1
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Desai SB, Ahdoot R, Malik F, Obert M, Hanna R. New guidelines and therapeutic updates for the management of lupus nephritis. Curr Opin Nephrol Hypertens 2024; 33:344-353. [PMID: 38334499 DOI: 10.1097/mnh.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE) can be a devastating condition, striking young patients often in their prime reproductive years. Lupus nephritis is a common and serious complication occurring in roughly 50% of SLE cases, indicating a high likelihood of disease progression, morbidity, and mortality. As the early trials of steroid therapy, and later cyclophosphamide (CYC), therapeutic changes had been stagnant. Then came the introduction of mycophenolate mofetil (MMF) in the 2000s. After the Aspreva Lupus Management Study, there had been a dearth of trials showing positive therapy results. Since 2020, new studies have emerged for lupus nephritis involving the use of anti-BLYS agents, novel calcineurin inhibitors, CD20 blockade, and antiinterferon agents. Nephrology and rheumatology society guidelines in the United States and across the world are still catching up. RECENT FINDINGS Although therapeutic guidelines are being developed, updates that have come through have focused on improved diagnostic and monitoring guidelines. One theme is the recommendation of increasingly tight proteinuria control and firmer guidelines for the rapid induction of remission. The reality of multitarget therapy and the expectation of rapid induction for a more complete remission are being widely recognized. SUMMARY The need for more complete and more rapid induction and control of lupus nephritis is undisputed according to the evidence and guidelines, and the medications to achieve this are growing at a rate not seen over the prior two decades. What remains is a stepwise approach to recognize how to best optimize therapy. Based on available evidence, an algorithm for induction and maintenance treatment of lupus nephritis used by the University of California Irvine Lupus Nephritis clinic, is recommended.
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Affiliation(s)
| | - Rebecca Ahdoot
- Division of Nephrology, Department of Medicine, University of California Irvine, Orange, California, USA
| | - Fatima Malik
- Division of Nephrology, Department of Medicine, University of California Irvine, Orange, California, USA
| | | | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine, Orange, California, USA
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2
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Tran MH, Patel S, Desai S, Ciurea S, Lee BJ, Hanna R. Thrombotic microangiopathy - the importance of a multidisciplinary approach. Curr Opin Nephrol Hypertens 2024; 33:247-256. [PMID: 38018789 DOI: 10.1097/mnh.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the importance of a multidisciplinary thrombotic microangiopathies (TMA) Team. This goal will be accomplished through review of the complement system, discuss various causes of thrombotic microangiopathies (TMA), and aspects of their diagnosis and management. In so doing, readers will gain an appreciation for the complexity of this family of disorders and realize the benefit of a dedicated multidisciplinary TMA Team. RECENT FINDINGS TMA causes derive from multiple specialty areas, are difficult to timely recognize, pose complex challenges, and require multidisciplinary management. Hematopoietic stem cell transplant-associated TMA (TA-TMA) and TA-TMA related multiorgan dysfunction syndrome (TA-TMA MODS) are areas of burgeoning research; use of complement testing and eculizumab precision-dosing has been found to better suppress complement activity in TA-TMA than standard eculizumab dosing. Newer tests are available to risk-stratify obstetric patients at risk for severe pre-eclampsia, whose features resemble those of TA-TMA MODS. Numerous disorders may produce TMA-like findings, and a systematic approach aids in their identification. TMA Teams elevate institutional awareness of increasingly recognized TMAs, will help expedite diagnostic and therapeutic interventions, and create pathways to future TMA-related research and facilitate access to clinical trials. SUMMARY Establishment of a TMA-Team is valuable in developing the necessary institutional expertise needed to promptly recognize and appropriately manage patients with TMA.
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Affiliation(s)
- Minh-Ha Tran
- University of California-Irvine, Department of Pathology-Division of Transfusion Medicine
| | - Samir Patel
- University of California Irvine, Department of Medicine - Division of Nephrology
| | - Sheetal Desai
- University of California-Irvine, Department of Medicine- Division of Rheumatology
| | - Stefan Ciurea
- University of California Irvine, Department of Medicine- Division of Hematology-Oncology-HSCT/CT Program
| | - Benjamin J Lee
- University of California Irvine, Department of Pharmacy, Irvine, California, USA
| | - Ramy Hanna
- University of California Irvine, Department of Medicine - Division of Nephrology
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3
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Gudsoorkar P, Abudayyeh A, Tchakarov A, Hanna R. Onconephrology and Thrombotic Microangiopathy: Looking Beyond the Horizon. Semin Nephrol 2023; 42:151345. [PMID: 37196461 DOI: 10.1016/j.semnephrol.2023.151345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Thrombotic microangiopathies (TMAs) represent a complex interaction of endothelial and podocyte biology, nephron physiology, complement genetics, and oncologic therapies with host immunology. The complexity of various factors, such as molecular causes, genetic expressions, and immune system mimicking, along with incomplete penetrance, make it difficult to find a straightforward solution. As a result, there may be variations in diagnosis, study, and treatment approaches, and achieving a consensus can be challenging. Here, we review the molecular biology, pharmacology, immunology, molecular genetics, and pathology of the various TMA syndromes in the setting of cancer. Controversies in etiology, nomenclature, and points requiring further clinical, translational, and bench research are discussed. Complement-mediated TMAs, chemotherapy drug-mediated TMAs, TMAs in monoclonal gammopathy, and other TMAs central to onconephrology practice are reviewed in detail. In addition, established and emerging therapies within the US Food and Drug Administration pipeline subsequently are discussed. Finally, a comprehensive review of critical areas of onconephrology clinical practice is presented as practical value to the clinical practitioner and seeds of investigation to be sown among the community of atypical hemolytic uremic syndrome researchers.
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Affiliation(s)
- Prakash Gudsoorkar
- Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, OH
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Amanda Tchakarov
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine Medical Center, Orange, CA.
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Hanna RM, Henriksen K, Kalantar-Zadeh K, Ferrey A, Burwick R, Jhaveri KD. Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers. Adv Chronic Kidney Dis 2022; 29:149-160.e1. [PMID: 35817522 DOI: 10.1053/j.ackd.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/11/2022]
Abstract
Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.
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Affiliation(s)
- Ramy M Hanna
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA.
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Kamyar Kalantar-Zadeh
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Antoney Ferrey
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenar D Jhaveri
- Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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5
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Torres EA, Chang Y, Desai S, Chang I, Zuckerman JE, Burwick R, Kalantar-Zadeh K, Hanna RM. Complement-Mediated Thrombotic Microangiopathy Associated with Lupus Nephritis Treated with Eculizumab: A Case Report. Case Rep Nephrol Dial 2021; 11:95-102. [PMID: 33977097 PMCID: PMC8077465 DOI: 10.1159/000512227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/20/2020] [Indexed: 11/19/2022] Open
Abstract
Thrombotic microangiopathies (TMAs) involve multiple organ systems due to the presence of microangiopathic hemolysis. One such condition, atypical hemolytic uremic syndrome (aHUS), is a complement-mediated process that is part of a spectrum of disorders that have underlying complement dysfunction of the alternative pathway due to overactivity or decreased self-nonself discrimination by innate immunity. Complement-amplifying conditions such as pregnancy may unmask a diagnosis of aHUS. We present an important case of a pregnant 23-year-old Hispanic female who presented in mid-gestation (21 weeks) with an initial diagnosis of systemic lupus erythematosus (SLE) complicated by aHUS. She met clinical criteria for aHUS on presentation and was found to have a pathogenic CFHR1–3 homozygous deletion. She has been treated with intravenous and oral steroids, cyclophosphamide, subsequently also with plasma exchange, and finally with eculizumab with partial improvement in renal function. This case adds to the emerging literature showing that SLE and aHUS (or complement-mediated TMA) can be successfully treated with C5 blockade.
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Affiliation(s)
| | - Yongen Chang
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California, Irvine, California, USA
| | - Sheetal Desai
- Division of Rheumatology, Department of Medicine, University of California, Irvine, California, USA
| | - Ian Chang
- Division of Rheumatology, Department of Medicine, University of California, Irvine, California, USA
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, California, USA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California, Irvine, California, USA
| | - Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California, Irvine, California, USA
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6
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Ryu SY, Kleine CE, Hsiung JT, Park C, Rhee CM, Moradi H, Hanna R, Kalantar-Zadeh K, Streja E. Association of lactate dehydrogenase with mortality in incident hemodialysis patients. Nephrol Dial Transplant 2021; 36:704-712. [PMID: 33367881 DOI: 10.1093/ndt/gfaa277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Lactate dehydrogenase (LDH) plays a role in the glucose metabolism of the human body. Higher LDH levels have been linked to mortality in various cancer types; however, the relationship between LDH and survival in incident hemodialysis (HD) patients has not yet been examined. We hypothesized that higher LDH level is associated with higher death risk in these patients. METHODS We examined the association of baseline and time-varying serum LDH with all-cause, cardiovascular and infection-related mortality among 109 632 adult incident HD patients receiving care from a large dialysis organization in the USA during January 2007 to December 2011. Baseline and time-varying survival models were adjusted for demographic variables and available clinical and laboratory surrogates of malnutrition-inflammation complex syndrome. RESULTS There was a linear association between baseline serum LDH levels and all-cause, cardiovascular and infection-related mortality in both baseline and time-varying models, except for time-varying infection-related mortality. Adjustment for markers of inflammation and malnutrition attenuated the association in all models. In fully adjusted models, baseline LDH levels ≥360 U/L were associated with the highest risk of all-cause mortality (hazard ratios = 1.19, 95% confidence interval 1.14-1.25). In time-varying models, LDH >280 U/L was associated with higher death risk in all three hierarchical models for all-cause and cardiovascular mortality. CONCLUSIONS Higher LDH level >280 U/L was incrementally associated with higher all-cause and cardiovascular mortality in incident dialysis patients, whereas LDH <240 U/L was associated with better survival. These findings suggest that the assessment of metabolic functions and monitoring for comorbidities may confer survival benefit to dialysis patients.
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Affiliation(s)
- Soh Young Ryu
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Hamid Moradi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Ramy Hanna
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA.,Nephrology Section, Tibor Rubin VA Medical Center, Long Beach, CA, USA
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7
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Hanna RM, Ferrey A, Rhee CM, Kalantar-Zadeh K. Renal-Cerebral Pathophysiology: The Interplay Between Chronic Kidney Disease and Cerebrovascular Disease. J Stroke Cerebrovasc Dis 2020; 30:105461. [PMID: 33199089 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Cerebrovascular disease has increasingly been linked to overall vascular health. Pathologic conditions like diabetes, hypertension, and kidney disease have been shown to affect brain health and cerebrovascular and nervous systems. Acute kidney injury (AKI) and chronic Kidney Disease (CKD) represent a variety of vascular insults that can adversely affect cerebral health. Hypertension, fluctuations in blood pressure, and diabetic vasculopathy are known risk factors for cerebrovascular disease associated with CKD. Other emerging areas of interest include endothelial dysfunction, vascular calcification due to calcium and phosphorus metabolism dysregulation, and uremic neuropathy present the next frontier of investigation in CKD and cerebrovascular health. METHODS It has become apparent that the interrelation of AKI and CKD with vascular health, chemical homeostasis, and hormonal regulation upset many aspects of cerebral health and functioning. Stroke is an obvious connection, with CKD patients demonstrating a higher proclivity for cerebrovascular accidents. Cerebral bleeding risk, uremic neuropathies, sodium dysregulation with impacts on nervous system, vascular calcification, and endothelial dysfunction are the next salient areas of research that are likely to reveal key breakthroughs in renal-cerebral pathophysiology. RESULTS In this review nephrological definition are discussed in a neuro-centric manner, and the areas of key overlap between CKD and cerebrovascular pathology are discussed. The multifaceted effects of renal function on the health of the brain are also examined. CONCLUSION This review article aims to create the background for ongoing and future neurological-nephrological collaboration on understanding the special challenges in caring for patients with cerebrovascular disease who also have CKD.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
| | - Antoney Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
| | - Connie M Rhee
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
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8
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Hanna RM, Tran NT, Patel SS, Hou J, Jhaveri KD, Parikh R, Selamet U, Ghobry L, Wassef O, Barsoum M, Bijol V, Kalantar-Zadeh K, Pai A, Amin A, Kupperman B, Kurtz IB. Thrombotic Microangiopathy and Acute Kidney Injury Induced After Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors VEGF Blockade-Related TMA After Intravitreal Use. Front Med (Lausanne) 2020; 7:579603. [PMID: 33117836 PMCID: PMC7577346 DOI: 10.3389/fmed.2020.579603] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/14/2020] [Indexed: 12/12/2022] Open
Abstract
Vascular endothelial growth factor (VEGF) inhibition can cause worsening hypertension, proteinuria, chronic kidney injury, and glomerular disease. Thrombotic microangiopathy (TMA) and other nephrotic disorders have been reported with systemic VEGF blockade. These same agents are given intravitreally for age-related macular degeneration (AMD) and diabetic retinopathy (DR), albeit at lower doses than those given for systemic indications. Systemic absorption of anti-VEGF agents when given intravitreally has been shown consistently along with evidence of significant intravascular VEGF suppression. While worsening hypertension has only been seen in some large-scale studies, case reports show worsening proteinuria and diverse glomerular diseases. These include TMA-associated lesions like focal and segmental glomerulosclerosis with collapsing features (cFSGS). In this paper, we report three cases of TMA likely associated with the use of intravitreal anti-VEGF therapy. These patients developed the signature lesion of VEGF blockade in a 6 to 11 month time frame after starting intravitreal VEGF inhibitors. The literature is reviewed showing similar cases. Intravitreal VEGF blockade may cause these adverse events in a hitherto unidentified subgroup of patients. Well-controlled prospective observational trials are needed to determine the event rate and identify which subgroups of patients are at increased risk. A registry for patients who develop worsening hypertension, proteinuria exacerbation, and glomerular diseases from intravitreal VEGF blockade is proposed.
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Affiliation(s)
- Ramy M. Hanna
- Division of Nephrology, Department of Medicine, University of California (UC) Irvine School of Medicine, Orange, CA, United States
| | - Ngoc-Tram Tran
- Division of Nephrology, Department of Medicine, Long Beach Memorial Medical Center, Long Beach, CA, United States
| | - Sapna S. Patel
- Division of Nephrology, Department of Medicine, Long Beach Memorial Medical Center, Long Beach, CA, United States
| | - Jean Hou
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States
| | - Rushang Parikh
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States
| | - Umut Selamet
- Division of Renal Medicine, Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Lena Ghobry
- School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Olivia Wassef
- Division of Nephrology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Marina Barsoum
- Keck School of Science and Technology, School of Pharmacy, Chapman University, Orange, CA, United States
| | - Vanesa Bijol
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of Medicine, University of California (UC) Irvine School of Medicine, Orange, CA, United States
| | - Alex Pai
- Division of Nephrology, Department of Medicine, University of California (UC) Irvine School of Medicine, Orange, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California (UC) Irvine, Orange, CA, United States
| | - Baruch Kupperman
- Herbert Gavin Eye Institute, Department of Ophthalmology, University of California (UC) Irvine, Irvine, CA, United States
| | - Ira B. Kurtz
- Division of Nephrology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Brain Research Institute, University of California Los Angeles (UCLA), Los Angeles, CA, United States
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9
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Hanna RM, Abdelnour L, Zuckerman JE, Ferrey AJ, Pai A, Vahabzadeh K, Wilson J, Torres EA, Kalantar-Zadeh K, Kurtz IB. Refractory scleroderma renal crisis precipitated after high-dose oral corticosteroids and concurrent intravitreal injection of bevacizumab. SAGE Open Med Case Rep 2020; 8:2050313X20952650. [PMID: 32913652 PMCID: PMC7443985 DOI: 10.1177/2050313x20952650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022] Open
Abstract
Scleroderma renal crisis is a serious complication that can develop in certain patients with systemic sclerosis. Some risks have been identified as potential triggers of scleroderma renal crisis, including the high-dose oral corticosteroids. Here, we present a patient who developed clinically severe systemic sclerosis and scleroderma renal crisis after exposure to oral corticosteroids and intravitreal vascular endothelial growth factor blockade with bevacizumab for cotton wool spots. The patient's scleroderma renal crisis was severe, progressive, and refractory to the standard of care therapy: oral captopril. Biopsy showed a diffuse thrombotic microangiopathy and findings consistent with scleroderma renal crisis. We hypothesize that depletion of systemic vascular endothelial growth factor with intravitreal anti-vascular endothelial growth factor injections likely contributed to the particularly severe presentation seen in this case. Though the finding of a monoclonal gammopathy of undetermined significance is another complicating factor, this case suggests that vascular endothelial growth factor inhibition may be a newly recognized trigger of scleroderma renal crisis.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
- UC Irvine School of Medicine, Orange,
CA, USA
| | - Lama Abdelnour
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Antoney J Ferrey
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Alex Pai
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | | | - James Wilson
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Everado A Torres
- Department of Medicine, University of
California Irvine, Irvine, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Ira B Kurtz
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Brain Research Institute, Westwood, CA,
USA
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10
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Hanna R, Zuckerman JE, Ferrey A, Torres EA, Tonthat S, Barsoum M, Ghobry L, Wassef O, Kalantarzadeh K. Finding of pathological thrombomodulin gene variant in a patient with idiopathic nodular glomerulosclerosis and chronic thrombotic microangiopathy-like changes. SAGE Open Med Case Rep 2020; 8:2050313X20940510. [PMID: 32699635 PMCID: PMC7357015 DOI: 10.1177/2050313x20940510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/17/2020] [Indexed: 11/27/2022] Open
Abstract
Idiopathic nodular glomerulosclerosis is an unusual histopathological finding that has commonly been observed in male smokers with hypertension. It has remained an enigmatic condition and is best described as a diabetic pattern of glomerular injury seen in non-diabetic patients. It is also one of the few nicotine (smoking)-associated/smoking-associated patterns of renal injury. We present an even more unusual manifestation of this pathological finding in a 59-year-old Hispanic female who presented with chronic kidney disease approaching need for renal replacement therapy. The patient had idiopathic nodular glomerulosclerosis on kidney biopsy, despite no prior history of diabetes, nor smoking history, including no secondhand smoking exposure. The patient did have hypertension. The renal biopsy also showed evidence of chronic thrombotic-microangiopathic changes within arteries and arterioles. Genetic testing of the alternative pathway revealed an unusual and likely pathological variant of thrombomodulin supporting complement dysfunction as having a role in the presentation.
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Affiliation(s)
- Ramy Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Irvine, CA, USA
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Antoney Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Irvine, CA, USA
| | | | - Sam Tonthat
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Irvine, CA, USA
| | - Marina Barsoum
- School of Pharmaceutical Sciences, Chapman University, Orange, CA, USA
| | - Lena Ghobry
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Olivia Wassef
- Division of Nephrology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kamyar Kalantarzadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Irvine, CA, USA
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Hanna RM, Merin N, Burwick RM, Abdelnour L, Selamet U, Yanny B, Bui P, Fouad M, Kurtz I. Successful use of eculizumab to treat atypical hemolytic uremic syndrome in patients with inflammatory bowel disease. Thromb J 2019; 17:18. [PMID: 31516395 PMCID: PMC6732828 DOI: 10.1186/s12959-019-0207-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/31/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome is a rare group of disorders that have in common underlying complement amplifying conditions. These conditions can accelerate complement activation that results in a positive feedback cycle. The known triggers for complement activation can be diverse and include, infection, autoimmune disease, and malignancy. Recent reports suggest that certain autoimmune and rheumatological triggers of complement activation may result in atypical hemolytic uremic syndrome that does not resolve despite treating the underlying disorder. Specifically, patients with systemic lupus erythematosus and microangiopathic hemolysis may not respond to treatment of their underlying rheumatological trigger but responded to complement blockade. CASE PRESENTATIONS We report two patients with inflammatory bowel disease complicated by development of atypical hemolytic uremic syndrome. In both cases, patients were on treatment for inflammatory bowel disease, that was not well controlled/flaring at the time. The first patient is a male who developed Crohn's disease and microangiopathic hemolysis at age 5 and was treated with eculizumab successfully. Discontinuation of the medication led to multiple relapses, and the patient currently is being treated with eculizumab and has normal hematological and stable renal parameters. The second patient is a 49-year-old female with Ulcerative Colitis treated with 6-Mercaptopurine. She developed acute kidney injury and microangiopathic hemolysis. Prompt diagnosis and treatment with eculizumab resulted in the recovery of kidney injury along with a complete hematological response. CONCLUSIONS These two cases are the fifth and sixth patients to be published in the literature with atypical hemolytic uremic syndrome and inflammatory bowel disease treated with complement blockade. This confirms that C5 complement blockade is effective in treating complement mediated thrombotic microangiopathy/atypical hemolytic uremic syndrome when it is triggered in patients with inflammatory bowel disease.
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Affiliation(s)
- Ramy M. Hanna
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Room 7-155, Factor Bldg. 700 Tiverton Ave, Los Angeles, CA 90095 USA
- Department of Medicine, Division of Nephrology, University of California Irvine School of Medicine, Irvine CA, USA
| | - Noah Merin
- Department of Medicine, Division of Hematology Oncology, Cedars Sinai Medical Center, Los Angeles, USA
| | - Richard M. Burwick
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Lama Abdelnour
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Room 7-155, Factor Bldg. 700 Tiverton Ave, Los Angeles, CA 90095 USA
| | - Umut Selamet
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Room 7-155, Factor Bldg. 700 Tiverton Ave, Los Angeles, CA 90095 USA
| | - Beshoy Yanny
- Department of Medicine, Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Patrick Bui
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Mary Fouad
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Ira Kurtz
- Department of Medicine, Division of Nephrology, UCLA David Geffen School of Medicine, Room 7-155, Factor Bldg. 700 Tiverton Ave, Los Angeles, CA 90095 USA
- UCLA Brain Research Institute, Los Angeles, USA
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