravascular coagulation or sepsis. Similarity in clinical presentation may hinder diagnosis and optimal treatment selection in the urgent setting in the ICU. However, there is currently no consensus on the diagnosis or treatment of aHUS for ICU specialists. This review aims to summarize available data on the diagnosis and treatment strategies of aHUS in the ICU to enhance the understanding of aHUS diagnosis and outcomes in patients managed in the ICU. To this end, a review of the recent literature (January 2009-March 2016) was performed to select the most relevant articles for ICU physicians. Based on the paucity of adult aHUS cases overall and within the ICU, no specific recommendations could be formally graded for the critical care setting. However, we recognize a core set of skills required by intensivists for diagnosing and managing patients with aHUS: recognizing thrombotic microangiopathies, differentiating aHUS from related conditions, recognizing involvement of other organ systems, understanding the pathophysiology of aHUS, knowing the diagnostic workup and relevant outcomes in critically ill patients with aHUS, and knowing the standard of care for patients with aHUS based on available data and guidelines. In conclusion, managing critically ill patients with aHUS requires basic skills that, in the absence of sufficient data from patients treated within the ICU, can be gleaned from an increasingly relevant literature outside the ICU. More data on critically ill patients with aHUS are needed to validate these conclusions within the ICU setting.
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Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Paris, France.
| | - Paul Knoebl
- Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | | | - Katerina Rusinova
- University Hospital, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | - Fekri Abroug
- Fattouma Bourguiba Teaching Hospital Monastir, Tunisia
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31
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Challis RC, Ring T, Xu Y, Wong EKS, Flossmann O, Roberts ISD, Ahmed S, Wetherall M, Salkus G, Brocklebank V, Fester J, Strain L, Wilson V, Wood KM, Marchbank KJ, Santibanez-Koref M, Goodship THJ, Kavanagh D. Thrombotic Microangiopathy in Inverted Formin 2 -Mediated Renal Disease. J Am Soc Nephrol 2017; 28:1084-1091. [PMID: 27974406 PMCID: PMC5373440 DOI: 10.1681/asn.2015101189] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 10/19/2016] [Indexed: 12/26/2022] Open
Abstract
The demonstration of impaired C regulation in the thrombotic microangiopathy (TMA) atypical hemolytic uremic syndrome (aHUS) resulted in the successful introduction of the C inhibitor eculizumab into clinical practice. C abnormalities account for approximately 50% of aHUS cases; however, mutations in the non-C gene diacylglycerol kinase-ε have been described recently in individuals not responsive to eculizumab. We report here a family in which the proposita presented with aHUS but did not respond to eculizumab. Her mother had previously presented with a post-renal transplant TMA. Both the proposita and her mother also had Charcot-Marie-Tooth disease. Using whole-exome sequencing, we identified a mutation in the inverted formin 2 gene (INF2) in the mutational hotspot for FSGS. Subsequent analysis of the Newcastle aHUS cohort identified another family with a functionally-significant mutation in INF2 In this family, renal transplantation was associated with post-transplant TMA. All individuals with INF2 mutations presenting with a TMA also had aHUS risk haplotypes, potentially accounting for the genetic pleiotropy. Identifying individuals with TMAs who may not respond to eculizumab will avoid prolonged exposure of such individuals to the infectious complications of terminal pathway C blockade.
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Affiliation(s)
- Rachel C Challis
- National Renal Complement Therapeutics Centre, Institutes of *Genetic Medicine and
| | - Troels Ring
- Department of Nephrology, Aalborg University Hospital and
| | - Yaobo Xu
- National Renal Complement Therapeutics Centre, Institutes of *Genetic Medicine and
| | - Edwin K S Wong
- National Renal Complement Therapeutics Centre, Institutes of *Genetic Medicine and
| | | | - Ian S D Roberts
- Department of Cellular Pathology, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom
| | - Saeed Ahmed
- Department of Nephrology, City Hospitals Sunderland National Health Service Foundation Trust, Sunderland, United Kingdom
| | - Michael Wetherall
- Department of Pathology, Gateshead Health National Health Service Foundation Trust, Gateshead, United Kingdom
| | - Giedrius Salkus
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Institutes of *Genetic Medicine and
| | | | - Lisa Strain
- National Renal Complement Therapeutics Centre, Northern Molecular Genetics Service and
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Northern Molecular Genetics Service and
| | - Katrina M Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Kevin J Marchbank
- Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Timothy H J Goodship
- National Renal Complement Therapeutics Centre, Institutes of *Genetic Medicine and
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Institutes of *Genetic Medicine and
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Afshar-Kharghan V. Atypical hemolytic uremic syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:217-225. [PMID: 27913483 PMCID: PMC6142509 DOI: 10.1182/asheducation-2016.1.217] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) that affects multiple organs and the kidneys in particular. aHUS can be sporadic or familial and is most commonly caused by dysregulation of the alternative complement pathway. The initial attack of aHUS can occur at any age, and is associated with a high rate of progression to end stage renal disease. Many aHUS patients relapse in the native or transplanted kidneys, and require close monitoring and long-term management. Availability of anticomplement therapy has revolutionized the management of aHUS, and can change the natural course of aHUS by inducing hematologic remission, improving or stabilizing kidney functions, and preventing graft failure. As a result, it is important to succeed in the challenging task of differentiating aHUS from other TMAs and initiate adequate treatment early during the course of disease. Considering the high cost of currently available anticomplement therapy, it is important also from a financial point of view to accurately diagnose aHUS early during the course of disease and determine the necessary length of therapy. This highlights the need for development of precise complement functional and genetic studies with rapid turnaround time.
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Renal Thrombotic Microangiopathy, Podocytopathy, and Chylous Ascites: A Hard-Nosed Diagnosis. Am J Med 2016; 129:e227-31. [PMID: 27154780 DOI: 10.1016/j.amjmed.2016.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 04/01/2016] [Accepted: 04/05/2016] [Indexed: 11/24/2022]
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Salvadori M, Rosso G. Reclassification of membranoproliferative glomerulonephritis: Identification of a new GN: C3GN. World J Nephrol 2016; 5:308-320. [PMID: 27458560 PMCID: PMC4936338 DOI: 10.5527/wjn.v5.i4.308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 03/31/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
This review revises the reclassification of the membranoproliferative glomerulonephritis (MPGN) after the consensus conference that by 2015 reclassified all the glomerulonephritis basing on etiology and pathogenesis, instead of the histomorphological aspects. After reclassification, two types of MPGN are to date recognized: The immunocomplexes mediated MPGN and the complement mediated MPGN. The latter type is more extensively described in the review either because several of these entities are completely new or because the improved knowledge of the complement cascade allowed for new diagnostic and therapeutic approaches. Overall the complement mediated MPGN are related to acquired or genetic cause. The presence of circulating auto antibodies is the principal acquired cause. Genetic wide association studies and family studies allowed to recognize genetic mutations of different types as causes of the complement dysregulation. The complement cascade is a complex phenomenon and activating factors and regulating factors should be distinguished. Genetic mutations causing abnormalities either in activating or in regulating factors have been described. The diagnosis of the complement mediated MPGN requires a complete study of all these different complement factors. As a consequence, new therapeutic approaches are becoming available. Indeed, in addition to a nonspecific treatment and to the immunosuppression that has the aim to block the auto antibodies production, the specific inhibition of complement activation is relatively new and may act either blocking the C5 convertase or the C3 convertase. The drugs acting on C3 convertase are still in different phases of clinical development and might represent drugs for the future. Overall the authors consider that one of the principal problems in finding new types of drugs are both the rarity of the disease and the consequent poor interest in the marketing and the lack of large international cooperative studies.
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The expanding phenotypic spectra of kidney diseases: insights from genetic studies. Nat Rev Nephrol 2016; 12:472-83. [PMID: 27374918 DOI: 10.1038/nrneph.2016.87] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Next-generation sequencing (NGS) has led to the identification of previously unrecognized phenotypes associated with classic kidney disease genes. In addition to improving diagnostics for genetically heterogeneous diseases and enabling a faster rate of gene discovery, NGS has enabled an expansion and redefinition of nephrogenetic disease categories. Findings from these studies raise the question of whether disease diagnoses should be made on clinical grounds, on genetic evidence or a combination thereof. Here, we discuss the major kidney disease-associated genes and gene categories for which NGS has expanded the phenotypic spectrum. For example, COL4A3-5 genes, which are classically associated with Alport syndrome, are now understood to also be involved in the aetiology of focal segmental glomerulosclerosis. DGKE, which is associated with nephrotic syndrome, is also mutated in patients with atypical haemolytic uraemic syndrome. We examine how a shared genetic background between diverse clinical phenotypes can provide insight into the function of genes and novel links with essential pathophysiological mechanisms. In addition, we consider genetic and epigenetic factors that contribute to the observed phenotypic heterogeneity of kidney diseases and discuss the challenges in the interpretation of genetic data. Finally, we discuss the implications of the expanding phenotypic spectra associated with kidney disease genes for clinical practice, genetic counselling and personalized care, and present our recommendations for the use of NGS-based tests in routine nephrology practice.
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Abstract
Biological therapeutics (biologics) that target autoimmune responses and inflammatory injury pathways have a marked beneficial impact on the management of many chronic diseases, including rheumatoid arthritis, psoriasis, inflammatory bowel disease, and ankylosing spondylitis. Accumulating data suggest that a growing number of renal diseases result from autoimmune injury - including lupus nephritis, IgA nephropathy, anti-neutrophil cytoplasmic antibody-associated glomerulonephritis, autoimmune (formerly idiopathic) membranous nephropathy, anti-glomerular basement membrane glomerulonephritis, and C3 nephropathy - and one can speculate that biologics might also be applicable to these diseases. As many autoimmune renal diseases are relatively uncommon, with long natural histories and diverse outcomes, clinical trials that aim to validate potentially useful biologics are difficult to design and/or perform. Some excellent consortia are undertaking cohort studies and clinical trials, but more multicentre international collaborations are needed to advance the introduction of new biologics to patients with autoimmune renal disorders. This Review discusses the key molecules that direct injurious inflammation and the biologics that are available to modulate them. The opportunities and challenges for the introduction of relevant biologics into treatment protocols for autoimmune renal diseases are also discussed.
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37
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Zhu J, Chaki M, Lu D, Ren C, Wang SS, Rauhauser A, Li B, Zimmerman S, Jun B, Du Y, Vadnagara K, Wang H, Elhadi S, Quigg RJ, Topham MK, Mohan C, Ozaltin F, Zhou XJ, Marciano DK, Bazan NG, Attanasio M. Loss of diacylglycerol kinase epsilon in mice causes endothelial distress and impairs glomerular Cox-2 and PGE2 production. Am J Physiol Renal Physiol 2016; 310:F895-908. [PMID: 26887830 DOI: 10.1152/ajprenal.00431.2015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 01/23/2016] [Indexed: 12/12/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a disorder characterized by microvascular occlusion that can lead to thrombocytopenia, hemolytic anemia, and glomerular damage. Complement activation is the central event in most cases of TMA. Primary forms of TMA are caused by mutations in genes encoding components of the complement or regulators of the complement cascade. Recently, we and others have described a genetic form of TMA caused by mutations in the gene diacylglycerol kinase-ε (DGKE) that encodes the lipid kinase DGKε (Lemaire M, Fremeaux-Bacchi V, Schaefer F, Choi MR, Tang WH, Le Quintrec M, Fakhouri F, Taque S, Nobili F, Martinez F, Ji WZ, Overton JD, Mane SM, Nurnberg G, Altmuller J, Thiele H, Morin D, Deschenes G, Baudouin V, Llanas B, Collard L, Majid MA, Simkova E, Nurnberg P, Rioux-Leclerc N, Moeckel GW, Gubler MC, Hwa J, Loirat C, Lifton RP. Nat Genet 45: 531-536, 2013; Ozaltin F, Li BH, Rauhauser A, An SW, Soylemezoglu O, Gonul II, Taskiran EZ, Ibsirlioglu T, Korkmaz E, Bilginer Y, Duzova A, Ozen S, Topaloglu R, Besbas N, Ashraf S, Du Y, Liang CY, Chen P, Lu DM, Vadnagara K, Arbuckle S, Lewis D, Wakeland B, Quigg RJ, Ransom RF, Wakeland EK, Topham MK, Bazan NG, Mohan C, Hildebrandt F, Bakkaloglu A, Huang CL, Attanasio M. J Am Soc Nephrol 24: 377-384, 2013). DGKε is unrelated to the complement pathway, which suggests that unidentified pathogenic mechanisms independent of complement dysregulation may result in TMA. Studying Dgke knockout mice may help to understand the pathogenesis of this disease, but no glomerular phenotype has been described in these animals so far. Here we report that Dgke null mice present subclinical microscopic anomalies of the glomerular endothelium and basal membrane that worsen with age and develop glomerular capillary occlusion when exposed to nephrotoxic serum. We found that induction of cyclooxygenase-2 and of the proangiogenic prostaglandin E2 are impaired in Dgke null kidneys and are associated with reduced expression of the antithrombotic cell adhesion molecule platelet endothelial cell adhesion molecule-1/CD31 in the glomerular endothelium. Notably, prostaglandin E2 supplementation was able to rescue motility defects of Dgke knockdown cells in vitro and to restore angiogenesis in a test in vivo. Our results unveil an unexpected role of Dgke in the induction of cyclooxygenase-2 and in the regulation of glomerular prostanoids synthesis under stress.
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Affiliation(s)
- Jili Zhu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Nephrology, Renmin Hospital, Wuhan University, Hubei, Wuhan, China
| | - Moumita Chaki
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dongmei Lu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chongyu Ren
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shan-Shan Wang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alysha Rauhauser
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Binghua Li
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Susan Zimmerman
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bokkyoo Jun
- Department of Neuroscience, Louisiana State University, New Orleans, Louisiana
| | - Yong Du
- Biomedical Engineering, University of Houston, Houston, Texas
| | - Komal Vadnagara
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hanquin Wang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute of Basic Medical Sciences, Hubei University of Medicine, Hubei, Shiyan, China
| | - Sarah Elhadi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Richard J Quigg
- Department of Medicine, University of Buffalo, Buffalo, New York
| | - Matthew K Topham
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Chandra Mohan
- Biomedical Engineering, University of Houston, Houston, Texas
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey; Nephrogenetics Laboratory, Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Xin J Zhou
- Renal Path Diagnostics, Pathologist BioMedical Laboratories and Department of Pathology, Baylor University Medical Center, Dallas, Texas; and
| | - Denise K Marciano
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicolas G Bazan
- Department of Neuroscience, Louisiana State University, New Orleans, Louisiana
| | - Massimo Attanasio
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Eugene McDermott Center for Growth and Development, The University of Texas Southwestern Medical Center, Dallas, Texas
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Angioi A, Fervenza FC, Sethi S, Zhang Y, Smith RJ, Murray D, Van Praet J, Pani A, De Vriese AS. Diagnosis of complement alternative pathway disorders. Kidney Int 2016; 89:278-88. [DOI: 10.1016/j.kint.2015.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 08/13/2015] [Accepted: 08/19/2015] [Indexed: 02/06/2023]
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