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Obata S, Hullekes F, Riella LV, Cravedi P. Recurrent complement-mediated Hemolytic uremic syndrome after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100857. [PMID: 38749097 DOI: 10.1016/j.trre.2024.100857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/16/2024]
Abstract
Hereditary forms of hemolytic uremic syndrome (HUS), formerly known as atypical HUS, typically involve mutations in genes encoding for components of the alternative pathway of complement, therefore they are often referred to as complement-mediated HUS (cHUS). This condition has a high risk of recurrence in the transplanted kidney, leading to accelerated graft loss. The availability of anti-complement component C5 antibody eculizumab has enabled successful transplantation with a notably reduced recurrence rate and improved prognosis. Open questions are related to the potential for complement inhibitor discontinuation, ideal timing of treatment withdrawal, and patient selection based on genetic abnormalities. Our review delves into the pathophysiology, classification, genetic predispositions, and management strategies for cHUS in the native and transplant kidneys.
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Affiliation(s)
- Shota Obata
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Frank Hullekes
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Paolo Cravedi
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Martin M, Llorens-Cebria C, León-Román J, Perurena-Prieto J, Perez-Beltran V, Saumell S, Torres IB, Agraz I, Sellarès J, Ramos N, Bestard O, López M, Moreso F, Ariceta G, Soler MJ, Hernandez-Gonzalez M, Jacobs-Cachá C. Ex vivo C5b-9 Deposition Test to Monitor Complement Activity in Clinical and Subclinical Atypical Hemolytic Uremic Syndrome and in Transplantation-Associated Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:2227-2239. [PMID: 39081726 PMCID: PMC11284441 DOI: 10.1016/j.ekir.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a complement system (CS)-mediated ultrarare disease that manifests as thrombotic microangiopathy (TMA) with preferential small kidney vessels involvement. Transient CS activation is also observed in secondary TMA or in patients at risk of developing aHUS. There is no gold standard test to monitor disease activity; however, the ex vivo C5b-9 deposition test seems to be a good approach. Methods We assessed the C5b-9 deposition induced by serum samples of patients with aHUS (n = 8) and with TMA associated with kidney (n = 2), lung (n = 1) or hematopoietic stem cell (HSC) transplantation (HSCT, n = 2) during the acute phase of the disease or in remission. As control for transplant-associated TMA (TA-TMA), we analyzed samples of clinically stable kidney and HSC-transplanted patients without signs of TMA. In addition, we studied 1 child with genetic risk of aHUS during an acute infection. Results In the acute disease phase or in patients with disease activity despite C5 blockade, a significant increase of C5b-9 deposition was detected. In all patients with clinical response to C5 blockade but one, levels of C5b-9 deposition were within the normal range. Finally, we detected increased C5b-9 deposition levels in an asymptomatic child with genetic risk of aHUS when a concomitant otitis episode was ongoing. Conclusion The ex vivo C5b-9 deposition test is an auspicious tool to monitor CS activity in aHUS and TA-TMA. In addition, we demonstrate that the test may be useful to detect subclinical increase of CS activity, which expands the spectrum of patients that would benefit from a better CS activity assessment.
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Affiliation(s)
- Maria Martin
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carmen Llorens-Cebria
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan León-Román
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Janire Perurena-Prieto
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Víctor Perez-Beltran
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Silvia Saumell
- Hematology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irina B. Torres
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irene Agraz
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Joana Sellarès
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Natàlia Ramos
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Bestard
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Mercedes López
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francesc Moreso
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Gema Ariceta
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Universitat Autonoma Barcelona, Barcelona, Spain
| | - Maria José Soler
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Hernandez-Gonzalez
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Conxita Jacobs-Cachá
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Biochemistry Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
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Quist SW, Postma AJ, Myrén KJ, de Jong LA, Postma MJ. Cost-effectiveness of ravulizumab compared with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria in the Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1455-1472. [PMID: 36633725 PMCID: PMC10550878 DOI: 10.1007/s10198-022-01556-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost-effectiveness of ravulizumab compared with eculizumab for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH) in the Netherlands. METHODS A cost-effectiveness analysis was conducted based on a Markov cohort model simulating the course of patients with PNH with clinical symptom(s) indicative of high disease activity, or who are clinically stable after having been treated with eculizumab for at least the past six months. Costs, quality of life, and the incremental cost-effectiveness ratio (ICER) were estimated over a lifetime horizon from a Dutch societal perspective. Several additional analyses were performed, including a one-way sensitivity analysis, a probabilistic sensitivity analysis, and scenario analysis. RESULTS When compared with eculizumab, ravulizumab saves €266,833 and 1.57 quality adjusted life years (QALYs) are gained, resulting in a dominant ICER. Drug costs account for the majority of the total costs in both intervention groups. Cost savings were driven by the difference in total treatment costs of ravulizumab compared with eculizumab caused by the reduced administration frequency, accounting for 98% of the total cost savings. The QALY gain with ravulizumab is largely attributable to the improved quality of life associated with less frequent infusions and BTH events. At a willingness-to-pay threshold of €20,000/QALY, there is a 76.6% probability that ravulizumab would be cost-effective. CONCLUSIONS The cost reduction and QALY gain associated with the lower rates of BTH and less frequent administration make ravulizumab a cost-saving and clinically beneficial substitute for eculizumab for adults with PNH in the Netherlands.
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Affiliation(s)
- S W Quist
- Asc Academics, Groningen, The Netherlands.
| | - A J Postma
- Asc Academics, Groningen, The Netherlands
| | - K J Myrén
- Alexion, AstraZeneca Rare Disease, Stockholm, Sweden
| | - L A de Jong
- Department of Health Sciences, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - M J Postma
- Department of Health Sciences, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, University of Groningen, Groningen, The Netherlands
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Pharmacological Management of Atypical Hemolytic Uremic Syndrome in Pediatric Patients: Current and Future. Paediatr Drugs 2023; 25:193-202. [PMID: 36637720 PMCID: PMC9839393 DOI: 10.1007/s40272-022-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
Atypical hemolytic uremic syndrome is a thrombotic microangiopathy characterized by hemolysis, thrombocytopenia, and acute kidney injury, usually caused by alternative complement system overactivation due to pathogenic genetic variants or antibodies to components or regulatory factors in this pathway. Previously, a lack of effective treatment for this condition was associated with mortality, end-stage kidney disease, and the risk of disease recurrence after kidney transplantation. Plasma therapy has been used for atypical hemolytic uremic syndrome treatment with inconsistent results. Complement-blocking treatment changed the outcome and prognosis of patients with atypical hemolytic uremic syndrome. Early administration of eculizumab, a monoclonal C5 antibody, leads to improvements in hematologic, kidney, and systemic manifestations in patients with atypical hemolytic uremic syndrome, even with apparent dialysis dependency. Pre- and post-transplant use of eculizumab is effective in the prevention of atypical hemolytic uremic syndrome recurrence. Evidence on eculizumab use in secondary hemolytic uremic syndrome cases is controversial. Recent data favor the restrictive use of eculizumab in carefully selected atypical hemolytic uremic syndrome cases, but close monitoring for relapse after drug discontinuation is emphasized. Prophylaxis for meningococcal infection is important. The long-acting C5 monoclonal antibody ravulizumab is now approved for atypical hemolytic uremic syndrome treatment, enabling a reduction in the dosing frequency and improving the quality of life in patients with atypical hemolytic uremic syndrome. New strategies for additional and novel complement blockage medications in atypical hemolytic uremic syndrome are under investigation.
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Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
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Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Boyer O, Niaudet P. Hemolytic-Uremic Syndrome in Children. Pediatr Clin North Am 2022; 69:1181-1197. [PMID: 36880929 DOI: 10.1016/j.pcl.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hemolytic uremic syndrome is characterized by a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Most cases are caused by Shiga-toxin-producing bacteria, especially Escherichia coli. Transmission occurs through ground beef and unpasteurized milk. STEC-HUS is the main cause of acute renal failure in children. Management remains supportive. Immediate outcome is most often. Atypical HUS represents about 5% of cases, has a relapsing course with more than half of the patients progressing to end-stage kidney failure. Most cases are due to variants in complement regulators of the alternative pathway. Complement inhibitors, such as eculizumab, have considerably improved the prognosis.
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Affiliation(s)
- Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France; Néphrologie Pédiatrique, Hôpital Necker, 149 Rue de Sèvres, Paris 75015, France
| | - Patrick Niaudet
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France.
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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A Multicenter Study Evaluating the Discontinuation of Eculizumab Therapy in Children with Atypical Hemolytic Uremic Syndrome. CHILDREN 2022; 9:children9111734. [DOI: 10.3390/children9111734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Background: Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening thrombotic microangiopathy (TMA), which has been treated successfully with eculizumab. The optimal duration of eculizumab in treating patients with aHUS remains poorly defined. Methods: We conducted a multicenter retrospective study in the Arabian Gulf region for children of less than 18 years of age who were diagnosed with aHUS and who discontinued eculizumab between June 2013 and June 2021 to assess the rate and risk factors of aHUS recurrence. Results: We analyzed 28 patients with a clinical diagnosis of aHUS who had discontinued eculizumab. The most common reason for the discontinuation of eculizumab was renal and hematological remission (71.4%), followed by negative genetic testing (28.6%). During a median follow-up period of 24 months after discontinuation, 8 patients (28.5%) experienced HUS relapse. The risk factors of recurrence were positive genetic mutations (p = 0.020). On the other hand, there was no significant relationship between the relapse and age of presentation, the need for acute dialysis, the duration of eculizumab therapy before discontinuation, or the timing of eculizumab after the presentation. Regarding the renal outcomes after discontinuation, 23 patients were in remission with normal renal function, while 4 patients had chronic kidney disease (CKD) (three of them had pre-existing chronic kidney disease (CKD) before discontinuation, and one case developed a new CKD after discontinuation) and one patient underwent transplantation. Conclusions: The discontinuation of eculizumab in patients with aHUS is not without risk; it can result in HUS recurrence. Eculizumab discontinuation can be performed with close monitoring of the patients. It is essential to assess risk the factors for relapse before eculizumab discontinuation, in particular in children with a positive complement variant and any degree of residual CKD, as HUS relapse may lead to additional loss of kidney function. Resuming eculizumab promptly after relapse is effective in most patients.
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Bouwmeester RN, Duineveld C, Wijnsma KL, Bemelman FJ, van der Heijden JW, van Wijk JA, Bouts AH, van de Wetering J, Dorresteijn E, Berger SP, Gracchi V, van Zuilen AD, Keijzer-Veen MG, de Vries AP, van Rooij RW, Engels FA, Altena W, de Wildt R, van Kempen E, Adang EM, ter Avest M, ter Heine R, Volokhina EB, van den Heuvel LP, Wetzels JF, van de Kar NC. Early Eculizumab Withdrawal in Patients With Atypical Hemolytic Uremic Syndrome in Native Kidneys Is Safe and Cost-Effective: Results of the CUREiHUS Study. Kidney Int Rep 2022; 8:91-102. [PMID: 36644349 PMCID: PMC9832049 DOI: 10.1016/j.ekir.2022.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction The introduction of eculizumab has improved the outcome in patients with atypical hemolytic uremic syndrome (aHUS). The optimal treatment strategy is debated. Here, we report the results of the CUREiHUS study, a 4-year prospective, observational study monitoring unbiased eculizumab discontinuation in Dutch patients with aHUS after 3 months of therapy. Methods All pediatric and adult patients with aHUS in native kidneys and a first-time eculizumab treatment were evaluated. In addition, an extensive cost-consequence analysis was conducted. Results A total of 21 patients were included in the study from January 2016 to October 2020. In 17 patients (81%), a complement genetic variant or antibodies against factor H were identified. All patients showed full recovery of hematological thrombotic microangiopathy (TMA) parameters after the start of eculizumab. A renal response was noted in 18 patients. After a median treatment duration of 13.6 weeks (range 2.1-43.9), eculizumab was withdrawn in all patients. During follow-up (80.7 weeks [0.0-236.9]), relapses occurred in 4 patients. Median time to first relapse was 19.5 (14.3-53.6) weeks. Eculizumab was reinitiated within 24 hours in all relapsing patients. At last follow-up, there were no chronic sequelae, i.e., no clinically relevant increase in serum creatinine (sCr), proteinuria, and/or hypertension in relapsing patients. The low sample size and event rate did not allow to determine predictors of relapse. However, relapses only occurred in patients with a likely pathogenic variant. The cost-effectiveness analysis revealed that the total medical expenses of our population were only 30% of the fictive expenses that would have been made when patients received eculizumab every fortnight. Conclusion It is safe and cost-effective to discontinue eculizumab after 3 months of therapy in patients with aHUS in native kidneys. Larger data registries are needed to determine factors associated with suboptimal kidney function recovery during eculizumab treatment, factors to predict relapses, and long-term outcomes of eculizumab discontinuation.
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Affiliation(s)
- Romy N. Bouwmeester
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands,Correspondence: Romy N. Bouwmeester, Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kioa L. Wijnsma
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Frederike J. Bemelman
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Joanna A.E. van Wijk
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Antonia H.M. Bouts
- Department of Pediatric Nephrology, Amsterdam University Medical Center, Emma Children’s Hospital, Amsterdam, the Netherlands
| | | | - Eiske Dorresteijn
- Department of Pediatric Nephrology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Stefan P. Berger
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Valentina Gracchi
- Department of Pediatric Nephrology, University Medical Center Groningen, University of Groningen, Beatrix Children’s Hospital, Groningen, the Netherlands
| | - Arjan D. van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mandy G. Keijzer-Veen
- Department of Pediatric Nephrology, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Aiko P.J. de Vries
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roos W.G. van Rooij
- Department of Pediatric Nephrology, Leiden University Medical Center, Willem-Alexander Children’s Hospital, Leiden, the Netherlands
| | - Flore A.P.T. Engels
- Department of Pediatric Nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Wim Altena
- Dutch Kidney Patient Association, Bussum, the Netherlands
| | - Renée de Wildt
- Dutch Kidney Patient Association, Bussum, the Netherlands
| | - Evy van Kempen
- Dutch Kidney Patient Association, Bussum, the Netherlands
| | - Eddy M. Adang
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Mendy ter Avest
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Rob ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Elena B. Volokhina
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Lambertus P.W.J. van den Heuvel
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Nicole C.A.J. van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
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Dunn S, Brocklebank V, Bryant A, Carnell S, Chadwick TJ, Johnson S, Kavanagh D, Lecouturier J, Malina M, Moloney E, Oluboyede Y, Weetman C, Wong EKS, Woodward L, Sheerin N. Safety and impact of eculizumab withdrawal in patients with atypical haemolytic uraemic syndrome: protocol for a multicentre, open-label, prospective, single-arm study. BMJ Open 2022; 12:e054536. [PMID: 36123058 PMCID: PMC9486193 DOI: 10.1136/bmjopen-2021-054536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/18/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Atypical haemolytic uraemic syndrome (aHUS) is a rare, life-threatening disease caused by excessive activation of part of the immune system called complement. Eculizumab is an effective treatment, controlling aHUS in 90% of patients. Due to the risk of relapse, lifelong treatment is currently recommended. Eculizumab treatment is not without problems, foremost being the risk of severe meningococcal infection, the burden of biweekly intravenous injections and the high cost.This paper describes the design of the Stopping Eculizumab Treatment Safely in aHUS trial that aims to establish whether a safety monitoring protocol, including the reintroduction of eculizumab for those who relapse, could be a safe, alternative treatment strategy for patients with aHUS. METHODS AND ANALYSIS This is a multicentre, non-randomised, open-label study of eculizumab withdrawal with continuous monitoring of thrombotic microangiopathy-related serious adverse events using the Bayes factor single-arm design. 30 patients will be recruited to withdraw from eculizumab and have regular blood and urine tests for 24 months, to monitor for disease activity. If relapse occurs, treatment will be restarted within 24 hours of presentation. 20 patients will remain on treatment and complete health economic questionnaires only. An embedded qualitative study will explore the views of participants. ETHICS AND DISSEMINATION A favourable ethical opinion and approval was obtained from the North East-Tyne & Wear South Research Ethics Committee. Outcomes will be disseminated via peer-reviewed articles and conference presentations. TRIAL REGISTRATION NUMBER EudraCT number: 2017-003916-37 and ISRCTN number: ISRCTN17503205.
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Affiliation(s)
- Sarah Dunn
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Victoria Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas J Chadwick
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jan Lecouturier
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Health Economics, Optimax Access, Newcastle upon Tyne, UK
| | - Yemi Oluboyede
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Weetman
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Edwin Kwan Soon Wong
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Len Woodward
- aHUS Alliance Global Action, Newcastle upon Tyne, UK
| | - Neil Sheerin
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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11
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Complement gene variant effect on relapse of complement-mediated thrombotic microangiopathy after eculizumab cessation. Blood Adv 2022; 7:340-350. [PMID: 35533258 PMCID: PMC9881046 DOI: 10.1182/bloodadvances.2021006416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Eculizumab is effective for complement-mediated thrombotic microangiopathy (CM-TMA), also known as atypical hemolytic uremic syndrome. Although lifelong therapy had been suggested, discontinuation does not universally lead to relapse. Comprehensive data evaluating risk factors for recurrence following discontinuation are limited. Our aim was to systematically review available literature assessing the role of complement genetic variants in this setting. Reports on CM-TMA and eculizumab withdrawal published before 1 January 2021, were included. Key reasons for patient exclusion were no follow-up after drug withdrawal and patients lacking complement genetic testing. Two-hundred eighty patients from 40 publications were included. Median age was 28 years, and 25 patients had a known history of renal transplant. Complement genetic variants were identified in 60%, most commonly in CFH (n = 59) and MCP/CD46 (n = 38). Of patients with a complement gene variant, 51.3% had ≥1 likely pathogenic/pathogenic variant whereas the remaining had variants of uncertain significance (VUS). Overall relapse rate after therapy discontinuation was 29.6%. Relapse rate was highest among patients with CFH variants and MCP/CD46 variants in canonical splice regions. VUS (P < .001) and likely pathogenic/pathogenic variants (P < .001) were associated with increased relapse. Presence of a renal allograft (P = .009); decreasing age (P = .029); and detection of variants in CFH (P < .001), MCP/CD46 (P < .001), or C3 (P < .001) were all independently associated with relapse after eculizumab discontinuation. Eculizumab discontinuation is appropriate in specific patients with CM-TMA. Caution should be exerted when attempting such a strategy in patients with high risk of recurrence, including a subgroup of patients with MCP/CD46 variants.
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12
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Vaisbich MH, de Andrade LGM, de Menezes Neves PDM, Palma LMP, de Castro MCR, Silva CAB, Barbosa MINDH, Penido MGMG, Neto OÂF, Sobral RML, Miranda SMC, de Almeida Araújo S, Pietrobom IG, Takase HM, Ribeiro C, da Silva RM, de Carvalho CAA, Machado DJB, Silva AMSTE, da Silva AR, Russo ER, Barros FHS, Nasserala JCL, de Oliveira LSC, Sylvestre LDC, Weissheimer R, Nascimento SO, Bianchini G, Barreto FDC, Veloso VSP, Fortes PM, Colares VS, Gomes JG, Leite AFP, Mesquita PGM, Vieira-Neto OM. Baseline characteristics and evolution of Brazilian patients with atypical hemolytic uremic syndrome: first report of The Brazilian aHUS Registry. Clin Kidney J 2022; 15:1601-1611. [PMID: 35892013 PMCID: PMC9308094 DOI: 10.1093/ckj/sfac097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 11/14/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare disease. Therefore, studies involving large samples are scarce, making registries powerful tools to evaluate cases. We present herein the first analysis of the Brazilian aHUS Registry (BRaHUS). Methods Analysis of clinical, laboratory, genetic and treatment data from patients inserted in the BRaHUS, from 2017 to 2020, as an initiative of the Rare Diseases Committee of the Brazilian Society of Nephrology. Results The cohort consisted of 75 patients (40 adults and 35 pediatric). There was a predominance of women (56%), median age at diagnosis of 20.7 years and a positive family history in 8% of cases. Renal involvement was observed in all cases and 37% had low C3 levels. In the <2 years of age group, males were predominant. Children presented lower levels of hemoglobin (P = .01) and platelets (P = .003), and higher levels of lactate dehydrogenase (LDH) (P = .004) than adults. Genetic analysis performed in 44% of patients revealed pathogenic variants in 66.6% of them, mainly in CFH and the CFHR1-3 deletion. Plasmapheresis was performed more often in adults (P = .005) and 97.3% of patients were treated with eculizumab and its earlier administration was associated with dialysis-free after 3 months (P = .08). Conclusions The cohort of BRaHUS was predominantly composed of female young adults, with renal involvement in all cases. Pediatric patients had lower hemoglobin and platelet levels and higher LDH levels than adults, and the most common genetic variants were identified in CFH and the CFHR1-3 deletion with no preference of age, a peculiar pattern of Brazilian patients.
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Affiliation(s)
- Maria Helena Vaisbich
- Pediatric Nephrology Service, Child Institute, University of São Paulo, São Paulo, Brazil
| | | | - Precil Diego Miranda de Menezes Neves
- Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
- Nephrology and Dialysis Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Cláudia Ribeiro
- Nephrology Center. Santa Casa de Belo Horizonte, Belo Horizonte, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Gilson Bianchini
- Nephrology Service. Federal University of Paraná. Curitiba, Brazil
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13
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Scurt FG, Morgenroth R, Bose K, Mertens PR, Chatzikyrkou C. Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management. Geburtshilfe Frauenheilkd 2022; 82:297-316. [PMID: 35250379 PMCID: PMC8893985 DOI: 10.1055/a-1666-0483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/09/2021] [Indexed: 10/29/2022] Open
Abstract
AbstractDespite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and
fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an
increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading
causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become
pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension
and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes
related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as
volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this
review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present
common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.
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Affiliation(s)
- Florian G. Scurt
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Germany
| | - Ronnie Morgenroth
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Germany
| | - Katrin Bose
- Universitätsklinik für Gastroenterologie, Hepatologie und Infektiologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Germany
| | - Peter R. Mertens
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Germany
| | - Christos Chatzikyrkou
- PHV-Dialysezentrum, Halberstadt, Germany
- Klinik für Nephrologie, Medizinische Hochschule Hannover, Hannover, Germany
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14
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Vitkauskaitė M, Vinikovas A, Miglinas M, Rimševičius L, Čerkauskaitė A, Mačionienė E, Ašakienė E. Complement inhibitor eculizumab in thrombotic microangiopathy: Single-center case series. Clin Case Rep 2022; 10:e05573. [PMID: 35317070 PMCID: PMC8922540 DOI: 10.1002/ccr3.5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Abstract
Our case series showed that eculizumab is efficacious and safe in treating thrombotic microangiopathy, as well as it has positive effects on quality of life. Further extensive studies are required to develop unified treatment guidelines.
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Affiliation(s)
| | - Artūras Vinikovas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Marius Miglinas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Laurynas Rimševičius
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Agnė Čerkauskaitė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Ernesta Mačionienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Eglė Ašakienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
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15
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Baskin E, Fidan K, Gulhan B, Gulleroglu K, Canpolat N, Yilmaz A, Parmakiz G, Ozcakar BZ, Ozaltin F, Soylemezoglu O. Eculizumab treatment and discontinuation in pediatric patients with atypical hemolytic uremic syndrome: a multicentric retrospective study. J Nephrol 2022; 35:1213-1222. [DOI: 10.1007/s40620-021-01212-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
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16
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Cugno M, Capone V, Griffini S, Grovetti E, Pintarelli G, Porcaro L, Clementi E, Ardissino G. Eculizumab treatment in atypical hemolytic uremic syndrome: correlation between functional complement tests and drug levels. J Nephrol 2022; 35:1205-1211. [PMID: 35013983 DOI: 10.1007/s40620-021-01187-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is characterized by platelet consumption, hemolysis, and renal injury. Eculizumab, a humanized antibody that blocks complement activity, has been successfully used in aHUS, but the best treatment schedule has not yet been clearly defined. METHODS Herein we report our experience with eculizumab maintenance treatment, in which the interval between subsequent doses was adjusted based on classical complement pathway (CCP) activity, targeted to < 30% for the prevention of relapses. Trough circulating levels of free eculizumab were determined by an immunoenzymatic method. Genetic and serologic characteristics of the patients were also assessed. RESULTS We report on 38 patients with aHUS with a median age of 25.0 years (range 0.5-60.0 years) treated with eculizumab. Once stable disease remission was obtained, the interval between eculizumab doses was extended based on target CCP activity. With this approach, presently, 22 patients regularly receive eculizumab infusion every 28 days and 16 receive it every 21. During a median observation period of 32.3 months (range 4.0-92.4 months) and a cumulative period of 1295 months, no patient relapsed. An inverse correlation between CCP activity and eculizumab circulating levels was present (r = - 0.690, p = 0.0001), with CCP activity being inhibited as long as free eculizumab was measurable in serum. CONCLUSIONS In patients with aHUS on eculizumab maintenance treatment, complement activity measurement can be used as a proxy for circulating levels of the drug. Monitoring complement activity allows for safe tailoring of the frequency of eculizumab administration, thus avoiding excessive drug exposure while keeping the disease in remission.
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Affiliation(s)
- Massimo Cugno
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università Degli Studi di Milano, Via Pace, 9, 20122, Milano, Italy.
| | - Valentina Capone
- Center for HUS Prevention, Control and Management at Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Samantha Griffini
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università Degli Studi di Milano, Via Pace, 9, 20122, Milano, Italy
| | - Elena Grovetti
- Medicina Interna, Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università Degli Studi di Milano, Via Pace, 9, 20122, Milano, Italy
| | - Giulia Pintarelli
- Medical Genetics Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Luigi Porcaro
- Medical Genetics Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Emilio Clementi
- Department of Biomedical and Clinical Sciences "L. Sacco", Unit of Clinical Pharmacology, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Università Degli Studi di Milano, Milano, Italy
| | - Gianluigi Ardissino
- Center for HUS Prevention, Control and Management at Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
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17
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Kamel MH, Jaberi A, Gordon CE, Beck LH, Francis J. The Complement System in the Modern Era of Kidney Transplantation: Mechanisms of Injury and Targeted Therapies. Semin Nephrol 2022; 42:14-28. [DOI: 10.1016/j.semnephrol.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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18
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Benoit SW, Fukuda T, VandenHeuvel K, Witte D, Fuller C, Willis J, Dixon BP, Drake KA. Case Report: Atypical HUS Presenting With Acute Rhabdomyolysis Highlights the Need for Individualized Eculizumab Dosing. Front Pediatr 2022; 10:841051. [PMID: 35281224 PMCID: PMC8906567 DOI: 10.3389/fped.2022.841051] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare orphan disease caused by dysregulated complement activation resulting in thrombotic microangiopathy. Although complement-mediated endothelial injury predominantly affects the renal microvasculature, extra-renal manifestations are present in a significant proportion of patients. While eculizumab has significantly improved the morbidity and mortality of this rare disease, optimizing therapeutic regimens of this highly expensive drug remains an active area of research in the treatment of aHUS. CASE PRESENTATION This report describes the case of a previously healthy 4 year-old male who presented with rhabdomyolysis preceding the development of aHUS with anuric kidney injury requiring dialysis. Clinical stabilization required increased and more frequent eculizumab doses compared with the standardized weight-based guidelines. In the maintenance phase of his disease, pharmacokinetic analysis indicated adequate eculizumab levels could be maintained with an individualized dosing regimen every 3 weeks, as opposed to standard 2 week dosing, confirmed in this patient over a 4 year follow up period. Cost analyses show that weight-based maintenance dosing costs $312,000 per year, while extending the dosing interval to every 3 weeks would cost $208,000, a savings of $104,000 per year, relative to the cost of $72,000 from more frequent eculizumab dosing during his initial hospitalization to suppress his acute disease. CONCLUSION This case exemplifies the potential of severe, multisystem involvement of aHUS presenting with extra-renal manifestations, including rhabdomyolysis as in this case, and highlights the possibility for improved clinical outcomes and higher value care with individualized eculizumab dosing in patients over the course of their disease.
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Affiliation(s)
- Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Tsuyoshi Fukuda
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Katherine VandenHeuvel
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - David Witte
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Christine Fuller
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | | | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Keri A Drake
- Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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19
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Ravulizumab: Characterization and quantitation of a new C5 inhibitor using isotype specific affinity purification and high-resolution mass spectrometry. J Mass Spectrom Adv Clin Lab 2021; 21:10-18. [PMID: 34820672 PMCID: PMC8601004 DOI: 10.1016/j.jmsacl.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Ravulizumab (RAVUL) is a new complement inhibitor, with a difference of 4 amino acids in the heavy chain from a predecessor compound, eculizumab (ECUL). Objectives First, to utilize mass spectrometry (MS) to characterize RAVUL and verify differences from its predecessor and, second, to validate and implement a lab developed test (LDT) for RAVUL that will allow for quantitative therapeutic monitoring. Methods A time-of-flight mass spectrometer (TOF-MS) was used to characterize and differentiate the molecular weight differences between RAVUL and ECUL by both digest and reduction experiments. In parallel, an LDT for RAVUL was validated and implemented utilizing IgG4 enrichment with light chain detection and quantitation on a high throughput orbitrap MS platform. Results The TOF-MS platform allowed for the mass difference between RAVUL and ECUL to be verified along with providing a proof of concept for a new intact protein quantitation software. An LDT on an orbitrap MS was validated and implemented using intact light chain quantitation, with the limitation that it cannot differentiate between ECUL and RAVUL. The LDT has an analytical measuring range from 5 to 600 mcg/mL, inter-assay imprecision of ≤13% CV (n = 13) and accuracy with <4% error from expected values (n = 20). Conclusion The TOF-MS is a versatile development platform that can be used to characterize and verify the molecular weight differences between the ECUL and RAVUL heavy chains. Routine laboratory testing for RAVUL was viable using an orbitrap-MS to quantitate using the mass of the intact light chain. These two platforms, combined, provide incomparable value in development of LDTs for the clinical laboratory.
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Key Words
- AMR, analytical measuring range
- C5, complement component 5
- DTT, dithiothreitol
- Da, daltons
- ECUL, eculizumab
- Eculizumab
- Fc, crystallizable fragment
- HPLC, high performance liquid chromatography
- IRB, Institutional Review Board
- IS, internal standard
- Intact light chain
- LC, liquid chromatography
- LDT, lab-developed test
- LLOD, lower limit of detection
- LLOQ, lower limit of quantitation
- LOB, limit of blankMS, mass spectrometry
- MW, molecular weight
- Mass spectrometry
- NHS, normal human serum
- NIVOL, nivolumab
- Orbitrap
- PBS, phosphate buffered saline
- PNH, paroxysmal nocturnal hemoglobinuria
- Q-TOF, quadrupole time-of-flight
- RAVUL, ravulizumab
- Ravulizumab
- Therapeutic monoclonal antibody
- Time of flight
- XIC, extracted ion chromatogram
- aHUS, atypical hemolytic uremic syndrome
- t-mAb, therapeutic monoclonal antibody
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20
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Hemoglobinuria for the early identification of STEC-HUS in high-risk children: data from the ItalKid-HUS Network. Eur J Pediatr 2021; 180:2791-2795. [PMID: 33759020 DOI: 10.1007/s00431-021-04016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/01/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
Hemolytic uremic syndrome (HUS) represents one of the main causes of severe acute kidney injury in children. The most frequent form of HUS is caused by Shiga toxin-2 (Stx2)-producing Escherichia coli. Hemoglobinuria and hematuria are markers of glomerular damage, but their use has never been validated in HUS. We retrospectively analyzed the presence of hemoglobinuria/urinary red blood cells (RBCs) in children with Stx2-positive bloody diarrhea (BD) or with already ongoing STEC-HUS with the aim of validating its role in early identifying HUS. We reviewed all the pediatric patients with Stx2+ BD (group 1) and with ongoing HUS (group 2) referred to our center from 2010 to 2019. A total of 100 children were eligible for the study. In group 1, 22 patients showed hemoglobinuria/hematuria, while 41 remained negative. In 15/22 positive patients (68.2%), blood tests ruled in HUS, while in 7 (31.8%), HUS was excluded. Among the 41 patients persistently negative for hemoglobinuria/hematuria, no one developed HUS. The 37 STEC-HUS children (group 2) all had hemoglobinuria/RBCs at admission.Conclusion: Hemoglobinuria/hematuria for the diagnosis of HUS in children with Stx2+ BD showed a sensitivity of 100% and a specificity of 85%. We strongly recommend patients with BD carrying Stx2 in stools to be closely monitored with urine dipstick/urinalysis to early identify HUS. What is Known • Children with bloody diarrhea secondary to Shiga toxin 2 are at high risk of hemolytic uremic syndrome, thus have to be carefully monitored for the development of the disease, in order to early be hospitalized and treated. What is New • Urine dipstick for hemoglobinuria can be used as an easy, inexpensive, and repeatable tool to early diagnose children with bloody diarrhea secondary to Shiga toxin 2 to have developed hemolytic uremic syndrome, with no risk of false-negative results.
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Outcomes of a clinician-directed protocol for discontinuation of complement inhibition therapy in atypical hemolytic uremic syndrome. Blood Adv 2021; 5:1504-1512. [PMID: 33683339 DOI: 10.1182/bloodadvances.2020003175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022] Open
Abstract
Terminal complement inhibition is the standard of care for atypical hemolytic uremic syndrome (aHUS). The optimal duration of complement inhibition is unknown, although indefinite therapy is common. Here, we present the outcomes of a physician-directed eculizumab discontinuation and monitoring protocol in a prospective cohort of 31 patients that started eculizumab for acute aHUS (and without a history of renal transplant). Twenty-five (80.6%) discontinued eculizumab therapy after a median duration on therapy of 2.37 (interquartile range: 1.06, 9.70) months. Eighteen patients discontinued per protocol and 7 because of nonadherence. Of these, 5 (20%) relapsed; however, relapse rate was higher in the case of nonadherence (42.8%) vs clinician-directed discontinuation and monitoring (11.1%). Four of 5 patients who relapsed were successfully retreated without a decline in renal function. One patient died because of recurrent aHUS and hypertensive emergency in the setting of nonadherence. Nonadherence to therapy (odds ratio, 8.25; 95% confidence interval, 1.02-66.19; P = .047) was associated with relapse, whereas the presence of complement gene variants (odds ratio, 1.39; 95% confidence interval, 0.39-4.87; P = .598) was not significantly associated with relapse. Relapse occurred in 40% (2 of 5) with a CFH or MCP variant, 33.3% (2 of 6) with other complement variants, and 0% (0 of 6) with no variants (P = .217). There was no decline in mean glomerular filtration rate from the date of stopping eculizumab until end of follow-up. In summary, eculizumab discontinuation with close monitoring is safe in most patients, with low rates of aHUS relapse and effective salvage with eculizumab retreatment in the event of recurrence.
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22
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Willrich MAV, Braun KMP, Moyer AM, Jeffrey DH, Frazer-Abel A. Complement testing in the clinical laboratory. Crit Rev Clin Lab Sci 2021; 58:447-478. [PMID: 33962553 DOI: 10.1080/10408363.2021.1907297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The complement system is the human's first line of defense against microbial pathogens because of its important housekeeping and infection/inflammation roles. It is composed of a series of soluble and cell-bound proteins that are activated in a cascade effect, similar to the coagulation pathways. There are different pattern recognizing molecules that activate the complement system in response to stimuli or threats, acting through three initiation pathways: classical, lectin, and alternative. All three activation pathways converge at the C3 component and share the terminal pathway. The main outputs of the complement system action are lytic killing of microbes, the release of pro-inflammatory anaphylatoxins, and opsonization of targets. Laboratory testing is relevant in the setting of suspected complement deficiencies, as well as in the emerging number of diseases related to dysregulation (over-activation) of complement. Most common assays measure complement lytic activity and the different complement component concentrations. Specialized testing includes the evaluation of autoantibodies against complement components, activation fragments, and genetic studies. In this review, we cover laboratory testing for complement and the conditions with complement involvement, as well as current challenges in the field.
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Affiliation(s)
| | - Karin M P Braun
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David H Jeffrey
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ashley Frazer-Abel
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Ardissino G, Cresseri D, Tel F, Giussani A, Salardi S, Sgarbanti M, Strumbo B, Testa S, Capone V, Griffini S, Grovetti E, Cugno M, Belingheri M, Tamburello C, Rodrigues EM, Perrone M, Cardillo M, Corti G, Consonni D, Furian L, Tedeschi S, Messa P, Beretta C. Kidney transplant in patients with atypical hemolytic uremic syndrome in the anti-C5 era: single-center experience with tailored Eculizumab. J Nephrol 2021; 34:2027-2036. [PMID: 33956337 DOI: 10.1007/s40620-021-01045-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/02/2021] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVE Patients with atypical hemolytic uremic syndrome (aHUS) have long been considered ineligible for kidney transplantation (KTx) in several centers due to the high risk of disease recurrence, graft loss and life-threatening complications. The availability of Eculizumab (ECU) has now overcome this problem. However, the best approach towards timing, maintenance schedule, the possibility of discontinuation and patient monitoring has not yet been clearly established. STUDY DESIGN This is a single center case series presenting our experience with KTx in aHUS. SETTING AND PARTICIPANTS This study included 26 patients (16 females) with a diagnosis of aHUS, who spent a median of 5.5 years on kidney replacement therapy before undergoing KTx. We compared the aHUS relapse rate in three groups of patients who underwent KTx: patients who received no prophylaxis, patients who underwent plasma exchange, those who received Eculizumab prophylaxis. Complement factor H-related disease was by far the most frequent etiology (n = 19 patients). RESULTS Untreated patients and patients undergoing pre-KTx plasma exchange prophylaxis had a relapse rate of 0.81 (CI 0.30-1.76) and 3.1 (CI 0.64-9.16) events per 10 years cumulative observation, respectively, as opposed to 0 events among patients receiving Eculizumab prophylaxis. The time between Eculizumab doses was tailored based on classic complement pathway activity (target to < 30%). Using this strategy, 12 patients are currently receiving Eculizumab every 28 days, 5 every 24-25 days, and 3 every 21 days. CONCLUSION Our experience supports the prophylactic use of Eculizumab in patients with a previous history of aHUS undergoing KTx, especially when complement dysregulation is well documented by molecular biology.
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Affiliation(s)
- Gianluigi Ardissino
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy.
| | - Donata Cresseri
- Nephrology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Tel
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Antenore Giussani
- Kidney Transplant Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Salardi
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Sgarbanti
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bice Strumbo
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Testa
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Valentina Capone
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Samantha Griffini
- Internal Medicine, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Grovetti
- Internal Medicine, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Internal Medicine, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Nephrology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Tamburello
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Evangeline Millicent Rodrigues
- Pediatric Nephrology, Dialysis and Transplantation Unit, Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, V. Commenda, 9, 20122, Milan, Italy
| | - Michela Perrone
- Neonatal Intensive Care Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- North Italian Transplant, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Grazia Corti
- Pharmacy, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Silvana Tedeschi
- Molecular Biology Laboratory, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Nephrology Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudio Beretta
- Kidney Transplant Unit, Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Sánchez-Moreno A, de la Cerda F, Rodríguez-Barba A, Fijo J, Bedoya R, Arjona E, de Córdoba SR. Is the atypical hemolytic uremic syndrome risk polymorphism in Membrane Cofactor Protein MCPggaac relevant in kidney transplantation? A case report. Pediatr Transplant 2021; 25:e13903. [PMID: 33217135 DOI: 10.1111/petr.13903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/08/2020] [Accepted: 10/06/2020] [Indexed: 12/26/2022]
Abstract
aHUS is a rare disease characterized by episodes of TMA that frequently progresses to CKD and often recurs after KT. The most frequent cause of aHUS is defective regulation of complement activation because of genetic anomalies. Eculizumab interrupts the process of TMA and improves renal function. We describe one female patient with aHUS who debuted in 2005 at 3-mo-old with extrarenal manifestations and progressed to end-stage kidney disease (ESKD) within a year. Her family history included several affected members with similar bad outcomes. Our patient carries a strong aHUS genetic predisposition consisting in a pathogenic gain-of-function mutation in complement factor B concurrent with the MCP aHUS risk haplotype MCPggaac. She received a kidney transplant in 2011 without eculizumab prophylaxis. The graft, which was negative for the MCPggaac risk haplotype, had an unexpected excellent evolution without aHUS recurrence. Different retrospective studies have shown that the risk of aHUS recurrence after KT correlates well with the genetic load of aHUS risk factors. Knowing important contribution of the MCPggaac risk haplotype to the risk of developing aHUS in Factor B mutations carriers, we speculate whether the absence of this polymorphism in the graft that our patient received may have decreased the risk of aHUS recurrence after KT.
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Affiliation(s)
- Ana Sánchez-Moreno
- Pediatric Nephrology Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Julia Fijo
- Pediatric Nephrology Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rafael Bedoya
- Pediatric Nephrology Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Emilia Arjona
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Enfermedades Raras, Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas and Centro de Investigación Biomédica en Enfermedades Raras, Madrid, Spain
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Risk of Atypical HUS Among Family Members of Patients Carrying Complement Regulatory Gene Abnormality. Kidney Int Rep 2021; 6:1614-1621. [PMID: 34169201 PMCID: PMC8207326 DOI: 10.1016/j.ekir.2021.03.885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 01/06/2023] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is mainly due to complement regulatory gene abnormalities with a dominant pattern but incomplete penetrance. Thus, healthy carriers can be identified in any family of aHUS patients, but it is unpredictable if they will eventually develop aHUS. Methods Patients are screened for 10 complement regulatory gene abnormalities and once a genetic alteration is identified, the search is extended to at-risk family members. The present cohort study includes 257 subjects from 71 families: 99 aHUS patients (71 index cases + 28 affected family members) and 158 healthy relatives with a documented complement gene abnormality. Results Fourteen families (19.7%) experienced multiple cases. Over a cumulative observation period of 7595 person-years, only 28 family members carrying gene mutations experienced aHUS (overall penetrance of 20%), leading to a disease rate of 3.69 events for 1000 person-years. The disease rate was 7.47 per 1000 person-years among siblings, 6.29 among offspring, 2.01 among parents, 1.84 among carriers of variants of uncertain significance, and 4.43 among carriers of causative variants. Conclusions The penetrance of aHUS seems a lot lower than previously reported. Moreover, the disease risk is higher in carriers of causative variants and is not equally distributed among generations: siblings and the offspring of patients have a much greater disease risk than parents. However, risk calculation may depend on variant classification that could change over time.
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Chaturvedi S, Braunstein EM, Brodsky RA. Antiphospholipid syndrome: Complement activation, complement gene mutations, and therapeutic implications. J Thromb Haemost 2021; 19:607-616. [PMID: 32881236 PMCID: PMC8080439 DOI: 10.1111/jth.15082] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
Antiphospholipid syndrome (APS) is an acquired thromboinflammatory disorder characterized by the presence of antiphospholipid antibodies as well as an increased frequency of venous or arterial thrombosis and/or obstetrical morbidity. The spectrum of disease varies from asymptomatic to a severe form characterized by widespread thrombosis and multiorgan failure, termed catastrophic APS (CAPS). CAPS affects only about ∼1% of APS patients, often presents as a thrombotic microangiopathy and has a fulminant course with >40% mortality, despite the best available therapy. Animal models have implicated complement in the pathophysiology of thrombosis in APS, with more recent data from human studies confirming the interaction between the coagulation and complement pathways. Activation of the complement cascade via antiphospholipid antibodies can cause cellular injury and promote coagulation via multiple mechanisms. Finally, analogous to classic complement-mediated diseases such as atypical hemolytic uremic syndrome, a subset of patients with APS may be at increased risk for development of CAPS because of the presence of germline variants in genes crucial for complement regulation. Together, these data make complement inhibition an attractive and potentially lifesaving therapy to mitigate morbidity and mortality in severe thrombotic APS and CAPS.
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Affiliation(s)
- Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Evan M Braunstein
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Eculizumab use in a tertiary care nephrology center: data from the Vienna TMA cohort. J Nephrol 2021; 35:451-461. [PMID: 33599971 PMCID: PMC8927043 DOI: 10.1007/s40620-021-00981-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/22/2021] [Indexed: 11/09/2022]
Abstract
Background Practice patterns of eculizumab use are not well described. We examined indications for, and outcomes of, eculizumab therapy in a tertiary care nephrology center. Methods We used the “Vienna TMA cohort” and the hospital pharmacy database at the Medical University of Vienna to identify patients that received eculizumab treatment between 2012 and 2019. We describe clinical characteristics, details of eculizumab use, and outcomes of patients with complement gene-variant mediated TMA (cTMA), secondary TMA (sTMA) and C3 glomerulopathy (C3G). Results As of December 2019, 23 patients received complement blockade at the Division of Nephrology and Dialysis: 15 patients were diagnosed with cTMA, 6 patients with sTMA and 2 patients with C3G. Causes of sTMA were bone marrow transplantation (n = 2), malignant hypertension, malignant tumor, systemic lupus erythematosus, antiphospholipid syndrome and lung transplantation (each n = 1). Across all indications, patients had a median age of 31 and were predominantly female (78%) and the median duration of treatment was 227 days. Hematological recovery was seen in most patients, while renal response was best in patients with cTMA. Adverse events were recorded in 26%. Conclusions In summary, eculizumab is the treatment of choice for cTMA patients that do not respond to plasma therapy. In patients with sTMA and C3G, the response rates to therapy are much lower and therefore, the decision to start therapy needs to be considered carefully. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-00981-8.
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Ariceta G, Fakhouri F, Sartz L, Miller B, Nikolaou V, Cohen D, Siedlecki AM, Ardissino G. Eculizumab discontinuation in atypical haemolytic uraemic syndrome: TMA recurrence risk and renal outcomes. Clin Kidney J 2021; 14:2075-2084. [PMID: 35261761 PMCID: PMC8894930 DOI: 10.1093/ckj/sfab005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background Eculizumab modifies the course of disease in patients with atypical haemolytic uraemic syndrome (aHUS), but data evaluating whether eculizumab discontinuation is safe are limited. Methods Patients enrolled in the Global aHUS Registry who received ≥1 month of eculizumab before discontinuing, demonstrated haematologic or renal response prior to discontinuation and had ≥6 months of follow-up were analysed. The primary endpoint was the proportion of patients suffering from thrombotic microangiopathy (TMA) recurrence after eculizumab discontinuation. Additional endpoints included: estimated glomerular filtration rate changes following eculizumab discontinuation to last available follow-up; number of TMA recurrences; time to TMA recurrence; proportion of patients restarting eculizumab; and changes in renal function. Results We analysed 151 patients with clinically diagnosed aHUS who had evidence of haematologic or renal response to eculizumab, before discontinuing. Thirty-three (22%) experienced a TMA recurrence. Univariate analysis revealed that patients with an increased risk of TMA recurrence after discontinuing eculizumab were those with a history of extrarenal manifestations prior to initiating eculizumab, pathogenic variants or a family history of aHUS. Multivariate analysis showed an increased risk of TMA recurrence in patients with pathogenic variants and a family history of aHUS. Twelve (8%) patients progressed to end-stage renal disease after eculizumab discontinuation; seven (5%) patients eventually received a kidney transplant. Forty (27%) patients experienced an extrarenal manifestation of aHUS after eculizumab discontinuation. Conclusions Eculizumab discontinuation in patients with aHUS is not without risk, potentially leading to TMA recurrence and renal failure. A thorough assessment of risk factors prior to the decision to discontinue eculizumab is essential.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Vall d'Hebron Hospital, and the Autonomous University of Barcelona, Barcelona, Spain
| | - Fadi Fakhouri
- Department of Nephrology and Immunology, CHU de Nantes, Nantes, France
| | - Lisa Sartz
- Department of Pediatrics, Skane University Hospital, Lund University, Lund, Sweden
| | | | | | - David Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Andrew M Siedlecki
- Department of Internal Medicine, Renal Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Gianluigi Ardissino
- Centro per la Cura e lo Studio della Sindrome Emolitico-Uremica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Brambilla M, Ardissino G, Paglialonga F, Testa S, Capone V, Montini G. Haemoglobinuria for the early identification of aHUS relapse: data from the ItalKId-HUS Network. J Nephrol 2021; 35:279-284. [PMID: 33459950 DOI: 10.1007/s40620-021-00965-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Atypical haemolytic uremic syndrome (aHUS) is at high risk of relapse at any time, therefore patients require lifelong monitoring. The most appropriate way to monitor patients is not yet clear. Patients could be monitored for relapse by urine dipstick testing for haemoglobinuria based on the hypothesis that thrombotic microangiopathy involving the glomerulus and associated with renal damage (like aHUS) cannot occur without haematuria. METHODS The aim of this retrospective study is to analyse our experience with this approach in aHUS patients who have never previously been treated, who are currently on treatment or who have discontinued C5 inhibition. The records of all aHUS patients (children and adults) managed by or referred to our Centre from January 2009 to March 2020 were included and the analysis for the presence of haemoglobinuria was restricted to the period following primary remission. A positive test was defined as haemoglobin ≥ 1 + . Patients reporting positive urine dipstick tests underwent laboratory investigations to rule in or out the diagnosis of aHUS relapse. RESULTS Eighty-four patients were included with 1517 determinations of haemoglobinuria during a cumulative observation period of 8904 patient-months. Haemoglobinuria for the early diagnosis of ongoing aHUS relapse shows a sensitivity of 100% and a specificity of 87.4% with a positive predictive value (PPV) of 10.5% and a negative predictive value (NPV) of 100%. The accuracy of the test was 87.6%. CONCLUSION Haemoglobinuria is a very sensitive and acceptably specific marker of aHUS relapse. This finding and its validation may have a positive impact on patients' quality of life and on the outcome of this life threatening disease via early diagnosis of relapse.
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Affiliation(s)
- Marta Brambilla
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy.
| | - Gianluigi Ardissino
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Fabio Paglialonga
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Sara Testa
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Valentina Capone
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy
| | - Giovanni Montini
- Dialysis and Transplant Unit, Center for HUS Prevention Control and Management at the Pediatric Nephrology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via della Commenda 9, 20122, Milan, Italy.,Giuliana and Bernardo Caprotti, Chairs of Pediatrics, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Turkmen K, Baloglu I, Ozer H. C3 glomerulopathy and atypical hemolytic uremic syndrome: an updated review of the literature on alternative complement pathway disorders. Int Urol Nephrol 2021; 53:2067-2080. [PMID: 33389509 DOI: 10.1007/s11255-020-02729-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
The complement system plays a significant role within the pathological process of C3 glomerulopathy (C3GP) and atypical hemolytic uremic syndrome (aHUS). In daily practice, clinicians should differentiate the subgroups of C3GP because of they should apply different treatment modalities. In the past, C3GP was considered as a part of membranoproliferative glomerulonephritis (MPGN). MPGN is defined as glomerular capillary thickening secondary to the synthesis of the new glomerular basement membrane and mesangial cellular hyperplasia with mesangial matrix expansion. Atypical hemolytic uremic syndrome is an ultra-rare disease that can be outlined by the triad of Coombs negative microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Recent advances demonstrated that these diseases share common abnormalities of the control of the alternative complement system. Therefore, nowadays, most researchers advocate that there may be overlap in the pathogenesis of C3GP and aHUS. This review will provide recent novel mechanisms and treatment options in these diseases. For the purposes that we mentioned above and to help clinicians, we aimed to describe the etiology, pathophysiology, and treatment of C3GP and aHUS in this comprehensive review.
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Affiliation(s)
- Kultigin Turkmen
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey.
| | - Ismail Baloglu
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
| | - Hakan Ozer
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
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Neto ME, de Moraes Soler L, Vasconcelos HVG, Nga HS, Bravin AM, Borges JCA, Gonçalves RC, Von Kriiger RB, Quinino RM, de Mello Santana VBB, de Holanda MI, Vaisbich MH, Naseri AP, Kirsztajn GM, Palma LMP, Andrade LGM. Eculizumab interruption in atypical hemolytic uremic syndrome due to shortage: analysis of a Brazilian cohort. J Nephrol 2021; 34:1373-1380. [PMID: 33387344 DOI: 10.1007/s40620-020-00920-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/15/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The risk of eculizumab therapy discontinuation in patients with atypical hemolytic uremic syndrome (aHUS) is unclear. The main objective of this study was to analyze the risk of aHUS relapse after eculizumab interruption due to drug shortage in Brazil. METHODS We screened all the registered dialysis centers in Brazil (n = 800), willing to participate in the aHUS Brazilian shortage cohort, through electronic mail and formal invitation by the Brazilian Society of Nephrology. We included patients with aHUS whose eculizumab therapy underwent unplanned discontinuation for at least 30 days between January 1st, 2016 and December 31st, 2019 during the maintenance phase of treatment. Relapse was defined by the development of thrombocytopenia, hemolytic anemia, acute kidney injury or thrombotic microangiopathy (TMA) in a kidney biopsy. RESULTS We analyzed 25 episodes of exposure to risk of relapse, from 24 patients. Median age was 33 (6-53) years, 18 (72%) were female, 9 (36%) had a functioning renal graft, 5 (20%) were undergoing dialysis. CFH variant was found in 8 (32%) episodes. There were 11 relapses. The risk of relapse was 34%, 44.5% and 58% at 114, 150 and 397 days, respectively. No baseline variable was related to relapse in Cox multivariate analysis, including CFH variant. CONCLUSIONS In this study, the cumulative incidence of aHUS relapse at 397 days was 58% after eculizumab interruption. The presence of complement variant does not seem to be associated with a higher relapse rate. The eculizumab interruption was deemed not safe, considering that the rate of relapse was high.
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Affiliation(s)
- Miguel Ernandes Neto
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil. .,Hospital BP-a Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil.
| | - Lucas de Moraes Soler
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil
| | | | - Hong Si Nga
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil
| | - Ariane Moyses Bravin
- Department of Internal Medicine, São Paulo State University (UNESP), Botucatu, SP, Brazil
| | | | | | | | - Raquel Martins Quinino
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | - Maria Izabel de Holanda
- Hospital Federal de Bonsucesso-Serviço de Nefrologia e Transplante, Rio de Janeiro, RJ, Brazil
| | | | - Alice Pignaton Naseri
- Setor de Nefrologia da Unidade de Gestão de Transplantes da Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | | | - Lilian Monteiro Pereira Palma
- Nefrologia Pediátrica-Departamento de Pediatria da Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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Hofer J, Riedl Khursigara M, Perl M, Giner T, Rosales A, Cortina G, Waldegger S, Jungraithmayr T, Würzner R. Early relapse rate determines further relapse risk: results of a 5-year follow-up study on pediatric CFH-Ab HUS. Pediatr Nephrol 2021; 36:917-925. [PMID: 33025207 PMCID: PMC7910231 DOI: 10.1007/s00467-020-04751-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/19/2020] [Accepted: 08/31/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND The complement factor H antibody (CFH-Ab)-associated hemolytic uremic syndrome (HUS) forms a distinct subgroup within the complement-mediated HUS disease spectrum. The autoimmune nature of this HUS subgroup implies the potential benefit of a targeted immunosuppressive therapy. Data on long-term outcome are scarce. METHODS This observational study evaluates the clinical outcome of 19 pediatric CFH-Ab HUS patients from disease onset until their 5-year follow-up. RESULTS All but one relapse occurred during the first 2 years, and patients who had no relapse within the first 6 months were relapse-free until the end of the observation period. Kidney function at disease onset determines long-term kidney function: all individuals with normal kidney function at disease onset had normal kidney function after 5 years, and all patients with reduced kidney function at onset had impaired kidney function at the last follow-up. Level of CFH-Ab titer at disease onset was not correlated with a higher risk of recurrences or worse long-term outcome after 5 years. Resolution of CFH-Ab titers after 5 years was common. CONCLUSIONS CFH-Ab HUS patients have a varied overall long-term course. Early relapses are common, making close surveillance during the first years essential, regardless of the initial CFH-Ab titer.
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Affiliation(s)
- Johannes Hofer
- Institute of Neurology of Senses and Language, Hospital of St John of God, Linz, Austria. .,Research Institute of Developmental Medicine, Johannes Kepler University Linz, Linz, Austria. .,Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria.
| | - Magdalena Riedl Khursigara
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria ,grid.17063.330000 0001 2157 2938Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Markus Perl
- grid.5361.10000 0000 8853 2677Department of Pediatrics III, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Giner
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Alejandra Rosales
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerard Cortina
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Siegfied Waldegger
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Therese Jungraithmayr
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria ,Department of Pediatric Nephrology, Hospital Memmingen, Memmingen, Germany
| | - Reinhard Würzner
- Institute of Hygiene & Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria.
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Passot C, Sberro-Soussan R, Bertrand D, Caillard S, Schvartz B, Domenger C, Contin-Bordes C, Paintaud G, Halimi JM, Ternant D, Gatault P. Feasibility and safety of tailored dosing schedule for eculizumab based on therapeutic drug monitoring: Lessons from a prospective multicentric study. Br J Clin Pharmacol 2020; 87:2236-2246. [PMID: 33118186 DOI: 10.1111/bcp.14627] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/13/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022] Open
Abstract
AIMS Eculizumab is an anti-C5 monoclonal antibody approved for rare diseases including atypical haemolytic-uraemic syndrome. The maintenance phase dosing regimen is identical for all adult patients: 1200 mg every 2 weeks. Recent studies reported an overexposure in many patients when considering a target trough concentration range of 50-100 mg/L. The aim of the present work was to validate the feasibility of therapeutic drug monitoring of eculizumab in atypical haemolytic-uraemic syndrome patients. METHODS We performed a 2-step prospective multicentre study. In the first phase, we developed a pharmacokinetic population model using data from 40 patients and identified patients for whom a 1-week lengthening of interval between infusions would lead to a trough concentration above 100 mg/L. In the second phase, selected patients were allocated a 1-week extension and eculizumab trough concentrations were monitored. RESULTS The model confirmed the previously reported influence of bodyweight on elimination clearance and predicted that 36 (90%) patients would be eligible for interval extension. In the second phase of the study, a 1-week lengthening of interval between infusions was performed in 15 patients whose trough concentration at the next visit was predicted with a Bayesian model to be above 100 mg/L. After interval extension, 10 patients (67%) presented measured trough concentrations over 100 mg/L. No biological or clinical recurrence of disease was observed, even in the 5 patients with concentrations below 100 mg/L in whom the initial dosing regimen was resumed. CONCLUSION Safe eculizumab interval adjustment is feasible with a PK monitoring.
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Affiliation(s)
- Christophe Passot
- EA7501, University of Tours, France.,Laboratory of Pharmacology-Toxicology, CHRU de Tours, France.,Integrated Center for Oncology, Angers, France
| | - Rebecca Sberro-Soussan
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Sophie Caillard
- Nephrology and Transplant Department, Strasbourg University Hospital, Strasbourg, France
| | | | | | | | - Gilles Paintaud
- EA7501, University of Tours, France.,Laboratory of Pharmacology-Toxicology, CHRU de Tours, France
| | - Jean-Michel Halimi
- EA4245 Transplant Immunology and Inflammation, Université de Tours, Tours, France.,Service de Néphrologie-Hypertension artérielle, Dialyses, Transplantation rénale, CHRU Tours, France
| | - David Ternant
- EA7501, University of Tours, France.,Laboratory of Pharmacology-Toxicology, CHRU de Tours, France
| | - Philippe Gatault
- EA4245 Transplant Immunology and Inflammation, Université de Tours, Tours, France.,Service de Néphrologie-Hypertension artérielle, Dialyses, Transplantation rénale, CHRU Tours, France
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34
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Wang Y, Johnston K, Popoff E, Myren KJ, Cheung A, Faria C, Tomazos I. A US cost-minimization model comparing ravulizumab versus eculizumab for the treatment of atypical hemolytic uremic syndrome. J Med Econ 2020; 23:1503-1515. [PMID: 33001704 DOI: 10.1080/13696998.2020.1831519] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIMS Ravulizumab, engineered from eculizumab, provides sustained C5 inhibition in atypical hemolytic uremic syndrome (aHUS) while reducing dosing frequency (every 8 vs 2 weeks, respectively). Treatment choice often carries significant financial implications. This study compared the economic consequences of ravulizumab and eculizumab for treating aHUS. MATERIALS AND METHODS A cost-minimization model compared direct medical costs for ravulizumab and eculizumab in treating aHUS, assuming equivalent efficacy and safety, and took a US payer perspective, a lifetime horizon, and a 3.0% cost discount rate. The base case modeled adult and pediatric treatment-naïve populations, with characteristics based on clinical trials, and treatment patterns (duration, discontinuation, re-initiation) derived from eculizumab studies with long-term follow-up. Treatment costs (2019 US$) were based on wholesale drug acquisition costs, Centers for Medicare & Medicaid fee schedules, and published disease management studies. Sensitivity analyses were conducted by adjusting relevant variables. RESULTS Ravulizumab provided lifetime per-patient cost reductions (discounted) of 32.4% and 35.5% vs eculizumab in adult and pediatric base cases, respectively. Total costs for ravulizumab vs eculizumab were $12,148,748 and $17,979,007, respectively, for adults, and $11,587,832 and $17,959,814, respectively, for children. Pre-discontinuation treatment contributed the largest proportion of total costs for ravulizumab (94.8% and 88.0%) and eculizumab (94.8% and 87.8%) in adults and children, respectively. Across sensitivity analyses, ravulizumab provided cost reductions vs eculizumab. LIMITATIONS The model included several typical assumptions. Base case patients with more severe stages of chronic kidney disease were assumed not to discontinue treatment, nor to experience an excess mortality risk in either treatment arm, which may not reflect real-world clinical observations. Additionally, rebates and discounts on medication acquisition or administration were not considered. CONCLUSIONS In US patients with aHUS, ravulizumab provided cost reductions of 32.4-35.5% vs eculizumab, with a reduced dosing frequency for ravulizumab. The magnitude of reductions was consistent across sensitivity analyses.
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Affiliation(s)
- Yan Wang
- Health Economics & Outcomes Research, Alexion Pharmaceuticals, Inc, Boston, MA, USA
| | | | | | - Karl-Johan Myren
- Health Economics & Outcomes Research, Alexion Pharmaceuticals, Inc, Boston, MA, USA
| | | | - Claudio Faria
- Health Economics & Outcomes Research, Alexion Pharmaceuticals, Inc, Boston, MA, USA
| | - Ioannis Tomazos
- Health Economics & Outcomes Research, Alexion Pharmaceuticals, Inc, Boston, MA, USA
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35
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Avila Bernabeu AI, Cavero Escribano T, Cao Vilarino M. Atypical Hemolytic Uremic Syndrome: New Challenges in the Complement Blockage Era. Nephron Clin Pract 2020; 144:537-549. [PMID: 32950988 DOI: 10.1159/000508920] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare cause of thrombotic microangiopathy (TMA), characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and multisystem end organ involvement, most commonly affecting the kidney. Diagnosis is clinical, after exclusion of other TMA causes. Primary aHUS arises from genetic abnormalities, resulting in uncontrolled complement activity, while a variety of clinical scenarios cause secondary aHUS, including infection, pregnancy, malignancy, autoimmune disease, and medications. They can also induce a temporary complement deregulation with an overlap between both scenarios, which can make differential diagnosis difficult. Primary aHUS can be sporadic or familial and is associated with a high rate of progression to ESRD. Many aHUS patients relapse in the native or transplanted kidneys, leading to kidney failure. The introduction of eculizumab has changed the prognosis of aHUS, by inducing hematologic remission, improving or stabilizing kidney functions, and preventing graft failure. The early institution of appropriate therapy can prevent multiorgan damage, so is essential to recognize and differentiate the TMA syndromes. Eculizumab is considered now the first-line treatment, and it is recommended lifelong therapy. However, the high cost of therapy has led to make efforts to develop precise complement functional and genetic studies that help physicians to determine the appropriate duration of eculizumab therapy. Nowadays, more studies are needed to select candidates to adjustment of therapy.
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36
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Kuroki Y, Mitsuiki K, Nakagawa K, Tsuruya K, Katafuchi R, Hirakata H, Nakano T. Late renal recovery after treatment over 1 year post-onset in an atypical hemolytic uremic syndrome: a case report. BMC Nephrol 2020; 21:236. [PMID: 32571244 PMCID: PMC7310110 DOI: 10.1186/s12882-020-01897-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/17/2020] [Indexed: 11/27/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is a life-threatening disease that leads to end-stage kidney disease if only a poor response to plasma exchanges (PEs) or eculizumab therapy is achieved. Case presentation A 58-year-old Japanese man presented with thrombocytopenia, anemia, and kidney failure requiring dialysis without any underlying disease. A kidney biopsy revealed marked mesangiolysis in all glomeruli, compatible with thrombotic microangiopathy (TMA). Based on the positive anti- factor H antibody and negative result for secondary TMA, we diagnosed him as aHUS. Despite eculizumab administration after eight sessions of PE, neither platelet normalization nor kidney recovery was achieved. Eight months later, we discontinued eculizumab therapy due to anaphylactic reaction. At 15 months after the onset of TMA, his platelet count increased gradually from 40 to 150 × 103/μL with a decreased serum creatinine level and increased urine output, eventually allowing the withdrawal of dialysis therapy. A second kidney biopsy showed mesangial widening compatible with the healing of TMA. Conclusions This case indicates that aHUS with PEs and eculizumab therapy has the potential for renal recovery even if over 1 year has passed.
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Affiliation(s)
- Yusuke Kuroki
- Nephrology & Dialysis Center, Japanese Red Cross Fukuoka Hospital, 3-1-1, Ogusu, Minami-ku, Fukuoka, 815-8555, Japan.
| | - Koji Mitsuiki
- Nephrology & Dialysis Center, Japanese Red Cross Fukuoka Hospital, 3-1-1, Ogusu, Minami-ku, Fukuoka, 815-8555, Japan
| | - Kaneyasu Nakagawa
- Nephrology & Dialysis Center, Japanese Red Cross Fukuoka Hospital, 3-1-1, Ogusu, Minami-ku, Fukuoka, 815-8555, Japan
| | | | - Ritsuko Katafuchi
- Division of Nephrology, National Hospital Organization Fukuokahigashi Medical Center, Koga, Japan
| | - Hideki Hirakata
- Nephrology & Dialysis Center, Japanese Red Cross Fukuoka Hospital, 3-1-1, Ogusu, Minami-ku, Fukuoka, 815-8555, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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37
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Soraru J, Isbel N, Wong G, Coates PT, Mantha M, Abraham A, Juneja R, Hsu D, Brown F, Bose B, Mudge D, Carroll R, Kausman J, Hughes P, Barbour T, Durkan A, Mount P, Lee D, Larkins N, Ranganathan D, Lim WH. Baseline characteristics of patients with atypical haemolytic uraemic syndrome (aHUS): The Australian cohort in a global aHUS registry. Nephrology (Carlton) 2020; 25:683-690. [PMID: 32378251 DOI: 10.1111/nep.13722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/27/2020] [Accepted: 04/14/2020] [Indexed: 11/27/2022]
Abstract
AIMS To describe the baseline characteristics and treatment of Australian patients diagnosed with atypical haemolytic uraemic syndrome (aHUS) reported to the Global aHUS Registry. METHODS Descriptive analysis of the Australian cohort with aHUS (n = 106) was undertaken for demographics, disease characteristics and prior treatment with eculizumab; comparing with the global cohort (n = 1688) for certain pre-specified disease characteristics. RESULTS In Australia, almost two-thirds of patients diagnosed with aHUS were female and over 80% of patients were Caucasians, with similar proportions reported in the global cohort. Less than 6% of patients in the Australia and global cohorts were reported to have a history of autoimmune disease (4% vs 2%, respectively; P = .21) or cancer (5% vs 5%, respectively; P = .93), conditions that have been associated with secondary HUS. In the Australian cohort, 26% had received a kidney transplant and 68% of patients had received eculizumab. Kidneys were the most common organ involvement, followed by gastrointestinal tract (26%) and cardiovascular system (19%), with 35% of patients reported to have had at least two organs involved within 6 months prior to baseline visit or entry into the registry. Complement factor H was the most common pathogenic complement gene variant in the Australian patients. CONCLUSION Data from the aHUS registry confirms and defines region-specific disease characteristics among a selected group of Australian children and adults with aHUS reported to the registry. Ongoing and more inclusive data will provide further information about temporal trends and treatment outcomes, representing a unique opportunity for clinicians and researchers to further develop knowledge surrounding this rare disease.
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Affiliation(s)
- Jacqueline Soraru
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Nicole Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patrick Toby Coates
- Central and Northern Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Murty Mantha
- Department of Nephrology, Cairns Base Hospital, Cairns, Queensland, Australia
| | - Abu Abraham
- Department of Nephrology and Renal Transplant, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Rajiv Juneja
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Danny Hsu
- Department of Haematology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Fiona Brown
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Bhadran Bose
- Department of Nephrology, Nepean Hospital, Blue Mountains, New South Wales, Australia
| | - David Mudge
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Robert Carroll
- Central and Northern Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Kausman
- Department of Nephrology and Renal Transplantation, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Peter Hughes
- Department of Nephrology and Transplantation, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Thomas Barbour
- Department of Nephrology and Transplantation, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anne Durkan
- Department of Nephrology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Peter Mount
- Department of Nephrology, Austin Health, Melbourne, Australia
| | - Darren Lee
- Department of Renal Medicine, Eastern Health Clinical School, Monash University Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Larkins
- Department of Nephrology and Hypertension, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Dwarakanathan Ranganathan
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, School of Medicine, Griffith University, Mount Gravatt, Queensland, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Abstract
The renaissance of complement diagnostics and therapeutics has introduced precision medicine into a widened field of complement-mediated diseases. In particular, complement-mediated diseases (or complementopathies) with ongoing or published clinical trials of complement inhibitors include paroxysmal nocturnal hemoglobinuria, cold agglutinin disease, hemolytic uremic syndrome, nephropathies, HELLP syndrome, transplant-associated thrombotic microangiopathy, antiphospholipid antibody syndrome, myasthenia gravis, and neuromyelitis optica. Recognizing that this field is rapidly expanding, we aim to provide a state-of-the-art review of (a) current understanding of complement biology for the clinician, (b) novel insights into complement with potential applicability to clinical practice, (c) complement in disease across various disciplines (hematology, nephrology, obstetrics, transplantation, rheumatology, and neurology), and (d) the potential future of precision medicine. Better understanding of complement diagnostics and therapeutics will not only facilitate physicians treating patients in clinical practice but also provide the basis for future research toward precision medicine in this field.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Robert A. Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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39
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Aigner C, Böhmig GA, Eskandary F, Herkner H, Prohászka Z, Csuka D, Kain R, Gaggl M, Sunder-Plassmann R, Müller-Sacherer T, Oszwald A, Fischer G, Schmidt A, Sunder-Plassmann G. Preemptive plasma therapy prevents atypical hemolytic uremic syndrome relapse in kidney transplant recipients. Eur J Intern Med 2020; 73:51-58. [PMID: 31791575 DOI: 10.1016/j.ejim.2019.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/14/2019] [Accepted: 11/07/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) frequently leads to renal failure, and kidney transplantation bears a high risk of disease recurrence and graft loss. METHODS Patients who received a kidney graft in our center were retrospectively identified using our Vienna Thrombotic Microangiopathy Cohort. Since 2005, the majority of aHUS patients received perioperative plasma exchange (PE) followed by plasma infusions (PI). Patients were switched to eculizumab in case of plasma intolerance or failure. Those with no preemptive therapy served as controls. We used proportional Cox regression and logistic regression to examine predictors of graft survival. RESULTS 19 aHUS patients received 32 grafts and had a follow-up > 1 year. Eight patients received preventive plasma therapy for eight transplants and 13 patients (including 2 patients who received plasma therapy for their last transplant) had no preventive therapy for 24 grafts. The median graft survival was 2.372 days in patients, that received preemptive therapy and 411 days in patients, that did not receive preemptive treatment (hazard ratio: 0.11; p= 0.03). Four patients were switched to eculizumab because of plasma intolerance or failure. Additionally, one patient, that was not transplanted according to the above-mentioned protocol, received eculizumab for aHUS relapse. Additionally, relapse of aHUS (p = 0.01) and year of transplantation (p<0.01) had an effect on graft failure. CONCLUSIONS This study shows that preemptive plasma therapy and eculizumab rescue in selected cases improve graft survival among kidney transplant recipients with aHUS.
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Affiliation(s)
- Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria.
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Dorottya Csuka
- Research Laboratory, 3rd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Renate Kain
- Department of Pathology, Medical University Vienna, Vienna, Austria
| | - Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Raute Sunder-Plassmann
- Genetics Laboratory, Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - Thomas Müller-Sacherer
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University Vienna, Vienna, Austria
| | - Gottfried Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University Vienna, Vienna, Austria
| | - Alice Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
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40
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Fayek SA, Allam SR, Martinez E, Pan G, Dao A, Rofaiel G. Atypical Hemolytic Uremic Syndrome After Kidney Transplantation: Lessons Learned From the Good, the Bad, and the Ugly. A Case Series With Literature Review. Transplant Proc 2020; 52:146-152. [PMID: 31924403 DOI: 10.1016/j.transproceed.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) after kidney transplantation is rare and carries a grave outcome. We present a single-center experience of all aHUS cases since the program's inception. Six patients were diagnosed with aHUS, all after kidney transplants, except for 1 patient. All had nonreactive crossmatches. Delayed graft function (DGF) occurred in 2 patients. Five patients developed aHUS after transplant; 4 (80%) of these patients manifested aHUS ≤ 14 days. All were confirmed by allograft biopsy. Genetic testing was abnormal in all patients except for 1 patient. Actual patient and graft survival during the first year was 100% and 83.3%, respectively. A single graft was lost early in the study secondary to aHUS (eculizumab was not used in the treatment process). Prophylactic and therapeutic use of eculizumab salvaged all other cases. At 1 year, mean creatinine level was 1.9 mg/dL (range, 1.3-2.5). After 6 months of eculizumab treatment (halted in 2 cases) 1 patient had recurrence 2 months later and eculizumab was restarted. However, graft function continued to worsen, and the graft was ultimately lost at 20 months after kidney transplantation. High index of suspicion, prompt diagnosis, and utilization of eculizumab are key to successful salvage of allografts in cases of aHUS after kidney transplantation. aHUS can be prevented by prophylactic use of eculizumab. It still needs to be determined when and if eculizumab therapy can be safely discontinued.
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Affiliation(s)
- Sameh A Fayek
- Department of Surgery, Section of Abdominal Transplantation, Inova Fairfax Medical Campus, Falls Church, VA, Unites States; Department of Surgery, Faculty of Medicine, Cairo University, Egypt.
| | - Sridhar R Allam
- Department of Transplantation, Medical City Fort Worth, Fort Worth, Texas, United States
| | - Eryberto Martinez
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Gilbert Pan
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, Utah, United States
| | - Ann Dao
- Department of Transplantation, Medical City Fort Worth, Fort Worth, Texas, United States
| | - George Rofaiel
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, Utah, United States
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41
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Kise T, Fukuyama S, Uehara M. Successful Treatment of Anti-Factor H Antibody-Associated Atypical Hemolytic Uremic Syndrome. Indian J Nephrol 2020; 30:35-38. [PMID: 32015599 PMCID: PMC6977382 DOI: 10.4103/ijn.ijn_336_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/17/2019] [Accepted: 05/07/2019] [Indexed: 12/01/2022] Open
Abstract
Anti-complement factor H (CFH) autoantibody (Ab)-associated atypical hemolytic uremic syndrome (aHUS) has a poor prognosis in terms of frequent relapses. Although eculizumab is an effective treatment for this type of aHUS, the method of eculizumab discontinuation is not yet established. Herein, we report a case of anti-CFH Ab-associated aHUS in a 6-year-old boy. Eculizumab induction therapy following plasma exchange improved his condition. After 14 months, eculizumab was discontinued because of meningococcal bacteremia. After 6 months of eculizumab cessation, prednisolone (20 mg/alternate days) and mycophenolate mofetil (500 mg/day) were initiated. There were no relapses or increases in anti-CFH Ab titers for 26 months after treatment initiation. We believe that eculizumab induction therapy, following plasma exchange and maintenance therapy with immunosuppressants after eculizumab discontinuation are effective treatments for anti-CFH Ab-related aHUS.
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Affiliation(s)
- Tomoo Kise
- Division of Pediatric Nephrology, Okinawa Prefectural Nanbu Medical Center, Children's Medical Center, Arakawa 118-1, Haebaru, Okinawa 901-1193, Japan
| | - Shigeru Fukuyama
- Division of Pediatric Nephrology, Okinawa Prefectural Nanbu Medical Center, Children's Medical Center, Arakawa 118-1, Haebaru, Okinawa 901-1193, Japan
| | - Masatsugu Uehara
- Division of Pediatric Nephrology, Okinawa Prefectural Nanbu Medical Center, Children's Medical Center, Arakawa 118-1, Haebaru, Okinawa 901-1193, Japan
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García-Martín E, Manrique-Rodríguez S, Martínez Fernández-Llamazares C, Goicoechea-Diezhondino M, Álvarez-Blanco O, García-Morín M, Sanjurjo-Sáez M. Variability in management and outcomes of therapy with eculizumab in atypical hemolytic uremic syndrome. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1703108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Estela García-Martín
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Silvia Manrique-Rodríguez
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | - Marian Goicoechea-Diezhondino
- Nephrology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Olalla Álvarez-Blanco
- Pediatric Nephrology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Marina García-Morín
- Pediatric Oncohematology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - María Sanjurjo-Sáez
- Director of Pharmacy Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
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43
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Zuber J, Frimat M, Caillard S, Kamar N, Gatault P, Petitprez F, Couzi L, Jourde-Chiche N, Chatelet V, Gaisne R, Bertrand D, Bamoulid J, Louis M, Sberro Soussan R, Navarro D, Westeel PF, Frimat L, Colosio C, Thierry A, Rivalan J, Albano L, Arzouk N, Cornec-Le Gall E, Claisse G, Elias M, El Karoui K, Chauvet S, Coindre JP, Rerolle JP, Tricot L, Sayegh J, Garrouste C, Charasse C, Delmas Y, Massy Z, Hourmant M, Servais A, Loirat C, Fakhouri F, Pouteil-Noble C, Peraldi MN, Legendre C, Rondeau E, Le Quintrec M, Frémeaux-Bacchi V. Use of Highly Individualized Complement Blockade Has Revolutionized Clinical Outcomes after Kidney Transplantation and Renal Epidemiology of Atypical Hemolytic Uremic Syndrome. J Am Soc Nephrol 2019; 30:2449-2463. [PMID: 31575699 DOI: 10.1681/asn.2019040331] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/26/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (HUS) is associated with high recurrence rates after kidney transplant, with devastating outcomes. In late 2011, experts in France recommended the use of highly individualized complement blockade-based prophylaxis with eculizumab to prevent post-transplant atypical HUS recurrence throughout the country. METHODS To evaluate this strategy's effect on kidney transplant prognosis, we conducted a retrospective multicenter study from a large French nationwide registry, enrolling all adult patients with atypical HUS who had undergone complement analysis and a kidney transplant since January 1, 2007. To assess how atypical HUS epidemiology in France in the eculizumab era evolved, we undertook a population-based cohort study that included all adult patients with atypical HUS (n=397) between 2007 and 2016. RESULTS The first study included 126 kidney transplants performed in 116 patients, 58.7% and 34.1% of which were considered to be at a high and moderate risk of atypical HUS recurrence, respectively. Eculizumab prophylaxis was used in 52 kidney transplants, including 39 at high risk of recurrence. Atypical HUS recurred after 43 (34.1%) of the transplants; in four cases, patients had received eculizumab prophylaxis and in 39 cases they did not. Use of prophylactic eculizumab was independently associated with a significantly reduced risk of recurrence and with significantly longer graft survival. In the second, population-based cohort study, the proportion of transplant recipients among patients with ESKD and atypical HUS sharply increased between 2012 and 2016, from 46.2% to 72.3%, and showed a close correlation with increasing eculizumab use among the transplant recipients. CONCLUSIONS Results from this observational study are consistent with benefit from eculizumab prophylaxis based on pretransplant risk stratification and support the need for a rigorous randomized trial.
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Affiliation(s)
- Julien Zuber
- Department of Nephrology and Kidney Transplantation, University Hospital Center (CHU) Necker, Paris Descartes University-Sorbonne Paris Cité, Paris, France; .,French Study Group of Atypical Hemolytic Uremic Syndrome, France
| | - Marie Frimat
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU Lille, University of Lille, Lille, France
| | - Sophie Caillard
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, The University Hospitals of Strasbourg, Strasbourg, France
| | - Nassim Kamar
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Organ Transplantation, CHU Rangueil, INSERM (Institut National de la Santé et de la Recherche Médicale) U1043, IFR-BMT (Institut Fédératif de Recherche Bio-Médicale de Toulouse), University Paul Sabatier, Toulouse, France
| | - Philippe Gatault
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Tours, Tours, France
| | | | - Lionel Couzi
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Bordeaux, Bordeaux University, CNRS-UMR (Centre National de la Recherche Scientifique-Unité Mixte de Recherche) 5164, Bordeaux, France
| | - Noemie Jourde-Chiche
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology, C2VN, INSERM, INRA (Institut National de la Recherche Agronomique), CHU de Marseille, Aix-Marseille University, Marseille, France
| | - Valérie Chatelet
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,University Center of Kidney Diseases, CHU de Caen, Caen, France
| | - Raphael Gaisne
- Department of Nephrology and Kidney Transplantation, CHU de Nantes, Nantes, France
| | - Dominique Bertrand
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Rouen, Rouen, France
| | - Jamal Bamoulid
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHRU de Besançon, Besançon, France
| | - Magali Louis
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Dijon, Dijon, France
| | - Rebecca Sberro Soussan
- Department of Nephrology and Kidney Transplantation, University Hospital Center (CHU) Necker, Paris Descartes University-Sorbonne Paris Cité, Paris, France.,French Study Group of Atypical Hemolytic Uremic Syndrome, France
| | - David Navarro
- Department of Nephrology and Kidney Transplantation, University Hospital Center (CHU) Necker, Paris Descartes University-Sorbonne Paris Cité, Paris, France.,Department of Nephrology and Kidney Transplantation, Curry Cabral Hospital, Central Lisbon University Hospital Centre, Lisbon, Portugal
| | - Pierre-Francois Westeel
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU d'Amiens, Amiens, France
| | - Luc Frimat
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Nancy, Nancy, France
| | - Charlotte Colosio
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Reims, Reims, France
| | - Antoine Thierry
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Poitiers, Poitiers, France
| | - Joseph Rivalan
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Rennes, Rennes, France
| | - Laetitia Albano
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Nice, Nice, France
| | - Nadia Arzouk
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU Pitié-Salpétrière, Paris, France
| | - Emilie Cornec-Le Gall
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Brest, Brest, France
| | - Guillaume Claisse
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Saint Etienne, St-Etienne, France
| | - Michelle Elias
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, Kremlin-Bicêtre Hospital, Paris, France
| | - Khalil El Karoui
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, Henri-Mondor Hospital, Créteil, France
| | - Sophie Chauvet
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology, Georges Pompidou European Hospital, Paris, France
| | - Jean-Philippe Coindre
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology, Hospital Center du Mans, Le Mans, France
| | - Jean-Philippe Rerolle
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Limoges, Limoges, France
| | - Leila Tricot
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CH de Foch, Suresnes, France
| | - Johnny Sayegh
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Angers, Angers, France
| | - Cyril Garrouste
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Clermont Ferrand, Clermont Ferrand, France
| | - Christophe Charasse
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology, CH du St Brieuc, St Brieuc, France
| | - Yahsou Delmas
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Bordeaux, Bordeaux University, CNRS-UMR (Centre National de la Recherche Scientifique-Unité Mixte de Recherche) 5164, Bordeaux, France
| | - Ziad Massy
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology, CHU Ambroise-Paré, Boulogne-Billancourt, France
| | - Maryvonne Hourmant
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Nantes, Nantes, France
| | - Aude Servais
- Department of Nephrology and Kidney Transplantation, University Hospital Center (CHU) Necker, Paris Descartes University-Sorbonne Paris Cité, Paris, France.,French Study Group of Atypical Hemolytic Uremic Syndrome, France
| | - Chantal Loirat
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology, University Hospital Robert Debré, Paris, France
| | - Fadi Fakhouri
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Nantes, Nantes, France
| | - Claire Pouteil-Noble
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Lyon, Lyon, France
| | - Marie-Noelle Peraldi
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU St Louis, Paris, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, University Hospital Center (CHU) Necker, Paris Descartes University-Sorbonne Paris Cité, Paris, France.,French Study Group of Atypical Hemolytic Uremic Syndrome, France
| | - Eric Rondeau
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU Tenon, Paris, France; and
| | - Moglie Le Quintrec
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Department of Nephrology and Kidney Transplantation, CHU de Montpellier, Montpellier, France
| | - Véronique Frémeaux-Bacchi
- French Study Group of Atypical Hemolytic Uremic Syndrome, France.,Cordelier Research Center, INSERM UMRS 1138, Paris, France
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Abstract
The thrombotic microangiopathies (TMAs) are a group of diseases characterised by microangiopathic haemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. Traditionally, TMAs have been classified as either thrombotic thrombocytopenic purpura (TTP) or haemolytic uremic syndrome (HUS) based on the clinical presentation, with neurological involvement predominating in the former and acute kidney injury in the latter. However, as our understanding of the pathogenesis of these conditions has increased, it has become clear that this is an over-simplification; there is significant overlap in the clinical presentation of TTP and HUS, there are different forms of HUS, and TMAs can occur in other, diverse clinical scenarios. This review will discuss recent developments in the diagnosis of HUS, focusing on the different forms of HUS and how to diagnose and manage these potentially life-threatening diseases.
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Affiliation(s)
- Neil S Sheerin
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Emily Glover
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
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45
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Knoop M, Haller H, Menne J. [Human genetics in atypical hemolytic uremic syndrome-its role in diagnosis and treatment]. Internist (Berl) 2019; 59:799-804. [PMID: 29995248 DOI: 10.1007/s00108-018-0455-9] [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] [Indexed: 12/31/2022]
Abstract
The atypical hemolytic uremic syndrome (aHUS), one of the three major forms of thrombotic microangiopathy, is characterized by genetic alterations in the area of the complement cascade, which can be detected in 40%-60% of all patients with aHUS. Mutations in over 10 different genes have now been identified. The most frequent and clinically relevant of these are mutations that result in a decreased or absent function of factor H, the formation of hybrid genes, or the formation of autoantibodies against factor H. Although genetics are not required for the diagnosis of aHUS, it is of great importance for the decision on how long to treat with the C5 inhibitor eculizumab. Also, knowledge of genetic alterations is absolutely essential if a living related donor is considered, in order to protect the living donor and recipient from developing aHUS.
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Affiliation(s)
- M Knoop
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - J Menne
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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46
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Wijnsma KL, Duineveld C, Volokhina EB, van den Heuvel LP, van de Kar NCAJ, Wetzels JFM. Safety and effectiveness of restrictive eculizumab treatment in atypical haemolytic uremic syndrome. Nephrol Dial Transplant 2019; 33:635-645. [PMID: 29106598 DOI: 10.1093/ndt/gfx196] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/10/2017] [Indexed: 11/12/2022] Open
Abstract
Background Atypical haemolytic uremic syndrome (aHUS) is a rare but severe form of thrombotic microangiopathy as a consequence of complement dysregulation. aHUS has a poor outcome with high mortality and >50% of patients developing end-stage renal disease. Since the end of 2012, these outcomes have greatly improved with the introduction of eculizumab. Currently the duration of treatment is debated. Most guidelines advise lifelong treatment. However, there is no hard evidence to support this advice. Historically, a substantial number of aHUS patients were weaned of plasma therapy, often without disease recurrence. Moreover, the long-term consequences of eculizumab treatment are unknown. In this retrospective study we describe 20 patients who received a restrictive treatment regimen. Methods All aHUS patients who presented in the Radboud University Medical Center, Nijmegen, The Netherlands, between 2012 and 2016 and who received eculizumab are described. Clinical, diagnostic and follow-up data were gathered and reviewed. Results Twenty patients (14 adults, 6 children) with aHUS have received eculizumab. Eculizumab was tapered in all and stopped in 17 patients. aHUS recurrence occurred in five patients. Due to close monitoring, recurrence was detected early and eculizumab was restarted. No clinical sequela such as proteinuria or progressive kidney dysfunction was detected subsequently. In total, eculizumab has been discontinued in 13 patients without aHUS recurrence, of which 5 are event free for >1 year. With this strategy ∼€11.4 million have been saved. Conclusions A restrictive eculizumab regimen in aHUS appears safe and effective. Prospective studies should further evaluate the most optimal treatment strategy.
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Affiliation(s)
- Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lambertus P van den Heuvel
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pediatrics, University Hospital Leuven, Leuven, Belgium
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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47
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Hanna RM, Hasnain H, Abdelnour L, Yanny B, Burwick RM. Atypical hemolytic uremic syndrome in a patient with protein-losing enteropathy. J Int Med Res 2019; 47:4027-4032. [PMID: 31364428 PMCID: PMC6726804 DOI: 10.1177/0300060519864808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare disease induced by many triggers, all of which produce a common end phenotype of microangiopathic hemolysis and thrombotic microangiopathy. We herein describe a 63-year-old woman with ongoing protein-losing enteropathy and frequent transudates caused by hypoalbuminemia. The patient was treated with eculizumab with a full hematologic and partial renal response. Protein-losing enteropathy is an inflammatory condition that has been linked with increased complement activation, which can trigger aHUS in patients with loss of CD55 expression. The patient in the present case had an increased estimated glomerular filtration rate but stage IV to V chronic kidney disease. One year later, she remains off dialysis with a stable estimated glomerular filtration rate. We herein report an unusual trigger of complement activation that in turn triggered aHUS in this patient.
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Affiliation(s)
- Ramy M Hanna
- 1 Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Huma Hasnain
- 1 Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Lama Abdelnour
- 1 Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Beshoy Yanny
- 2 Department of Medicine, Division of Digestive Diseases, Hepatology UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Richard M Burwick
- 3 Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
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48
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Eculizumab en el síndrome hemolítico urémico atípico. ¿Hasta cuándo mantenerlo? Nefrologia 2019; 39:440-442. [DOI: 10.1016/j.nefro.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/13/2019] [Indexed: 01/06/2023] Open
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49
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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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50
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Aigner C, Schmidt A, Gaggl M, Sunder-Plassmann G. An updated classification of thrombotic microangiopathies and treatment of complement gene variant-mediated thrombotic microangiopathy. Clin Kidney J 2019; 12:333-337. [PMID: 31198225 PMCID: PMC6543965 DOI: 10.1093/ckj/sfz040] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Indexed: 12/21/2022] Open
Abstract
Conditions presenting with signs of thrombotic microangiopathies (TMAs) comprise a wide spectrum of different diseases. While pathological hallmarks are thrombosis of arterioles and capillaries, clinical signs are mechanical haemolysis, thrombocytopenia and acute renal injury or neurological manifestations. The current classification of various syndromes of TMA is heterogeneous and often does not take the underlying pathophysiology into consideration. Therefore we propose a simplified classification based on the aetiology of different syndromes leading to TMA. We propose to categorize different TMA syndromes in hereditary and acquired forms and classify them based on the genetic background or underlying conditions. Of course, this classification is not always distinctly applicable in each case and from time to time reassessment of the established diagnosis is strongly recommended. The recommended treatment of TMA in the past was plasma exchange (PE). However, recently, the terminal complement inhibitor eculizumab became commercially available and has shown promising results in different open-label studies and case series. In our centre, first-line therapy is PE; however, patients are instantly switched to complement inhibitory therapy in case of treatment failure or intolerance.
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Affiliation(s)
- Christof Aigner
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Alice Schmidt
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Martina Gaggl
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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