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Duineveld C, Glover EK, Bouwmeester RN, van de Kar NCAJ, Kavanagh D, Wetzels JFM, Sheerin NS. Kidney Transplantation in Patients With aHUS: A Comparison of Eculizumab Prophylaxis Versus Rescue Therapy. Transplantation 2024:00007890-990000000-00827. [PMID: 39049128 DOI: 10.1097/tp.0000000000005135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND Guidelines advise eculizumab prophylaxis for most kidney transplant recipients with atypical hemolytic uremic syndrome (aHUS). However, recurrence rates may be overestimated, and starting eculizumab at relapse ("rescue therapy") may prevent graft loss. Randomized controlled trials have not compared the efficacy, safety, and costs of different treatment strategies. We performed a comparative study, including a previously described Dutch cohort treated with rescue therapy and a UK cohort using eculizumab prophylaxis. METHODS In the Netherlands, we selected all adult patients with aHUS who received a kidney transplant between 2010 and 2021 in the Radboud University Medical Center (n = 30) and enriched this cohort with 8 patients who received rescue therapy in other centers. The UK cohort included all adult patients with aHUS at moderate or high risk of recurrence, transplanted between 2013 and 2017 with prophylactic eculizumab. RESULTS We included 38 Dutch patients and 35 UK patients. Characteristics were comparable, although the UK cohort included more patients with a complement factor H SCR20 mutation or hybrid gene (31% versus 5%; P < 0.01), and more Dutch patients received living donor kidneys (66% versus 20%; P < 0.001). Follow-up was comparable (the Dutch patients 70.8 mo, range, 10-134; UK patients 55.4 mo, range, 2-95). Eighteen (47%) Dutch patients received rescue therapy. Death-censored graft survival was not significantly different (the Dutch patients 1 y, 3 y, and 6 y: 97.4%, 91.2%, and 87.1%, respectively; UK patients 1 y, 3 y, and 6 y: 97.1%, 88.2%, and 65.6%, respectively, log-rank P = 0.189). CONCLUSIONS In a population characterized by low prevalence of "very high risk" genes, who were predominantly transplanted using an endothelial protective regime, death-censored graft survival with eculizumab rescue therapy was not inferior to prophylaxis.
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Affiliation(s)
- Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Radboudumc Research Institute, Nijmegen, Gelderland, the Netherlands
| | - Emily K Glover
- National Renal Complement Therapeutics Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Romy N Bouwmeester
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Radboudumc Research Institute, Nijmegen, Gelderland, the Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Radboudumc Research Institute, Nijmegen, Gelderland, the Netherlands
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboudumc Research Institute, Nijmegen, Gelderland, the Netherlands
| | - Neil S Sheerin
- National Renal Complement Therapeutics Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
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Imanifard Z, Liguori L, Remuzzi G. TMA in Kidney Transplantation. Transplantation 2023; 107:2329-2340. [PMID: 36944606 DOI: 10.1097/tp.0000000000004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Thrombotic microangiopathy (TMA) is a rare and devastating complication of kidney transplantation, which often leads to graft failure. Posttransplant TMA (PT-TMA) may occur either de novo or as a recurrence of the disease. De novo TMA can be triggered by immunosuppressant drugs, antibody-mediated rejection, viral infections, and ischemia/reperfusion injury in patients with no evidence of the disease before transplantation. Recurrent TMA may occur in the kidney grafts of patients with a history of atypical hemolytic uremic syndrome (aHUS) in the native kidneys. Studies have shown that some patients with aHUS carry genetic abnormalities that affect genes that code for complement regulators (CFH, MCP, CFI) and components (C3 and CFB), whereas in 10% of patients (mostly children), anti-FH autoantibodies have been reported. The incidence of aHUS recurrence is determined by the underlying genetic or acquired complement abnormality. Although treatment of the causative agents is usually the first line of treatment for de novo PT-TMA, this approach might be insufficient. Plasma exchange typically resolves hematologic abnormalities but does not improve kidney function. Targeted complement inhibition is an effective treatment for recurrent TMA and may be effective in de novo PT-TMA as well, but it is necessary to establish which patients can benefit from different therapeutic options and when and how these can be applied.
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Affiliation(s)
- Zahra Imanifard
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
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3
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Balwani MR, Pasari AS, Bawankule C, Bhawane A, Tolani P, Katekhaye VM. ABO Incompatible Kidney Transplant in a Patient With Atypical Hemolytic Uremic Syndrome: Case Report. Transplant Proc 2023; 55:1913-1916. [PMID: 37451872 DOI: 10.1016/j.transproceed.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Abstract
Kidney transplant (KT) or renal transplant is 1 of the preferred treatment options for patients with end-stage renal disease, but the presence of atypical hemolytic uremic syndrome (aHUS) further increases the risk of reoccurrence with graft rejection, and poor outcomes. ABO incompatibility further adds to the rejection risk. Here, we present a case of a young adult with a history of aHUS undergoing a successful ABO-incompatible (ABOi) renal transplant. ABO incompatibility desensitization was carried out, and the antibody titer was reduced to nullify the risk of rejection. Graft acceptance was facilitated by triple immunosuppression (steroid, tacrolimus, and mycophenolate mofetil), and 4-month serum creatinine follow-up indicated the absence of antibody-mediated rejection and recurrence of aHUS. This case demonstrates that in patients with aHUS, ABOi renal transplant can be performed successfully.
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Affiliation(s)
- Manish R Balwani
- Department of Nephrology, Saraswati Kidney Care Center, Nagpur, India; Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, Wardha, India.
| | - Amit S Pasari
- Department of Nephrology, Saraswati Kidney Care Center, Nagpur, India; Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, Wardha, India
| | | | - Amol Bhawane
- Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Nagpur, India
| | - Priyanka Tolani
- Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, Wardha, India
| | - Vijay M Katekhaye
- Department of Clinical Research, Saraswati Kidney Care Center, Nagpur, India; Avanvi Research and Technologies Pvt. Ltd, Nagpur, India
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4
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Lim MA, Bloom RD. How to maximize graft survival. Curr Opin Organ Transplant 2023; 28:55-63. [PMID: 36579685 DOI: 10.1097/mot.0000000000001039] [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: 12/30/2022]
Abstract
PURPOSE OF REVIEW Kidney transplant failure results in significant patient morbidity and mortality, increased financial burden and exacerbates the organ shortage faced by kidney transplant candidates. The different strategies to maximize graft survival in kidney transplant recipients is presented in this review. RECENT FINDINGS Maximizing kidney graft survival requires optimizing immunosuppression, preventing and managing recurrent disease and using general chronic kidney disease strategies to slow allograft injury. Herein, we review: 1) strategies to tailor immunosuppression to the individual patient to avoid over and underimmunosuppression, and avoid immunosuppression-related drug toxicities, 2) latest findings in the following recurrent diseases: focal segmental glomerulosclerosis, membranous nephropathy, complement-mediated kidney disease and monoclonal gammopathy of renal significance, and, 3) approaches to slow allograft injury including BP control, and the use of antiproteinuric agents and SGLT-2 inhibitors. SUMMARY The last two decades has seen significant improvement in allograft outcomes resulting from advances in immunosuppression. With the federal government's renewed focus on kidney disease and transplantation, and recent advances in biomarkers, genetic testing, big data analytics and machine learning, we hope to see further outcome improvements in the next decade.
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Affiliation(s)
- Mary Ann Lim
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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5
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Eculizumab Rescue Therapy in Patients with Recurrent Atypical Hemolytic Uremic Syndrome After Kidney Transplantation. Kidney Int Rep 2023; 8:715-726. [PMID: 37069997 PMCID: PMC10105043 DOI: 10.1016/j.ekir.2023.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
Introduction Since 2016, kidney transplantation in patients with atypical hemolytic uremic syndrome (aHUS) in the Netherlands is performed without eculizumab prophylaxis. Eculizumab is given in case of posttransplant aHUS recurrence. Eculizumab therapy is monitored in the CUREiHUS study. Methods All participating kidney transplant patients who received eculizumab therapy for a suspected posttransplant aHUS recurrence were evaluated. Overall recurrence rate was monitored prospectively at Radboud University Medical Center. Results In the period from January 2016 until October 2020, we included 15 (12 females, 3 males; median age 42 years, range 24-66 years) patients with suspected aHUS recurrence after kidney transplantation in this study. The time interval to recurrence showed a bimodal distribution. Seven patients presented early after transplantation (median 3 months, range 0.3-8.8 months), with typical aHUS features: rapid loss of estimated glomerular filtration rate (eGFR) and laboratory signs of thrombotic microangiopathy (TMA). Eight patients presented late (median 46 months, range 18-69 months) after transplantation. Of these, only 3 patients had systemic TMA, whereas 5 patients presented with slowly deteriorating eGFR without systemic TMA. Treatment with eculizumab resulted in improvement or stabilization of eGFR in 14 patients. Eculizumab discontinuation was tried in 7 patients; however, it was successful only in 3. At the end of the follow-up (median 29 months, range 3-54 months after start of eculizumab), 6 patients had eGFR <30 ml/min per 1.73 m2. Graft loss had occurred in 3 of them. Overall, aHUS recurrence rate without eculizumab prophylaxis was 23%. Conclusions Rescue treatment of posttransplant aHUS recurrence is effective; however, some patients suffer from irreversible loss of kidney function, likely caused by delayed diagnosis and treatment and/or too aggressive discontinuation of eculizumab. Physicians should be aware that recurrence of aHUS can present without evidence of systemic TMA.
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6
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Htet Z, Karim M. Thrombotic microangiopathy with renal injury: an approach for the general physician. J R Coll Physicians Edinb 2021; 50:25-31. [PMID: 32539032 DOI: 10.4997/jrcpe.2020.107] [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] [Indexed: 11/19/2022] Open
Abstract
Thrombotic microangiopathy with renal dysfunction is a haematological and renal emergency warranting urgent diagnosis and intervention. As the potential underlying causes may be complex, assessment and management can be challenging for treating clinicians, and a timely and collaborative approach between general physicians, haematologists and nephrologists may be extremely helpful in order to optimise clinical outcomes. This paper will aim to build an understanding of different potential presentations of thrombotic microangiopathies and provide a practical framework for diagnosis and management, using a case-based discussion format, for acute and general physicians. Some aspects of subsequent specialist management are also discussed.
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Affiliation(s)
- Zay Htet
- Department of Renal Medicine, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK,
| | - Mahzuz Karim
- Department of Renal Medicine, Norfolk and Norwich University Hospital, Norwich, UK
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7
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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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8
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Makatsariya AD, Slukhanchuk EV, Bitsadze VO, Khizroeva JKH, Tretyakova MV, Tsibizova VI, Elalamy I, Gris JC, Grandone E, Makatsariya NA, Mashkova T. Thrombotic microangiopathy, DIC-syndrome and COVID-19: link with pregnancy prothrombotic state. J Matern Fetal Neonatal Med 2020; 35:2536-2544. [PMID: 32627622 DOI: 10.1080/14767058.2020.1786811] [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] [Indexed: 12/21/2022]
Abstract
For last months, humanity has faced a formidable unknown enemy, which is presented as a new coronavirus infection. Despite the fact that the causative agents of new diseases appear at a certain frequency and that the virus SARS-CoV-2 has certain common properties with its predecessors, at the moment we are dealing with a new unknown pathogenesis of the development of severe complications in patients with risk factors. A final understanding of pathological process mechanisms is the goal of the scientific community. Summarizing research data from different countries, it became obvious that in severe cases of viral infection, we are dealing with a combination of the systemic inflammatory response syndrome, disseminated intravascular coagulation and thrombotic microangiopathy (TMA). Thrombotic microangiopathy is represented by a group of different conditions in which thrombocytopenia, hemolytic anemia, and multiple organ failure occur. The article reflects the main types of TMA, pathogenesis and principles of therapy. The main participants in the process are described in detail, including the von Willebrand factor and ADAMTS-13. Based on the knowledge available, as well as new data obtained from patients with COVID-19, we proposed possible models for the implementation of conditions such as sepsis, TMA, and DIC in patients with severe new coronavirus infection. Through a deeper understanding of pathogenesis, it will be possible to develop more effective diagnosis and therapy.
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Affiliation(s)
- A D Makatsariya
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia
| | - E V Slukhanchuk
- Head of Gynecology Unit, Petrovsky National Research Center of Surgery, Moscow, Russia
| | - V O Bitsadze
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia
| | - J K H Khizroeva
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia
| | - M V Tretyakova
- Gynecology Department, «Medical Center» LLC, Moscow, Russia
| | - V I Tsibizova
- Almazov National Medical Research Centre, Saint Petersburg, Health Ministry of Russian Federation, Saint Petersburg, Russia
| | - I Elalamy
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia.,Director of Hematology Department of Thrombosis Center, Medicine Sorbonne University, Paris, France
| | - J-C Gris
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia.,University Montpellier, Montpellier, France
| | - E Grandone
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia.,Hemostasis and Thrombosis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Puglia, Italy
| | - N A Makatsariya
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia
| | - T Mashkova
- Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, (Sechenov University), Moscow, Russia
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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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10
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Siedlecki AM, Isbel N, Vande Walle J, James Eggleston J, Cohen DJ. Eculizumab Use for Kidney Transplantation in Patients With a Diagnosis of Atypical Hemolytic Uremic Syndrome. Kidney Int Rep 2019; 4:434-446. [PMID: 30899871 PMCID: PMC6409407 DOI: 10.1016/j.ekir.2018.11.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/05/2018] [Accepted: 11/19/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Recurrence of atypical hemolytic uremic syndrome (aHUS) in renal allografts is common, leading to dialysis and graft failure. Pretransplant versus posttransplant initiation of eculizumab treatment in patients with aHUS has not been rigorously investigated. We hypothesized eculizumab pretransplant would reduce dialysis incidence posttransplant. METHODS Of patients enrolled in the Global aHUS Registry (n = 1549), 344 had ≥1 kidney transplant. Of these, 188 had received eculizumab. Eighty-eight patients (47%) were diagnosed with aHUS and received eculizumab before, and during, their most recent transplant (group 1). A total of 100 patients (53%; group 2) initiated eculizumab posttransplantation. This second group was subdivided into those diagnosed with aHUS before (n = 52; group 2a) or after (n = 48; group 2b) their most recent transplant. RESULTS Within 5 years of transplantation, 47 patients required dialysis; the risk of dialysis after transplantation was significantly increased in group 2b (hazard ratio [HR] 4.6; confidence interval [CI] 1.7-12.4) but not 2a (HR 2.3; CI 0.9-6.2). Graft function within 6 months of transplantation was significantly better in group 1 (median estimated glomerular filtration rate of 60.6 ml/min per 1.73 m2) compared with 31.5 and 9.6 ml/min per 1.73 m2 in groups 2a (P = 0.004) and 2b (P = 0.0001), respectively. One meningococcal infection (resolved with treatment) and 3 deaths (deemed unrelated to eculizumab) were reported. CONCLUSIONS Outcomes for transplant patients with aHUS treated with eculizumab were improved compared with previous reports of patients with aHUS not treated with eculizumab. Our findings suggest delayed aHUS diagnosis and therefore treatment is associated with an increased risk of dialysis posttransplantation and reduced allograft function.
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Affiliation(s)
| | - Nicole Isbel
- The University of Queensland and Princess Alexandra Hospital, Brisbane, Australia
| | | | | | - David J. Cohen
- Columbia University Medical Center, New York, New York, USA
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11
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De Novo Atypical Haemolytic Uremic Syndrome after Kidney Transplantation. Case Rep Nephrol 2018; 2018:1727986. [PMID: 29732228 PMCID: PMC5872611 DOI: 10.1155/2018/1727986] [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: 11/15/2017] [Revised: 01/23/2018] [Accepted: 02/14/2018] [Indexed: 11/29/2022] Open
Abstract
De novo thrombotic microangiopathy (TMA) can occur after kidney transplantation. An abnormality of the alternative pathway of complement must be suspected and searched for, even in presence of a secondary cause. We report the case of a 23-year-old female patient who was transplanted with a kidney from her mother for end-stage renal disease secondary to Hinman syndrome. Early after transplantation, she presented with 2 episodes of severe pyelonephritis, associated with acute kidney dysfunction and biological and histological features of TMA. Investigations of the alternative pathway of the complement system revealed atypical haemolytic uremic syndrome secondary to complement factor I mutation, associated with mutations in CD46 and complement factor H related protein genes. Plasma exchanges followed by eculizumab injections allowed improvement of kidney function without, however, normalization of creatinine.
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