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Moronti V, Carubbi F, Sollima L, Piscitani L, Ferri C. End stage renal disease in patient with microscopic polyangiitis and atypical hemolytic-uremic syndrome arose 3 weeks after the third dose of anti-SARS-CoV2 vaccine mRNA-1273: A case report with literature revision. Medicine (Baltimore) 2023; 102:e36560. [PMID: 38115241 PMCID: PMC10727565 DOI: 10.1097/md.0000000000036560] [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: 08/16/2023] [Revised: 11/09/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
RATIONALE Immune system deregulation, including AAV, is a key event that may potentially evolve into ESRD. Abnormal activation of the cAP is also a cardinal feature of TMA, particularly aHUS. The kidney is the most frequently involved organ, and renal-limited forms of TMA are often encountered in clinical practice. Isolated case reports described the occurrence of renal TMA in AAV patients. Some cases of both de novo and relapses of AAV and/or TMAs after anti-SARS-CoV2 vaccination have been reported. We reported, for the 1st time, a case of patients with new-onset MPA and aHUS occurring 3 weeks after the third dose of mRNA-1273 vaccine anti-SARS-CoV2. PATIENT CONCERNS We present a 67-year-old man, affected by arterial hypertension, reported, after mRNA-1273 vaccine anti-SARS-CoV2, anuria, fatigue, anorexia and nausea. Laboratory data revealed acute renal failure. DIAGNOSIS Positivity of MPO-ANCA was observed. 7 days after admission, we observed a worsening of anemia and thrombocytopenia with haptoglobin reduction, LDH increase and presence of schistocytes. Plasma levels of ADAMTS-13 were normal. A renal biopsy was performed, and findings were consistent with microscopic polyangiitis, with features of micro-thrombotic glomerulopathy. Genetic tests revealed absence of hybrid genes associated with the increased risk of aHUS. INTERVENTIONS AND OUTCOMES We started renal replacement treatment, including hemodialysis, and pulsed methylprednisolone, with no improvement of laboratory parameters. Then, plasma exchange was performed leading to partial haematological response. Only with Eculizumab, a human C5 inhibitor, we observed a normalization of haptoglobin levels and platelets' count. However, three months after discharge, the patient still required hemodialysis. LESSONS To our knowledge we observed the first case aHUS, without genetic predisposition, associated with MPA occurring after the third dose of anti-SARS-CoV2 vaccine. This case report highlights the potential link between anti-SARS-CoV2 vaccine as a trigger of MPA and aHUS. This systematic review offers additional perspectives. It is plausible to hypothesize that the vaccine was the trigger for the development of these 2 diseases.Solid evidence on the mechanisms of interaction between vaccine and immune system, the role of genetic predisposition, and other variables, will shed additional light on the controversial link between anti-SARS-CoV2 vaccine and autoimmunity.
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Affiliation(s)
- Veronica Moronti
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Francesco Carubbi
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Laura Sollima
- Anatomy and Pathological Histology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Luca Piscitani
- Nephrology and Dialysis Division, Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
| | - Claudio Ferri
- University of L’Aquila, Department of Life, Health and Environmental Sciences; Internal Medicine and Nephrology Division, ASL 1 Avezzano-Sulmona-L’Aquila, San Salvatore Hospital, L’Aquila, Italy
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Cabarcas-Barbosa O, Aroca-Martínez G, Musso CG, Ramos-Bolaños E, González-Tórres H, Espitaleta-Vergara Z, Domínguez-Vargas A, Ararat-Rodriguez E, Orozco J, Castillo-Parodi L, Conde-Manotas J, Daza-Arnedo R, Rodríguez-SanJuan V, Gómez-Navarro L, Acosta-Madiedo R, Barros-Camargo L, Aduen-Carrillo A, Ayola-Anaya F, Pulgar-Emiliani M, Cadena-Bonfanti A. Atypical hemolytic uremic syndrome in the Colombian Caribbean: its particular characteristics. Int Urol Nephrol 2021; 54:1323-1330. [PMID: 34643860 PMCID: PMC8513378 DOI: 10.1007/s11255-021-03011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/04/2021] [Indexed: 11/26/2022]
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a rare and genetically mediated systemic disease most often caused by uncontrolled and chronic complement activation that leads to systemic thrombotic microangiopathy, renal and extra-renal damage. Materials and methods This is descriptive, retrospective and multicenter study, which reports demographic, clinical, laboratory, and genetic characteristics, as well as their treatment response and outcome of 20 aHUS patients diagnosed between 2014 and 2018. Results Most patients were female adults (75%) and 30% were associated to pregnancy/postpartum, 15% to autoimmune disease, and 65% to infections. Gastrointestinal involvement (75%) was the most frequent extra-renal organ damage. Antenatal mortality and mortality rate were 5% and 10%, respectively. 25% of the patients progressed to end-stage renal disease. In 4/8 of patients treated within 1 week of presentation, eculizumab treatment restored multi-organ function after 4 weeks of treatment. CFH (37%) and CFI (25%) mutations were the most frequent. Conclusion This is the first series of aHUS cases of Colombian Caribbean region which reports the clinical and epidemiological characteristics of this condition in this region.
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Affiliation(s)
- Omar Cabarcas-Barbosa
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Gustavo Aroca-Martínez
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Carlos G Musso
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia.
- Unidad de Biología Del Envejecimiento, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - Henry González-Tórres
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Zilac Espitaleta-Vergara
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Alex Domínguez-Vargas
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | | | - José Orozco
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Luis Castillo-Parodi
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Juan Conde-Manotas
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica San Rafael, Sabanalarga, Colombia
| | - Rodrigo Daza-Arnedo
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Servicio de Cuidados Intensivos Obstétricos, Hospital Niño Jesús, Barranquilla, Colombia
| | | | | | | | | | | | | | - María Pulgar-Emiliani
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Andrés Cadena-Bonfanti
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
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Tehrani HA, Darnahal M, Vaezi M, Haghighi S. COVID-19 associated thrombotic thrombocytopenic purpura (TTP) ; A case series and mini-review. Int Immunopharmacol 2021; 93:107397. [PMID: 33524803 PMCID: PMC7825972 DOI: 10.1016/j.intimp.2021.107397] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Thrombotic microangiopathies are a group of disorders that are mainly related to endothelial dysfunction. This category of endothelial dysfunction results of several imbalances between platelets, endothelium and immune system, also cytokine production. AIM OF THIS STUDY To report cases with thrombotic thrombocytopenic purpura (TTP) and COVID-19 and review COVID-19 endothelial dysfunction literature. METHODS Primary laboratory data, peripheral blood smear, ADAMTS13 antigen activity level, and antibody ordered for each of these four patients. Treatments for COVID-19 administered for all patients. Traditional treatments for TTP also were administered. RESULTS There were numerous schistocytes (more than 5%) in peripheral blood smears for each patient. ADAMTS13 antigen activity level was below 10%, and ADAMTS13 antibody was elevated for each patient. COVID-19 PCR was positive for all patients, and CT-Scans were indicative of the involvement of COVID-19. CONCLUSION In this case series, we reported four COVID-19 patients who presented with signs and symptoms of anemia and thrombocytopenia, resulting in thrombotic thrombocytopenic purpura.
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Affiliation(s)
- Hamed Azhdari Tehrani
- Department of Hematology and Medical Oncology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Darnahal
- Department of Hematology and Medical Oncology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Haghighi
- Department of Hematology and Medical Oncology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Different approaches to long-term treatment of aHUS due to MCP mutations: a multicenter analysis. Pediatr Nephrol 2021; 36:463-471. [PMID: 32715379 PMCID: PMC7815604 DOI: 10.1007/s00467-020-04714-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare, life-threatening microangiopathy, frequently causing kidney failure. Inhibition of the terminal complement complex with eculizumab is the only licensed treatment but mostly requires long-term administration and risks severe side effects. The underlying genetic cause of aHUS is thought to influence the severity of initial and recurring episodes, with milder courses in patients with mutations in membrane cofactor protein (MCP). METHODS Twenty pediatric cases of aHUS due to isolated heterozygous MCP mutations were reported from 12 German pediatric nephrology centers to describe initial presentation, timing of relapses, treatment, and kidney outcome. RESULTS The median age of onset was 4.6 years, with a female to male ratio of 1:3. Without eculizumab maintenance therapy, 50% (9/18) of the patients experienced a first relapse after a median period of 3.8 years. Kaplan-Meier analysis showed a relapse-free survival of 93% at 1 year. Four patients received eculizumab long-term treatment, while 3 patients received short courses. We could not show a benefit from complement blockade therapy on long term kidney function, independent of short-term or long-term treatment. To prevent 1 relapse with eculizumab, the theoretical number-needed-to-treat (NNT) was 15 for the first year and 3 for the first 5 years after initial presentation. CONCLUSION Our study shows that heterozygous MCP mutations cause aHUS with a risk of first relapse of about 10% per year, resulting in large NNTs for prevention of relapses with eculizumab. More studies are needed to define an optimal treatment schedule for patients with MCP mutations to minimize the risks of the disease and treatment.
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Covid-19 associated autoimmune thrombotic thrombocytopenic purpura: Report of a case. Thromb Res 2020; 195:136-138. [PMID: 32688098 PMCID: PMC7335418 DOI: 10.1016/j.thromres.2020.07.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/03/2020] [Indexed: 01/08/2023]
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Person F, Rinschen MM, Brix SR, Wulf S, Noriega MDLM, Fehrle W, Schmitz J, Schwarz A, Ivanyi P, Steinmetz OM, Reinhard L, Hoxha E, Zipfel PF, Bräsen JH, Wiech T. Bevacizumab-associated glomerular microangiopathy. Mod Pathol 2019; 32:684-700. [PMID: 30552416 DOI: 10.1038/s41379-018-0186-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 11/09/2022]
Abstract
Bevacizumab is a humanized monoclonal IgG1 antibody, which neutralizes vascular endothelial growth factor and is used for treating multiple cancer types. As a known and frequent adverse event, this therapy can lead to renal damage including proteinuria and nephrotic syndrome. In a retrospective approach, we analyzed 17 renal biopsies from patients receiving bevacizumab treatment. We observed a distinctive histopathological pseudothrombotic pattern different from the previously reported thrombotic microangiopathy. Since this pattern includes some features similar to acute and chronic thrombotic microangiopathy, focal segmental glomerulosclerosis and cryoglobulinemic membranoproliferative glomerulonephritis, biopsies with these diagnoses were included for comparison. Clinical, laboratory, light microscopic, immunohistochemical (including a proximity ligation assay), proteomic and electron microscopic features were assessed. Nephrotic syndrome was present in 15 of the 17 bevacizumab-treated patients. All 17 displayed a patchy pattern of variably PAS-positive hyaline pseudothrombi occluding markedly dilated glomerular capillaries in their biopsies. Mass spectrometry-based proteome analysis revealed a special protein pattern demonstrating some features of thrombotic microangiopathy and some of cryoglobulinemic glomerulonephritis, including a strong accumulation of IgG in the pseudothrombi. Proximity ligation assay did not show interaction of IgG with C1q, arguing for accumulation without classic pathway complement activation. In contrast to thrombi in thrombotic microangiopathy cases, the hyaline pseudothrombi did not contain clusters of CD61-positive platelets. Electron microscopy of bevacizumab cases did not show fibrin polymers or extensive loss of podocyte foot processes. Even though cases of bevacizumab-associated microangiopathy share some features with thrombotic microangiopathy, its overall histopathological pattern is quite different from acute or chronic thrombotic microangiopathy cases. We conclude that bevacizumab therapy can lead to a unique hyaline occlusive glomerular microangiopathy, likely arising from endothelial leakage followed by subendothelial accumulation of serum proteins. It can be diagnosed by light microscopy and is an important differential diagnosis in cancer patients with nephrotic syndrome.
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Affiliation(s)
- Fermin Person
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Markus M Rinschen
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Silke R Brix
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sonia Wulf
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Wilfried Fehrle
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Anke Schwarz
- Clinic for Nephrology, Hannover Medical School, Hannover, Germany
| | - Philipp Ivanyi
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Oliver M Steinmetz
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Reinhard
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter F Zipfel
- Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Jan Hinrich Bräsen
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Thorsten Wiech
- Institute of Pathology and Nephropathology Section, University Hospital Hamburg Eppendorf, Hamburg, Germany.
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Fakhouri F, Hourmant M, Campistol JM, Cataland SR, Espinosa M, Gaber AO, Menne J, Minetti EE, Provôt F, Rondeau E, Ruggenenti P, Weekers LE, Ogawa M, Bedrosian CL, Legendre CM. Terminal Complement Inhibitor Eculizumab in Adult Patients With Atypical Hemolytic Uremic Syndrome: A Single-Arm, Open-Label Trial. Am J Kidney Dis 2016; 68:84-93. [DOI: 10.1053/j.ajkd.2015.12.034] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 12/28/2015] [Indexed: 02/06/2023]
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Greenbaum LA, Fila M, Ardissino G, Al-Akash SI, Evans J, Henning P, Lieberman KV, Maringhini S, Pape L, Rees L, van de Kar NCAJ, Vande Walle J, Ogawa M, Bedrosian CL, Licht C. Eculizumab is a safe and effective treatment in pediatric patients with atypical hemolytic uremic syndrome. Kidney Int 2016; 89:701-11. [PMID: 26880462 DOI: 10.1016/j.kint.2015.11.026] [Citation(s) in RCA: 189] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 10/24/2015] [Accepted: 11/12/2015] [Indexed: 11/17/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is caused by alternative complement pathway dysregulation, leading to systemic thrombotic microangiopathy (TMA) and severe end-organ damage. Based on 2 prospective studies in mostly adults and retrospective data in children, eculizumab, a terminal complement inhibitor, is approved for aHUS treatment. Here we prospectively evaluated efficacy and safety of weight-based dosing of eculizumab in eligible pediatric patients with aHUS in an open-label phase II study. The primary end point was complete TMA response by 26 weeks. Twenty-two patients (aged 5 months-17 years) were treated; 16 were newly diagnosed, 12 had no prior plasma exchange/infusion during current TMA symptomatology, 11 received baseline dialysis and 2 had prior renal transplants. By week 26, 14 achieved a complete TMA response, 18 achieved hematologic normalization, and 16 had 25% or better improvement in serum creatinine. Plasma exchange/infusion was discontinued in all, and 9 of the 11 patients who required dialysis at baseline discontinued, whereas none initiated new dialysis. Eculizumab was well tolerated; no deaths or meningococcal infections occurred. Bone marrow failure, wrist fracture, and acute respiratory failure were reported as unrelated severe adverse events. Thus, our findings establish the efficacy and safety of eculizumab for pediatric patients with aHUS and are consistent with proposed immediate eculizumab initiation following diagnosis in children.
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Affiliation(s)
- Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
| | - Marc Fila
- CHRU de Montpellier - Hôpital Arnaud de Villeneuve, Montpellier, France
| | | | | | - Jonathan Evans
- Nottingham University Hospitals, Nottingham, United Kingdom
| | - Paul Henning
- Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | | | | | - Lars Pape
- Hannover Medical School, Hannover, Germany
| | - Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | | | | | - Masayo Ogawa
- Alexion Pharmaceuticals, Inc., Cheshire, Connecticut, USA
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Licht C, Ardissino G, Ariceta G, Cohen D, Cole JA, Gasteyger C, Greenbaum LA, Johnson S, Ogawa M, Schaefer F, Vande Walle J, Frémeaux-Bacchi V. The global aHUS registry: methodology and initial patient characteristics. BMC Nephrol 2015; 16:207. [PMID: 26654630 PMCID: PMC4674928 DOI: 10.1186/s12882-015-0195-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 11/25/2015] [Indexed: 02/07/2023] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is a rare, genetically-mediated systemic disease most often caused by chronic, uncontrolled complement activation that leads to systemic thrombotic microangiopathy (TMA) and renal and other end-organ damage. Methods The global aHUS Registry, initiated in April 2012, is an observational, noninterventional, multicenter registry designed to collect demographic characteristics, medical and disease history, treatment effectiveness and safety outcomes data for aHUS patients. The global aHUS Registry will operate for a minimum of 5 years of follow-up. Enrollment is open to all patients with a clinical diagnosis of aHUS, with no requirement for identified complement gene mutations, polymorphisms or autoantibodies or particular type of therapy/management. Results As of September 30, 2014, 516 patients from 16 countries were enrolled. At enrollment, 315 (61.0 %) were adults (≥18 years) and 201 (39.0 %) were <18 years of age. Mean (standard deviation [SD]) age at diagnosis was 22.7 (20.5) years. Nineteen percent of patients had a family history of aHUS, 60.3 % had received plasma exchange/plasma infusion, 59.5 % had a history of dialysis, and 19.6 % had received ≥1 kidney transplant. Overall, 305 patients (59.1 %) have received eculizumab. Conclusions As enrollment and follow-up proceed, the global aHUS Registry is expected to yield valuable baseline, natural history, medical outcomes, treatment effectiveness and safety data from a diverse population of patients with aHUS. Trial registration US National Institutes of Health www.ClinicalTrials.gov Identifier NCT01522183. Registered January 18, 2012.
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Affiliation(s)
- Christoph Licht
- Division of Nephrology and Program in Cell Biology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Gianluigi Ardissino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Comenda 9, Milan, 20122, Italy.
| | - Gema Ariceta
- Pediatric Nephrology, University Hospital Vall d'Hebron, Pg Vall d' Hebron, 119-129, Barcelona, Spain.
| | - David Cohen
- Columbia University Medical Center, 622 West 168 Street, Room PH4-124, New York, NY, USA.
| | - J Alexander Cole
- Alexion Pharmaceuticals, Inc., 352 Knotter Drive, Cheshire, CT, USA.
| | - Christoph Gasteyger
- Alexion Pharma International, Avenue du Tribunal Fédéral 34, Lausanne, Switzerland.
| | - Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, USA.
| | - Sally Johnson
- Great North Children's Hospital, Sir James Spence Institute, 4th floor, Royal Victoria Infirmary, Newcastle, United Kingdom.
| | - Masayo Ogawa
- Alexion Pharmaceuticals, Inc., 352 Knotter Drive, Cheshire, CT, USA.
| | - Franz Schaefer
- Heidelberg University Medical Center, Im Neuenheimer Feld 672, 69120, Heidelberg, Germany.
| | | | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris, France.
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Greenwood GT. Case report of atypical hemolytic uremic syndrome with retinal arterial and venous occlusion treated with eculizumab. Int Med Case Rep J 2015; 8:235-9. [PMID: 26508891 PMCID: PMC4610771 DOI: 10.2147/imcrj.s90640] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease caused by chronic, uncontrolled activation of the alternative complement pathway, leading to thrombotic microangiopathy. Renal impairment and progression to end-stage renal disease are common in untreated patients with aHUS, and extrarenal manifestations are being increasingly characterized in the literature. Ocular involvement remains rare in aHUS. This report describes a patient with aHUS with bilateral central retinal artery and vein occlusion, vitreous hemorrhage, and blindness in addition to renal impairment. The patient's hematologic and renal parameters and ocular manifestation improved following initiation of eculizumab therapy.
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Eculizumab reduces complement activation, inflammation, endothelial damage, thrombosis, and renal injury markers in aHUS. Blood 2015; 125:3253-62. [PMID: 25833956 DOI: 10.1182/blood-2014-09-600411] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 03/16/2015] [Indexed: 12/30/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a genetic, life-threatening disease characterized by uncontrolled complement activation, systemic thrombotic microangiopathy (TMA), and vital organ damage. We evaluated the effect of terminal complement blockade with the anti-C5 monoclonal antibody eculizumab on biomarkers of cellular processes involved in TMA in patients with aHUS longitudinally, during up to 1 year of treatment, compared with in healthy volunteers. Biomarker levels were elevated at baseline in most patients, regardless of mutational status, plasma exchange/infusion use, platelet count, or lactate dehydrogenase or haptoglobin levels. Eculizumab reduced terminal complement activation (C5a and sC5b-9) and renal injury markers (clusterin, cystatin-C, β2-microglobulin, and liver fatty acid binding protein-1) to healthy volunteer levels and reduced inflammation (soluble tumor necrosis factor receptor-1), coagulation (prothrombin fragment F1+2 and d-dimer), and endothelial damage (thrombomodulin) markers to near-normal levels. Alternative pathway activation (Ba) and endothelial activation markers (soluble vascular cell adhesion molecule-1) decreased but remained elevated, reflecting ongoing complement activation in aHUS despite complete terminal complement blockade. These results highlight links between terminal complement activation and inflammation, endothelial damage, thrombosis, and renal injury and underscore ongoing risk for systemic TMA and progression to organ damage. Further research regarding underlying complement dysregulation is warranted. This trial was registered at www.clinicaltrials.gov as #NCT01194973.
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Chen SF, Wang H, Huang YM, Li ZY, Wang SX, Yu F, Zhao MH, Chen M. Clinicopathologic characteristics and outcomes of renal thrombotic microangiopathy in anti-neutrophil cytoplasmic autoantibody-associated glomerulonephritis. Clin J Am Soc Nephrol 2015; 10:750-8. [PMID: 25749534 DOI: 10.2215/cjn.07910814] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Thrombotic microangiopathy (TMA) in ANCA-associated vasculitis (AAV) has been mainly reported in isolated case reports. The aim of this study was to analyze clinical and pathologic characteristics and prognosis of patients with renal TMA in ANCA-associated GN in a large cohort of Chinese patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Clinical and renal histopathologic data of 220 patients with biopsy-proven ANCA-associated GN from 1996 to 2013 were retrospectively analyzed. Patients were followed up for a median period of 32 (interquartile range [IQR], 12-65) months, and outcomes of patients were analyzed. RESULTS Among the 220 patients with ANCA-associated GN, 30 were identified having concomitant renal TMA by pathologic evaluation. Compared with the non-TMA group, patients with renal TMA presented with more severe renal injury, as evidenced clinically by a higher level of serum creatinine at diagnosis (5.0 [IQR, 3.5-9.0] versus 3.2 [IQR, 1.7-6.8] mg/dl; P=0.02) and pathologically by a higher percentage of cellular crescents (15.0% [IQR, 6.9%-34.9%] versus 6.9% [IQR, 0%-21.1%]; P=0.04) and more severe interstitial infiltration (2 [IQR, 2-2] versus 2 [IQR, 1-2]; P=0.03) in renal biopsies. Furthermore, multivariate analysis showed that renal TMA was independently associated with mortality of patients with AAV after adjusting for age, sex, initial serum creatinine, tubular atrophy, and interstitial fibrosis (hazard ratio, 1.92; 95% confidence interval, 1.08 to 3.41; P=0.03) or for age, sex, the histopathologic classification scheme proposed by Berden et al. (J Am Soc Nephrol 21: 1628-1636, 2010), tubular atrophy, and interstitial fibrosis (hazard ratio, 1.95; 95% confidence interval, 1.07 to 3.55; P=0.03). CONCLUSIONS Renal TMA in ANCA-associated GN is not rare and presents with more severe renal injury. Renal TMA is independently associated with all-cause mortality in patients with AAV.
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Affiliation(s)
- Su-Fang Chen
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
| | - Huan Wang
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
| | - Yi-Min Huang
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
| | - Zhi-Ying Li
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University, First Hospital, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China; and
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Efficacy and safety of eculizumab in atypical hemolytic uremic syndrome from 2-year extensions of phase 2 studies. Kidney Int 2015; 87:1061-73. [PMID: 25651368 PMCID: PMC4424817 DOI: 10.1038/ki.2014.423] [Citation(s) in RCA: 288] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 09/30/2014] [Accepted: 10/30/2014] [Indexed: 12/11/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare, possibly life-threatening disease characterized by platelet activation, hemolysis and thrombotic microangiopathy (TMA) leading to renal and other end-organ damage. We originally conducted two phase 2 studies (26 weeks and 1 year) evaluating eculizumab, a terminal complement inhibitor, in patients with progressing TMA (trial 1) and those with long duration of aHUS and chronic kidney disease (trial 2). The current analysis assessed outcomes after 2 years (median eculizumab exposure 100 and 114 weeks, respectively). At all scheduled time points, eculizumab inhibited terminal complement activity. In trial 1 with 17 patients, the platelet count was significantly improved from baseline, and hematologic normalization was achieved in 13 patients at week 26, and in 15 patients at both 1 and 2 years. The estimated glomerular filtration rate (eGFR) was significantly improved compared with baseline and year 1. In trial 2 with 20 patients, TMA event-free status was achieved by 16 patients at week 26, 17 patients at year 1, and 19 patients at year 2. Criteria for hematologic normalization were met by 18 patients at each time point. Improvement of 15 ml/min per 1.73 m2 or more in eGFR was achieved by 1 patient at week 26, 3 patients at 1 year, and 8 patients at 2 years. The mean change in eGFR was not significant compared with baseline, week 26, or year 1. Eculizumab was well tolerated, with no new safety concerns or meningococcal infections. Thus, a 2-year analysis found that the earlier clinical benefits achieved by eculizumab treatment of aHUS were maintained at 2 years of follow-up.
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Yenerel MN. Atypical Hemolytic Uremic Syndrome: Differential Diagnosis from TTP/HUS and Management. Turk J Haematol 2014; 31:216-25. [PMID: 25319590 PMCID: PMC4287021 DOI: 10.4274/tjh.2013.0374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 07/09/2014] [Indexed: 01/17/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare form of thrombotic microangiopathy (TMA). It has an unfavorable outcome with death rates as high as 25% during the acute phase and up to 50% of cases progressing to end-stage renal failure. Uncontrolled complement activation through the alternative pathway is thought to be the main underlying pathopysiology of aHUS and corresponds to all the deleterious findings of the disease. Thrombotic thrombocytopenic purpura (TTP) and Shiga toxin-associated HUS are the 2 other important TMA diseases. Although differentiating HUS from TTP is relatively easy in children with a preceding diarrheal illness or invasive S. pneumoniae, differentiating aHUS from TTP or other microangiopathic disorders can present a major diagnostic challenge in adults. ADAMTS13 analysis is currently the most informative diagnostic test for differentiating TTP, congenital TTP, and aHUS. Today empiric plasma therapy still is recommended by expert opinion to be used as early as possible in any patient with symptoms of aHUS. The overall treatment goal remains restoration of a physiological balance between activation and control of the alternative complement pathway. So it is a reasonable approach to block the terminal complement complex with eculizumab in order to prevent further organ injury and increase the likelihood organ recovery. Persistence of hemolysis or lack of improvement of renal function after 3-5 daily plasmaphereses have to be regarded as the major criteria for uncontrolled TMA even if platelet count has normalized and as an indication to switch the treatment to eculizumab. Eculizumab has changed the future perspectives of patients with aHUS and both the FDA and the EMA have approved it as life-long treatment. However, there are still some unresolved issues about the follow-up such as the optimal duration of eculizumab treatment and whether it can be stopped or how to stop the therapy.
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Affiliation(s)
- Mustafa N Yenerel
- İstanbul University İstanbul Faculty of Medicine, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey. E-ma-il:
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15
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Cataland SR, Wu HM. Diagnosis and management of complement mediated thrombotic microangiopathies. Blood Rev 2014; 28:67-74. [DOI: 10.1016/j.blre.2014.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/21/2014] [Accepted: 01/24/2014] [Indexed: 02/08/2023]
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Pan FF, Hidayati L, Hughes P, Murugasu A, Masterson R. Case report: thrombotic microangiopathy post-intravenous immunoglobulin in the context of BK nephropathy and renal transplantation. Transplant Proc 2014; 46:278-80. [PMID: 24507067 DOI: 10.1016/j.transproceed.2013.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/28/2013] [Indexed: 10/25/2022]
Abstract
Intravenous immunoglobulin (IVIg) is a blood product with immunomodulating properties that have been widely applied in the management of renal transplant recipients. In general, IVIg has been considered a relatively safe therapy, with most adverse events being mild and transient. Although rare, a serious and well-recognized complication of IVIg is large-vessel thrombotic events, which are thought to be related to hyperviscosity. We describe here two cases in which there was a temporal relationships between the administration of IVIg, an acute decline in allograft function, and the histologic finding of de novo thrombotic microangiopathy (TMA). In both cases, IVIg had been administered to facilitate immunosuppressive dose reduction in the context of BK nephropathy. We believe this is the first report of TMA associated with IVIg administration in renal allograft recipients.
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Affiliation(s)
- F F Pan
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - L Hidayati
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - P Hughes
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - A Murugasu
- Department of Anatomical Pathology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - R Masterson
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.
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17
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Han H, Jia LJ. Concurrent thrombotic thrombocytopenic purpura and spontaneous rupture of the spleen. J Emerg Med 2014; 47:e25-6. [PMID: 24472354 DOI: 10.1016/j.jemermed.2013.11.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 10/17/2013] [Accepted: 11/17/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Hui Han
- Department of Emergency Medicine, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Li-Jing Jia
- Department of Emergency Medicine, General Hospital of Chinese People's Liberation Army, Beijing, China
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18
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Legendre CM, Licht C, Muus P, Greenbaum LA, Babu S, Bedrosian C, Bingham C, Cohen DJ, Delmas Y, Douglas K, Eitner F, Feldkamp T, Fouque D, Furman RR, Gaber O, Herthelius M, Hourmant M, Karpman D, Lebranchu Y, Mariat C, Menne J, Moulin B, Nürnberger J, Ogawa M, Remuzzi G, Richard T, Sberro-Soussan R, Severino B, Sheerin NS, Trivelli A, Zimmerhackl LB, Goodship T, Loirat C. Terminal complement inhibitor eculizumab in atypical hemolytic-uremic syndrome. N Engl J Med 2013; 368:2169-81. [PMID: 23738544 DOI: 10.1056/nejmoa1208981] [Citation(s) in RCA: 1033] [Impact Index Per Article: 93.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atypical hemolytic-uremic syndrome is a genetic, life-threatening, chronic disease of complement-mediated thrombotic microangiopathy. Plasma exchange or infusion may transiently maintain normal levels of hematologic measures but does not treat the underlying systemic disease. METHODS We conducted two prospective phase 2 trials in which patients with atypical hemolytic-uremic syndrome who were 12 years of age or older received eculizumab for 26 weeks and during long-term extension phases. Patients with low platelet counts and renal damage (in trial 1) and those with renal damage but no decrease in the platelet count of more than 25% for at least 8 weeks during plasma exchange or infusion (in trial 2) were recruited. The primary end points included a change in the platelet count (in trial 1) and thrombotic microangiopathy event-free status (no decrease in the platelet count of >25%, no plasma exchange or infusion, and no initiation of dialysis) (in trial 2). RESULTS A total of 37 patients (17 in trial 1 and 20 in trial 2) received eculizumab for a median of 64 and 62 weeks, respectively. Eculizumab resulted in increases in the platelet count; in trial 1, the mean increase in the count from baseline to week 26 was 73×10(9) per liter (P<0.001). In trial 2, 80% of the patients had thrombotic microangiopathy event-free status. Eculizumab was associated with significant improvement in all secondary end points, with continuous, time-dependent increases in the estimated glomerular filtration rate (GFR). In trial 1, dialysis was discontinued in 4 of 5 patients. Earlier intervention with eculizumab was associated with significantly greater improvement in the estimated GFR. Eculizumab was also associated with improvement in health-related quality of life. No cumulative toxicity of therapy or serious infection-related adverse events, including meningococcal infections, were observed through the extension period. CONCLUSIONS Eculizumab inhibited complement-mediated thrombotic microangiopathy and was associated with significant time-dependent improvement in renal function in patients with atypical hemolytic-uremic syndrome. (Funded by Alexion Pharmaceuticals; C08-002 ClinicalTrials.gov numbers, NCT00844545 [adults] and NCT00844844 [adolescents]; C08-003 ClinicalTrials.gov numbers, NCT00838513 [adults] and NCT00844428 [adolescents]).
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Affiliation(s)
- C M Legendre
- Université Paris Descartes and Assistance Publique–Hôpitaux de Paris, Hôpital Necker, INSERM Unité 845, Paris, France.
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19
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Campos LM, Silvia Spadoni M, Michelin CM, Jesus AA, Carneiro JD, Almeida da Silva CA. Púrpura trombocitopênica trombótica na apresentação de pacientes com lúpus eritematoso sistêmico juvenil. REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000100012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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20
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Schmidtko J, Peine S, El-Housseini Y, Pascual M, Meier P. Treatment of atypical hemolytic uremic syndrome and thrombotic microangiopathies: a focus on eculizumab. Am J Kidney Dis 2012; 61:289-99. [PMID: 23141475 DOI: 10.1053/j.ajkd.2012.07.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 07/26/2012] [Indexed: 12/19/2022]
Abstract
Uncontrolled complement activation is central to the occurrence of atypical hemolytic uremic syndrome (aHUS) and can result in thrombotic microangiopathies (TMAs). These terms encompass a group of heterogenic inherited or acquired diseases that recent research suggests may be triggered by the complement cascade. Pathogenetic triggers of complement activation include immunologic disorders, genetics, infections, systemic diseases, pregnancy, drug administration, metabolic diseases, transplantation, or triggers of mixed cause. Hallmarks of aHUS and other TMAs include increased vascular endothelium thromboresistance, leukocyte adhesion to damaged endothelium, complement consumption, coagulation abnormalities, and vascular shear stress, whereas common end points of these mechanisms include hemolytic anemia, thrombocytopenia with microvascular infarction, and predisposition for decreased kidney function and other organ involvement. The central role of the complement cascade as a disease trigger suggests a possible therapeutic target. Eculizumab, a first-in-class humanized monoclonal anti-C5 antibody that has been successful in the treatment of paroxysmal nocturnal hemoglobinuria, a disorder of complement-induced hemolytic anemia, received approval for the treatment of aHUS in the United States and Europe in late 2011. We review the treatment of aHUS and other TMAs, focusing on the role of eculizumab, including its pharmacology, mechanism of action, and approved dosing recommendations and health economic considerations. Finally, the potential for future indications for eculizumab use in other complement-driven diseases is discussed.
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Affiliation(s)
- Jan Schmidtko
- Division de Néphrologie, Reseau Santé Valais, Hôpital du Valais, Sion, Switzerland.
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21
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Morel N, Berthoux E, Colombe B, Bosseray A, Massot C. Micro-angiopathie thrombotique avec anticorps anti-ADAMTS 13 révélant une fièvre Q aiguë. Rev Med Interne 2012; 33:640-2. [DOI: 10.1016/j.revmed.2012.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 07/18/2012] [Accepted: 08/12/2012] [Indexed: 11/25/2022]
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22
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Abstract
In the past decade, a large body of evidence has accumulated in support of the critical role of dysregulation of the alternative complement pathway in atypical haemolytic uraemic syndrome (aHUS) and C3 glomerulopathies. These findings have paved the way for innovative therapeutic strategies based on complement blockade, and eculizumab, a monoclonal antibody targeting the human complement component 5, is now widely used to treat aHUS. In this article, we review 28 case reports and preliminary data from 37 patients enrolled in prospective trials of eculizumab treatment for episodes of aHUS involving either native or transplanted kidneys. Eculizumab may be considered as an optimal first-line therapy when the diagnosis of aHUS is unequivocal and this treatment has the potential to rescue renal function when administered early after onset of the disease. However, a number of important issues require further study, including the appropriate duration of treatment according to an individual's genetic background and medical history, the optimal strategy to prevent post-transplantation recurrence of aHUS and a cost-efficacy analysis. Data regarding the efficacy of eculizumab in the control of C3 glomerulopathies are more limited and less clear, but several observations suggest that eculizumab may act on the most inflammatory forms of this disorder.
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Hatti K, Rojas M, Kouides P. Rare case of hemolytic uremic syndrome associated with only one transient low platelet count. J Hematop 2012. [DOI: 10.1007/s12308-011-0130-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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24
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Dierkes F, Andriopoulos N, Sucker C, Kuhr K, Hollenbeck M, Hetzel GR, Burst V, Teschner S, Rump LC, Benzing T, Grabensee B, Kurschat CE. Indicators of acute and persistent renal damage in adult thrombotic microangiopathy. PLoS One 2012; 7:e30886. [PMID: 22292070 PMCID: PMC3264649 DOI: 10.1371/journal.pone.0030886] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 12/28/2011] [Indexed: 11/29/2022] Open
Abstract
Background Thrombotic microangiopathies (TMA) in adults such as thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are life-threatening disorders if untreated. Clinical presentation is highly variable and prognostic factors for clinical course and outcome are not well established. Methods We performed a retrospective observational study of 62 patients with TMA, 22 males and 40 females aged 16 to 76 years, treated with plasma exchange at one center to identify clinical risk factors for the development of renal insufficiency. Results On admission, 39 of 62 patients (63%) had acute renal failure (ARF) with 32 patients (52%) requiring dialysis treatment. High systolic arterial pressure (SAP, p = 0.009) or mean arterial pressure (MAP, p = 0.027) on admission was associated with acute renal failure. Patients with SAP>140 mmHg on admission had a sevenfold increased risk of severe kidney disease (OR 7.464, CI 2.097–26.565). MAP>100 mmHg indicated a fourfold increased risk for acute renal failure (OR 4.261, CI 1.400–12.972). High SAP, diastolic arterial pressure (DAP), and MAP on admission were also independent risk factors for persistent renal insufficiency with the strongest correlation for high MAP. Moreover, a high C-reactive protein (CRP) level on admission correlated with renal failure in the course of the disease (p = 0.003). At discharge, renal function in 11 of 39 patients (28%) had fully recovered, 14 patients (23%) remained on dialysis, and 14 patients (23%) had non-dialysis-dependent chronic kidney disease. Seven patients (11%) died. We identified an older age as risk factor for death. Conclusions High blood pressure as well as high CRP serum levels on admission are associated with renal insufficiency in TMA. High blood pressure on admission is also a strong predictor of sustained renal insufficiency. Thus, adult TMA patients with high blood pressure may require special attention to prevent persistent renal failure.
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Affiliation(s)
- Firuseh Dierkes
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Nikolaos Andriopoulos
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
| | - Christoph Sucker
- Department of Hemostasis and Transfusion Medicine, Heinrich-Heine-University Medical Center, Düsseldorf, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Markus Hollenbeck
- Department of Nephrology and Rheumatology, Knappschaftskrankenhaus, Bottrop, Germany
| | - Gerd R. Hetzel
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Burst
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
| | - Sven Teschner
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
| | - Lars C. Rump
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Thomas Benzing
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
| | - Bernd Grabensee
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christine E. Kurschat
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
- * E-mail:
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Casamento AJ, Isbister GK. Thrombotic microangiopathy in two tiger snake envenomations. Anaesth Intensive Care 2012; 39:1124-7. [PMID: 22165369 DOI: 10.1177/0310057x1103900622] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thrombotic microangiopathies are a rare group of disorders with features such as microangiopathic haemolytic anaemia, thrombocytopenia and renal failure. Thrombotic microangiopathy has been previously reported in association with envenomation from a number of snake species. We present the first two reported cases of thrombotic microangiopathy caused by envenomation from the common tiger snake (Notechis scutatus). Both patients had classical features of thrombotic microangiopathy with microangiopathic haemolytic anaemia, thrombocytopenia and renal failure commencing in the first 48 hours after envenomation. The presentations and recovery were similar to case presentations of other snakebite envenomation associated thrombotic microangiopathies. Normal ADAMTS13 activity suggests that plasmapharesis may not be beneficial, although this needs further investigation.
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Affiliation(s)
- A J Casamento
- Intensive Care Department, The Northern Hospital, Epping, Victoria, Australia.
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Abstract
The kidneys are the major organs affected in diarrhea-associated hemolytic uremic syndrome (D(+)HUS). The pathophysiology of renal disease in D(+)HUS is largely the result of the interaction between bacterial virulence factors such as Shiga toxin and lipopolysaccharide and host cells in the kidney and in the blood circulation. This chapter describes in detail the current knowledge of how these bacterial toxins may lead to kidney disease and renal failure. The toxin receptors expressed by specific blood and resident renal cell types are also discussed as are the actions of the toxins on these cells.
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Abstract
Thrombotic microangiopathies encompass a group of disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia associated with hyaline thrombi (comprised primarily of platelet aggregates in the microcirculation), and varying degrees of end-organ failure. Many primary (genetic) and secondary etiological predisposing factors have been described-namely pregnancy, autoimmune disorders, cancer, drugs and antineoplastic therapy, bone marrow transplantation/solid organ transplantation, and infections. In the setting of infectious diseases, the association with Shiga or Shiga-like exotoxin of Escherichia coli 0157:h7 or Shigella dysenteriae type 1-induced typical hemolytic uremic syndrome is well known. Recently however, an increasing body of evidence suggests that viruses may also play an important role as trigger factors in the pathogenesis of thrombotic microangiopathies. This is a comprehensive review focusing on the current understanding of viral associated/induced endothelial stimulation and damage that ultimately leads to the development of this life-threatening multisystemic disorder.
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Affiliation(s)
- Rodrigo Lopes da Silva
- Hospital Santo António dos Capuchos, Centro Hospitalar Lisboa Center, Alameda Capuchos, Lisboa, Portugal.
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28
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Novel developments in thrombotic microangiopathies: is there a common link between hemolytic uremic syndrome and thrombotic thrombocytic purpura? Pediatr Nephrol 2011; 26:1947-56. [PMID: 21671028 DOI: 10.1007/s00467-011-1923-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 04/05/2011] [Accepted: 04/11/2011] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathies (TMA) represent a spectrum of related disorders associated with newly formed thrombi that block perfusion and thus affect the function of either renal or neurological organs and tissue. Recent years have seen a dramatic development in the field of TMA and for the two major forms hemolytic uremic syndrome (HUS) and thrombocytopenic purpura (TTP), new genetic causes and also autoimmune forms have been identified. This development indicates a similar pathophysiology and suggests that the two acute disorders are based on common principles. HUS is primarily a kidney disease and TTP also develops in the kidney and at neurological sites. In HUS thrombi formation is likely due to a deregulated complement activation and inappropriate platelet activity. In TTP thrombi formation occurs because of inappropriate processing of released multimers of von Willebrand Factor (vWF). Defining both the similarities and the unique features of each disorder will open up new ways and concepts that are relevant for diagnosis, for therapy, and for the prognostic outcome of kidney transplantations. Here we summarize the most relevant topics and timely issues that were presented and discussed at the 4th International Workshop on Thrombotic Microangiopathies held in Weimar in October 2009 (www.hus-ttp.de).
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Sullivan M, Rybicki LA, Winter A, Hoffmann MM, Reiermann S, Linke H, Arbeiter K, Patzer L, Budde K, Hoppe B, Zeier M, Lhotta K, Bock A, Wiech T, Gaspert A, Fehr T, Woznowski M, Berisha G, Malinoc A, Goek ON, Eng C, Neumann HPH. Age-related penetrance of hereditary atypical hemolytic uremic syndrome. Ann Hum Genet 2011; 75:639-47. [PMID: 21906045 DOI: 10.1111/j.1469-1809.2011.00671.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hereditary atypical hemolytic uremic syndrome (aHUS), a dramatic disease frequently leading to dialysis, is associated with germline mutations of the CFH, CD46, or CFI genes. After identification of the mutation in an affected aHUS patient, single-site gene testing of relatives is the preventive care perspective. However, clinical data for family counselling are scarce. From the German-Speaking-Countries-aHUS-Registry, 33 index patients with mutations were approached for permission to offer relatives screening for their family-specific mutations and to obtain demographic and clinical data. Mutation screening was performed using direct sequencing. Age-adjusted penetrance of aHUS was calculated for each gene in index cases and in mutation-positive relatives. Sixty-one relatives comprising 41 parents and 20 other relatives were enrolled and mutations detected in 31/61. In total, 40 research participants had germline mutations in CFH, 19 in CD46 and in 6 CFI. Penetrance at age 40 was markedly reduced in mutation-positive relatives compared to index patients overall with 10% versus 67% (P < 0.001); 6% vs. 67% (P < 0.001) in CFH mutation carriers and 21% vs. 70% (P= 0.003) in CD46 mutation carriers. Age-adjusted penetrance for hereditary aHUS is important to understand the disease, and if replicated in the future, for genetic counselling.
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Affiliation(s)
- Maren Sullivan
- Department of Nephrology, Section of Preventive Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
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Vehaskari VM. Genetics and CKD. Adv Chronic Kidney Dis 2011; 18:317-23. [PMID: 21896372 DOI: 10.1053/j.ackd.2011.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 07/10/2011] [Accepted: 07/11/2011] [Indexed: 01/15/2023]
Abstract
The diagnosis of hereditary monogenic kidney diseases is frequently delayed, in part because of physicians' unfamiliarity with the relatively rare conditions or because of the late onset of symptoms in some patients. Molecular biology methods have clarified the underlying mutations in several types of CKD, and in the process have revealed previously unknown genes and pathogenetic pathways. Mutations affecting the integrity of the glomerular filtration barrier cause proteinuria or nephrotic syndrome; different types of Alport syndrome are caused by mutations in glomerular basement membrane type IV collagen; dysfunction of the primary cilium of tubule cells may lead to a variety of inherited progressive tubulointerstitial diseases; atypical hemolytic-uremic syndrome is frequently caused by inherited complement deficiencies; and progressive kidney injury develops in many inherited systemic or metabolic disorders. Some genetic diseases may not manifest until late childhood or adulthood. Accurate diagnosis is important for appropriate treatment, prognosis, genetic counseling, and possible renal transplantation.
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Abstract
Microangiopathic disorders present with thrombocytopenia, hemolytic anemia, and multiorgan damage. In pregnancy, these disorders present a challenge both diagnostically and therapeutically, with widely overlapping clinical scenarios and disparate treatments. Although rare, a clear understanding of these diseases is important because devastating maternal and fetal outcomes may ensue if there is misdiagnosis and improper treatment. Microangiopathic disorders presenting in pregnancy are thus best assessed and treated by both obstetric and hematology teams. As a better understanding of the pathophysiology underlying each of the disease processes is gained, new diagnostic testing and therapies will be available, which will lead to improved outcomes.
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Affiliation(s)
- Salley G Pels
- Section of Hematology Oncology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8063, USA.
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Noris P, Balduini CL. Investigational drugs in thrombotic thrombocytopenic purpura. Expert Opin Investig Drugs 2011; 20:1087-98. [DOI: 10.1517/13543784.2011.588599] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type-1 motifs 13) has been shown to be of major pathophysiological importance for thrombotic microangiopathy (TMA) in the setting of thrombocytic thrombocytopenic purpura (TTP) when either lacking (inherited TTP) or if antibodies against ADAMTS13 are present (acquired TTP). A potential pathophysiological role of ADAMTS13 has also been postulated in other diseases i.e. myocardial infarction, atrial fibrillation and diabetic angiopathy. Recent data provides evidence, however, for a completely different role of ADAMTS13 in vascular physiology and pathophysiology. In the present issue of Nephrology Dialysis and Transplantation, Bockmeyer et al. documented a physiological expression of ADAMTS13 in arteriolar vascular smooth muscle cells (VSMCs) which is maintained in the early, so-called benign nephrosclerosis, i.e. under conditions of early hypertensive vascular damage, and is completely lost if the damage proceeds to late, fibrotic stages of vascular injury. Thus, the recent report identifies ADAMTS13 as a new marker for the contractile phenotype of VSMC which is maintained in the early, hyalinotic phase of vascular damage, but is lost in later, more fibrotic stages of benign nephrosclerosis. This finding adds a novel and potentially important aspect to the unsolved and underestimated problem of benign or hypertensive nephrosclerosis.
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Ellchuk TN, Shah LM, Hewlett RH, Osborn AG. Suspicious neuroimaging pattern of thrombotic microangiopathy. AJNR Am J Neuroradiol 2011; 32:734-8. [PMID: 21292795 DOI: 10.3174/ajnr.a2351] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The TMAs are a group of microvascular occlusive disorders characterized by thrombocytopenia and intravascular hemolysis. Literature review reveals a spectrum of neuroimaging findings, including a single case report of multifocal hemorrhagic infarctions. We present a series of 12 patients with TMA demonstrating a similar pattern of multifocal cortical and subcortical hemorrhagic infarctions.
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Affiliation(s)
- T N Ellchuk
- Department of Radiology, University of Utah, Salt Lake City, Utah 84132-2140, USA
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Abstract
Shiga toxin-producing Escherichia coli is a contaminant of food and water that in humans causes a diarrheal prodrome followed by more severe disease of the kidneys and an array of symptoms of the central nervous system. The systemic disease is a complex referred to as diarrhea-associated hemolytic uremic syndrome (D+HUS). D+HUS is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. This review focuses on the renal aspects of D+HUS. Current knowledge of this renal disease is derived from a combination of human samples, animal models of D+HUS, and interaction of Shiga toxin with isolated renal cell types. Shiga toxin is a multi-subunit protein complex that binds to a glycosphingolipid receptor, Gb3, on select eukaryotic cell types. Location of Gb3 in the kidney is predictive of the sites of action of Shiga toxin. However, the toxin is cytotoxic to some, but not all cell types that express Gb3. It also can cause apoptosis or generate an inflammatory response in some cells. Together, this myriad of results is responsible for D+HUS disease.
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Affiliation(s)
- Tom G Obrig
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, 685 W. Baltimore St., HSF I Suite 380, Baltimore, MD 21201, USA; ; Tel.: +1-410-706-6917
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