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Urra M, Lyons S, Teodosiu CG, Burwick R, Java A. Thrombotic Microangiopathy in Pregnancy: Current Understanding and Management Strategies. Kidney Int Rep 2024; 9:2353-2371. [PMID: 39156177 PMCID: PMC11328568 DOI: 10.1016/j.ekir.2024.05.016] [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] [Received: 10/27/2023] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 08/20/2024] Open
Abstract
Thrombotic microangiopathy (TMA) represents a heterogeneous group of disorders characterized by microvascular thrombosis and end-organ damage. Pregnancy-associated thrombotic microangiopathy (p-TMA) has emerged as a distinct clinical entity with unique diagnostic challenges. Identifying the specific form of p-TMA is critical for appropriate and timely management. This review offers a comprehensive overview of the various forms of thrombotic microangiopathies associated with pregnancy, highlighting our current understanding of their pathophysiology and the evolving landscape of diagnosis and treatment for each.
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Affiliation(s)
- Manuel Urra
- Department of Renal Medicine and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Shannon Lyons
- Department of Renal Medicine and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Richard Burwick
- Maternal Fetal Medicine, San Gabriel Valley Perinatal Medical Group, Pomona Valley Hospital Medical Center, Pomona, California, USA
| | - Anuja Java
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Duran MN, Beyazit F, Erbaş M, Özkavak O, Acar C, Bakirdogen S. Successful treatment with eculizumab in a patient with pregnancy-associated atypical hemolytic uremic syndrome. Obstet Med 2023; 16:130-133. [PMID: 37441667 PMCID: PMC10334036 DOI: 10.1177/1753495x211019902] [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: 10/18/2020] [Revised: 05/01/2021] [Accepted: 05/01/2021] [Indexed: 06/04/2024] Open
Abstract
Pregnancy-associated atypical haemolytic uraemic syndrome is a rare and potentially lethal complement-mediated disorder. It can mimic preeclampsia, gestational hypertension, thrombotic thrombocytopenic purpura and hemolysis, elevated liver enzymes and low platelets syndrome. Thus, it can be hard to distinguish pregnancy-associated atypical haemolytic uraemic syndrome from other causes in peri/post-partum women presenting with features of microangiopathic haemolytic anemia, thrombocytopenia and acute kidney injury. We present a case of a 35-year-old woman in her third pregnancy at 32 weeks' gestation who underwent caesarean section due to fetal distress. She developed severe renal impairment, thrombocytopenia and neurologic symptoms within 24 hours after delivery. A diagnosis of pregnancy-associated atypical haemolytic uraemic syndrome was provided, and treatment with plasma therapy followed by eculizumab was initiated. A rapid improvement of both clinical and laboratory parameters was observed. This case demonstrates the significance of early initiation of anti-complement therapy to prevent irreversible renal damage and possible death in women with pregnancy-associated atypical haemolytic uraemic syndrome.
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Affiliation(s)
- Mehmet Nuri Duran
- Department of Obstetrics and Gynecology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fatma Beyazit
- Department of Obstetrics and Gynecology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Mesut Erbaş
- Department of Anesthesiology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Onur Özkavak
- Department of Obstetrics and Gynecology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Celal Acar
- Department of Hematology, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Serkan Bakirdogen
- Department of Nephrology, Canakkale Onsekiz Mart University, Canakkale, Turkey
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Burwick RM, Moyle K, Java A, Gupta M. Differentiating Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome and Atypical Hemolytic Uremic Syndrome in the Postpartum Period. Hypertension 2021; 78:760-768. [PMID: 34275337 DOI: 10.1161/hypertensionaha.121.17311] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Richard M Burwick
- From the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA (R.M.B.)
| | - Kimberly Moyle
- Department of Obstetrics and Gynecology, University of Utah Health (K.M.)
| | - Anuja Java
- Division of Nephrology, Department of Medicine, Washington University School of Medicine in St. Louis (A.J.)
| | - Megha Gupta
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT (M.G.)
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Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group. Blood 2021; 136:2103-2117. [PMID: 32808006 DOI: 10.1182/blood.2020005221] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022] Open
Abstract
Pregnancy and postpartum are high-risk periods for different forms of thrombotic microangiopathy (TMA). However, the management of pregnancy-associated TMA remains ill defined. This report, by an international multidisciplinary working group of obstetricians, nephrologists, hematologists, intensivists, neonatologists, and complement biologists, summarizes the current knowledge of these potentially severe disorders and proposes a practical clinical approach to diagnose and manage an episode of pregnancy-associated TMA. This approach takes into account the timing of TMA in pregnancy or postpartum, coexisting symptoms, first-line laboratory workup, and probability-based assessment of possible causes of pregnancy-associated TMA. Its aims are: to rule thrombotic thrombocytopenic purpura (TTP) in or out, with urgency, using ADAMTS13 activity testing; to consider alternative disorders with features of TMA (preeclampsia/eclampsia; hemolysis elevated liver enzymes low platelets syndrome; antiphospholipid syndrome); or, ultimately, to diagnose complement-mediated atypical hemolytic uremic syndrome (aHUS; a diagnosis of exclusion). Although they are rare, diagnosing TTP and aHUS associated with pregnancy, and postpartum, is paramount as both require urgent specific treatment.
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Tshilanda M, Kanmounye US, Tendobi C, Mbuyi F. Diagnostic dilemma in postpartum associated hemolytic uremic syndrome in a 38th week pregnant 31-year-old Congolese: a case report. BMC Pregnancy Childbirth 2020; 20:495. [PMID: 32854648 PMCID: PMC7457258 DOI: 10.1186/s12884-020-03185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy is associated with HELLP syndrome, thrombotic thrombocytopenic purpura, or atypical hemolytic uremic syndrome (aHUS) during pregnancy. Standard laboratory and physical examinations can help distinguish between these three diseases promptly and guide their management. This is critical because their managements and prognoses differ considerably. The ADAMTS13 test, complement tests, and biopsies can help ascertain the diagnosis; however, they take time, and are not widely available. In this case report, we present a case that highlights the diagnostic and therapeutic dilemmas associated with the aforementioned diseases. CASE PRESENTATION A 31-year old P3G3 patient presented at 38 weeks with high blood pressure, bilateral pitting edema, and a low fetal heart rate. A cesarean section was performed to extract the fetus. On postoperative day 2, the suites were marked by anemia, low platelet count, acute kidney injury, declining liver function, and the presence of schistocytes on the peripheral thin smear. The patient was lucid, coherent, and presented no neurological deficits. The ADAMTS13 test and anti-complement therapy were not readily available, so the team made a presumptive diagnosis of aHUS based on the history, clinical presentation, and standard laboratory results. Due to a lack of anticomplement therapy, the patient was prescribed four sessions of hemodialysis. The renal function and platelet count gradually increased, and the patient was discharged on postoperative day 18. The patient was followed for over a year and did not present relapses of thrombocytopenia or microangiopathic hemolytic anemia. CONCLUSIONS The prompt diagnosis and management of aHUS lead to favorable outcomes. Healthcare providers should be able to rapidly differentiate between pregnancy-associated thrombotic microangiopathies and prescribe appropriate management. Here, we highlighted the challenges of diagnosing and managing postpartum associated aHUS in a low-resource setting.
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Affiliation(s)
- Marc Tshilanda
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME) Monkolé, Kinshasa, Democratic Republic of Congo
- Faculty of Medicine, Université Notre-Dame du Kasayi, Kananga, Democratic Republic of Congo
| | - Ulrick Sidney Kanmounye
- Faculty of Medicine, Université Technologique Bel Campus, Kinshasa, Democratic Republic of Congo.
| | - Céline Tendobi
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME) Monkolé, Kinshasa, Democratic Republic of Congo
| | - Freddy Mbuyi
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME) Monkolé, Kinshasa, Democratic Republic of Congo
- Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
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Abstract
OBJECTIVE To evaluate disease presentation, diagnosis, treatment, and clinical outcomes in pregnancy-associated atypical hemolytic uremic syndrome (aHUS). DATA SOURCES We searched PubMed, MEDLINE, Cochrane Library, ClinicalTrials.gov, Web of Science, EMBASE and Google Scholar, from inception until March 2018. METHODS OF STUDY SELECTION We included English-language articles describing aHUS in pregnancy or postpartum. The diagnosis of aHUS was characterized by hemolysis, thrombocytopenia, and renal failure and was distinguished from typical diarrhea-associated hemolytic uremic syndrome. Patients were excluded if individual data could not be obtained, the diagnosis was unclear, or an alternative etiology was more likely, such as thrombotic thrombocytopenic purpura or Shiga toxin-producing Escherichia coli. Reports were appraised by two reviewers, with disagreements adjudicated by a third reviewer. TABULATION, INTEGRATION, AND RESULTS The search identified 796 articles. After review of titles, abstracts, and full text, we identified 48 reports describing 60 unique cases of pregnancy-associated aHUS, with 66 pregnancies. Twelve cases involved pregnancy in women with known aHUS, and 54 cases involved first-episode pregnancy-associated aHUS. Women with known aHUS, particularly those with baseline creatinine at or above 1.5 mg/dL, had a high rate of adverse pregnancy outcomes. For first-episode pregnancy-associated aHUS, diagnosis most often occurred postpartum (94%), after a cesarean delivery (70%), in nulliparous women (58%). Preceding obstetric complications were common and included fetal death, preeclampsia, and hemorrhage. Diagnosis was usually made clinically, based on the triad of microangiopathic hemolysis, thrombocytopenia, and renal failure. Additional testing included renal biopsy, complement genetic testing, and ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) testing. Treatment modalities included corticosteroids, plasma exchange, dialysis, and eculizumab. More women with first-episode pregnancy-associated aHUS achieved disease remission when treated with eculizumab, compared with those not treated with eculizumab (88% vs 57%, P=.02). CONCLUSION Pregnancy-associated aHUS usually presents in the postpartum period, often after a pregnancy complication, and eculizumab is effective for achieving disease remission. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019129266.
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Situmorang PC, Ilyas S, Hutahaean S, Rosidah R. Effect of Nanoherbal Andaliman (Zanthoxylum acanthopodium) and Extra Virgin Olive Oil Combination on Preeclamptic Rats Liver Histology. Open Access Maced J Med Sci 2019; 7:2226-2231. [PMID: 31592268 PMCID: PMC6765073 DOI: 10.3889/oamjms.2019.651] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/01/2019] [Accepted: 07/12/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Andaliman (Zanthoxylum acanthopodium) is a spice traditional Northen Sumatera, Indonesia and these fruits contain alkaloids, steroids and terpenoids. Extra Virgin Olive Oil (EVOO) contains antioxidants. Combination of this plant have activities to reduce preeclampsia. AIM To know the safety of the combination of nano herbal andaliman and Extra virgin olive oil (EVOO) on preeclampsia patients' liver. METHODS Pregnant rats were made to have preeclampsia with 3 ml of NaCl 6% injections. This research consists of 5 groups: K- (negative control): normal pregnant rats, K+: preeclampsia rats; P1: PE rats were given nano herbal andaliman 1 ml EVOO / day / 20 gBW from the 13th to the 19th day of pregnancy, P2: PE rats were given nano herbal andaliman 100 mg/day / 200 gBW from the 13th to the 19th day of pregnancy, P3: PE was given the combination of 1 ml EVOO/day / 200 gBW and andaliman nano herbal 100 mg/day/200 gBW on the 13th day of pregnancy to the 19th day given orally. Then on the 20th day of pregnancy, the subjects were dissected. RESULTS There were significant differences (p < 0.05) on the value of SGOT, SGPT, and the average damage of the hepatocyte cells except parenchymatous degeneration after being given the nano herbal andaliman and EVOO. The compared mean of normal hepatocytes cell, hydropic degeneration and necrosis value between all groups were p < 0.05 and p < 0.01 compared to (K-). The non-significant difference was found in the mean of parenchymatous degeneration between the groups (p = 0.058). CONCLUSION The combination of nano herbal andaliman (Zanthoxylum acanthopodium) and EVOO affected the level of necrosis in hepatocyte cells on preeclampsia rats.
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Affiliation(s)
- Putri Cahaya Situmorang
- Department of Biology, Faculty of Mathematics and Natural Sciences, Universitas Sumatera Utara, Medan 20155, Indonesia
| | - Syafruddin Ilyas
- Faculty of Pharmacy, Universitas Sumatera Utara, Medan 20155, Indonesia
| | - Salomo Hutahaean
- Department of Biology, Faculty of Mathematics and Natural Sciences, Universitas Sumatera Utara, Medan 20155, Indonesia
| | - Rosidah Rosidah
- Faculty of Pharmacy, Universitas Sumatera Utara, Medan 20155, Indonesia
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Pillay C, Clark K. Postpartum care of women with renal disease. Best Pract Res Clin Obstet Gynaecol 2019; 57:89-105. [PMID: 31122756 DOI: 10.1016/j.bpobgyn.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
Abstract
Twenty-three percent of women with known chronic kidney disease (CKD) have been reported to demonstrate the first decline in kidney function between giving birth and six-weeks postpartum. As such, these women warrant close monitoring during the postpartum period irrespective of their pregnancy journey. Substantial haemodynamic variability during pregnancy and postpartum renders estimated glomerular filtration rate inaccurate, and poorly defined normal ranges of markers of kidney function at this time pose challenges for accurate assessment of renal complications. Multi-disciplinary specialist care is therefore essential, with consideration of specific implications of any known renal diagnosis and with observation for the development of postpartum complications of pregnancy. Furthermore, the postpartum period affords time to further investigate and diagnose kidney disease revealed by pregnancy. Good care planning and communication in the postpartum period has the potential to improve long-term health outcomes for women with known or new CKD and will be discussed in this review.
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Affiliation(s)
- Camilla Pillay
- Department of Renal Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Katherine Clark
- Antental Hypertension Clinic, King's College Hospital, 16-20, Windsor Walk, London, SE5 8BB, UK.
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Ma L, Li L, Han P, Meng F, Jiao C, Zhang H. Effect of the drug combination of magnesium sulfate and phentolamine on homocysteine and C-reactive protein in the serum of patients with pregnancy-induced hypertension syndrome. Exp Ther Med 2019; 17:3682-3688. [PMID: 30988752 PMCID: PMC6447783 DOI: 10.3892/etm.2019.7385] [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: 11/08/2018] [Accepted: 02/22/2019] [Indexed: 12/22/2022] Open
Abstract
Effect and clinical efficacy of magnesium sulfate combined with phentolamine on homocysteine and C-reactive protein in the serum of patients with pregnancy-induced hypertension syndrome were investigated. A total of 96 patients with pregnancy-induced hypertension syndrome who were diagnosed and treated in Jining No. 1 People's Hospital from February 2016 to January 2018 were retrospectively analyzed. The patients were grouped according to the dosage regimen. The patients who received the combination treatment of magnesium sulfate and phentolamine on the basis of magnesium sulfate were included in the observation group, and the patients who were treated with the intravenous infusion of magnesium sulfate alone were included in the control group. Mean arterial pressure (MAP), the content of 24 h urine protein, systolic blood pressure (SBP), diastolic blood pressure (DBP), Hcy, and CRP of the pregnant women were observed. MAP and the content of 24 h urine protein, SBP and DBP of the patients in the observation group after the treatment were significantly lower than those of the patients in the control group (P<0.001). Hcy and CRP of the patients in the observation group after the treatment were significantly lower than those of the patients in the control group (P<0.001). The total effective rate of the patients in the observation group was significantly higher than that of the patients in the control group (P<0.05). In conclusion, the meliorative effect of magnesium sulphate combined with phentolamine on the level of MAP, the content of 24 h urine protein, SBP, DBP, Hcy and CRP in pregnant woman had a greater impact than that of the single use of the intravenous infusion of magnesium sulfate in the treatment of pregnancy-induced hypertension syndrome, and the clinical efficacy of magnesium sulphate combined with phentolamine was better, thus worthwhile to promote widely in clinic.
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Affiliation(s)
- Li Ma
- Department of Obstetrics, Jining No. 1 People's Hospital, Jining, Shandong 272011, P.R. China
| | - Liang Li
- Department of Pharmacy, Yidu Central Hospital of Weifang, Weifang, Shandong 262500, P.R. China
| | - Ping Han
- Department of Respiratory Medicine, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Fanchun Meng
- Department of Obstetric Delivery Room, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Chunhong Jiao
- Rehabilitation, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Hongmei Zhang
- Ward 1, Department of Gynecology, Jining No. 1 People's Hospital, Jining, Shandong 272011, P.R. China
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Socié G, Caby-Tosi MP, Marantz JL, Cole A, Bedrosian CL, Gasteyger C, Mujeebuddin A, Hillmen P, Vande Walle J, Haller H. Eculizumab in paroxysmal nocturnal haemoglobinuria and atypical haemolytic uraemic syndrome: 10-year pharmacovigilance analysis. Br J Haematol 2019; 185:297-310. [PMID: 30768680 PMCID: PMC6594003 DOI: 10.1111/bjh.15790] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/14/2018] [Indexed: 12/25/2022]
Abstract
Eculizumab is the first and only medication approved for paroxysmal nocturnal haemoglobinuria (PNH) and atypical haemolytic uraemic syndrome (aHUS) treatment. However, eculizumab safety based on long‐term pharmacovigilance is unknown. This analysis summarises safety data collected from spontaneous and solicited sources from 16 March 2007 through 1 October 2016. Cumulative exposure to eculizumab was 28 518 patient‐years (PY) (PNH, 21 016 PY; aHUS, 7502 PY). Seventy‐six cases of meningococcal infection were reported (0·25/100 PY), including eight fatal PNH cases (0·03/100 PY). Susceptibility to meningococcal infections remained the key risk in patients receiving eculizumab. The meningococcal infection rate decreased over time; related mortality remained steady. The most commonly reported serious nonmeningococcal infections were pneumonia (11·8%); bacteraemia, sepsis and septic shock (11·1%); urinary tract infection (4·1%); staphylococcal infection (2·6%); and viral infection (2·5%). There were 434 reported cases of eculizumab exposure in pregnant women; of 260 cases with known outcomes, 70% resulted in live births. Reporting rates for solid tumours (≈0·6/100 PY) and haematological malignancies (≈0·74/100 PY) remained stable over time. No new safety signals affecting the eculizumab benefit‐risk profile were identified. Continued awareness and implementation of risk mitigation protocols are essential to minimise risk of meningococcal and other Neisseria infections in patients receiving eculizumab.
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Affiliation(s)
- Gérard Socié
- Hematology/Transplantation, APHP Hospital Saint Louis, University Paris VII, Paris, France
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Tsai HM. Atypical Hemolytic Uremic Syndrome: Beyond Hemolysis and Uremia. Am J Med 2019; 132:161-167. [PMID: 30145224 DOI: 10.1016/j.amjmed.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/08/2018] [Accepted: 08/11/2018] [Indexed: 12/20/2022]
Abstract
Atypical hemolytic uremic syndrome commonly presents with the triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal function impairment without an antecedent hemorrhagic diarrhea. Less known are extrarenal complications due to abnormal vascular permeability, although these are a major cause of morbidity and mortality for the patients. Furthermore, it is increasingly recognized that the disease may present with hypertension or renal function impairment with no or mild thrombocytopenia and microangiopathic hemolytic anemia. Awareness of the full spectrum of atypical hemolytic uremic syndrome may facilitate its diagnosis and treatment before serious complications or death occurs.
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Affiliation(s)
- Han-Mou Tsai
- Division of Hematology/Oncology, State University of New York Downstate Medical Center, Brooklyn, NY.
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12
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Tsai HM. Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndromes. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00042-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW Significant and intricate immune adaptations are essential for the establishment and maintenance of normal pregnancy. Preeclampsia is a morbid, potentially life-threatening disease for both mother and neonate that occurs uniquely in pregnancy, at least in part, due to maternal immune maladaptation. We aim to review the literature that focuses on case reports, diagnostic approaches, and treatment strategies for disorders of the complement alternative pathway (CAP) as related to preeclampsia. RECENT FINDINGS There is evidence of complement dysregulation in preeclampsia and HELLP syndrome, similar to that observed in a few rare types of thrombotic microangiopathies. Complement dysregulation may be identified with functional laboratory testing as well as genetic testing. Increased utilization of a standardized diagnostic approach to establish whether persistent and/or severe cases of preeclampsia and HELLP syndrome are complement-mediated may lead to development of future treatment strategies, such as complement-targeted therapy.
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Gupta M, Feinberg BB, Burwick RM. Thrombotic microangiopathies of pregnancy: Differential diagnosis. Pregnancy Hypertens 2018; 12:29-34. [PMID: 29674195 DOI: 10.1016/j.preghy.2018.02.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/08/2018] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathy (TMA) disorders are characterized by microangiopathic hemolytic anemia, thrombocytopenia and end-organ injury. In pregnancy and postpartum, TMA is most commonly encountered with HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) or preeclampsia with severe features, but rarely TMA is due to thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS). Due to overlapping clinical and laboratory features, TTP and aHUS are often mistaken for preeclampsia or HELLP. Unfortunately, delays in appropriate diagnosis and treatment may be life-threatening. Our objective is to alert obstetrician-gynecologists, certified nurse midwives, family medicine providers, and subspecialty consultants, to the range of TMA disorders that may occur in and around pregnancy. To do this, we have provided a review of individual disorders that comprise the differential diagnosis of pregnancy TMA, and we have proposed a systematic approach to make an accurate diagnosis with readily available clinical and laboratory data. In complex or critical cases, we recommend a multidisciplinary team approach (e.g., Critical Care, Hematology, Maternal Fetal Medicine, Nephrology) to expedite diagnosis and treatment, which may be life-saving.
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Affiliation(s)
- M Gupta
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - B B Feinberg
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - R M Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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15
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Huerta A, Arjona E, Portoles J, Lopez-Sanchez P, Rabasco C, Espinosa M, Cavero T, Blasco M, Cao M, Manrique J, Cabello-Chavez V, Suñer M, Heras M, Fulladosa X, Belmar L, Sempere A, Peralta C, Castillo L, Arnau A, Praga M, Rodriguez de Cordoba S. A retrospective study of pregnancy-associated atypical hemolytic uremic syndrome. Kidney Int 2017; 93:450-459. [PMID: 28911789 DOI: 10.1016/j.kint.2017.06.022] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/23/2017] [Accepted: 06/30/2017] [Indexed: 12/24/2022]
Abstract
Pregnancy-associated atypical hemolytic uremic syndrome (aHUS) refers to the thrombotic microangiopathy resulting from uncontrolled complement activation during pregnancy or the postpartum period. Pregnancy-associated aHUS is a devastating disease for which there is a limited clinical understanding and treatment experience. Here we report a retrospective study to analyze the clinical and prognostic data of 22 cases of pregnancy-associated aHUS from the Spanish aHUS Registry under different treatments. Sixteen patients presented during the first pregnancy and as many as nine patients required hemodialysis at diagnosis. Identification of inherited complement abnormalities explained nine of the 22 cases, with CFH mutations and CFH to CFHR1 gene conversion events being the most prevalent genetic alterations associated with this disorder (66%). In thirteen of the cases, pregnancy complications were sufficient to trigger a thrombotic microangiopathy in the absence of genetic or acquired complement alterations. The postpartum period was the time with highest risk to develop the disease and the group shows an association of cesarean section with pregnancy-associated aHUS. Seventeen patients underwent plasma treatments with a positive renal response in only three cases. In contrast, ten patients received eculizumab with an excellent renal response in all, independent of carrying or not inherited complement abnormalities. Although the cohort is relatively small, the data suggest that pregnancy-associated aHUS is not different from other types of aHUS and suggest the efficacy of eculizumab treatment over plasma therapies. This study may be useful to improve prognosis in this group of aHUS patients.
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Affiliation(s)
- Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain.
| | - Emilia Arjona
- Department of Cellular and Molecular Medicine, Center for Biological Research, Madrid, Spain; Center for Biomedical Network Research on Rare Diseases, Madrid, Spain
| | - Jose Portoles
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain; RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain
| | - Paula Lopez-Sanchez
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Cristina Rabasco
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Mario Espinosa
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Teresa Cavero
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Miquel Blasco
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mercedes Cao
- Department of Nephrology, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Joaquin Manrique
- Department of Nephrology, Clinica Universitaria de Navarra, Pamplona, Spain
| | | | - Marta Suñer
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Manuel Heras
- Department of Nephrology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Xavier Fulladosa
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital de Bellvitge, Barcelona, Spain
| | - Lara Belmar
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Amparo Sempere
- Department of Hematology, Hospital Universitari Politecnic La Fe, Valencia, Spain
| | - Carmen Peralta
- Department of Nephrology, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Lorena Castillo
- Department of Nephrology, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Alvaro Arnau
- Department of Nephrology, Hospital Universitario Donostia, Donostia, Spain
| | - Manuel Praga
- RedinRen RD016/009/009, Instituto de Salud Carlos III, Madrid, Spain; Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Santiago Rodriguez de Cordoba
- Department of Cellular and Molecular Medicine, Center for Biological Research, Madrid, Spain; Center for Biomedical Network Research on Rare Diseases, Madrid, Spain.
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16
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Atypical hemolytic uremic syndrome in the setting of complement-amplifying conditions: case reports and a review of the evidence for treatment with eculizumab. J Nephrol 2016; 30:347-362. [PMID: 27848226 PMCID: PMC5437142 DOI: 10.1007/s40620-016-0357-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/14/2016] [Indexed: 01/20/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare, genetic, progressive, life-threatening form of thrombotic microangiopathy (TMA) predominantly caused by dysregulation of the alternative pathway of the complement system. Complement-amplifying conditions (CACs), including pregnancy complications [preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome], malignant hypertension, autoimmune diseases, transplantation, and others, are associated with the onset of TMA in up to 69 % of cases of aHUS. CACs activate the alternative pathway of complement and may be comorbid with aHUS or may unmask a previously undiagnosed case. In this review, three case reports are presented illustrating the onset and diagnosis of aHUS in the setting of different CACs (pregnancy complications, malignant hypertension, renal transplantation). The report also reviews the evidence for a variety of CACs, including those mentioned above as well as infections and drug-induced TMA, and the overlap with aHUS. Finally, we introduce an algorithm for diagnosis and treatment of aHUS in the setting of CACs. If TMA persists despite initial management for the specific CAC, aHUS should be considered. The terminal complement inhibitor eculizumab should be initiated for all patients with confirmed diagnosis of aHUS, with or without a comorbid CAC.
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17
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Regal JF, Strehlke ME, Peterson JM, Wing CR, Parker JE, Nieto NF, Bemis LT, Gilbert JS, Fleming SD. Role of IgM and angiotensin II Type I receptor autoantibodies in local complement activation in placental ischemia-induced hypertension in the rat. Mol Immunol 2016; 78:38-47. [PMID: 27588825 DOI: 10.1016/j.molimm.2016.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/17/2016] [Accepted: 08/23/2016] [Indexed: 01/27/2023]
Abstract
Preeclampsia is characterized by development of hypertension during pregnancy and reduced placental perfusion. Previous studies in a rat model of placental ischemia-induced hypertension demonstrated that inhibiting complement activation attenuated increased maternal blood pressure with C3a and C5a identified as the important products of complement activation. Given that in other forms of ischemia both natural IgM and antigen antibody complexes initiate complement activation, we hypothesized that placental ischemia exposes neoepitopes recognized by IgM to cause local complement activation and hypertension. Alternatively, we postulated that autoantibody to angiotensin II Type 1 receptor (AT1-AA) interacts with AT1 receptors to cause complement activation. Since complement activation occurs in kidney and placenta in preeclampsia, we used immunohistochemistry to determine IgM deposition and local complement activation in each organ (C3 deposition), and quantitative real-time polymerase chain reaction (qRT-PCR) to quantitate mRNA for endogenous regulators of complement activation CD55, CD59 and Complement receptor 1-related gene/protein y (Crry). On gestation day (GD)14.5, timed pregnant Sprague Dawley rats underwent Sham surgery or placement of clips on inferior abdominal aorta and ovarian arteries to create placental ischemia using the reduced utero-placental perfusion pressure (RUPP) model. As previously reported, RUPP surgery increased mean arterial pressure and circulating C3a on GD19.5. In placenta, IgM and C3 deposition increased, whereas mRNA for complement regulators Crry and CD59 decreased along with Crry protein in RUPP compared to Sham treated animals. In kidney, IgM deposition increased in animals subjected to RUPP vs Sham surgery without a significant change in C3 deposition and coincident with an increase in mRNA for CD55 and CD59. The AT1 receptor antagonist losartan prevents placental ischemia-induced hypertension as well as AT1-AA interaction with AT1 receptors. However, losartan did not attenuate complement activation as measured by circulating C3a or placental C3 deposition. Importantly, our studies indicate that following placental ischemia, complement activation is not due to AT1-AA but is associated with IgM deposition. These studies suggest a role for natural antibodies interacting with placental ischemia-induced neoepitopes to activate complement and contribute to hypertension.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Megan E Strehlke
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Jenna M Peterson
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Cameron R Wing
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Jordan E Parker
- Division of Biology, Kansas State University, Manhattan, KS, United States.
| | | | - Lynne T Bemis
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Sherry D Fleming
- Division of Biology, Kansas State University, Manhattan, KS, United States.
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18
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From Gestational Hypertension and Preeclampsia to Atypical Hemolytic Uremic Syndrome. Obstet Gynecol 2016; 128:657. [PMID: 27548541 DOI: 10.1097/aog.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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