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Bobrova LA, Kozlovskaya NL. [Lupus nephritis and thrombotic microangiopathy: A review]. TERAPEVT ARKH 2024; 96:628-634. [PMID: 39106505 DOI: 10.26442/00403660.2024.06.202731] [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: 07/07/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
Lupus nephritis (LN) is one of the most common organ-specific manifestations of systemic lupus erythematosus (SLE). Various clinical signs of LN develop in at least 50% of patients with SLE. In addition to LN, the spectrum of renal lesions associated with SLE also includes vascular pathology. One of the variants of renal microvascular injury is thrombotic microangiopathy (TMA), the mechanisms of which are diverse. The review focuses on the main forms of TMA, including antiphospholipid syndrome and nephropathy associated with antiphospholipid syndrome, TMA caused by complement system regulation disorders and deficiency of ADAMTS13. In most cases, these forms of TMA are combined with LN. However, they may also exist as a single form of kidney damage. This article discusses the TMA pathogenesis, the impact on kidney prognosis, and treatment options.
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Affiliation(s)
- L A Bobrova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N L Kozlovskaya
- Patrice Lumumba People's Friendship University of Russia
- Yeramishantsev City Clinical Hospital
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2
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Zhang P, Yang X, Fu MZ, Gao CL, Fang X, Xia ZK. Risk Factors and Clinical Outcomes of Renal Thrombotic Microangiopathy in Children with Lupus Nephritis in Terms of Pathological and Clinical Features. Nephron Clin Pract 2024; 148:609-617. [PMID: 38852577 DOI: 10.1159/000538240] [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: 05/20/2022] [Accepted: 03/05/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is an important risk factor for the prognosis of lupus nephritis (LN). Patients with LN complicated with TMA tend to be critically ill with high mortality and poor prognosis. In the present study, we retrospectively analyzed the clinical manifestations, laboratory results, renal pathological manifestations, and prognosis of children with LN-TMA and analyzed the risk factors for end-stage renal disease (ESRD) in children with LN-TMA. METHODS Seventy-four patients with LN and renal TMA (rTMA) were selected and compared to 128 LN controls without TMA (1:2 ratio) matched according to demographics, pathological type and treatments. RESULTS The mean values of systolic blood pressure, diastolic blood pressure (DBP), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), urinary protein quantitation (PRO), urine red blood cells, N-acetyl-β-D-glucosidase (NAG), retinol-binding protein, systemic lupus erythematosus disease activity score (SLEDAI), and activity index (AI) scores in the TMA group were all higher than those in the non-TMA group (p < 0.05 and p < 0.01). The mean values of complement C3, hemoglobin, platelets, estimated glomerular filtration rate, and chronic index (CI) score in the TMA group were all lower than those in the non-TMA group (p < 0.05 and p < 0.01). The number of cases of glomerular crescent, fibrous crescent, endocapillary proliferation, tubular atrophy, interstitial fibrosis, C3 and C1q deposition in the TMA group was higher than that in the non-TMA group (p < 0.05 and p < 0.01). The 3-year and 5-year renal survival rates in the TMA group (88.93% vs. 97.00%, p < 0.05) and TMA group (61.41% vs. 82.31%, p < 0.05) were significantly lower than those in the non-TMA group. Multivariate Cox regression analysis showed that serum creatinine before treatment (≥110 μmol/L), TMA and interstitial fibrosis were independent risk factors for the development of ESRD in LN children. CONCLUSION The general condition of children with TMA is critical, and the prognosis is poor. Early detection, early treatment and the development of new treatments are key to improving LN-TMA outcomes in children.
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Affiliation(s)
- Pei Zhang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China,
| | - Xiao Yang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Meng-Zhen Fu
- Department of Pediatric Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Chun-Lin Gao
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Xiang Fang
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zheng-Kun Xia
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
- Department of Pediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
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Jha VK, Kumar MH, Akal RS, Harikrishnan S, Tirumala NS. Postpartum Pulmonary-Renal Syndrome with Thrombotic Microangiopathy in Systemic Lupus Erythematosus. Indian J Nephrol 2023; 33:128-131. [PMID: 37234428 PMCID: PMC10208545 DOI: 10.4103/ijn.ijn_78_22] [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: 02/21/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 11/04/2022] Open
Abstract
Postpartum pulmonary syndrome as lupus flares in inactive or mild lupus is uncommon. The diagnosis and management of postpartum lupus flare in second pregnancy presenting with crescentic lupus nephritis (LN), secondary thrombotic microangiopathy (TMA), and severe lupus vasculitis in an undiagnosed systemic lupus erythematosus is extremely challenging. Here, in this case report, we present a young lady who presented with postpartum acute kidney injury (AKI) with systemic complaints about 4 weeks post-term uneventful delivery. Renal biopsy was suggestive of crescentic LN with severe lupus vasculitis. The stormy course was further complicated with diffuse alveolar hemorrhage, portal venous thrombosis, TMA, and anuric AKI requiring renal replacement therapy. She received multiple sessions of plasmapheresis, steroid, intravenous immunoglobulin, inj. cyclophosphamide, and started showing improvement after about 6 weeks of presentation.
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Affiliation(s)
- Vijoy Kumar Jha
- Department of Nephrology, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India
| | - M. Harish Kumar
- Department of Rheumatology, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India
| | - Ramanjit Singh Akal
- Department of Nephrology, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India
| | - S Harikrishnan
- Departments of Medicine, Medical Division, Command Hospital Air Force (CHAF), Bengaluru, Karnataka, India
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4
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Vitkauskaitė M, Vinikovas A, Miglinas M, Rimševičius L, Čerkauskaitė A, Mačionienė E, Ašakienė E. Complement inhibitor eculizumab in thrombotic microangiopathy: Single-center case series. Clin Case Rep 2022; 10:e05573. [PMID: 35317070 PMCID: PMC8922540 DOI: 10.1002/ccr3.5573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Abstract
Our case series showed that eculizumab is efficacious and safe in treating thrombotic microangiopathy, as well as it has positive effects on quality of life. Further extensive studies are required to develop unified treatment guidelines.
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Affiliation(s)
| | - Artūras Vinikovas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Marius Miglinas
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Laurynas Rimševičius
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Agnė Čerkauskaitė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Ernesta Mačionienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
| | - Eglė Ašakienė
- Faculty of Medicine Vilnius University Vilnius Lithuania
- Clinic of Gastroenterology, Nephro-Urology and Surgery Faculty of Medicine Institute of Clinical Medicine Vilnius University Vilnius Lithuania
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5
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Shah S, Joseph C, Srivaths P. Role of therapeutic apheresis in the treatment of pediatric kidney diseases. Pediatr Nephrol 2022; 37:315-328. [PMID: 33991255 DOI: 10.1007/s00467-021-05093-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 04/01/2021] [Accepted: 04/22/2021] [Indexed: 11/26/2022]
Abstract
Therapeutic apheresis utilizes apheresis procedures in the treatment of a variety of conditions including kidney disease. Therapeutic plasma exchange (TPE) is the most common modality employed with the rationale of rapid reduction of a pathogenic substance distributed primarily in the intravascular compartment; however other techniques which adsorb such pathogenic substances or alter the immune profile have been utilized in diseases affecting native and transplanted kidneys. This article discusses the modalities and technical details of therapeutic apheresis and summarizes its role in individual diseases affecting the kidney. Complications related to pediatric apheresis procedures and specifically related to apheresis in kidney disease are also discussed. Though therapeutic apheresis modalities are employed frequently in children with kidney disease, most experiences are extrapolated from adult studies. International and national registries need to be established to elucidate the role of apheresis modalities in children with kidney disease.
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Affiliation(s)
- Shweta Shah
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Catherine Joseph
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Leone P, Prete M, Malerba E, Bray A, Susca N, Ingravallo G, Racanelli V. Lupus Vasculitis: An Overview. Biomedicines 2021; 9:1626. [PMID: 34829857 PMCID: PMC8615745 DOI: 10.3390/biomedicines9111626] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.
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Affiliation(s)
- Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Eleonora Malerba
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Antonella Bray
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Nicola Susca
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Giuseppe Ingravallo
- Section of Pathology, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy;
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
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Figueiredo CR, Escoli R, Santos P, Sofia F, Lopes K. Thrombotic microangiopathy in a patient with systemic lupus erythematosus and anti-factor H autoantibodies. CEN Case Rep 2021; 11:26-30. [PMID: 34269998 DOI: 10.1007/s13730-021-00627-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a serious complication that may occur in patients with systemic lupus erythematosus (SLE), adversely affecting the prognosis and increasing mortality. The pathogenesis of TMA in these patients may be multifactorial and overlap between different entities may exist. We present a case of a 24-year-old man, previously diagnosed with SLE, class IV lupus nephritis, and antiphospholipid antibody syndrome, who was admitted with acute kidney injury, severe pancytopenia, and other features consistent with lupus flare. A clinical TMA diagnosis was made and the patient was treated with plasmapheresis, rituximab and immunoglobulin endovenous (EV) infusions. Hemodialysis was initiated during hospitalization and, despite the hematological recovery, the patient remained dialysis dependent. The complementary study revealed high levels of anti-factor H (fH) autoantibodies with no pathogenic mutations on complement genes (namely CFHR1 and CFHR3). Initially, the most likely cause of TMA seemed to be secondary to SLE, but the presence of anti-fH antibodies in our patient may suggest a concomitant complement-mediated TMA.
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Affiliation(s)
- Cátia Raquel Figueiredo
- Nephrology Department, Centro Hospitalar Do Médio Tejo. Av, Xanana Gusmao Ap 45, 2350-754, Torres Novas, Santarém, Portugal.
| | - Rachele Escoli
- Nephrology Department, Centro Hospitalar Do Médio Tejo. Av, Xanana Gusmao Ap 45, 2350-754, Torres Novas, Santarém, Portugal
| | - Paulo Santos
- Nephrology Department, Centro Hospitalar Do Médio Tejo. Av, Xanana Gusmao Ap 45, 2350-754, Torres Novas, Santarém, Portugal
| | - Flora Sofia
- Nephrology Department, Centro Hospitalar Do Médio Tejo. Av, Xanana Gusmao Ap 45, 2350-754, Torres Novas, Santarém, Portugal
| | - Karina Lopes
- Nephrology Department, Centro Hospitalar Do Médio Tejo. Av, Xanana Gusmao Ap 45, 2350-754, Torres Novas, Santarém, Portugal
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Strufaldi FL, Menezes Neves PDMDM, Dias CB, Yu L, Woronik V, Cavalcante LB, Malheiros DMAC, Jorge LB. Renal thrombotic microangiopathy associated to worse renal prognosis in Lupus Nephritis. J Nephrol 2021; 34:1147-1156. [PMID: 33570723 DOI: 10.1007/s40620-020-00938-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/29/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Renal thrombotic microangiopathy (rTMA) is one of many vascular findings in Lupus Nephritis (LN). However, the influence of rTMA on prognosis has not been well established. The objective of this study was to evaluate the clinical and pathological aspects of patients with lupus and rTMA in kidney biopsy. METHODS Analysis of medical reports and kidney biopsy of 253 patients with LN, between January 2012 and December 2018. RESULTS Among our 253 patients, 43 (17%) showed acute or chronic TMA lesions on kidney histology This group had a significantly lower estimated glomerular filtration rate (eGFR) at the time of biopsy (24.1 vs. 64.15 ml/min/1.73m2, p < 0.001), at 1 year of follow up (28.1 vs. 90.7 ml/min/1.73m2, p < 0.001), and at the end of follow up (25.4 vs. 81.55 ml/min/1.73m2, p < 0.001). More patients in the rTMA group reached the composite endpoint of eGFR < 15 mL/min/1.73m2 or death or dialysis (82.9% vs. 32.9%, p < 0.001). When comparing the classical clinical TMA features, the rTMA group had higher percentages of anemia, thrombocytopenia, low haptoglobin levels, but not higher lactate dehydrogenase (LDH) levels (> 214 U/L). Combining these variables in a definition of clinical TMA, the rTMA group had a statistically higher percentage of clinical TMA (20.9% vs. 4.33%, p = 0.001). As expected, TMA group showed higher systolic blood pressure (SBP) (130 vs 129.5 mmHg, p = 0.01). Concerning histopathological features, rTMA group had significantly higher activity (9.0 vs. 6.0, p = 0.001) and chronicity (4.0 vs. 3.0, p = 0.001) scores, also a higher percentage of patients presented with crescents (76.7% vs. 57.1%, p = 0.012). CONCLUSIONS The classical clinical TMA criteria were unable to predict the presence of tissue TMA, suggesting a probably renal-limited TMA that may occur independently of systemic evident factors. Therefore, renal biopsy remains the critical method for diagnosing an important prognostic feature.
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Affiliation(s)
| | | | | | - Luis Yu
- Nephrology Division, School of Medicine, University of São Paulo, São Paulo-SP, Brazil
| | - Viktoria Woronik
- Nephrology Division, School of Medicine, University of São Paulo, São Paulo-SP, Brazil
| | - Livia Barreira Cavalcante
- Pathology Division, University of São Paulo School of Medicine, Av. Dr. Enéas de Carvalho Aguiar, 255, 7º andar, Cerqueira Cesar, São Paulo-SP, Brazil
| | - Denise Maria Avancini Costa Malheiros
- Pathology Division, University of São Paulo School of Medicine, Av. Dr. Enéas de Carvalho Aguiar, 255, 7º andar, Cerqueira Cesar, São Paulo-SP, Brazil
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Tseng MH, Fan WL, Liu H, Yang CY, Ding JJ, Lee HJ, Huang SM, Lin SH, Huang JL. Complement Factor I Mutation May Contribute to Development of Thrombotic Microangiopathy in Lupus Nephritis. Front Med (Lausanne) 2021; 7:621609. [PMID: 33614676 PMCID: PMC7892619 DOI: 10.3389/fmed.2020.621609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/31/2020] [Indexed: 12/30/2022] Open
Abstract
Objective: Renal thrombotic microangiopathy (TMA) is associated with complement overactivation and poor outcome in patients with lupus nephritis (LN). The role of genetic makeup of complement system in these patients remains to be elucidated. Methods: The clinical and laboratory characteristics of 100 patients with LN during 2010-2017 were retrospectively analyzed. LN patients with renal TMA and condition-matched LN patients without renal TMA were studied. Twenty normal subjects were also enrolled for comparison. Whole exome sequence followed by Sanger sequence was used in our study cohort. Results: Eight patients with renal TMA and eight condition-matched patients were enrolled from 100 LN patients with mean age 11.2 ± 2.0 years. Compared with condition-matched LN patients without renal TMA, LN patients with renal TMA exhibited statistically higher serum urea. Although most patients with renal TMA responded to plasma exchange, they had significantly higher relapse rate of nephritis, lower remission rate, and higher risk of end-stage renal disease and mortality. Compared with patients without renal TMA and normal subjects, those with renal TMA had significantly lower serum complement factor H (CFH) and plasma ADAMTS13 activity. Molecular analysis of all 100 patients with LN uncovered that three patients with renal TMA harbored mutations, two missense and non-sense, on CFI and CFHR2. The non-sense mutation, E302X, on CFI may impair its interaction C3b/CFH complex by loss of the heavy chain of complement factor I on simulation model. Conclusion: In addition to low serum CFH level and plasma ADAMTS13 activity, defects in genes responsible for complement regulatory proteins may contribute to the development of renal TMA in patients with LN.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Pediatrics, Xiamen Chang Gung Hospital, Ximen, China
| | - Wen-Lang Fan
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsuan Liu
- College of Medicine, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan.,Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan.,Division of Colon and Rectal Surgery, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Yu Yang
- College of Medicine, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan.,Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan.,Department of Microbiology and Immunology, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jhao-Jhuang Ding
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hwei-Jen Lee
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jing-Long Huang
- Division of Asthma, Allergy, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
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Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Kaneda T, Tanaka E, Akutsu Y, Kanamori T, Mouri M, Morio T, Mori M. Refractory secondary thrombotic microangiopathy with kidney injury associated with systemic lupus erythematosus in a pediatric patient. CEN Case Rep 2020; 9:301-307. [PMID: 32304042 DOI: 10.1007/s13730-020-00475-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/02/2020] [Indexed: 11/30/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is generally diagnosed through clinical features characterized as microangiopathic hemolytic anemia, thrombocytopenia, and multiple organ injury, as well as by pathological findings such as vascular damage and endothelial cell injury. Rheumatic and autoimmune diseases could be accompanied by secondary TMA; in fact, systemic lupus erythematosus (SLE) is a common disease associated with secondary TMA, and SLE complicated with TMA has been reported to have a poor prognosis. Although TMA occurs rarely in pediatric SLE patients, it often leads to severe clinical conditions. Here, we report a rare case of severe juvenile-onset SLE complicated with TMA and kidney injury. The 5-year-old patient showed renal dysfunction, thrombocytopenia, hemolytic anemia, nephrotic syndrome, hypocomplementemia, and elevation of anti-dsDNA IgG levels. Kidney biopsy revealed mesangial proliferation and endocapillary proliferation, as well as plumped endothelial cells, with full-house pattern deposits in immunofluorescence study. Combination treatment of methylprednisolone pulse therapy followed by oral prednisolone, mycophenolate mofetil, and plasma exchange was effective, whereas eculizumab did not show therapeutic effects. The patient further showed recurrent deterioration, and we initiated intravenous cyclophosphamide in addition to combination treatment and eventually succeeded in controlling the disease. Genome analysis by whole-exome sequencing revealed no particular gene mutation related to either complement disorders or type-1 interferon. Further elucidations concerning the pathogenic mechanisms causing juvenile-onset SLE are needed to establish an efficient treatment strategy for TMA with SLE.
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Affiliation(s)
- Tomoya Kaneda
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eriko Tanaka
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan. .,Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
| | - Yuko Akutsu
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toru Kanamori
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mariko Mouri
- Department of Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
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Abstract
Renal microvascular lesions, common in lupus nephritis (LN), are associated with long-term poor outcomes. There are mainly five pathological types of renal microvascular lesions in LN: (1) vascular immune complex deposits (ICD), (2) arteriosclerosis (AS), (3) thrombotic microangiopathy (TMA), (4) non-inflammatory necrotizing vasculopathy (NNV), and (5) true renal vasculitis (TRV). The pathogenesis of renal microvascular lesions in LN remains to be elucidated. The activation and dysfunction of endothelial cells, in addition to the contribution of immune system dysfunction, especially the immune complex-induced vascular inflammation and antiphospholipid antibody-associated thrombotic events, are key mechanisms in the development of vascular lesions in LN that need to be further investigated. Alteration of the microvascular environment produces an acute immunological response that recruits immune cells, such as T cells, monocytes, and macrophages, which induces platelet aggregation with microthrombus formation. There is also increased cytotoxicity caused by cytokines produced by immune cells in the kidney. Identifying the mechanism underlying the pathogenesis of renal microvascular lesions in LN might provide potential targets for the development of novel therapies.
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Affiliation(s)
- Ying Ding
- Department of Nephrology, Peking University International Hospital, Beijing, PR. China.,Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, PR. China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, PR. China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, PR. China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, PR. China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
| | - Zhen Qu
- Department of Nephrology, Peking University International Hospital, Beijing, PR. China
| | - Feng Yu
- Department of Nephrology, Peking University International Hospital, Beijing, PR. China.,Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, PR. China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, PR. China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, PR. China
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13
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Kotzen ES, Roy S, Jain K. Antiphospholipid Syndrome Nephropathy and Other Thrombotic Microangiopathies Among Patients With Systemic Lupus Erythematosus. Adv Chronic Kidney Dis 2019; 26:376-386. [PMID: 31733722 DOI: 10.1053/j.ackd.2019.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/07/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023]
Abstract
Antiphospholipid syndrome (APS) and other causes of thrombotic microangiopathy (TMA) negatively impact the renal outcomes of patients with systemic lupus erythematosus (SLE) and lupus nephritis. Here we review the diagnosis and management of occlusive renal vascular lesions due to APS and other TMAs, with a focus on patients with SLE and lupus nephritis. The presence of a thrombotic event, unexplained hypertension, thrombocytopenia, or hemolytic anemia should prompt consideration for TMA syndromes. The differential diagnosis of a TMA in a patient with SLE includes APS, thrombocytopenic purpura, complement-mediated or infection-associated hemolytic uremic syndrome, drug-mediated TMA (particularly due to calcineurin inhibitor toxicity), and malignant hypertension. Treatment of APS with a documented thrombotic event focuses on anticoagulation to reduce the risk for further thrombotic events. Treatment of classic presentations of thrombocytopenic purpura and hemolytic uremic syndrome in the SLE population is the same as in patients without SLE. Treatment of APS nephropathy or TMA when it is diagnosed by biopsy with concomitant lupus nephritis presents a challenge to clinicians because there is no clear standard of care. Small and retrospective studies suggest potential benefit of complement inhibition, mammalian target of rapamycin (mTOR) inhibition, B cell depleting therapy, and plasma exchange therapy for patients with lupus nephritis and TMA, and prospective investigation of these therapies should be a research priority.
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14
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Al Hamzi HA, Al-Mayouf SM, Al Shaikh AA, Al-Sheikh HA, Alshomar AA, Al Humaidan HA, Al Dalaan AN, Al Saleh SS. Early and late effects of therapeutic plasma exchange in patients with systemic lupus erythematosus and antineutrophil cytoplasmic antibody-associated vasculitis: A single-center experience. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2019; 30:775-780. [PMID: 31464233 DOI: 10.4103/1319-2442.265452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Therapeutic plasma exchanges (TPE) is considered as one of the treatment modalities that is used in systemic autoimmune diseases. This study aimed to describe the early and late effect of TPE in patients with systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) presented with acute kidney injury (AKI). Retrospective study comprised patients with SLE and AAV with AKI seen between January 2000 and June 2014 at King Faisal Specialist Hospital and Research Center in Riyadh. All patients underwent TPE. Retrospectively, all patients were assessed for early and late renal outcome at 12- month and 24-month intervals. Renal outcome was assessed according to serum creatinine level, glomerular filtration rate, active urine sediment, and proteinuria. P <0.05 was considered significant. A total of 68 patients were included, 58 patients (51 females) had SLE and 10 patients (7 females) had AAV completed TPE. All patients had active disease and had AKI. At the first 12 months, 18 patients (17 SLE and 1 AAV) showed complete response and 14 patients had partial response while 22 patients did not show therapeutic benefit. The nonresponders (22 patients) entered the late assessment interval (24 months) without any therapeutic response. Statistically, there was no significant difference between the patient's response to TPE at the first and second assessment intervals and the baseline serum creatinine level. TPE might be an alternative rescue treatment in lupus nephritis with AKI.
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Affiliation(s)
- Hanan A Al Hamzi
- Department of Medicine, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Sulaiman M Al-Mayouf
- Department of Pediatric Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmad A Al Shaikh
- Adult Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Haifa A Al-Sheikh
- Adult Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmad A Alshomar
- Adult Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hind A Al Humaidan
- Blood Bank and Transfusion Services; Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah N Al Dalaan
- Adult Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Salman S Al Saleh
- Adult Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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15
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Pattanashetti N, Ramachandran R, Rathi M, Nada R, Gupta KL. Plasma exchange in lupus nephritis with thrombotic microangiopathy. Nephrology (Carlton) 2019; 24:877-878. [PMID: 31044483 DOI: 10.1111/nep.13542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Navin Pattanashetti
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan L Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kello N, Khoury LE, Marder G, Furie R, Zapantis E, Horowitz DL. Secondary thrombotic microangiopathy in systemic lupus erythematosus and antiphospholipid syndrome, the role of complement and use of eculizumab: Case series and review of literature. Semin Arthritis Rheum 2018; 49:74-83. [PMID: 30598332 DOI: 10.1016/j.semarthrit.2018.11.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/25/2018] [Accepted: 11/26/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Thrombotic microangiopathy (TMA) is a life-threatening, albeit infrequent, complication of systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APS). Recommendations for the treatment of SLE- and APS-related secondary TMA are currently based solely on case reports and expert opinion. Unfortunately, interventions may not yield timely results or effectively halt the progression of TMA. Since complement activation plays a key role in the pathogenesis of secondary TMA due to SLE, APS, a therapy that targets the complement pathway is an attractive intervention. Eculizumab, a recombinant, fully humanized IgG2/IgG4 monoclonal antibody inhibits C5 activation and is FDA-approved for PNH and atypical HUS (aHUS). However, limited case reports are available on its use in treatment of secondary TMA. CASE PRESENTATION AND RESULTS We present the largest case series to date that includes 9 patients with SLE and/or APS who were successfully treated with eculizumab for refractory secondary TMA. In this case series, we report significant responses in hematology values, renal function and other organs following treatment with eculizumab. At 4 weeks, 75% improvement in platelet counts was observed in 78% of patients. Two-thirds of patients demonstrated >75% improvement of haptoglobin and LDH at four weeks. At 4 weeks, eGFR improved by 25% in half of the patients, and 43% had reductions in proteinuria. Two of 3 patients that required hemodialysis were able to be taken off hemodialysis. CONCLUSION Based on these observations, we suggest that eculizumab may be a potential treatment option for acutely ill patients with secondary TMA due to SLE and/or APS who have failed standard of care. A collective approach is needed to better elucidate the role and optimal timing of eculizumab use in the management of TMA complicating SLE and/or APS.
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Affiliation(s)
- Nina Kello
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA.
| | - Lara El Khoury
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Galina Marder
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Richard Furie
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Ekaterini Zapantis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
| | - Diane Lewis Horowitz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 865 Northern Boulevard, Suite 302, Great Neck, NY 11021, USA
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Attar RZ, Ramel EI, Safdar OY, Desoky S. A case of patient with renal lupus with an initial presentation of hemolytic uremic syndrome triggered by streptococcal infection. Clin Case Rep 2018; 6:712-718. [PMID: 29636946 PMCID: PMC5889269 DOI: 10.1002/ccr3.1425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/30/2017] [Accepted: 01/05/2018] [Indexed: 11/23/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a systemic disease that is presented in a myriad of ways. Renal involvement is common in SLE and usually presents clinically as glomerulonephritis. We describe patients with SLE presented initially with hemolytic uremic syndrome which is a distinctive initial presentation.
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Affiliation(s)
- Rahaf Z. Attar
- College of medicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Enas I. Ramel
- College of medicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Osama Y. Safdar
- Faculty of MedicinePediatric Nephrology Center of ExcellenceKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Sherif Desoky
- Faculty of MedicinePediatric Nephrology Center of ExcellenceKing Abdulaziz UniversityJeddahSaudi Arabia
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18
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Zickuhr L, Herlitz LC, Chatterjee S. A 22-Year-Old Woman With Systemic Lupus Erythematosus Presents With Two Damaged Kidneys, One Seizure, No Platelets, and Many Possible Diagnoses. Arthritis Care Res (Hoboken) 2018; 70:1686-1693. [PMID: 29579358 DOI: 10.1002/acr.23561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/20/2018] [Indexed: 11/09/2022]
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19
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Du J, Wang Y, Li YC, Wang TT, Zhou YL, Ying ZH. Acute diffuse alveolar haemorrhage accompanied by gastrointestinal bleeding in a patient with serious systemic lupus erythematosus: A case report. J Int Med Res 2018; 46:2046-2053. [PMID: 29557269 PMCID: PMC5991244 DOI: 10.1177/0300060517749666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that affects many organs, but multisystem dysfunction is rare. Here, we report a case of a 29-year-old woman who was initially diagnosed with SLE complications including lupus nephritis, lupus encephalopathy, renal hypertension, thrombocytopenia, anaemia and hyperkalaemia. She recovered following treatment with high dose methylprednisolone, intravenous immunoglobulin (IVIG) and continuous renal replacement therapy (CRRT). However, a few days after hospital discharge, she developed gastrointestinal bleeding. Although intensive treatment was administered, the patient deteriorated rapidly and had a progressive decline in oxygen saturation followed by diffuse alveolar haemorrhage and acute left heart failure. Inotropic therapy, mechanical ventilation, blood transfusion, CRRT, antibiotics, intravenous glucocorticoids and other support therapies were initiated and gradually the patient's vital signs stabilized and haemoptysis subsided. This case report emphasises that complications of SLE can occur at any stage of the disease, especially in patients with active SLE. Therefore, it is important for clinicians to be aware of the rare presentations of SLE and its complex management. For multisystem dysfunction, early intensive treatment with high dose corticosteroids and cyclophosphamide is advocated.
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Affiliation(s)
- Jing Du
- Department of Laboratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Ying Wang
- Department of Transfusion Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yan-chun Li
- Department of Pathology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Tong-Tong Wang
- The Second Clinical Medical College, Zhejiang Chinese Medicine University, Hangzhou, China
| | - Yong-lie Zhou
- Department of Laboratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
- Zhen-hua Ying and Yong-lie Zhou, Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China; Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China. Emails: ;
| | - Zhen-hua Ying
- Department of Rheumatology and Immunology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
- Zhen-hua Ying and Yong-lie Zhou, Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China; Zhejiang Provincial People’s Hospital, Hangzhou, 310014, Zhejiang, China. Emails: ;
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20
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Kronbichler A. Therapeutic Plasma Exchange Strategy in Complement-Mediated Diseases: An Overview. Ther Apher Dial 2018; 22:8-10. [PMID: 29405620 DOI: 10.1111/1744-9987.12640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 09/14/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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21
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Soyuöz A, Karadağ Ö, Karaağaç T, Kılıç L, Bilgen ŞA, Özcebe Oİ. Therapeutic plasma exchange for refractory SLE: A comparison of outcomes between different sub-phenotypes. Eur J Rheumatol 2017; 5:32-36. [PMID: 29657872 DOI: 10.5152/eurjrheum.2017.17088] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/03/2017] [Indexed: 12/18/2022] Open
Abstract
Objective Therapeutic plasma exchange (TPE) offers an alternative therapeutic modality for patients with systemic lupus erythematosus (SLE) and primary antiphospholipid syndrome (APS). However, there is conflicting evidence regarding its efficacy in different sub-phenotypes. This study aimed to investigate the main clinical characteristics and outcomes of patients with different phenotypes of SLE and APS treated with TPE at a tertiary care center. Methods The database of the Blood and Apheresis Unit between 2001 and 2013 was screened for patients with SLE and primary APS. SLE disease activity index (SELENA-SLEDAI), the indications for treatment, complications, and outcomes were obtained from a review of medical records and phone calls. A total of 24 patients (SLE: 20, APS: 4) were recruited for the study. Results Mean ages of SLE (M/F: 1/19) and primary APS (PAPS) patients (M/F: 2/2) were 32.4±12.89 and 52.0±10.7 years, respectively. The main indications for TPE were hematologic, neurologic, and pulmonary involvement and APS-related symptoms. TPE was preferred in eight patients because of leucopenia and co-infection. SLEDAI was significantly decreased after TPE (16.7±8.3 before vs. 8.8±3.1 after, p=0.001). Both primary APS and SLE-related catastrophic APS (CAPS) patients had completely responded to TPE. The success rate of TPE in patients with thrombocytopenia was lower than patients with hemolytic anemia. The median (IQR 25%-75%) number of TPE sessions was 6.5 (5-10.5). In total, five patients experienced TPE-related major adverse events (catheter infections in three patients, bleeding in one patient, and hypotension in one patient). The median (IQR 25%-75%) follow-up time was 33.5 (6.75-81.25) months. In total, four patients died during follow up, of which three died during the period of TPE administration. Conclusion Our data suggest that CAPS and other APS-related problems respond well to the TPE treatment. TPE should be kept in mind for the treatment of patients with other features of SLE, especially those resistant to other agents and in the presence of leucopenia.
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Affiliation(s)
- Aynur Soyuöz
- Division of Haemotology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ömer Karadağ
- Division of Haemotology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tülay Karaağaç
- Blood and Apheresis Unit of Hacettepe University School of Medicine Hospital, Ankara, Turkey
| | - Levent Kılıç
- Division of Haemotology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Şule Apraş Bilgen
- Division of Haemotology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Osman İlhami Özcebe
- Division of Haemotology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.,Blood and Apheresis Unit of Hacettepe University School of Medicine Hospital, Ankara, Turkey
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22
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de Holanda MI, Pôrto LC, Wagner T, Christiani LF, Palma LMP. Use of eculizumab in a systemic lupus erythemathosus patient presenting thrombotic microangiopathy and heterozygous deletion in CFHR1-CFHR3. A case report and systematic review. Clin Rheumatol 2017; 36:2859-2867. [PMID: 28905254 DOI: 10.1007/s10067-017-3823-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 02/01/2023]
Abstract
The association of thrombotic microangiopathy (TMA) with systemic lupus erythematosus (SLE) has been described in 0.5 to 10% of cases, and patients present worse outcome. TMA is described as the association of microangiopathic hemolytic anemia, thrombocytopenia, and an organ injury, frequently the kidney. This study describes a successful case of use of eculizumab in a patient with SLE and TMA refractory to standard therapy, and provides a literature review. Case description and search in PubMed and MEDLINE using systemic lupus erythemathous and/or antiphospholipid syndrome (APS) and eculizumab retrieved 15 case reports. Eighteen-year-old female presented acute renal failure and TMA and was diagnosed with SLE. Steroids and IV cyclophosphamide were started together with plasma exchange. After 55 days, she still persisted with microangiopathic anemia, thrombocytopenia, and anuria, and eculizumab was introduced. She had rapid improvement in hematological parameters, and dialysis was discontinued 25 days after the first dose. Genetic analysis showed large heterozygous deletion encompassing the entire CFHR1 and CFHR3, a finding previously associated with patients presenting atypical hemolytic-uremic syndrome (aHUS). Twenty patients who received eculizumab with SLE and/or APS have been published to date: 11 were female and mean age at presentation was 31 years. Seven out of the 20 patients presented only SLE, 5 patients only APS and 8 patients both SLE and APS. Eighteen patients underwent plasma exchange, with a mean of 20 (4-120) sessions per patient. Thirteen patients received rituximab. Hematological response was evident in 100% and kidney recovery in 85% of patients. The terminal complement blockade with eculizumab is an optional treatment for patients with SLE and/or APS presenting TMA and refractory to current immunosuppression therapies. Genetic testing may help recognize patients with aHUS and SLE/APS and therefore help to determine length of treatment with eculizumab.
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Affiliation(s)
- Maria Izabel de Holanda
- Department of Nephrology and Kidney Transplant, Hospital Federal de Bonsucesso, Av. Londres 616, Prédio 1, segundo andar, Departamento de Nefrologia e Transplante Renal, Rio de Janeiro, Brazil.
| | - Luis Cristóvão Pôrto
- Histocompatibility and Cryopreservation Laboratory, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Teresa Wagner
- Department of Nephrology and Kidney Transplant, Hospital Federal de Bonsucesso, Av. Londres 616, Prédio 1, segundo andar, Departamento de Nefrologia e Transplante Renal, Rio de Janeiro, Brazil
| | - Luis Fernando Christiani
- Department of Nephrology and Kidney Transplant, Hospital Federal de Bonsucesso, Av. Londres 616, Prédio 1, segundo andar, Departamento de Nefrologia e Transplante Renal, Rio de Janeiro, Brazil
| | - Lilian M P Palma
- Department of Pediatric Nephrology, Unicamp, State University of Campinas, Campinas, Brazil
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