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Burke L, Sethi SK, Boyer O, Licht C, McCulloch M, Shah R, Luyckx VA, Raina R. Voice of a caregiver: call for action for multidisciplinary teams in the care for children with atypical hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:1961-1963. [PMID: 37782345 DOI: 10.1007/s00467-023-06158-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023]
Affiliation(s)
| | - Sidharth Kumar Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Olivia Boyer
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Raghav Shah
- Northeast Ohio Medical University, Rootstown, OH, USA
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Valerie A Luyckx
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rupesh Raina
- Northeast Ohio Medical University, Rootstown, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Nephrology, Cleveland Clinic Akron General and Akron Children's Hospital, Akron, OH, USA.
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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3
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Trivin-Avillach C, Jaberi A, Henderson JM, Beck LH, Francis J. Eculizumab Use in Scleroderma Renal Crisis With Thrombotic Microangiopathy: A Case Report. Kidney Med 2024; 6:100753. [PMID: 38225975 PMCID: PMC10788495 DOI: 10.1016/j.xkme.2023.100753] [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] [Indexed: 01/17/2024] Open
Abstract
A Black woman in her 40s with past medical history significant for obesity treated with Roux-en-Y bypass surgery and a history of Raynaud's phenomenon, presented with acute pulmonary edema secondary to severe malignant hypertension and critically accelerated acute kidney injury, with evidence of systemic microangiopathic hemolytic anemia in the setting of clinical suspicion of systemic sclerosis sine scleroderma. Renin-angiotensin system blockade (angiotensin-converting enzyme inhibitor) was immediately started at the maximum possible dose in the setting of scleroderma renal crisis. Despite better control of blood pressure and volume status, kidney function continued to rapidly decline, thus a decision was made to go ahead with a kidney biopsy on day 3 of admission, which revealed severe features of scleroderma renal crisis with active thrombotic microangiopathy. The multidisciplinary team elected to treat the patient with terminal complement blockade using eculizumab in addition to high dose lisinopril and blood pressure control. Her serum creatinine peaked at 9.3 mg/dL shortly after eculizumab initiation, but improved soon after, dropping to 2.8 mg/dL after completion of the final eculizumab dose and 1.8 mg/dL 3 years later.
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Affiliation(s)
- Claire Trivin-Avillach
- Department of Pathology and Laboratory Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Aala Jaberi
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Joel M. Henderson
- Department of Pathology and Laboratory Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Laurence H. Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Jean Francis
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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4
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Siniard RC, Gangaraju R, May JE, Marques MB. Challenges in the diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:861-869. [PMID: 37767808 DOI: 10.1080/17474086.2023.2265058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/26/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Immune-mediated TTP (iTTP) is a rare condition without pathognomonic signs and symptoms. For this reason, the diagnosis of iTTP may be delayed or even missed, with potentially catastrophic consequences. AREAS COVERED The authors performed an extensive literature review on the diagnosis of iTTP and its challenges combined with their own experience in a referral center for patients with iTTP. EXPERT OPINION Although a definitive diagnosis of iTTP depends on the ADAMTS13 activity result, timely testing is rarely available at many centers to which patients present. If less complex tests were to become available, they would decrease the chances of late and/or missed diagnoses of iTTP throughout the world. While clinical scores to estimate the likelihood of iTTP exist, they are not well known, and can be misleading if used in the wrong context. Furthermore, the three scoring systems (PLASMIC, Bentley, and French) only moderately correlate with each other, which further complicates the landscape. The existence of these scores and how they should be used in practice is but one opportunity that can be seized through more robust programs to educate nonspecialist clinicians on how to recognize and treat patients with iTTP.
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Affiliation(s)
- Rance C Siniard
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Radhika Gangaraju
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jori E May
- Department of Medicine, Division of Hematology Oncology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marisa B Marques
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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5
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Postsurgical Thrombotic Microangiopathy and Deregulated Complement. J Clin Med 2022; 11:jcm11092501. [PMID: 35566627 PMCID: PMC9100095 DOI: 10.3390/jcm11092501] [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: 04/05/2022] [Revised: 04/17/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023] Open
Abstract
Postsurgical thrombotic microangiopathy (TMA) is a complication associated with significant morbidity and mortality. Still, the pathophysiological underlying mechanism of postsurgical TMA, a diagnosis often overlooked in postoperative patients with acute kidney injury and thrombocytopenia, is largely unknown. Here, we report the case of a 56-year-old male that developed anuric acute kidney injury, Coombs-negative hemolysis, and thrombocytopenia after surgical aortic arch replacement. Massive ex vivo complement activation on the endothelium, a rare complement gene variant in C2, at-risk haplotype MCPggaac, and excellent response to therapeutic complement inhibition, points to the pivotal role of complement in the pathophysiology of disease. Moreover, the importance of a multidisciplinary team approach in (postsurgical) thrombocytopenia is emphasized.
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Halimi JM, Thoreau B, von Tokarski F, Bauvois A, Gueguen J, Goin N, Barbet C, Cloarec S, Mérieau E, Lachot S, Garot D, Lemaignen A, Gyan E, Perrotin F, Pouplard C, Maillot F, Gatault P, Sautenet B, Rusch E, Frémeaux-Bacchi V, Vigneau C, Bayer G, Fakhouri F. What is the impact of blood pressure on neurological symptoms and the risk of ESKD in primary and secondary thrombotic microangiopathies based on clinical presentation: a retrospective study. BMC Nephrol 2022; 23:39. [PMID: 35057750 PMCID: PMC8781095 DOI: 10.1186/s12882-022-02672-3] [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: 04/15/2021] [Accepted: 01/05/2022] [Indexed: 12/26/2022] Open
Abstract
Abstract
Background
The impact of blood pressure on neurological symptoms and risk of end-stage kidney disease (ESKD) is unknown in primary and secondary thrombotic microangiopathies (TMAs).
Methods
We measured baseline systolic (SBP) and diastolic (DBP) BP in consecutive 563 patients with adjudicated primary and secondary TMAs, and assessed its association with the risk of ESKD.
Results
Normal BP, grade 1, 2 and 3 hypertension were present in 243 (43.1%), 132 (23.4%), 101 (17.9%) and 88 (15.6%), respectively.
Significant BP differences were noted in relation to the cause of TMA: highest BP values were found in patients with atypical hemolytic-uremic syndrome (aHUS), pregnancy, transplantation and auto-immune-related TMAs. Normal BP or grade 1 hypertension was found in 17/18 (94.4%) patients with thrombotic thrombocytopenic patients (only 1/18 (5.6%) had a SBP value>150 mmHg). In contrast, BP values could not differentiate isolated “essential” malignant hypertension (MH) from MH associated with aHUS (isolated MH (n=15): BP (median (IQR)): 220 (182-249)/132 (101-150) mmHg; MH with aHUS (n=5): BP: 223 (196-245)/131 (111-144) mmHg).
The risk of vigilance disturbances (6.9%, 15.0%, 25.0%, respectively), epileptic seizures (1.5%, 4.0%, 12.5%, respectively) and posterior reversible encephalopathy syndrome (0.76%, 2.97%, 6.82%, respectively) increased with increasing baseline BP values from grade 1 to grade 3 hypertension.
ESKD occurred in 35/563 (6.2%) patients (1.23%, 2.27%, 11.9% and 19.3% of patients with normal BP, grade 1, 2 and 3 hypertension, respectively). As compared to patients with normal BP (<120/139 mmHg), grade 1, grade 2 and grade 3 hypertension were associated with a greater risk of ESKD in univariate (OR: 1.91 [0.83-4.40], 13.2 [3.56-48.9] and 34.8 [9.31-130], respectively) and multivariate (OR: 0.89 [0.30-2.69], 7.00 [1.57-31.3] and 19.7 [4.53-85.2], respectively) analyses. The association between BP and the risk of ESRD was unchanged after adjustment on eculizumab use (OR: 3.46 [1.41-8.49], 17.7 [4.44-70.0] and 70.6 [8.61-579], respectively). Patients with MH, regardless of its cause, had a greater risk of ESKD (OR: 26.4 [10.0-69.8] vs other patients).
Conclusions
Baseline BP differs in primary and secondary TMAs. High BP reduces the neurological tolerance of TMAs and is a powerful independent risk factor of ESKD, even after adjustment on TMA’s cause.
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Thoreau B, von Tokarski F, Bauvois A, Bayer G, Barbet C, Cloarec S, Mérieau E, Lachot S, Garot D, Bernard L, Gyan E, Perrotin F, Pouplard C, Maillot F, Gatault P, Sautenet B, Rusch E, Frémeaux-Bacchi V, Vigneau C, Fakhouri F, Halimi JM. Infection in Patients with Suspected Thrombotic Microangiopathy Based on Clinical Presentation. Clin J Am Soc Nephrol 2021; 16:1355-1364. [PMID: 34497111 PMCID: PMC8729578 DOI: 10.2215/cjn.17511120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In contrast to shigatoxin-associated Escherichia coli (STEC) causing hemolytic uremic syndrome, STEC-unrelated infections associated with thrombotic microangiopathy are less characterized. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our retrospective study in a four-hospital institution of 530 consecutive patients with adjudicated thrombotic microangiopathies during the 2009-2016 period studied STEC-unrelated infections' epidemiology and major outcomes (death, acute dialysis, and major cardiovascular events). RESULTS STEC-unrelated infection was present in 145 of 530 (27%) patients, thrombotic microangiopathies without infection were present in 350 of 530 (66%) patients, and STEC causing hemolytic and uremic syndrome was present in 35 of 530 (7%) patients. They (versus thrombotic microangiopathy without infection) were associated with age >60 years (36% versus 18%), men (53% versus 27%), altered consciousness (32% versus 11%), mean BP <65 mm Hg (21% versus 4%), lower hemoglobin and platelet count, and AKI (72% versus 49%). They were associated with more than one pathogen in 36 of 145 (25%) patients (either isolated [14%] or combined [86%] to other causes of thrombotic microangiopathy); however, no significant clinical or biologic differences were noted between the two groups. They were more frequently due to bacteria (enterobacteria [41%], Staphylococcus aureus [11%], and Streptococcus pneumonia [3%]) than viruses (Epstein-Barr [20%], cytomegalovirus [18%], influenza [3%], hepatitis C [1%], HIV [1%], and rotavirus [1%]). STEC-unrelated infections were independent risk factors for in-hospital death (odds ratio, 2.22; 95% confidence interval, 1.18 to 4.29), major cardiovascular event (odds ratio, 3.43; 95% confidence interval, 1.82 to 6.69), and acute dialysis (odds ratio, 3.48; 95% confidence interval, 1.78 to 7.03). Bacteria (versus other pathogens), and among bacteria, enterobacteria, presence of more than one bacteria, and E. coli without shigatoxin were risk factors for acute dialysis. CONCLUSIONS Infections are frequent thrombotic microangiopathy triggers or causes, and they are mostly unrelated to STEC. Infections convey a higher risk of death and major complications. The most frequent pathogens were enterobacteria, S. aureus, Epstein-Barr virus, and cytomegalovirus. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_09_07_CJN17511120.mp3.
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Affiliation(s)
- Benjamin Thoreau
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Florent von Tokarski
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Adeline Bauvois
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Guillaume Bayer
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Christelle Barbet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Sylvie Cloarec
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Elodie Mérieau
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France
| | - Sébastien Lachot
- Service d'Hématologie Biologique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Denis Garot
- Service de Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Louis Bernard
- Service de Maladies Infectieuses, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Emmanuel Gyan
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHU Tours, Equipe de recherche Labellisée, Centre National pour le Recherche Scientifique 7001, Université de Tours, Tours, France
| | - Franck Perrotin
- Service de Gynécologie Obstétrique B. Maternité Olympe de Gouges, Hôpital Bretonneau, CHU Tours, Tours, France.,Institut National de la Santé et de la Recherche Médicale U1253 Imaging and Brain (iBrain), Université de Tours, Tours, France
| | - Claire Pouplard
- Service d'Hématologie-Hémostase, Hôpital Trousseau, CHU Tours, Tours, France.,EA7501, François-Rabelais University, Tours, France
| | - François Maillot
- Service de Médecine interne, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Philippe Gatault
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France.,EA4245, François-Rabelais University, Tours, France
| | - Bénédicte Sautenet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France.,Institut National de la Santé et de la Recherche Médicale U1246 the methodS in Patient-centered outcomes and HEalth ResEarch, Université de Tours, Université de Nantes, Tours, France
| | - Emmanuel Rusch
- Laboratoire de Santé Publique, Hôpital Bretonneau, CHU Tours, Tours, France
| | | | - Cécile Vigneau
- CHU Pontchaillou, Service de Néphrologie, Rennes, France.,Université Rennes 1, Institut National de la Santé et de la Recherche Médicale Institut de Recherche en Santé, environnement et Travail, Unité Mixte de Recherche 1085, Rennes, France
| | - Fadi Fakhouri
- Service of Nephrology, Department of Medicine, Centre Hospitalier Universitaire Vaudois and Université de Lausanne, Lausanne, Switzerland
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, Néphrologie Pédiatrique, Hôpital Bretonneau et Hôpital Clocheville, Centre Hospitalier Universitaire (CHU) Tours, Tours, France et French Clinical Research Network Infrastructure-Cardiovascular and Renal Clinical Trialists, Tours, France .,EA4245, François-Rabelais University, Tours, France
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8
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Neves PDMDM, Souza RA, Torres FM, Reis FA, Pinheiro RB, Dias CB, Yu L, Woronik V, Furukawa LS, Cavalcante LB, de Almeida Araújo S, Wanderley DC, Malheiros DM, Jorge LB. Evidences of histologic thrombotic microangiopathy and the impact in renal outcomes of patients with IgA nephropathy. PLoS One 2020; 15:e0233199. [PMID: 33147224 PMCID: PMC7641451 DOI: 10.1371/journal.pone.0233199] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/30/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION IgA nephropathy (IgAN) is the most common primary glomerulopathy worldwide. According to the Oxford Classification, changes in the kidney vascular compartment are not related with worse outcomes. This paper aims to assess the impact of thrombotic microangiopathy (TMA) in the outcomes of Brazilian patients with IgAN. MATERIALS AND METHODS Analysis of clinical data and kidney biopsy findings from patients with IgAN to assess the impact of TMA on renal outcomes. RESULTS The majority of the 118 patients included were females (54.3%); mean age of 33 years (25;43); hypertension and hematuria were observed in 67.8% and 89.8%, respectively. Median creatinine: 1.45mg/dL; eGFR: 48.8ml/min/1.73m2; 24-hour proteinuria: 2.01g; low serum C3: 12.5%. Regarding to Oxford Classification: M1: 76.3%; E1: 35.6%; S1: 70.3%; T1/T2: 38.3%; C1/C2: 28.8%. Average follow-up: 65 months. Histologic evidence of TMA were detected in 21 (17.8%) patients and those ones presented more frequently hypertension (100% vs. 61%, p <0.0001), hematuria (100% vs 87.6%, p = 0.0001), worse creatinine levels (3.8 vs. 1.38 mg/dL, p = 0.0001), eGFR (18 vs. 60 ml/min/1.73m2), p = 0.0001), low serum C3 (28.5% vs. 10.4%, p = 0.003), lower hemoglobin levels (10.6 vs. 12.7g/dL, p<0.001) and platelet counts (207,000 vs. 267,000, p = 0.001). Biopsy findings of individuals with TMA revealed only greater proportions of E1 (68% vs. 32%, p = 0.002). Individuals with TMA were followed for less time (7 vs. 65 months, p<0.0001) since they progressed more frequently to chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) (71.4% vs. 21,6%, p<0.0001). Male sex, T1/T2, and TMA were independently associated with progression to CKD-KRT. CONCLUSIONS In this study patients with TMA had worse clinical manifestations and outcomes. In terms of histologic evidence, E1 distinguished patients with TMA from other patients. Further studies are necessary to analyze the impact of vascular lesions on IgAN prognosis.
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Affiliation(s)
| | - Rafael A. Souza
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Fábio M. Torres
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Fábio A. Reis
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Rafaela B. Pinheiro
- Pathology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Cristiane B. Dias
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Luis Yu
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Viktoria Woronik
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Luzia S. Furukawa
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Lívia B. Cavalcante
- Pathology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Stanley de Almeida Araújo
- Nephropathology Institute, Belo Horizonte, MG, Brazil
- Pathology Division, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - David Campos Wanderley
- Nephropathology Institute, Belo Horizonte, MG, Brazil
- Pathology Division, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Denise M. Malheiros
- Pathology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Lectícia B. Jorge
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
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9
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Godara A, Migliozzi DR, Pilichowska M, Goyal N, Varga C, Gordon CE. Use of Eculizumab in Transplant-Associated Thrombotic Microangiopathy in a Patient With Polycystic Kidney Disease Immediately Post-Kidney Transplant: A Case Report. Kidney Med 2020; 2:652-656. [PMID: 33089142 PMCID: PMC7568057 DOI: 10.1016/j.xkme.2020.06.007] [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] [Indexed: 02/06/2023] Open
Abstract
Transplant-associated thrombotic microangiopathy (TMA) in the post-organ transplantation setting occurs from a number of potential inciting factors, such as the use of calcineurin inhibitors, ischemic injury, infections, or antibody-mediated rejection leading to unchecked complement activation and end-organ damage. Delayed recognition of this condition can result in allograft loss. In this case description, we describe the first case of de novo TMA in a patient with polycystic kidney disease that occurred immediately after kidney transplantation. The diagnosis was made promptly on the basis of clinical and laboratory characteristics by a multidisciplinary team and confirmed through kidney biopsy, which showed acute TMA. The patient was successfully managed by replacing tacrolimus with belatacept, which targets cytotoxic T lymphocyte antigen 4, and use of eculizumab, a C5 inhibitor. Eculizumab treatment was discontinued after 3 months of complement inhibition on the patient's request, and relapse of TMA has not been encountered after more than 1 year of follow-up.
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Affiliation(s)
- Amandeep Godara
- Department of Hematology-Oncology, Tufts Medical Center, Boston, MA
| | - Daniel R Migliozzi
- Kidney Transplant Team, Division of Nephrology, Tufts Medical Center, Boston, MA
| | | | - Nitender Goyal
- Kidney Transplant Team, Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Cindy Varga
- Department of Hematology-Oncology, Tufts Medical Center, Boston, MA
| | - Craig E Gordon
- Division of Nephrology, Tufts Medical Center, Boston, MA
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10
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Raina R, Grewal MK, Radhakrishnan Y, Tatineni V, DeCoy M, Burke LLG, Bagga A. Optimal management of atypical hemolytic uremic disease: challenges and solutions. Int J Nephrol Renovasc Dis 2019; 12:183-204. [PMID: 31564951 PMCID: PMC6732511 DOI: 10.2147/ijnrd.s215370] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a chronic life threatening condition that arises from genetic abnormalities resulting in uncontrolled complement amplifying activity. The introduction of eculizumab, the humanized monoclonal antibody, has brought about a paradigm shift in the management of aHUS. However, there are many knowledge gaps, diagnostic issues, access and cost issues, and patient or physician challenges associated with the use of this agent. Limited data on the natural history of aHUS along with the underlying genetic mutations make it difficult to predict the relapses and thereby raising concerns about the appropriate duration and monitoring of treatment. In this review, we discuss the safety and efficacy of eculizumab in patients with aHUS and its associated challenges.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | - Manpreet K Grewal
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | | | - Vineeth Tatineni
- Department of Internal Medicine, Summa Health, Akron City Hospital, Akron, OH, USA
| | - Meredith DeCoy
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Linda LG Burke
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Arvind Bagga
- Division of Paediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
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11
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Singh P, Chen H, Gordon CE, Ghai S, Sloan JM, Quillen K, Moradi S, Chitalia V, Gautam A, Henderson J, Francis JM. Monoclonal IgG4/2κ Deposition Following Eculizumab Therapy for Recurrent Atypical Hemolytic Uremic Syndrome in Kidney Transplantation. Kidney Med 2019; 1:139-143. [PMID: 32734194 PMCID: PMC7380410 DOI: 10.1016/j.xkme.2019.03.005] [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] [Indexed: 11/08/2022] Open
Abstract
Eculizumab is an emerging therapy for atypical hemolytic uremic syndrome (aHUS). Early identification and treatment of recurrent aHUS after kidney transplantation requires a high clinical suspicion but results in improved graft function and patient outcome. We present a patient who developed recurrent aHUS after kidney transplantation that responded to eculizumab therapy. A kidney biopsy was performed to confirm resolution of thrombotic microangiopathy 8 weeks after eculizumab treatment initiation and revealed no features of thrombotic microangiopathy. Instead, the biopsy revealed monoclonal immunoglobulin G (IgG)4/2κ deposition in the glomerular tufts, vasculature, and atrophic tubular basement membranes. IgG4/2κ deposits are a rare pathologic finding following eculizumab therapy, and the long-term effect of these deposits on kidney function remains unknown.
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Affiliation(s)
- Priyamvada Singh
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA.,Transplant Nephrology Section, Department of Medicine, Ohio State University, Columbus, OH
| | - Hui Chen
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, MA
| | - Craig E Gordon
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Sandeep Ghai
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - J Mark Sloan
- Hematology, Oncology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Karen Quillen
- Hematology, Oncology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Sara Moradi
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, MA
| | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA.,Whitaker Institute, Boston University School of Medicine, Boston, MA
| | - Amitabh Gautam
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Joel Henderson
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, MA
| | - Jean M Francis
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston, MA
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12
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Bayer G, von Tokarski F, Thoreau B, Bauvois A, Barbet C, Cloarec S, Mérieau E, Lachot S, Garot D, Bernard L, Gyan E, Perrotin F, Pouplard C, Maillot F, Gatault P, Sautenet B, Rusch E, Buchler M, Vigneau C, Fakhouri F, Halimi JM. Etiology and Outcomes of Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2019; 14:557-566. [PMID: 30862697 PMCID: PMC6450353 DOI: 10.2215/cjn.11470918] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 02/04/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Thrombotic microangiopathies constitute a diagnostic and therapeutic challenge. Secondary thrombotic microangiopathies are less characterized than primary thrombotic microangiopathies (thrombotic thrombocytopenic purpura and atypical hemolytic and uremic syndrome). The relative frequencies and outcomes of secondary and primary thrombotic microangiopathies are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective study in a four-hospital institution in 564 consecutive patients with adjudicated thrombotic microangiopathies during the 2009-2016 period. We estimated the incidence of primary and secondary thrombotic microangiopathies, thrombotic microangiopathy causes, and major outcomes during hospitalization (death, dialysis, major cardiovascular events [acute coronary syndrome and/or acute heart failure], and neurologic complications [stroke, cognitive impairment, or epilepsy]). RESULTS We identified primary thrombotic microangiopathies in 33 of 564 patients (6%; thrombotic thrombocytopenic purpura: 18 of 564 [3%]; atypical hemolytic and uremic syndrome: 18 of 564 [3%]). Secondary thrombotic microangiopathies were found in 531 of 564 patients (94%). A cause was identified in 500 of 564 (94%): pregnancy (35%; 11 of 1000 pregnancies), malignancies (19%), infections (33%), drugs (26%), transplantations (17%), autoimmune diseases (9%), shiga toxin due to Escherichia coli (6%), and malignant hypertension (4%). In the 31 of 531 patients (6%) with other secondary thrombotic microangiopathies, 23% of patients had sickle cell disease, 10% had glucose-6-phosphate dehydrogenase deficiency, and 44% had folate deficiency. Multiple causes of thrombotic microangiopathies were more frequent in secondary than primary thrombotic microangiopathies (57% versus 19%; P<0.001), and they were mostly infections, drugs, transplantation, and malignancies. Significant differences in clinical and biologic differences were observed among thrombotic microangiopathy causes. During the hospitalization, 84 of 564 patients (15%) were treated with dialysis, 64 of 564 patients (11%) experienced major cardiovascular events, and 25 of 564 patients (4%) had neurologic complications; 58 of 564 patients (10%) died, but the rates of complications and death varied widely by the cause of thrombotic microangiopathies. CONCLUSIONS Secondary thrombotic microangiopathies represent the majority of thrombotic microangiopathies. Multiple thrombotic microangiopathies causes are present in one half of secondary thrombotic microangiopathies. The risks of dialysis, neurologic and cardiac complications, and death vary by the cause of thrombotic microangiopathies.
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Affiliation(s)
- Guillaume Bayer
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | - Florent von Tokarski
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | - Benjamin Thoreau
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | - Adeline Bauvois
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | - Christelle Barbet
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | - Sylvie Cloarec
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | - Elodie Mérieau
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
| | | | - Denis Garot
- Service de Médecine Intensive Réanimation, Hôpital Bretonneau
| | - Louis Bernard
- Service de Maladies Infectieuses, Hôpital Bretonneau
| | - Emmanuel Gyan
- Service d’Hématologie et Thérapie Cellulaire, Hôpital Bretonneau
- Équipe de Recherche Labellisée Centre National de la Recherche Scientifique 7001, Université de Tours, Tours, France
| | | | - Claire Pouplard
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau
- Équipe d'accueil7501 and
| | | | - Philippe Gatault
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
- Équipe d'accueil4245, François Rabelais University, Tours, France
| | - Bénédicte Sautenet
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
- Institut National de la Santé et de la Recherche Médicale U1246, Hôpital Bretonneau, and
| | - Emmanuel Rusch
- Laboratoire de Santé Publique, Hôpital Bretonneau, Centre Hospitalier Universitaire Tours, Tours, France
| | - Matthias Buchler
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
- Équipe d'accueil4245, François Rabelais University, Tours, France
| | - Cécile Vigneau
- Centre Hospitalier Universitaire Pontchaillou, Service de Néphrologie, Rennes, France
- Université Rennes 1, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1085, Rennes, France; and
| | - Fadi Fakhouri
- Centre de recherche en Transplantation et immunologie, Unité Mixte de Recherche 1064, Institut National de la Santé et de la Recherche Médicale, Université de Nantes et département de Néphrologie et Immunologie, Centre Hospitalier Universitaire Nantes, Nantes, France
| | - Jean-Michel Halimi
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau et hôpital Clocheville
- Équipe d'accueil4245, François Rabelais University, Tours, France
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Romero S, Sempere A, Gómez-Seguí I, Román E, Moret A, Jannone R, Moreno I, Mendizábal S, Espí J, Peris A, Carbonell R, Cervera J, Pemán J, Bonanad S, de la Rubia J, Jarque I. Guía práctica de tratamiento urgente de la microangiopatía trombótica. Med Clin (Barc) 2018. [DOI: 10.1016/j.medcli.2018.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Severe renal failure and thrombotic microangiopathy induced by malignant hypertension successfully treated with spironolactone. Ann Cardiol Angeiol (Paris) 2018; 67:208-214. [PMID: 29753419 DOI: 10.1016/j.ancard.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 11/23/2022]
Abstract
Malignant hypertension can cause thrombotic microangiopathy (TMA) characterized by hemolytic anemia and thrombocytopenia. On the other hand, severe hypertension is sometimes associated with hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). Distinguishing these entities is important because of therapeutic implications. Plasmapheresis should be initiated as soon as possible if we are dealing with TTP. We describe the case of a 30-year-old man referred to our hospital with malignant hypertension, severe renal failure and TMA: haemoglobin=9g/dL, total bilirubin=0.4mg/dL, haptoglobin≤10mg/dL, platelet count=59,000/μL and schistocytes on peripheral smear. He required initiation of hemodialysis. Additionally, we considered that the possible cause of TMA was malignant hypertension according to the presence of hypertensive retinopathy and thrombocytopenia which remitted only with blood pressure control, hence, plasmapheresis was not given. Renal function did not improve and the patient remained chronic hemodialysis. Intensive therapy for hypertension with a combination of antihypertensive drugs including spironolactone successfully lowered his blood pressure without developing hyperkalemia.
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Yıldız S, Demirkan F. What is the evidence for the role of therapeutic apheresis in the management of complement-associated thrombotic microangiopathies? Transfus Apher Sci 2018; 57:31-34. [PMID: 29506907 DOI: 10.1016/j.transci.2018.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMAs) are disorders characterized by endothelial cell activation, microangiopathic hemolytic anemia, thrombocytopenia and organ failure of variable intensity. The pathophysiology of various types of TMAs have become an interesting field of study. Alternative complement system activation plays an important role in several pathophysiological conditions. Complement activation is also described in an increasing number of TMAs. Inherited defects in complement regulatory genes and acquired autoantibodies against complement regulatory proteins have been described. Atypical hemolytic uremic synrome (HUS) is caused by uncontrolled activation of the alternative complement system, now called complement-mediated TMAs. Recently, application of a monoclonal antibody that specifically binds to C5 became available to treat patients with complement-mediated TMAs. Eculizumab is a humanized monoclonal antibody that blocks complement C5 activation. Empiric therapeutic apheresis is also recommended in all forms of complement-mediated TMAs. The justification for therapeutic apheresis use in all forms of complement-mediated TMAs is that it can effectively remove the autoantibodies or mutated circulating complement regulators while replacing absent or defective complement regulators. Currently, therapeutic apheresis and eculizumab are the available treatment options for complement-mediated TMAs. In this paper, we review the evidence for the role of therapeutic apheresis in the management of complement-associated TMAs.
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Affiliation(s)
- Serkan Yıldız
- Dokuz Eylul University, Division of Nephrology, Department of Internal Medicine, Izmir, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University, Division of Hematology, Department of Internal Medicine, 35340, Inciralti, Izmir, Turkey.
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