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Kesarwani V, Bukhari MH, Kahlenberg JM, Wang S. Urinary complement biomarkers in immune-mediated kidney diseases. Front Immunol 2024; 15:1357869. [PMID: 38895123 PMCID: PMC11184941 DOI: 10.3389/fimmu.2024.1357869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/09/2024] [Indexed: 06/21/2024] Open
Abstract
The complement system, an important part of the innate system, is known to play a central role in many immune mediated kidney diseases. All parts of the complement system including the classical, alternative, and mannose-binding lectin pathways have been implicated in complement-mediated kidney injury. Although complement components are thought to be mainly synthesized in the liver and activated in the circulation, emerging data suggest that complement is synthesized and activated inside the kidney leading to direct injury. Urinary complement biomarkers are likely a better reflection of inflammation within the kidneys as compared to traditional serum complement biomarkers which may be influenced by systemic inflammation. In addition, urinary complement biomarkers have the advantage of being non-invasive and easily accessible. With the rise of therapies targeting the complement pathways, there is a critical need to better understand the role of complement in kidney diseases and to develop reliable and non-invasive biomarkers to assess disease activity, predict treatment response and guide therapeutic interventions. In this review, we summarized the current knowledge on urinary complement biomarkers of kidney diseases due to immune complex deposition (lupus nephritis, primary membranous nephropathy, IgA nephropathy) and due to activation of the alternative pathway (C3 glomerulopathy, thrombotic microangiography, ANCA-associated vasculitis). We also address the limitations of current research and propose future directions for the discovery of urinary complement biomarkers.
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Affiliation(s)
- Vartika Kesarwani
- Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Muhammad Hamza Bukhari
- Department of Medicine, Johns Hopkins Howard County Medical Center, Columbia, MD, United States
| | - J. Michelle Kahlenberg
- Division of Rheumatology, Department of Medicine, University of Michigan, Columbia, MI, United States
| | - Shudan Wang
- Division of Rheumatology, Department of Medicine, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States
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2
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Qureshi ZA, Altaf F, Khanzada M, Thet A, Espinosa L. Ceftriaxone-Induced Thrombotic Thrombocytopenic Purpura Treated Successfully With Plasmapheresis and Eculizumab: A Rare Case Report. Cureus 2023; 15:e48898. [PMID: 38024015 PMCID: PMC10653270 DOI: 10.7759/cureus.48898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a subtype of thrombotic microangiopathy (TMA) resulting in thrombocytopenia, anemia, fever, renal and neurological deficits. Although many drugs have been associated with drug-induced TTP, ceftriaxone has never been reported. Our case reports a patient who was started on ceftriaxone and developed TTP. Peripheral smear showed schistocytes and thrombocytopenia. Surprisingly, antibody formation against the metalloproteinase (ADAMTS13) levels were low-normal. The patient was treated with plasmapheresis and eczulimab, leading to platelet recovery and symptom resolution. TTP is a rare disorder and can be acquired or idiopathic. TTP can be diagnosed with normal ADAMTS13 as well. Further research is required to assess the mechanism by which ceftriaxone causes TTP. Physicians should consider the possibility of TTP in patients with similar presentations following ceftriaxone therapy and use it for timely diagnosis and treatment. Early diagnosis and treatment of ceftriaxone-induced TTP can prevent devastating consequences.
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Affiliation(s)
- Zaheer A Qureshi
- Internal Medicine, The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, USA
- Internal Medicine, BronxCare Health System, Bronx, USA
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | - Faryal Altaf
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Aung Thet
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Luis Espinosa
- Internal Medicine, BronxCare Health System, Bronx, USA
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3
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Cheung CK, Dormer JP, Barratt J. The role of complement in glomerulonephritis-are novel therapies ready for prime time? Nephrol Dial Transplant 2023; 38:1789-1797. [PMID: 36307926 DOI: 10.1093/ndt/gfac296] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Indexed: 08/01/2023] Open
Abstract
The complement system plays a key pathogenic role in glomerular diseases with a diverse range of aetiologies, including C3 glomerulopathy, immunoglobulin A nephropathy, membranous nephropathy, ANCA-associated vasculitis and lupus nephritis. Several novel therapies targeting complement activity have recently been developed, which have now been approved or are in the late stages of clinical development. In this review, potential benefits and challenges of targeting the complement system in glomerular disease are discussed. We summarize current understanding of the role of complement, and the novel targeted therapies that are being developed for the treatment of glomerular disease.
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Affiliation(s)
- Chee Kay Cheung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - John P Dormer
- Department of Histopathology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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4
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Mahmoudjafari Z, Alencar MC, Alexander MD, Johnson DJ, Yeh J, Evans MD. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy and the role of advanced practice providers and pharmacists. Bone Marrow Transplant 2023:10.1038/s41409-023-01951-3. [PMID: 37059738 DOI: 10.1038/s41409-023-01951-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/16/2023]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a severe and potentially life-threatening complication. HSCT-TMA is often underdiagnosed due to multifactorial pathophysiology and a historic lack of standard diagnostic criteria. Identification of the multi-hit hypothesis and the key role of the complement system, particularly the lectin pathway of complement, has led to development of treatments targeting the underlying pathogenesis of HSCT-TMA. Additional research is ongoing to investigate the efficacy and safety of these targeted therapies in patients with HSCT-TMA. Advanced practice providers (APPs; nurse practitioners and physician assistants) and pharmacists are critical members of the multidisciplinary HSCT team and ensure management of patients throughout the continuum of care. Additionally, pharmacists and APPs can improve patient care through medication management of complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives to improve outcomes. Understanding the presentation, prognosis, pathophysiology, and treatment options for HSCT-TMA can improve each of these efforts. Collaborative practice model for monitoring and care of HSCT-TMA. Advanced practice providers and pharmacists contribute to many aspects of patient care in transplant centers, including medication management for complex regimens; transplant education for patients, staff, and trainees; evidence-based protocol and clinical guideline development; assessment and reporting of transplant-related outcomes; and quality improvement initiatives. HSCT-TMA is a severe and potentially life-threatening complication that is often underdiagnosed. The collaboration of a multidisciplinary team of advanced practice providers, pharmacists, and physicians can optimize recognition, diagnosis, management, and monitoring of patients with HSCT-TMA, thereby improving outcomes for these patients.
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Affiliation(s)
- Zahra Mahmoudjafari
- Department of Pharmacy, University of Kansas Cancer Center, Kansas City, KS, USA.
| | - Maritza C Alencar
- Oncology Service Line, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maurice D Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Darren J Johnson
- Pediatric Hematology and Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jason Yeh
- Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | - Misty D Evans
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- Sarah Cannon Pediatric Hematology/Oncology & Cellular Therapy at TriStar Centennial, Nashville, TN, USA
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5
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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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6
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Les inhibiteurs du complément : une vue d’ensemble. Rev Med Interne 2022; 43:703-712. [DOI: 10.1016/j.revmed.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/28/2022] [Accepted: 09/06/2022] [Indexed: 11/23/2022]
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7
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Thompson GL, Kavanagh D. Diagnosis and treatment of thrombotic microangiopathy. Int J Lab Hematol 2022; 44 Suppl 1:101-113. [PMID: 36074708 PMCID: PMC9544907 DOI: 10.1111/ijlh.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic haemolytic anaemia and end organ damage. TMAs have varying underlying pathophysiology and can therefore present with an array of clinical presentations. Renal involvement is common as the kidney is particularly susceptible to the endothelial damage and microvascular occlusion. TMAs require rapid assessment, diagnosis, and commencement of appropriate treatment due to the high morbidity and mortality associated with them. Ground-breaking research into the pathogenesis of TMAs over the past 20 years has driven the successful development of targeted therapeutics revolutionizing patient outcomes. This review outlines the clinical presentations, pathogenesis, diagnostic tests and treatments for TMAs.
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Affiliation(s)
- Gemma L Thompson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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8
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Schön MP. The tick and I: Parasite-host interactions between ticks and humans. J Dtsch Dermatol Ges 2022; 20:818-853. [PMID: 35674196 DOI: 10.1111/ddg.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022]
Abstract
Ticks, particularly hard ticks (Ixodidae), which are among the most important vectors of dangerous infectious agents, feed on their hosts for extended periods of time. With this lifestyle, numerous adaptations have evolved in ticks and their hosts, the pharmacological importance of which is increasingly being recognized. Many bioactive substances in tick saliva are being considered as the basis of new drugs. For example, components of tick cement can be developed into tissue adhesives or wound closures. Analgesic and antipruritic salivary components inhibit histamine or bradykinin, while other tick-derived molecules bind opioid or cannabinoid receptors. Tick saliva inhibits the extrinsic, intrinsic, or common pathway of blood coagulation with implications for the treatment of thromboembolic diseases. It contains vasodilating substances and affects wound healing. The broad spectrum of immunomodulatory and immunosuppressive effects of tick saliva, such as inhibition of chemokines or cellular immune responses, allows development of drugs against inflammation in autoimmune diseases and/or infections. Finally, modern vaccines against ticks can curb the spread of serious infections. The medical importance of the complex tick-host interactions is increasingly being recognized and translated into first clinical applications. Using selected examples, an overview of the mutual adaptations of ticks and hosts is given here, focusing on their significance to medical advance.
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Affiliation(s)
- Michael P Schön
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Germany
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9
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Schön MP. Die Zecke und ich: Parasiten-Wirt-Interaktionen zwischen Zecken und Menschen. J Dtsch Dermatol Ges 2022; 20:818-855. [PMID: 35711058 DOI: 10.1111/ddg.14821_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Michael P Schön
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen
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10
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Bandaru SS. Atypical Hemolytic Uremic Syndrome Caused by a Rare Complement Factor B Mutation. Cureus 2022; 14:e23207. [PMID: 35317246 PMCID: PMC8934198 DOI: 10.7759/cureus.23207] [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] [Accepted: 03/15/2022] [Indexed: 12/04/2022] Open
Abstract
Thrombotic microangiopathy (TMA), a rare and diagnostically challenging condition, commonly presents with a triad of thrombocytopenia, hemolytic anemia, and end-organ damage, such as renal failure. Most cases of the hemolytic uremic syndrome (HUS) are mediated by Shiga toxin-producing Escherichia coli, but some cases present as an atypical HUS, which includes thrombotic thrombocytopenic purpura and complement-mediated thrombotic microangiopathy (C-TMA). Although C-TMA occurs because of genetic and acquired mutations in the complement regulatory factors, it is usually hereditary. The currently available treatment options include therapeutic plasma exchange and administration of eculizumab, which is a monoclonal antibody against C5. Here, we report a diagnostically challenging and extremely rare case of a middle-aged Caucasian man who was diagnosed with atypical HUS that was caused by a mutation in complement factor B. This case highlights the importance of not overlooking rare causes of TMAs because the diagnostic evaluation is important for guiding appropriate management and obtaining a favorable prognosis.
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11
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Hanna RM, Henriksen K, Kalantar-Zadeh K, Ferrey A, Burwick R, Jhaveri KD. Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers. Adv Chronic Kidney Dis 2022; 29:149-160.e1. [PMID: 35817522 DOI: 10.1053/j.ackd.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/11/2022]
Abstract
Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.
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Affiliation(s)
- Ramy M Hanna
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA.
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Kamyar Kalantar-Zadeh
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Antoney Ferrey
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenar D Jhaveri
- Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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12
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Akpinar S, Tekgunduz E, Esen R, Yilmaz M, Karakus V, Vural F, Gediz F, Aydogdu I, Kaynar L, Goker H, Kelkitli E, Ayyildiz O, Demirkan F. Prospective registry of adult patients receiving therapeutic plasma exchange with a presumptive diagnosis of thrombotic microangiopathy (TMA): The Turkish hematology research and education group (ThREG)-TMA02 study. Transfus Apher Sci 2022; 61:103365. [PMID: 35120823 DOI: 10.1016/j.transci.2022.103365] [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] [Indexed: 11/17/2022]
Abstract
Thrombotic microanjiopathy (TMA) is a pathological diagnosis characterized by abnormalities of small vessels leading to microvascular thrombosis of arterioles and capillaries. The current prospective, non-interventional, multicenter study aimed to define the distribution of different TMA forms in adult Turkish patients who were referred for therapeutic plasma exchange (TPE) for presumptive diagnosis of TMA. Patients with serum ADAMTS13 activity <5% were diagnosed as having acquired thrombotic thrombocytopenic purpura (aTTP). Patients presenting with ADAMTS13 activity 6-10 % / normal renal function and patients with ADAMTS13 activity >10 %, normal renal function and no secondary TMA were treated as unclassified TMA. The study included a total of 80 patients (women: 50; man: 30) with a median age of 48 (20-74). Detailed evaluation at 1 month after hospital admission revealed aTTP, secondary TMA, infection/complement-associated hemolytic uremic syndrome and unclassified TMA in 29 (36.2 %), 22 (27.5 %), 23 (28.8 %) and 6 (7.5 %) patients respectively. As subclassification of various TMAs will dictate specific therapy, proper diagnosis in a timely manner is of utmost clinical significance.
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Affiliation(s)
- Seval Akpinar
- Namık Kemal University Medical School, Department of Internal Medicine, Division of Hematology, Tekirdag, Turkey.
| | - Emre Tekgunduz
- Memorial Bahcelievler Hospital Adult Hematology and BMT Clinic, Istanbul, Turkey
| | - Ramazan Esen
- Yuzuncu Yıl University Medical School, Department of Internal Medicine, Division of Hematology, Van, Turkey
| | - Mehmet Yilmaz
- Sanko University Medical School, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Volkan Karakus
- Mugla Sıtkı Kocman University Medical School, Department of Internal Medicine, Division of Hematology, Mugla, Turkey
| | - Filiz Vural
- Ege University Medical School, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
| | - Fusun Gediz
- Medicalpark Hospital, Hematology and BMT Clinic, Izmir, Turkey
| | - Ismet Aydogdu
- Celal Bayar University Medical School, Department of Internal Medicine, Division of Hematology, Manisa, Turkey
| | - Leylagul Kaynar
- Erciyes University Medical School, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Hakan Goker
- Hacettepe University Medical School, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Engin Kelkitli
- Ondokuz Mayis University Medical School, Department of Internal Medicine, Division of Hematology, Samsun, Turkey
| | - Orhan Ayyildiz
- Dicle University Medical School, Department of Internal Medicine, Division of Hematology, Diyarbakir, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University Medical School, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
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13
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Akpınar S, Tekgunduz E, Erkurt MA, Esen R, Yılmaz M, Karakus V, Vural F, Gediz F, Aydogdu I, Kaynar L, Korkmaz S, Goker H, Kelkitli E, Ayyıldız O, Demirkan F. Prospective registry of adult patients receiving therapeutic plasma exchange with a presumptive diagnosis of thrombotic microangiopathy (TMA): The Turkish hematology research and education group (ThREG)-TMA02 study. Transfus Apher Sci 2021:103312. [PMID: 34799244 DOI: 10.1016/j.transci.2021.103312] [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: 11/19/2022]
Abstract
Thrombotic microangiopathy(TMA) is a pathological diagnosis characterized by abnormalities of small vessels leading to microvascular thrombosis of arterioles and capillaries. The current prospective, non-interventional, multicenter (n:18) study aimed to define distribution of different TMA forms in adult Turkish patients who were referred for therapeutic plasma exchange (TPE) for a presumptive diagnosis of TMA. Patients with serum ADAMTS13 activity <5% were diagnosed as acquired thrombotic thrombocytopenic purpura (aTTP). Patients presenting with ADAMTS13 activity 6-10 % / normal renal function and patients with ADAMTS13 activity >10 %, normal renal function and no secondary TMA were treated as unclassified TMA. The study included a total of 97 patients (female: 60; male: 30) with a median age of 48 (18-74). Detailed evaluation at 1 month after hospital admission revealed aTTP, secondary TMA, infection/complement-associated hemolytic uremic syndrome and unclassified TMA in 32 (33 %), 33 (34 %), 26 (27 %) and 6 (6%) patients respectively. As subclassification of various TMAs will dictate specific therapy, proper diagnosis in a timely manner is of utmost clinical significance.
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Affiliation(s)
- Seval Akpınar
- Namık Kemal University Medical School, Department of Internal Medicine, Division of Hematology, Tekirdağ, Turkey.
| | - Emre Tekgunduz
- Memorial Bahcelievler Hospital Adult Hematology and BMT Clinic, Istanbul, Turkey
| | - Mehmet Ali Erkurt
- Inonu University Medical School, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Ramazan Esen
- Yuzuncu Yıl University Medical School, Department of Internal Medicine, Division of Hematology, Van, Turkey
| | - Mehmet Yılmaz
- Sanko University Medical School, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Volkan Karakus
- Mugla Sıtkı Kocman University Medical School, Department of Internal Medicine, Division of Hematology, Mugla, Turkey
| | - Filiz Vural
- Ege University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
| | - Fusun Gediz
- Medicalpark Hospital, Hematology and BMT Clinic, Izmir, Turkey
| | - Ismet Aydogdu
- Celal Bayar University Medical Faculty, Department of Internal Medicine, Division of Hematology, Manisa, Turkey
| | - Leylagul Kaynar
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| | - Serdal Korkmaz
- University of Health Sciences, Kayseri City Training and Research Hospital, Department of Hematology, Kayseri, Turkey
| | - Hakan Goker
- Hacettepe University Faculty of Medicine, Department of Hematology, Ankara, Turkey
| | - Engin Kelkitli
- Ondokuz Mayis University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Samsun, Turkey
| | - Orhan Ayyıldız
- Dicle University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Diyarbakir, Turkey
| | - Fatih Demirkan
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, Izmir, Turkey
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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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15
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Zhang Y, Yang C, Zhou X, Hu R, Quan S, Zhou Y, Li Y, Xing G. Association between thrombotic microangiopathy and activated alternative complement pathway in malignant nephrosclerosis. Nephrol Dial Transplant 2020; 36:gfaa280. [PMID: 33367879 DOI: 10.1093/ndt/gfaa280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Malignant nephrosclerosis, defined as renal microangiopathy in the setting of severe hypertension, remains a critical renal emergency leading to end-stage renal disease despite aggressive anti-hypertensive treatment. Recently, activation of the complement alternative pathway (AP) has been reported to play a prominent role in the pathogenesis of malignant nephrosclerosis. However, subsequent study failed to recapitulate the findings of genetic complement abnormalities in the disease. This study aimed to determine the presence of AP activation and genetic complement defects and establish their correlations to renal microangiopathy lesions, clinical features and prognosis in patients with malignant nephrosclerosis. METHODS Fifty patients with malignant hypertension and concomitant thrombotic microangiopathy (TMA) proven by renal biopsy were investigated; 25 cases of kidney donors who received zero-hour allograft biopsies were used as normal controls. Various renal TMA lesions in patients with malignant nephrosclerosis were reviewed and evaluated using a semi-quantitative scoring system. Deposition of C5b-9, C3a, C5a, C4d and mannose-binding lectin was assessed by immunohistochemistry. Co-localization of C5b-9 and CD34 was detected by confocal microscopy. Complement factor B (FB), factor P (FP; properdin), factor D (FD), factor H (FH), C3a and C5a levels were quantified by enzyme-linked immonosorbent assay in plasma and urine samples of patients with malignant nephrosclerosis and controls. Genetic abnormalities of complement components were analysed by whole-exome sequencing. RESULTS Renal biopsies of malignant nephrosclerosis showed identical histopathological and ultrastructural features to atypical haemolytic uraemic syndrome. C5b-9, C3a and C5a deposits were found along the walls of arteries/arterioles and glomerular capillaries and localized in the endothelial cells. Elevated plasma and urinary levels of FB, FP, FD, C3a and C5a as well as decreased FH levels were observed in patients with malignant nephrosclerosis compared with normal controls. The urinary levels of complement AP components, but not the plasma levels, were correlated with renal functions, prognosis and active TMA lesions except for arteriolar thrombi. Finally, mutations of the MCP, CFB, CFH and CFHR5 genes were identified in 8 of 20 patients with malignant nephrosclerosis. CONCLUSIONS Aberrant complement AP dysregulation was demonstrated and associated with the activity, severity and renal outcomes of malignant nephrosclerosis. This observation warrants screening for complement defects in patients with malignant nephrosclerosis for the potential use of complement regulators and also highlights the need for further investigation of the precise role of AP in the pathogenesis of the disease.
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Affiliation(s)
- Ying Zhang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chaona Yang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinjin Zhou
- Renal Path Diagnostics at Pathologists BioMedical Laboratories, Lewisville, TX, USA
| | - Ruimin Hu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Songxia Quan
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yali Zhou
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan Li
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guolan Xing
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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16
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Duineveld C, Wetzels JFM. Complement inhibitors are not useful in secondary hemolytic uremic syndromes. Kidney Int 2020; 96:829-833. [PMID: 31543154 DOI: 10.1016/j.kint.2019.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/12/2019] [Accepted: 08/06/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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Hoevenaar M, Goossens D, Roorda J. Angiotensin-converting enzyme 2, the complement system, the kallikrein-kinin system, type-2 diabetes, interleukin-6, and their interactions regarding the complex COVID-19 pathophysiological crossroads. J Renin Angiotensin Aldosterone Syst 2020; 21:1470320320979097. [PMID: 33283602 PMCID: PMC7724427 DOI: 10.1177/1470320320979097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022] Open
Abstract
Because of the current COVID-19-pandemic, the world is currently being held hostage in various lockdowns. ACE2 facilitates SARS-CoV-2 cell-entry, and is at the very center of several pathophysiological pathways regarding the RAAS, CS, KKS, T2DM, and IL-6. Their interactions with severe COVID-19 complications (e.g. ARDS and thrombosis), and potential therapeutic targets for pharmacological intervention, will be reviewed.
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Affiliation(s)
| | | | - Janne Roorda
- Medical Doctor, General Practice
van Dijk, Oisterwijk, The Netherlands
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18
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Brocklebank V, Kumar G, Howie AJ, Chandar J, Milford DV, Craze J, Evans J, Finlay E, Freundlich M, Gale DP, Inward C, Mraz M, Jones C, Wong W, Marks SD, Connolly J, Corner BM, Smith-Jackson K, Walsh PR, Marchbank KJ, Harris CL, Wilson V, Wong EKS, Malina M, Johnson S, Sheerin NS, Kavanagh D. Long-term outcomes and response to treatment in diacylglycerol kinase epsilon nephropathy. Kidney Int 2020; 97:1260-1274. [PMID: 32386968 PMCID: PMC7242908 DOI: 10.1016/j.kint.2020.01.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/15/2020] [Accepted: 01/31/2020] [Indexed: 12/19/2022]
Abstract
Recessive mutations in diacylglycerol kinase epsilon (DGKE) display genetic pleiotropy, with pathological features reported as either thrombotic microangiopathy or membranoproliferative glomerulonephritis (MPGN), and clinical features of atypical hemolytic uremic syndrome (aHUS), nephrotic syndrome or both. Pathophysiological mechanisms and optimal management strategies have not yet been defined. In prospective and retrospective studies of aHUS referred to the United Kingdom National aHUS service and prospective studies of MPGN referred to the National Registry of Rare Kidney Diseases for MPGN we defined the incidence of DGKE aHUS as 0.009/million/year and so-called DGKE MPGN as 0.006/million/year, giving a combined incidence of 0.015/million/year. Here, we describe a cohort of sixteen individuals with DGKE nephropathy. One presented with isolated nephrotic syndrome. Analysis of pathological features reveals that DGKE mutations give an MPGN-like appearance to different extents, with but more often without changes in arterioles or arteries. In 15 patients presenting with aHUS, ten had concurrent substantial proteinuria. Identified triggering events were rare but coexistent developmental disorders were seen in six. Nine with aHUS experienced at least one relapse, although in only one did a relapse of aHUS occur after age five years. Persistent proteinuria was seen in the majority of cases. Only two individuals have reached end stage renal disease, 20 years after the initial presentation, and in one, renal transplantation was successfully undertaken without relapse. Six individuals received eculizumab. Relapses on treatment occurred in one individual. In four individuals eculizumab was withdrawn, with one spontaneously resolving aHUS relapse occurring. Thus we suggest that DGKE-mediated aHUS is eculizumab non-responsive and that in individuals who currently receive eculizumab therapy it can be safely withdrawn. This has important patient safety and economic implications.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gurinder Kumar
- Division of Paediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Alexander J Howie
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jayanthi Chandar
- Division of Pediatric Nephrology, University of Miami, Miami, Florida, USA
| | - David V Milford
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Janet Craze
- Department of General Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan Evans
- Children's Renal and Urology Unit, Nottingham Children's Hospital, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Eric Finlay
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michael Freundlich
- Division of Pediatric Nephrology, University of Miami, Miami, Florida, USA
| | - Daniel P Gale
- Department of Renal Medicine, University College London, UK
| | - Carol Inward
- Department of Paediatric Nephrology, Bristol Royal Hospital For Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Martin Mraz
- Department of Paediatric Nephrology, Bristol Royal Hospital For Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - William Wong
- Department of Paediatric Nephrology, Starship Children's Hospital, Grafton, Auckland, New Zealand
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - John Connolly
- Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Bronte M Corner
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Kate Smith-Jackson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Patrick R Walsh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Kevin J Marchbank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Claire L Harris
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Edwin K S Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michal Malina
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, UK
| | - Sally Johnson
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, UK
| | - Neil S Sheerin
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
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19
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Rodziewicz M, D'Cruz DP. An update on the management of antiphospholipid syndrome. Ther Adv Musculoskelet Dis 2020; 12:1759720X20910855. [PMID: 32523633 PMCID: PMC7236388 DOI: 10.1177/1759720x20910855] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/30/2020] [Indexed: 11/21/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by recurrent venous or arterial thrombosis with or without pregnancy morbidity in the presence of persistent antiphospholipid (aPL) autoantibodies. Anticoagulation has, until now, formed the cornerstone of treatment but a significant proportion of patients continue to experience thrombosis and pregnancy morbidity despite this treatment. Thrombosis is the most common cause of mortality and accounts for two fifths of deaths. Direct oral anticoagulant drugs represent an attractive alternative to conventional vitamin K antagonist drugs but emerging evidence suggests these may not be suitable for high-risk patients with thrombotic APS. Laboratory studies and case reports of the successful use of different classes of drugs in APS is increasing our understanding of the other pathophysiological mechanisms which may contribute to the high morbidity of APS. This review summarizes current accepted anticoagulant treatment for APS and examines other potential drugs such as immunomodulating agents, statins and novel agents such as sirolimus and defibrotide.
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Affiliation(s)
- Mia Rodziewicz
- Louise Coote Lupus Unit, Guy's Hospital, 4th Floor Tower Wing, Great Maze Pond, London SE1 9RT, UK
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20
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Carr JM, Cabezas-Falcon S, Dubowsky JG, Hulme-Jones J, Gordon DL. Dengue virus and the complement alternative pathway. FEBS Lett 2020; 594:2543-2555. [PMID: 31943152 DOI: 10.1002/1873-3468.13730] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/21/2019] [Accepted: 01/07/2020] [Indexed: 01/20/2023]
Abstract
Dengue disease is an inflammatory-driven pathology, and complement overactivation is linked to disease severity and vascular leakage. Additionally, dysregulation of complement alternative pathway (AP) components has been described, such as upregulation of complement factor D and downregulation of complement factor H (FH), which activate and inhibit the AP, respectively. Thus, the pathology of severe dengue could in part result from AP dysfunction, even though complement and AP activation usually provide protection against viral infections. In dengue virus-infected macrophages and endothelial cells (ECs), the site of replication and target for vascular pathology, respectively, the AP is activated. The AP activation, reduced FH and vascular leakage seen in dengue disease in part parallels other complement AP pathologies associated with FH deficiency, such as atypical haemolytic uraemic syndrome (aHUS). aHUS can be therapeutically targeted with inhibitors of complement terminal activity, raising the idea that strategies such as inhibition of complement or delivery of FH or other complement regulatory components to EC may be beneficial to combat the vascular leakage seen in severe dengue.
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Affiliation(s)
- Jillian M Carr
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Sheila Cabezas-Falcon
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,TGR Biosciences, Adelaide, SA, Australia
| | - Joshua G Dubowsky
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Jarrod Hulme-Jones
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - David L Gordon
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,SA Pathology, Flinders Medical Centre, Adelaide, SA, Australia
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21
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Bongetti E, Kavanagh D, Martin K, Bendall A, Hill P, Steinberg A, Rajaram Y, Ierino F. Cocaine-associated atypical haemolytic uraemic syndrome in a genetically susceptible individual. Nephrology (Carlton) 2020; 25:518-521. [PMID: 31900968 DOI: 10.1111/nep.13690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/21/2019] [Accepted: 12/02/2019] [Indexed: 11/27/2022]
Abstract
Atypical haemolytic uraemic syndrome (aHUS) is a severe, life-threatening condition that requires early recognition and urgent treatment. In aHUS rare genetic variants in CFH, CFI, CD46, C3 and CFB predispose to complement over activation. This case describes a case of aHUS in which there was a strong temporal association between disease onset and the use of smoked cocaine. The patient was found to have a rare genetic variant in the CFI gene which may have been unmasked by first-time exposure to cocaine. The patient stabilized and improved with early administration of eculizumab, supporting the notion of an underlying immunological pathogenesis and the importance of early intervention.
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Affiliation(s)
- Elisa Bongetti
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - David Kavanagh
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kylie Martin
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Anna Bendall
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Prue Hill
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Adam Steinberg
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Yogeshwar Rajaram
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
| | - Francesco Ierino
- Department of Nephrology, St. Vincent's Hospital, Melbourne, Australia
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22
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Sheludchenko VM, Kozlovskaya NL, Smirnova TV, Krasnolutskaya EI. [Ophthalmic aspects of vascular and functional changes in malignant arterial hypertension of renal origin]. Vestn Oftalmol 2020; 136:324-332. [PMID: 32880158 DOI: 10.17116/oftalma2020136042324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Malignant arterial hypertension is a clinical syndrome characterized by severe diastolic arterial hypertension with signs of ischemic damage to target organs - kidneys, heart, brain, eyes. Malignant arterial hypertension can be one of the reasons, as well as a consequence of thrombotic microangiopathy - a special type of vascular lesions of the organ microvasculature. Ocular manifestations of arterial hypertension include hypertensive retinopathy of varying severity, choriopathy. The appearance of new diagnostic research methods allows a detailed study of eye damage in malignant arterial hypertension, whether associated or not with thrombotic microangiopathy, and to analyze the relationship of ocular and systemic manifestations of this disease to determine the nature and degree of involvement of the organ of vision in the pathological process and identify prognostic signs of disease progression and its forms.
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Affiliation(s)
| | | | - T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
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23
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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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24
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Circulating Heme Oxygenase-1 and Complement Activation in Transplant-Associated Thrombotic Microangiopathy. Biol Blood Marrow Transplant 2019; 25:1486-1491. [DOI: 10.1016/j.bbmt.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
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25
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Complement-mediated microangiopathy in IgA nephropathy and IgA vasculitis with nephritis. Mod Pathol 2019; 32:1147-1157. [PMID: 30936425 DOI: 10.1038/s41379-019-0259-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 12/20/2022]
Abstract
Complement factor C4d was recently observed in renal biopsies from patients who had IgA nephropathy and a poor prognosis. We previously reported that C4d is a common denominator in microangiopathies. In this retrospective cohort study, we investigated whether C4d is a marker of microangiopathy in both IgA nephropathy and IgA vasculitis with nephritis, and whether patients with C4d and microangiopathy have poor renal outcome. We examined 128 renal biopsies from adult and pediatric patients, including normotensive and hypertensive patients, who presented with IgA nephropathy or IgA vasculitis with nephritis. Biopsies were re-evaluated in accordance with the Oxford classification, scored for additional lesions, and stained for complement proteins using immunohistochemistry, including C4d and C5b-9. Clinical data were collected with a mean (±SD) follow-up period of 51 ± 39 months. Changes in estimated glomerular filtration rate over time were compared using linear mixed-effects models. Renal survival was analyzed using multivariable Cox regression. Microangiopathic lesions were present in 20% of all biopsies (23% and 9% of patients with IgA nephropathy and IgA vasculitis with nephritis, respectively). Microangiopathy was associated with C4d and C5b-9 deposits, a higher number of chronic lesions, and hypertension (all p < 0.05). Patients with C4d and microangiopathic lesions had significantly poorer renal survival than patients without these findings, corrected for hypertension (p < 0.01). In conclusion, patients with IgA nephropathy or IgA vasculitis with nephritis with a combination of C4d positivity and microangiopathy comprise a clinical subgroup with an increased number of chronic lesions, lower estimated glomerular filtration rate, and poorer renal survival, even when corrected for hypertension. These data suggest that complement activation is involved in the development of microangiopathy in patients with IgA nephropathy and IgA vasculitis with nephritis, and that complement-mediated microangiopathy contributes to disease progression.
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26
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Chmelař J, Kotál J, Kovaříková A, Kotsyfakis M. The Use of Tick Salivary Proteins as Novel Therapeutics. Front Physiol 2019; 10:812. [PMID: 31297067 PMCID: PMC6607933 DOI: 10.3389/fphys.2019.00812] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
The last three decades of research into tick salivary components have revealed several proteins with important pharmacological and immunological activities. Two primary interests have driven research into tick salivary secretions: the search for suitable pathogen transmission blocking or “anti-tick” vaccine candidates and the search for novel therapeutics derived from tick salivary components. Intensive basic research in the field of tick salivary gland transcriptomics and proteomics has identified several major protein families that play important roles in tick feeding and overcoming vertebrate anti-tick responses. Moreover, these families contain members with unrealized therapeutic potential. Here we review the major tick salivary protein families exploitable in medical applications such as immunomodulation, inhibition of hemostasis and inflammation. Moreover, we discuss the potential, opportunities, and challenges in searching for novel tick-derived drugs.
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Affiliation(s)
- Jindřich Chmelař
- Department of Medical Biology, Faculty of Science, University of South Bohemia in České Budějovice, České Budějovice, Czechia
| | - Jan Kotál
- Department of Medical Biology, Faculty of Science, University of South Bohemia in České Budějovice, České Budějovice, Czechia.,Laboratory of Genomics and Proteomics of Disease Vectors, Biology Centre CAS, Institute of Parasitology, České Budějovice, Czechia
| | - Anna Kovaříková
- Department of Medical Biology, Faculty of Science, University of South Bohemia in České Budějovice, České Budějovice, Czechia
| | - Michail Kotsyfakis
- Department of Medical Biology, Faculty of Science, University of South Bohemia in České Budějovice, České Budějovice, Czechia.,Laboratory of Genomics and Proteomics of Disease Vectors, Biology Centre CAS, Institute of Parasitology, České Budějovice, Czechia
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27
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Smith-Jackson K, Yang Y, Denton H, Pappworth IY, Cooke K, Barlow PN, Atkinson JP, Liszewski MK, Pickering MC, Kavanagh D, Cook HT, Marchbank KJ. Hyperfunctional complement C3 promotes C5-dependent atypical hemolytic uremic syndrome in mice. J Clin Invest 2019; 129:1061-1075. [PMID: 30714990 PMCID: PMC6391106 DOI: 10.1172/jci99296] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/18/2018] [Indexed: 12/13/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is frequently associated in humans with loss-of-function mutations in complement-regulating proteins or gain-of-function mutations in complement-activating proteins. Thus, aHUS provides an archetypal complement-mediated disease with which to model new therapeutic strategies and treatments. Herein, we show that, when transferred to mice, an aHUS-associated gain-of-function change (D1115N) to the complement-activation protein C3 results in aHUS. Homozygous C3 p.D1115N (C3KI) mice developed spontaneous chronic thrombotic microangiopathy together with hematuria, thrombocytopenia, elevated creatinine, and evidence of hemolysis. Mice with active disease had reduced plasma C3 with C3 fragment and C9 deposition within the kidney. Therapeutic blockade or genetic deletion of C5, a protein downstream of C3 in the complement cascade, protected homozygous C3KI mice from thrombotic microangiopathy and aHUS. Thus, our data provide in vivo modeling evidence that gain-of-function changes in complement C3 drive aHUS. They also show that long-term C5 deficiency is not accompanied by development of other renal complications (such as C3 glomerulopathy) despite sustained dysregulation of C3. Our results suggest that this preclinical model will allow testing of novel complement inhibitors with the aim of developing precisely targeted therapeutics that could have application in many complement-mediated diseases.
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Affiliation(s)
- Kate Smith-Jackson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Yi Yang
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Harriet Denton
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Isabel Y Pappworth
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Katie Cooke
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paul N Barlow
- Department of Chemistry, University of Edinburgh, Edinburgh, United Kingdom
| | - John P Atkinson
- Division of Rheumatology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - M Kathryn Liszewski
- Division of Rheumatology, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - David Kavanagh
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - H Terence Cook
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Kevin J Marchbank
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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Ortiz A, Vinck C. The new Clinical Kidney Journal, 4 years later. Clin Kidney J 2019; 12:1-5. [PMID: 30746126 PMCID: PMC6366135 DOI: 10.1093/ckj/sfy139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022] Open
Abstract
The February 2015 issue of ckj started a new era with renewed efforts to be useful to the training and practicing nephrologists and a new focus on Clinical and Translational Nephrology. Four years later, it has become a truly global journal with contributors and readers from all over the world. The increase in quality of the published material has resulted in a nearly exponential growth of citations. Since 2016, ckj is listed in the new Emerging Sources Citation Index (ESCI) database from Clarivate Analytics and from January 2019 it will be listed in the full Science Citation Index. ckj will therefore receive its first official impact factor based upon 2018 citation to 2016 and 2017 articles. While no official impact factor was awarded for 2017, the estimated impact factors calculated from data available in Clarivate's Web of Science database rose to 2.987 in 2017, which would correspond to an estimated journal impact factor percentile of 72.4% in the Urology and Nephrology field.
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Affiliation(s)
- Alberto Ortiz
- Editor-in-Chief, Clinical Kidney Journal, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid; Fundacion Renal Iñigo Alvarez de Toledo-IRSIN and REDINREN, Madrid, Spain
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Smith-Jackson K, Marchbank KJ. Targeting properdin in the treatment of atypical haemolytic uraemic syndrome: better than eculizumab? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:S62. [PMID: 30613637 DOI: 10.21037/atm.2018.10.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Kate Smith-Jackson
- NRCTC and Newcastle University, The medical school, Farmington place, Newcastle-upon-Tyne, UK
| | - Kevin J Marchbank
- NRCTC and Newcastle University, The medical school, Farmington place, Newcastle-upon-Tyne, UK
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Chang JC. TTP-like syndrome: novel concept and molecular pathogenesis of endotheliopathy-associated vascular microthrombotic disease. Thromb J 2018; 16:20. [PMID: 30127669 PMCID: PMC6087012 DOI: 10.1186/s12959-018-0174-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023] Open
Abstract
TTP is characterized by microangiopathic hemolytic anemia and thrombocytopenia associated with brain and kidney dysfunction. It occurs due to ADAMTS13 deficiency. TTP-like syndrome occurs in critically ill patients with the similar hematologic changes and additional organ dysfunction syndromes. Vascular microthrombotic disease (VMTD) includes both TTP and TTP-like syndrome because their underlying pathology is the same disseminated intravascular microthrombosis (DIT). Microthrombi are composed of platelet-unusually large von Willebrand factor multimers (ULVWF) complexes. TTP occurs as a result of accumulation of circulating ULVWF secondary to ADAMTS13 deficiency. This protease deficiency triggers microthrombogenesis, leading to "microthrombi" formation in microcirculation. Unlike TTP, TTP-like syndrome occurs in critical illnesses due to complement activation. Terminal C5b-9 complex causes channel formation to endothelial membrane, leading to endotheliopathy, which activates two different molecular pathways (i.e., inflammatory and microthrombotic). Activation of inflammatory pathway triggers inflammation. Activation of microthrombotic pathway promotes platelet activation and excessive endothelial exocytosis of ULVWF from endothelial cells (ECs). Overexpressed and uncleaved ULVWF become anchored to ECs as long elongated strings to recruit activated platelets, and assemble "microthrombi". In TTP, circulating microthrombi typically be lodged in microvasculature of the brain and kidney, but in TTP-like syndrome, microthrombi anchored to ECs of organs such as the lungs and liver as well as the brain and kidneys, leading to multiorgan dysfunction syndrome. TTP occurs as hereditary or autoimmune disease and is the phenotype of ADAMTS13 deficiency-associated VMTD. But TTP-like syndrome is hemostatic disorder occurring in critical illnesses and is the phenotype of endotheliopathy-associated VMTD. Thus, this author's contention is TTP and TTP-like syndrome are two distinctly different disorders with dissimilar underlying pathology and pathogenesis.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA USA
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Zhang Y, Sun L, Zhou S, Xu Q, Xu Q, Liu D, Liu L, Hu R, Quan S, Xing G. Intrarenal Arterial Lesions Are Associated with Higher Blood Pressure, Reduced Renal Function and Poorer Renal Outcomes in Patients with IgA Nephropathy. Kidney Blood Press Res 2018; 43:639-650. [PMID: 29698975 DOI: 10.1159/000489290] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Arterial fibrotic intimal thickening and arteriolar hyaline are considered common pathological features in immunoglobulin A nephropathy (IgAN), whereas little is known about the acute pathological manifestations of endothelial cell injury. The aim of this study was to investigate characteristics of intrarenal arterial lesions and to estimate their prognostic values in patients with IgAN. The primary renal endpoint was a 50% reduction in estimated glomerular filtration rate (eGFR) or end-stage renal disease (ESRD). METHODS Various renal arterial lesions (arterial fibrotic intimal thickening, arteriolar hyaline, arteriolar endotheliocyte swelling, arteriolar inflammatory cell infiltration, and arteriolar thrombosis) in 1683 patients with IgAN were reviewed and reclassified using a semi-quantitative scoring system. Their correlations with clinical features, pathological characteristics, and renal outcomes were evaluated. RESULTS The prevalence of intrarenal arterial lesions was up to 72.2% in IgAN patients. There were 978 patients (58.1%) with arterial fibrotic intimal thickening, 350 patients (20.8%) with arteriolar hyaline, 432 patients (25.7%) with arteriolar endotheliocyte swelling, 356 patients (21.2%) with arteriolar inflammatory cell infiltration and 43 patients (2.6%) with arteriolar thrombosis. Arterial fibrotic intimal thickening and arteriolar hyaline were strongly associated with higher mean arterial pressure (MAP) and reduced eGFR (P < 0.001) but were not related to proteinuria at the time of renal biopsy. In contrast, arteriolar endotheliocyte swelling and arteriolar thrombosis were correlated with heavier proteinuria as well as higher MAP and reduced eGFR. During follow-up, patients with vascular lesions received more renin-angiotensin system (RAS) blockade and less glucocorticoid and showed poorer renal outcomes. Univariate Cox model showed that the presence of renal vascular lesions [hazard ratio (HR) = 25.01, 95% confidence interval (CI): 6.19 to 101.03, P < 0.001] was a risk factor for renal outcomes. However, in multivariable Cox analysis, which included clinical factors and the Oxford-MEST-C, vascular lesions were not significantly associated with an increased risk of renal failure. Remarkably, the impact of vascular lesions on the survival from ESRD or 50% reduction in renal function was eliminated by the use of RAS blockade after adjustment for eGFR, proteinuria, and MAP. CONCLUSION Our study demonstrates the high prevalence of vascular lesions, including the chronic and acute arterial pathological changes, in patients with IgAN. The presence of vascular lesions is associated with higher MAP, reduced eGFR and poorer renal outcomes, which could be influenced by the RAS blockade treatment.
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Affiliation(s)
- Ying Zhang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lili Sun
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Suhan Zhou
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qihe Xu
- Medical Research Council Centre for Transplantation, King's College London, London, United Kingdom
| | - Qiannan Xu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dongyu Liu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lu Liu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruimin Hu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Songxia Quan
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guolan Xing
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Kremer Hovinga JA, Heeb SR, Skowronska M, Schaller M. Pathophysiology of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. J Thromb Haemost 2018; 16:618-629. [PMID: 29356300 DOI: 10.1111/jth.13956] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Thrombotic microangiopathies are rare disorders characterized by the concomitant occurrence of severe thrombocytopenia, microangiopathic hemolytic anemia, and a variable degree of ischemic end-organ damage. The latter particularly affects the brain, the heart, and the kidneys. The primary forms, thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), although their clinical presentations often overlap, have distinctive pathophysiologies. TTP is the consequence of a severe ADAMTS-13 deficiency, either immune-mediated as a result of circulating autoantibodies, or caused by mutations in ADAMTS-13. HUS develops following an infection with Shiga-toxin producing bacteria, or as the result of excessive activation of the alternative pathway of the complement system because of mutations in genes encoding complement system proteins.
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Affiliation(s)
- J A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - S R Heeb
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - M Skowronska
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - M Schaller
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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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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Tekgündüz E, Yılmaz M, Erkurt MA, Kiki I, Kaya AH, Kaynar L, Alacacioglu I, Cetin G, Ozarslan I, Kuku I, Sincan G, Salim O, Namdaroglu S, Karakus A, Karakus V, Altuntas F, Sari I, Ozet G, Aydogdu I, Okan V, Kaya E, Yildirim R, Yildizhan E, Ozgur G, Ozcebe OI, Payzin B, Akpinar S, Demirkan F. A multicenter experience of thrombotic microangiopathies in Turkey: The Turkish Hematology Research and Education Group (ThREG)-TMA01 study. Transfus Apher Sci 2018; 57:27-30. [PMID: 29503132 DOI: 10.1016/j.transci.2018.02.012] [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] [Indexed: 12/17/2022]
Abstract
Thrombotic microangiopathies (TMAs) are rare, but life-threatening disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) associated with multiorgan dysfunction as a result of microvascular thrombosis and tissue ischemia. The differentiation of the etiology is of utmost importance as the pathophysiological basis will dictate the choice of appropriate treatment. We retrospectively evaluated 154 (99 females and 55 males) patients who received therapeutic plasma exchange (TPE) due to a presumptive diagnosis of TMA, who had serum ADAMTS13 activity/anti-ADAMTS13 antibody analysis at the time of hospital admission. The median age of the study cohort was 36 (14-84). 67 (43.5%), 32 (20.8%), 27 (17.5%) and 28 (18.2%) patients were diagnosed as thrombotic thrombocytopenic purpura (TTP), infection/complement-associated hemolytic uremic syndrome (IA/CA-HUS), secondary TMA and TMA-not otherwise specified (TMA-NOS), respectively. Patients received a median of 18 (1-75) plasma volume exchanges for 14 (153) days. 81 (52.6%) patients received concomitant steroid therapy with TPE. Treatment responses could be evaluated in 137 patients. 90 patients (65.7%) achieved clinical remission following TPE, while 47 (34.3%) patients had non-responsive disease. 25 (18.2%) non-responsive patients died during follow-up. Our study present real-life data on the distribution and follow-up of patients with TMAs who were referred to therapeutic apheresis centers for the application of TPE.
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Affiliation(s)
- Emre Tekgündüz
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey.
| | - Mehmet Yılmaz
- Gaziantep University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Mehmet Ali Erkurt
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Ilhami Kiki
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Ali Hakan Kaya
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Leylagul Kaynar
- Erciyes University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Inci Alacacioglu
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
| | - Guven Cetin
- Bezmialem University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul, Turkey
| | - Ibrahim Ozarslan
- Gaziantep University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Irfan Kuku
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Gulden Sincan
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Ozan Salim
- Akdeniz University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Antalya, Turkey
| | - Sinem Namdaroglu
- Bozyaka Education and Research Hospital, Hematology Clinic, Izmir, Turkey
| | - Abdullah Karakus
- Dicle University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Diyarbakir, Turkey
| | - Volkan Karakus
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Mugla, Turkey
| | - Fevzi Altuntas
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Ismail Sari
- Pamukkale University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Denizli, Turkey
| | - Gulsum Ozet
- Ankara Numune Education and Research Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Ismet Aydogdu
- Celal Bayar University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Manisa, Turkey
| | - Vahap Okan
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Emin Kaya
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Rahsan Yildirim
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Esra Yildizhan
- Erciyes University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Gokhan Ozgur
- Gulhane Military Medical Academy University, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Osman Ilhami Ozcebe
- Hacettepe University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Bahriye Payzin
- Katip Celebi University, Ataturk Training and Research Hospital, Hematology Clinic, Izmir, Turkey
| | - Seval Akpinar
- Sisli Hamidiye Etfal Education and Research Hospital, Hematology Clinic, Istanbul, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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Wong EKS, Kavanagh D. Diseases of complement dysregulation-an overview. Semin Immunopathol 2018; 40:49-64. [PMID: 29327071 PMCID: PMC5794843 DOI: 10.1007/s00281-017-0663-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/01/2017] [Indexed: 02/07/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS), C3 glomerulopathy (C3G), and paroxysmal nocturnal hemoglobinuria (PNH) are prototypical disorders of complement dysregulation. Although complement overactivation is common to all, cell surface alternative pathway dysregulation (aHUS), fluid phase alternative pathway dysregulation (C3G), or terminal pathway dysregulation (PNH) predominates resulting in the very different phenotypes seen in these diseases. The mechanism underlying the dysregulation also varies with predominant acquired autoimmune (C3G), somatic mutations (PNH), or inherited germline mutations (aHUS) predisposing to disease. Eculizumab has revolutionized the treatment of PNH and aHUS although has been less successful in C3G. With the next generation of complement therapeutic in late stage development, these archetypal complement diseases will provide the initial targets.
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Affiliation(s)
- Edwin K S Wong
- The National Renal Complement Therapeutics Centre, aHUS Service, Building 26, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre, aHUS Service, Building 26, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK. .,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
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