1
|
Akaeva MI, Kozlovskaya NL, Bobrova LA, Vorobyeva OA, Stoliarevich ES, Shatalov PA, Smirnova TV, Anan'eva AO. [Clinical characteristics and genetic profile of complement system in renal thrombotic microangiopathy in patients with severe forms of arterial hypertension]. TERAPEVT ARKH 2024; 96:571-579. [PMID: 39106497 DOI: 10.26442/00403660.2024.06.202724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 07/06/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND The spectrum of diseases characterized by the development of renal thrombotic microangiopathy (TMA) encompasses the malignant hypertension (MHT). TMA in MHT has conventionally been regarded as a variation of secondary TMA, the treatment of which is restricted to the stabilization of blood pressure levels, a measure that frequently fails to prevent the rapid progression to end-stage renal disease in patients. Nevertheless, there exists a rationale to suggest that, in certain instances, endothelial damage in MHT might be rooted in the dysregulation of the complement system (CS), thereby presenting potential opportunities for the implementation of complement-blocking therapy. AIM To study clinical manifestations and genetic profile of CS in patients with morphologically confirmed renal TMA combined with severe AH. MATERIALS AND METHODS 28 patients with morphologically verified renal TMA and severe AH were enrolled to the study. Patients with signs of microangiopathic hemolysis and thrombocytopenia were not included in the study due to possible compliance with the criteria for atypical hemolytic uremic syndrome (aHUS). The prevalence of rare genetic defects (GD) of the CS was assessed by molecular genetic analysis (search for mutations in the clinically significant part of the human genome - exome) by next-generation sequencing technology (NGS). RESULTS GD of CS were detected in a quarter of patients. Rare genetic variants classified as "likely pathogenic" including defects in CFI, C3, CD46, CFHR4, CFHR5 genes were detected in five cases. Two patients were found to have chromosomal deletions containing CFH-related proteins genes (CFHR1, CFHR3). CONCLUSION Rare variants of CS genes linked to aHUS were found in 25% of patients with renal TMA, the genesis of which was originally thought to be secondary and attributed to MHT, with partial or complete absence of hematological manifestations of microangiopathic pathology. The key to confirming TMA associated with MHT, particularly in the absence of microangiopathic hemolysis and thrombocytopenia, elucidating its nature, and potentially effective complement-blocking therapy in patients with GD of CS, appears to be a genetic study of CS combined with a morphological study of a renal biopsy.
Collapse
Affiliation(s)
- M I Akaeva
- Sechenov First Moscow State Medical University (Sechenov University)
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - N L Kozlovskaya
- Patrice Lumumba People's Friendship University of Russia
- Yeramishantsev City Clinical Hospital
| | - L A Bobrova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O A Vorobyeva
- National Center for Clinical Morphological Diagnostics
| | | | | | | | | |
Collapse
|
2
|
Ghimire A, Brassington R, Solez K, Bello A. Chronic thrombotic microangiopathy presenting as acute nephrotic syndrome in a patient with renal cancer receiving tyrosine kinase inhibitor therapy. BMJ Case Rep 2024; 17:e255841. [PMID: 38182165 PMCID: PMC10773325 DOI: 10.1136/bcr-2023-255841] [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] [Accepted: 12/23/2023] [Indexed: 01/07/2024] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but serious side effect of tyrosine kinase inhibitor (TKI) therapy. Previous case reports of renal TMA have usually occurred in the first few months of TKI initiation with only very few cases occurring within 2-3 years. We report a case of a patient who was referred to the Nephrology service for nephrotic syndrome and worsening renal function after 8 years of sunitinib therapy for metastatic clear cell carcinoma of the kidney. Renal biopsy showed chronic TMA without another secondary aetiology identified. With discontinuation of sunitinib and pharmacological optimisation of his hypertension, his renal function and proteinuria both significantly improved. No relapse or recurrence of disease activity was noted after a year of follow-up. This case highlights the importance of remaining vigilant for the development of renal TMA even after an extended duration of TKI therapy.
Collapse
Affiliation(s)
- Anukul Ghimire
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rebecca Brassington
- Pathology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kim Solez
- Pathology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu Bello
- Nephrology and Immunology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
3
|
Rajarajan AP, Shaji A, Sethi J, Sekar A, Nada R, Kohli HS. Pulmonary Renal Syndrome due to Atypical HUS in a Young Gentleman. Indian J Nephrol 2023; 33:313-314. [PMID: 37781545 PMCID: PMC10503574 DOI: 10.4103/ijn.ijn_31_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 07/01/2022] [Accepted: 07/30/2022] [Indexed: 10/03/2023] Open
Affiliation(s)
- Arun P. Rajarajan
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alan Shaji
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmine Sethi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir S. Kohli
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
Thrombotic microangiopathies in critically ill children: The MATUCIP registry in Spain. An Pediatr (Barc) 2023; 98:194-203. [PMID: 36842880 DOI: 10.1016/j.anpede.2023.02.006] [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: 09/06/2022] [Accepted: 11/23/2022] [Indexed: 02/28/2023] Open
Abstract
INTRODUCTION Thrombotic microangiopathies (TMA) are rare diseases usually presenting with renal, haematological, neurologic and cardiovascular involvement and nonspecific but severe symptoms. A registry of TMA cases managed in Spanish paediatric intensive care units (the MATUCIP Registry) was established with the aim of gaining knowledge on their clinical characteristics, diagnosis and acute-phase treatment. METHODS We conducted a prospective multicentre observational study in 20 paediatric intensive care units (PICUs) in Spain from January 2017 to December 2021 in children aged more than 1 month with TMAs, who were followed up through the discharge from the PICU. RESULTS The sample included 97 patients (51.5% female) with a median age of 2.6 years (interquartile range [IQR], 1.6-5.7). The initial manifestations were gastrointestinal (74.2%), respiratory (14.4%), fever (5.2%), neurologic (3.1%) and other (3.1%). At admission, 75.3% of patients had microangiopathic haemolytic anaemia, 95.9% thrombocytopenia and 94.8% acute kidney injury. Of the total sample, 57.7% of patients received a diagnosis of Shiga toxin-associated haemolytic uraemic syndrome (HUS), 14.4% of Streptococcus pneumoniae-associated HUS, 15.6% of atypical HUS, 10.3% of secondary TMA and 2.1% of thrombotic thrombocytopenic purpura. Eighty-seven patients (89.7%) developed arterial hypertension, and 49.5% gastrointestinal, 22.7% respiratory, 25.8% neurologic and 12.4% cardiac manifestations. Also, 60.8% required renal replacement therapy and 2.1% plasma exchange. Twenty patients received eculizumab. The median PICU stay was 8.5 days (IQR, 5-16.5). Two children died. CONCLUSIONS The MATUCIP registry demonstrates the clinical variability of TMA cases requiring admission to the PICU. Knowledge of the presentation and outcomes of TMAs can facilitate early aetiological diagnosis. This registry can help improve our understanding of the clinical spectrum of these diseases, for which there is a dearth of published data.
Collapse
|
5
|
Microangiopatías trombóticas en niños críticamente enfermos. Registro español MATUCIP. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
6
|
Kovala M, Seppälä M, Kaartinen K, Meri S, Honkanen E, Räisänen-Sokolowski A. Vascular Occlusion in Kidney Biopsy Is Characteristic of Clinically Manifesting Thrombotic Microangiopathy. J Clin Med 2022; 11:jcm11113124. [PMID: 35683519 PMCID: PMC9181253 DOI: 10.3390/jcm11113124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) can sometimes manifest only histologically. Our aim was to retrospectively compare biopsy-proven adult TMA patients showing only histological (h-TMA) or both histological and clinical (c-TMA) TMA in 2006–2017. All native kidney biopsies with TMA were included. Biopsies were re-evaluated by light and electron microscopy, and immunofluorescence. Clinical characteristics, laboratory variables, and treatments were recorded from the electronic medical database. Patients were categorized into h-TMA and c-TMA and these groups were compared. In total, 30 biopsy-proven cases among 7943 kidney biopsies were identified and, of these, 15 had h-TMA and 15 c-TMA. Mean follow-up was 6.3 y, and 73.3% had secondary hemolytic uremic syndrome (HUS) and the rest were atypical HUS. Patient characteristics, treatments, and kidney, and patient survival in the groups were similar. Statistically significant differences were found in histological variables. Vascular myxoid swelling and vascular onion-skinning were almost exclusively detected in c-TMA and, thus, vascular occlusive changes indicate clinically apparent rather than merely histological TMA. In addition, regardless of clinical presentation, kidney and patient survival times were similar in the patient groups highlighting the importance of a kidney biopsy in the case of any kidney-related symptoms.
Collapse
Affiliation(s)
- Marja Kovala
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
- Correspondence:
| | - Minna Seppälä
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Kati Kaartinen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Seppo Meri
- Department of Bacteriology and Immunology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
| | - Eero Honkanen
- Department of Nephrology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland; (M.S.); (K.K.); (E.H.)
| | - Anne Räisänen-Sokolowski
- Department of Pathology, Helsinki University Hospital and Helsinki University, 00029 Helsinki, Finland;
| |
Collapse
|
7
|
IgA nephropathy and atypical hemolytic uremic syndrome: a case series and a literature review. J Nephrol 2021; 35:1091-1100. [PMID: 34757577 DOI: 10.1007/s40620-021-01189-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) has been anecdotally reported in association with atypical hemolytic uremic syndrome (aHUS). The association likely portends poor renal outcome, and the possible relationship with complement overactivation has yet to be elucidated. We evaluated a series of IgAN patients with aHUS and reviewed the available literature. METHODS Adult patients who received a diagnosis of IgAN and developed aHUS between January 2009 and December 2019 were included in this retrospective review. RESULTS We identified six IgAN-aHUS patients, all of whom developed end-stage kidney disease. At aHUS presentation all patients had decreased serum C3 levels. Predisposing pathogenetic variants and risk haplotypes for aHUS in CFH gene heterozygosity were documented in four out of six patients. Anti-CFH antibodies were found to be negative in the five tested patients. In the literature we identified 21 case reports involving aHUS-IgAN and six retrospective studies evaluating the presence of TMA at the time of renal biopsy. Hypertension, severe proteinuria, reduced sC3 and a worse renal prognosis were the common features of most cases. CONCLUSION Our case series and literature review show that the onset of either aHUS or renal TMA in the course of IgAN are associated with very poor renal outcome. Activation of the alternative pathway revealed by consumption of serum C3 seems to play a major role. Our hypothesis is that the presence of a predisposing factor (e.g. dysregualtion of complement alternative pathway and/or other intrarenal precipitating factors) might be at the heart of aHUS-IgAN pathophysiology.
Collapse
|
8
|
Haydock L, Garneau AP, Tremblay L, Yen HY, Gao H, Harrisson R, Isenring P. Genetic abnormalities in biopsy-proven, adult-onset hemolytic uremic syndrome and C3 glomerulopathy. J Mol Med (Berl) 2021; 100:269-284. [PMID: 34714369 PMCID: PMC8770394 DOI: 10.1007/s00109-021-02102-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/25/2022]
Abstract
Abstract Atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy (C3G) have been linked to mutations in many of the proteins that are involved in alternative complement pathway activation. Age and etiology confounded, the prevalence of such mutations has been reported to be over 30 to 50% in these diseases. However, the cohorts studied included many children or individuals with a familial history of complement-related disorders and genetic tests were usually limited to exome sequencing of known causative or risk-associated genes. In this study, a retrospective adult cohort of 35 patients with biopsy-proven thrombotic microangiopathy (the largest in Canada) and 10 patients with C3 glomerulopathy was tested through an extended exome panel to identify causative defects in associated or candidate genes including those of the alternative and terminal complement pathways. A variant of unknown significance was also analyzed for pathogenicity through in vitro studies. To our surprise, the prevalence of known causative or risk-associated variants in either of these cohorts was found to be less than ~ 15% overall. However, the panel used and analyses carried out allowed to identify novel variants of potential clinical significance and a number of candidate genes. The prevalence of known genetic defects in adult-onset aHUS and C3G is thus probably much lower than 30 to 50%. Our results also point towards the importance of investigating diseases of the alternative complement pathway through extended exome panels and in vitro analyses. Key messages The alternative complement pathway plays a major role in the pathogenesis of hemolytic uremic syndrome and C3 glomerulopathy. Based on previous studies, both disorders have been commonly linked to variants in the various intermediates that sustain or regulate this pathway. The prevalence of such mutations in the adult-onset and sporadic forms of these diseases is probably much lower than expected based on larger series. The sporadic forms of complementopathies are likely to involve additional genes that are yet to be uncovered.
Supplementary information The online version contains supplementary material available at 10.1007/s00109-021-02102-1.
Collapse
Affiliation(s)
- Ludwig Haydock
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada
| | - Alexandre P Garneau
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada.,Cardiometabolic Axis, School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montréal, 900, rue Saint-Denis, Montreal, QC, H2X 0A9, Canada
| | - Laurence Tremblay
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada
| | - Hai-Yun Yen
- Fulgent Genetics, Temple City, CA, 91780, USA
| | - Hanlin Gao
- Fulgent Genetics, Temple City, CA, 91780, USA
| | - Raphaël Harrisson
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada
| | - Paul Isenring
- Nephrology Research Group, L'Hôtel-Dieu de Québec Research Center, Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, G1R2J6, Canada.
| |
Collapse
|
9
|
Daviet F, Rouby F, Poullin P, Moussi‐Francès J, Sallée M, Burtey S, Mancini J, Duffaud F, Sabatier R, Pourroy B, Grandvuillemin A, Grange S, Frémeaux‐Bacchi V, Coppo P, Micallef J, Jourde‐Chiche N. Thrombotic microangiopathy associated with gemcitabine use: Presentation and outcome in a national French retrospective cohort. Br J Clin Pharmacol 2019; 85:403-412. [PMID: 30394581 PMCID: PMC6339967 DOI: 10.1111/bcp.13808] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS Gemcitabine has been associated with thrombotic microangiopathy (TMA). We conducted a national retrospective study of gemcitabine-associated TMA (G-TMA). METHODS From 1998 to 2015, all cases of G-TMA reported to the French Pharmacovigilance Network and the French TMA Reference Center, and cases explored for complement alternative pathway abnormalities, were analysed. RESULTS G-TMA was diagnosed in 120 patients (median age 61.5 years), after a median of 210 days of treatment, and a cumulative dose of 12 941 mg m-2 . Gemcitabine indications were: pancreatic (52.9%), pulmonary (12.6%) and breast (7.6%) cancers, metastatic in 34.2% of cases. Main symptoms were oedema (56.7%) and new-onset or exacerbated hypertension (62.2%). Most patients presented with haemolytic anaemia (95.6%) and thrombocytopenia (74.6%). Acute kidney injury was reported in 97.4% and dialysis was required in 27.8% of patients. Treatment consisted of: plasma exchange (PE; 39.8%), fresh frozen plasma (21.4%), corticosteroids (15.3%) and eculizumab (5.1%). A complete remission of TMA was obtained in 42.1% of patients and haematological remission in 23.1%, while 34.7% did not improve. The survival status was known for 52 patients, with 29 deaths (54.7%). Patients treated with PE, despite a more severe acute kidney injury, requiring dialysis more frequently, displayed comparable rates of remission, but with more adverse events. No abnormality in complement alternative pathway was documented in patients explored. CONCLUSION This large cohort confirms the severity of G-TMA, associated with severe renal failure and death. Oedema and hypertension could be monitored in patients treated with gemcitabine to detect early TMA. The benefit of PE or eculizumab deserves further investigation.
Collapse
Affiliation(s)
- Florence Daviet
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Franck Rouby
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Pascale Poullin
- Department of Apheresis, Regional Reference Center for Thrombotic MicroangiopathyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Julie Moussi‐Francès
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Marion Sallée
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Stéphane Burtey
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Julien Mancini
- Department of Public HealthAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Florence Duffaud
- Department of Clinical OncologyAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Renaud Sabatier
- Department of Clinical Oncology, Institut Paoli Calmettes, Laboratory of Molecular OncologyAix‐Marseille UniversityCRCM INSERM UMR 1068MarseilleFrance
| | - Bertrand Pourroy
- Department of Parmacy, OncoPharma UnitAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | | | - Steven Grange
- Medical intensive care unit, Regional Center for Thrombotic Microangiopathy, Hôpital Charles NicolleRouen University HospitalRouenFrance
| | | | - Paul Coppo
- Department of Hematology, French Reference Center for Thrombotic Microangiopathy (www.cnr‐mat.fr)Paris 6 UniversityParisFrance
| | - Joëlle Micallef
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Noémie Jourde‐Chiche
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| |
Collapse
|
10
|
Baghli S, Abendroth C, Farooq U, Schaub JA. Atypical Presentation of Pregnancy-Related Hemolytic Uremic Syndrome. Am J Kidney Dis 2018; 72:451-456. [DOI: 10.1053/j.ajkd.2017.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/08/2017] [Indexed: 01/27/2023]
|
11
|
Wöchtl B, Gunzer F, Gerner W, Gasse H, Koch M, Bagó Z, Ganter M, Weissenböck H, Dinhopl N, Coldewey SM, von Altrock A, Waldmann KH, Saalmüller A, Zimmermann K, Steinmann J, Kehrmann J, Klein-Hitpass L, Blom J, Ehricht R, Engelmann I, Hennig-Pauka I. Comparison of clinical and immunological findings in gnotobiotic piglets infected with Escherichia coli O104:H4 outbreak strain and EHEC O157:H7. Gut Pathog 2017; 9:30. [PMID: 28559930 PMCID: PMC5445466 DOI: 10.1186/s13099-017-0179-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/17/2017] [Indexed: 11/26/2022] Open
Abstract
Background Shiga toxin (Stx) producing Escherichia coli (E. coli) (STEC) is the most frequent cause of diarrhoea-positive haemolytic uraemic syndrome (D + HUS) in humans. In 2011, a huge outbreak with an STEC O104:H4 strain in Germany highlighted the limited possibilities for causative treatment of this syndrome. The responsible STEC strain was found to combine Stx production with adherence mechanisms normally found in enteroaggregative E. coli (EAEC). Pathotypes of E. coli evolve and can exhibit different adhesion mechanisms. It has been shown previously that neonatal gnotobiotic piglets are susceptible for infection with STEC, such as STEC O157:H7 as well as for EAEC, which are considered to be the phylogenetic origin of E. coli O104:H4. This study was designed to characterise the host response to infection with the STEC O104:H4 outbreak strain in comparison to an STEC O157:H7 isolate by evaluating clinical parameters (scoring) and markers of organ dysfunction (biochemistry), as well as immunological (flow cytometry, assessment of cytokines/chemokines and acute phase proteins) and histological alterations (light- and electron microscopy) in a gnotobiotic piglet model of haemolytic uraemic syndrome. Results We observed severe clinical symptoms, such as diarrhoea, dehydration and neurological disorders as well as attaching-and-effacing lesions (A/E) in the colon in STEC O157:H7 infected piglets. In contrast, STEC O104:H4 challenged animals exhibited only mild clinical symptoms including diarrhoea and dehydration and HUS-specific/severe histopathological, haematological and biochemical alterations were only inconsistently presented by individual piglets. A specific adherence phenotype of STEC O104:H4 could not be observed. Flow cytometric analyses of lymphocytes derived from infected animals revealed an increase of natural killer cells (NK cells) during the course of infection revealing a potential role of this subset in the anti-bacterial activity in STEC disease. Conclusions Unexpectedly, E. coli O104:H4 infection caused only mild symptoms and minor changes in histology and blood parameters in piglets. Outcome of the infection trial does not reflect E. coli O104:H4 associated human disease as observed during the outbreak in 2011. The potential role of cells of the innate immune system for STEC related disease pathogenesis should be further elucidated.
Collapse
Affiliation(s)
- Bettina Wöchtl
- University Clinic for Swine, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Florian Gunzer
- Institute of Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Wilhelm Gerner
- Institute of Immunology, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Hagen Gasse
- Institute of Anatomy, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Michaela Koch
- University Clinic for Swine, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Zoltán Bagó
- Institute for Veterinary Disease Control Mödling, Austrian Agency for Health and Food Safety, Robert-Koch-Gasse 17, 2340 Mödling, Austria
| | - Martin Ganter
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Herbert Weissenböck
- Institute for Pathology and Forensic Veterinary Medicine, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Nora Dinhopl
- Institute for Pathology and Forensic Veterinary Medicine, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany.,Centre for Innovation Competence (ZIK) Septomics, University Hospital Jena, Albert-Einstein-Strasse 10, 07745 Jena, Germany
| | - Alexandra von Altrock
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Karl-Heinz Waldmann
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Armin Saalmüller
- Institute of Immunology, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | | | - Jörg Steinmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Jan Kehrmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Ludger Klein-Hitpass
- Institute of Cell Biology, Medical Faculty, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Jochen Blom
- Bioinformatics and Systems Biology, Justus-Liebig-University Giessen, Heinrich-Buff-Ring 58, 35392 Gießen, Germany
| | - Ralf Ehricht
- Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany
| | - Ines Engelmann
- Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany
| | - Isabel Hennig-Pauka
- University Clinic for Swine, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| |
Collapse
|
12
|
Thachil J, Warkentin TE. How do we approach thrombocytopenia in critically ill patients? Br J Haematol 2016; 177:27-38. [PMID: 27982413 DOI: 10.1111/bjh.14482] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A low platelet count is a frequently encountered haematological abnormality in patients treated in intensive treatment units (ITUs). Although severe thrombocytopenia (platelet count <20 × 109 /l) can be associated with bleeding, even moderate-degree thrombocytopenia is associated with organ failure and adverse prognosis. The aetiology for thrombocytopenia in ITU is often multifactorial and correcting one aetiology may not normalise the low platelet count. The classical view for thrombocytopenia in this setting is consumption associated with thrombin-mediated platelet activation, but other concepts, including platelet adhesion to endothelial cells and leucocytes, platelet aggregation by increased von Willebrand factor release, red cell damage and histone release, and platelet destruction by the complement system, have recently been described. The management of severe thrombocytopenia is platelet transfusion in the presence of active bleeding or invasive procedure, but the risk-benefit of prophylactic platelet transfusions in this setting is uncertain. In this review, the incidence and mechanisms of thrombocytopenia in patients with ITU, its prognostic significance and the impact on organ function is discussed. A practical approach based on the authors' experience is described to guide management of a critically ill patient who develops thrombocytopenia.
Collapse
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
13
|
Kozlovskaya NL, Chebotareva NV, Nikogosova AD, Demyanova KA, Varshavsky VA, Roshchupkina SV. [Incomplete thrombotic microangiopathy as a variant of hemolytic-uremic syndrome]. TERAPEVT ARKH 2016; 88:77-79. [PMID: 27296266 DOI: 10.17116/terarkh201688677-79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The described case illustrates difficulties in diagnosing atypical hemolytic-uremic syndrome (aHUS) in incomplete thrombotic microangiopathy (TMA) in the absence of thrombocytopenia, one of the signs of the classic triad of aHUS, which has resulted in the delayed verification of its diagnosis and in progressive kidney injury. The paper discusses the need to carry out kidney biopsy and to include sHUS in both the presence of a complete set of symptoms of this disease and in the absence of one of them into a range of diagnostic search.
Collapse
Affiliation(s)
- N L Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - N V Chebotareva
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - A D Nikogosova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - K A Demyanova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - V A Varshavsky
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - S V Roshchupkina
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| |
Collapse
|
14
|
Campistol JM, Arias M, Ariceta G, Blasco M, Espinosa L, Espinosa M, Grinyó JM, Macía M, Mendizábal S, Praga M, Román E, Torra R, Valdés F, Vilalta R, Rodríguez de Córdoba S. An update for atypical haemolytic uraemic syndrome: diagnosis and treatment. A consensus document. Nefrologia 2015; 35:421-47. [PMID: 26456110 DOI: 10.1016/j.nefro.2015.07.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/03/2015] [Indexed: 02/07/2023] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a clinical entity defined as the triad of nonimmune haemolytic anaemia, thrombocytopenia, and acute renal failure, in which the underlying lesions are mediated by systemic thrombotic microangiopathy (TMA). Different causes can induce the TMA process that characterizes HUS. In this document we consider atypical HUS (aHUS) a sub-type of HUS in which the TMA phenomena are the consequence of the endotelial damage in the microvasculature of the kidneys and other organs due to a disregulation of the activity of the complement system. In recent years, a variety of aHUs-related mutations have been identified in genes of the the complement system, which can explain approximately 60% of the aHUS cases, and a number of mutations and polymorphisms have been functionally characterized. These findings have stablished that aHUS is a consequence of the insufficient regulation of the activiation of the complement on cell surfaces, leading to endotelial damage mediated by C5 and the complement terminal pathway. Eculizumab is a monoclonal antibody that inhibits the activation of C5 and blocks the generation of the pro-inflammatory molecule C5a and the formation of the cell membrane attack complex. In prospective studies in patients with aHUS, the use of Eculizumab has shown a fast and sustained interruption of the TMA process and it has been associated with significative long-term improvements in renal function, the interruption of plasma therapy and important reductions in the need of dialysis. According to the existing literature and the accumulated clinical experience, the Spanish aHUS Group published a consensus document with recommendations for the treatment of aHUs (Nefrologia 2013;33[1]:27-45). In the current online version of this document, we update the aetiological classification of TMAs, the pathophysiology of aHUS, its differential diagnosis and its therapeutic management.
Collapse
Affiliation(s)
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
| | - Miguel Blasco
- Servicio de Nefrología, Hospital Clínic, Barcelona, España
| | - Laura Espinosa
- Servicio de Nefrología Pediátrica, Hospital La Paz, Madrid, España
| | - Mario Espinosa
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, España
| | - Josep M Grinyó
- Servicio de Nefrología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Manuel Macía
- Servicio de Nefrología, Hospital Virgen de la Candelaria, Santa Cruz de Tenerife, España
| | | | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Elena Román
- Servicio de Nefrología Pediátrica, Hospital La Fe, Valencia, España
| | - Roser Torra
- Enfermedades Renales Hereditarias, Fundació Puigvert, Barcelona, España
| | - Francisco Valdés
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, España
| | - Ramón Vilalta
- Servicio de Nefrología Pediátrica, Hospital Universitari Materno-Infantil Vall d'Hebrón, Universidad Autónoma de Barcelona, Barcelona, España
| | | |
Collapse
|
15
|
Belingheri M, Possenti I, Tel F, Paglialonga F, Testa S, Salardi S, Ardissino G. Cryptic activity of atypical hemolytic uremic syndrome and eculizumab treatment. Pediatrics 2014; 133:e1769-71. [PMID: 24843058 DOI: 10.1542/peds.2013-2921] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening disease often related to uncontrolled complement activation. The use of eculizumab has changed the management and the outcome of aHUS, becoming the frontline treatment of the acute disease and for the prevention of relapses. We report the case of a male patient with aHUS due to complement factor H gene mutation who was shifted from plasmatherapy to eculizumab for preventing disease relapses. The shift to eculizumab was associated with a significant decrease in proteinuria, revealing disease activity otherwise unsuspected, being the classic criteria of disease activity (platelet, haptoglobin, LDH, schistocytes), all in the normal range.The condition of proteinuria as the only sign of thrombotic microangiopathy activity is here designated as "cryptic activity of aHUS."
Collapse
Affiliation(s)
- Mirco Belingheri
- Center for Hemolitic Uremic Syndrome Control, Prevention and Management, and
| | - Ilaria Possenti
- Center for Hemolitic Uremic Syndrome Control, Prevention and Management, and
| | - Francesca Tel
- Center for Hemolitic Uremic Syndrome Control, Prevention and Management, and
| | - Fabio Paglialonga
- Center for Hemolitic Uremic Syndrome Control, Prevention and Management, and
| | - Sara Testa
- Center for Hemolitic Uremic Syndrome Control, Prevention and Management, and
| | - Stefania Salardi
- Department of Pathophysiology and Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Ardissino
- Center for Hemolitic Uremic Syndrome Control, Prevention and Management, and
| |
Collapse
|
16
|
Manenti L, Gnappi E, Vaglio A, Allegri L, Noris M, Bresin E, Pilato FP, Valoti E, Pasquali S, Buzio C. Atypical haemolytic uraemic syndrome with underlying glomerulopathies. A case series and a review of the literature. Nephrol Dial Transplant 2013; 28:2246-59. [DOI: 10.1093/ndt/gft220] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
17
|
Sallée M, Ismail K, Fakhouri F, Vacher-Coponat H, Moussi-Francés J, Frémaux-Bacchi V, Burtey S. Thrombocytopenia is not mandatory to diagnose haemolytic and uremic syndrome. BMC Nephrol 2013; 14:3. [PMID: 23298275 PMCID: PMC3554580 DOI: 10.1186/1471-2369-14-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 01/02/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hemolytic and uremic syndrome (HUS) diagnosis involves association of non immune hemolytic anemia, thrombocytopenia, and renal failure. HUS without thrombocytopenia has been observed, we call it partial HUS. Its real frequency and outcome are unknown. The aim of this study was to determine the prevalence of patients with normal platelets count in two HUS cohorts and to compare their outcome to patients with thrombocytopenia. METHODS We retrospectively identified HUS diagnosis in two different cohorts. The first cohort was from a single center and consisted of all cases of HUS whatever the aetiology, the second was multicentric and consisted of atypical HUS patients. These cohorts were divided into two groups depending on the presence or absence of thrombocytopenia. Clinical and biological data were compared between thrombopenic and non thrombopenic group. RESULTS We identified 13% (20/150) of patients with normal platelets count: 10 episodes (18%) of HUS in six patients (14%) in the monocentric cohort and 14 patients (13%) with 17 episodes (12%) in the multicentric cohort of atypical HUS. Groups differed in platelets count and LDH level. In both cohorts, renal outcome was similar to patient presenting with thrombocytopenia. CONCLUSION HUS with normal platelets count is not infrequent. Relative to classical clinical presentation of HUS, partial HUS has similar characteristics and identical poor renal outcome and so must be treated in the same way.
Collapse
Affiliation(s)
- Marion Sallée
- APHM, Hopital de la Conception, centre de néphrologie et transplantation rénale, Aix-Marseille Univ, Marseille, 13005, France
| | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
BACKGROUND Hemolytic and uremic syndrome (HUS) diagnosis involves association of non immune hemolytic anemia, thrombocytopenia, and renal failure. HUS without thrombocytopenia has been observed, we call it partial HUS. Its real frequency and outcome are unknown. The aim of this study was to determine the prevalence of patients with normal platelets count in two HUS cohorts and to compare their outcome to patients with thrombocytopenia. METHODS We retrospectively identified HUS diagnosis in two different cohorts. The first cohort was from a single center and consisted of all cases of HUS whatever the aetiology, the second was multicentric and consisted of atypical HUS patients. These cohorts were divided into two groups depending on the presence or absence of thrombocytopenia. Clinical and biological data were compared between thrombopenic and non thrombopenic group. RESULTS We identified 13% (20/150) of patients with normal platelets count: 10 episodes (18%) of HUS in six patients (14%) in the monocentric cohort and 14 patients (13%) with 17 episodes (12%) in the multicentric cohort of atypical HUS. Groups differed in platelets count and LDH level. In both cohorts, renal outcome was similar to patient presenting with thrombocytopenia. CONCLUSION HUS with normal platelets count is not infrequent. Relative to classical clinical presentation of HUS, partial HUS has similar characteristics and identical poor renal outcome and so must be treated in the same way.
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW In the following study new aspects and insights into the epidemiology, pathogenesis and typical morphology of kidney involvement in thrombotic microangiopathy (TMA) are discussed. TMA comprises a spectrum of microvascular thrombosis syndromes associated with multiple pathogenetic factors, that is, typical and atypical haemolytic uraemic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), malignant hypertension, drugs or systemic autoimmune diseases or antibody-mediated rejection. RECENT FINDINGS The present article will put particular emphasis on new pathophysiological insights into the development of TMA in the various settings. In addition, new options in the therapeutic management of TMA in atypical HUS are discussed. The pathogenesis of TMA in atypical HUS primarily involves hereditary or acquired deficiencies and disturbances of the complement system. Eculizumab is a promising new therapeutic option that has been discovered recently. SUMMARY In HUS/TTP the kidney shows characteristic vascular changes due to endothelial damage, that is, TMA, which should be clinically and morphologically differentiated from other diseases. Recent genetic and molecular studies have shed more light on the pathogenesis of TMA in atypical HUS, that is, disturbances of various aspects of the complement system, and in TTP, that is, von Willebrand factor regulation by ADAMTS13, which are also helpful in the differential diagnosis.
Collapse
|