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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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2
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Young HL, Brown CC, Crawford B, Blaszak RT, Prodhan P. Streptococcus pneumoniae associated hemolytic uremic syndrome in children. Front Pediatr 2023; 11:1268971. [PMID: 38027264 PMCID: PMC10665843 DOI: 10.3389/fped.2023.1268971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Previous small-scale, single-center investigations of Streptococcus pneumoniae associated hemolytic uremic syndrome (SpHUS) have shown increased disease severity among SpHUS relative to non-SpHUS patients. Our study compares the impact of S. pneumoniae on patient outcomes between SpHUS cases and non-SpHUS controls using the national, multicenter retrospective Pediatric Health Information Systems (PHIS) Database. Methods Children <18 years of age with a diagnosis of HUS were included. Univariate analyses and multivariable linear and logistic regressions were utilized to assess the impact of S. pneumoniae on mortality, length of stay (LOS), intensive care unit admission (ICU), and mechanical ventilation use. Models were adjusted for demographic and clinical characteristics, including cardiac, neurologic, pulmonary, gastrointestinal, immunologic and renal clinical complications. Results Of 3,952 index HUS hospitalizations, 231 (5.8%) were due to SpHUS. SpHUS patients had worse outcomes, including longer hospital stays, increased rate of ICU admission, and increased use of mechanical ventilation (p < 0.001 for all). There was a strong positive relationship between clinical complications and adverse outcomes. After adjusting for covariates, SpHUS was associated with an increase in hospital LOS by 3.47 days (p = 0.009) and overall ICU-LOS by 4.21 days (p < 0.001). SpHUS was also associated with increased likelihood of mechanical ventilation (OR: 3.08; p < 0.001), with no increase in ICU admission (p = 0.070) and in-hospital mortality (p = 0.3874). Discussion Our study highlights that SpHUS patients are at increased risk of multiple adverse outcomes likely due to the summative impact of pneumococcal infection and HUS as well as more frequent clinical complications.
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Affiliation(s)
- Heather L. Young
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Clare C. Brown
- Health Policy and Management Department, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Brendan Crawford
- Division of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Richard T. Blaszak
- Division of Pediatric Nephrology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Parthak Prodhan
- Division of Cardiology/Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Battista M, Hoffmann B, Bachelot Y, Zimmermann L, Teuber L, Jost A, Linde S, Westermann M, Müller MM, Slevogt H, Hammerschmidt S, Figge MT, Vilhena C, Zipfel PF. The role of pneumococcal extracellular vesicles on the pathophysiology of the kidney disease hemolytic uremic syndrome. mSphere 2023; 8:e0014223. [PMID: 37358300 PMCID: PMC10449520 DOI: 10.1128/msphere.00142-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 06/27/2023] Open
Abstract
Streptococcus pneumoniae-induced hemolytic uremic syndrome (Sp-HUS) is a kidney disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. This disease is frequently underdiagnosed and its pathophysiology is poorly understood. In this work, we compared clinical strains, isolated from infant Sp-HUS patients, with a reference pathogenic strain D39, for host cytotoxicity and further explored the role of Sp-derived extracellular vesicles (EVs) in the pathogenesis of an HUS infection. In comparison with the wild-type strain, pneumococcal HUS strains caused significant lysis of human erythrocytes and increased the release of hydrogen peroxide. Isolated Sp-HUS EVs were characterized by performing dynamic light-scattering microscopy and proteomic analysis. Sp-HUS strain released EVs at a constant concentration during growth, yet the size of the EVs varied and several subpopulations emerged at later time points. The cargo of the Sp-HUS EVs included several virulence factors at high abundance, i.e., the ribosomal subunit assembly factor BipA, the pneumococcal surface protein A, the lytic enzyme LytC, several sugar utilization, and fatty acid synthesis proteins. Sp-HUS EVs strongly downregulated the expression of the endothelial surface marker platelet endothelial cell adhesion molecule-1 and were internalized by human endothelial cells. Sp-HUS EVs elicited the release of pro-inflammatory cytokines (interleukin [IL]-1β, IL-6) and chemokines (CCL2, CCL3, CXCL1) by human monocytes. These findings shed new light on the overall function of Sp-EVs, in the scope of infection-mediated HUS, and suggest new avenues of research for exploring the usefulness of Sp-EVs as therapeutic and diagnostic targets. IMPORTANCE Streptococcus pneumoniae-associated hemolytic uremic syndrome (Sp-HUS) is a serious and underdiagnosed deadly complication of invasive pneumococcal disease. Despite the introduction of the pneumococcal vaccine, cases of Sp-HUS continue to emerge, especially in children under the age of 2. While a lot has been studied regarding pneumococcal proteins and their role on Sp-HUS pathophysiology, little is known about the role of extracellular vesicles (EVs). In our work, we isolate and initially characterize EVs from a reference pathogenic strain (D39) and a strain isolated from a 2-year-old patient suffering from Sp-HUS. We demonstrate that despite lacking cytotoxicity toward human cells, Sp-HUS EVs are highly internalized by endothelial cells and can trigger cytokine and chemokine production in monocytes. In addition, this work specifically highlights the distinct morphological characteristics of Sp-HUS EVs and their unique cargo. Overall, this work sheds new light into potentially relevant players contained in EVs that might elucidate about pneumococcal EVs biogenesis or pose as interesting candidates for vaccine design.
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Affiliation(s)
- Miriana Battista
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Bianca Hoffmann
- Applied Systems Biology, HKI-Center for Systems Biology of Infection, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute (HKI), Jena, Germany
| | - Yann Bachelot
- Applied Systems Biology, HKI-Center for Systems Biology of Infection, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute (HKI), Jena, Germany
| | - Lioba Zimmermann
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Laura Teuber
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Aurélie Jost
- Microverse Imaging Center, Cluster of Excellence “Balance of the Microverse,” Friedrich Schiller University, Jena, Germany
| | - Susanne Linde
- Center for Electron Microscopy, Jena University Hospital, Jena, Germany
| | - Martin Westermann
- Center for Electron Microscopy, Jena University Hospital, Jena, Germany
| | - Mario M. Müller
- Septomics Research Center, Jena University Hospital, Jena, Germany
| | - Hortense Slevogt
- Septomics Research Center, Jena University Hospital, Jena, Germany
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Marc Thilo Figge
- Applied Systems Biology, HKI-Center for Systems Biology of Infection, Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute (HKI), Jena, Germany
- Faculty of Biological Sciences, Institute of Microbiology, Friedrich Schiller University, Jena, Germany
| | - Cláudia Vilhena
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Peter F. Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
- Faculty of Biological Sciences, Institute of Microbiology, Friedrich Schiller University, Jena, Germany
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Donadelli R, Sinha A, Bagga A, Noris M, Remuzzi G. HUS and TTP: traversing the disease and the age spectrum. Semin Nephrol 2023; 43:151436. [PMID: 37949684 DOI: 10.1016/j.semnephrol.2023.151436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenia purpura (TTP) are rare diseases sharing a common pathological feature, thrombotic microangiopathy (TMA). TMA is characterized by microvascular thrombosis with consequent thrombocytopenia, microangiopathic hemolytic anemia and/or multiorgan dysfunction. In the past, the distinction between HUS and TTP was predominantly based on clinical grounds. However, clinical presentation of the two syndromes often overlaps and, the differential diagnosis is broad. Identification of underlying pathogenic mechanisms has enabled the classification of these syndromes on a molecular basis: typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS); atypical HUS or complement-mediated TMA (aHUS/CM-TMA) associated with genetic or acquired defects leading to dysregulation of the alternative pathway (AP) of complement; and TTP that results from a severe deficiency of the von Willebrand Factor (VWF)-cleaving protease, ADAMTS13. The etiology of TMA differs between pediatric and adult patients. Childhood TMA is chiefly caused by STEC-HUS, followed by CM-TMA and pneumococcal HUS (Sp-HUS). Rare conditions such as congenital TTP (cTTP), vitamin B12 metabolism defects, and coagulation disorders (diacylglycerol epsilon mutation) present as TMA chiefly in children under 2 years of age. In contrast secondary causes and acquired ADAMT13 deficiency are more common in adults. In adults, compared to children, diagnostic delays are more frequent due to the wide range of differential diagnoses. In this review we focus on the three major forms of TMA, STEC-HUS, aHUS and TTP, outlining the clinical presentation, diagnosis and management of the affected patients, to help highlight the salient features and the differences between adult and pediatric patients which are relevant for management.
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Affiliation(s)
- Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Aditi Sinha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy.
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Routray SS, Tripathy S, Das P, Ray GK. Minor Cross-Matching in the Diagnosis of Pneumococcal Hemolytic Uremic Syndrome in an 18-Month-Old Boy. Lab Med 2023; 54:215-219. [PMID: 36124770 DOI: 10.1093/labmed/lmac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In developing nations, limitations in diagnostic facilities act as a barrier for differentiation of hemolytic uremic syndrome (HUS) based on the etiology. A sick-looking 18-month-old boy presented to our hospital in Bhubaneswar, India, with clinical signs and symptoms of left lobar pneumonia, abnormal hematological and renal parameters, no growth in blood culture, a negative direct antiglobulin test (DAT) result, and low complement levels. A rapid deterioration in his clinical condition necessitated intensive care support, blood transfusion, and renal replacement therapy (peritoneal dialysis and hemodialysis). Because his health care team suspected atypical HUS, therapeutic plasma exchange (TPE) was initiated as soon as possible. In the absence of a lectin panel, minor cross-matching confirmed T-antigen exposure. With a diagnosis of HUS induced by Streptococcus pneumoniae (sp-HUS), TPE was stopped immediately, and washed blood components were administered. Despite the aforementioned measures, the boy died of HUS on day 20 after presentation. This case emphasized the role of minor cross-matching in the detecting of polyagglutination in resolving the diagnostic dilemma of sp-HUS.
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Affiliation(s)
- Suman Sudha Routray
- Department of Transfusion Medicine and Blood Centre, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Sukanta Tripathy
- Department of Transfusion Medicine and Blood Centre, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Palash Das
- Department of Transfusion Medicine and Blood Centre, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Gopal Krushna Ray
- Department of Transfusion Medicine and Blood Centre, Kalinga Institute of Medical Sciences, Bhubaneswar, India
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Thrombotic microangiopathies in critically ill children: The MATUCIP registry in Spain. An Pediatr (Barc) 2023; 98:194-203. [PMID: 36842880 DOI: 10.1016/j.anpede.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/23/2022] [Indexed: 02/28/2023] Open
Abstract
INTRODUCTION Thrombotic microangiopathies (TMA) are rare diseases usually presenting with renal, haematological, neurologic and cardiovascular involvement and nonspecific but severe symptoms. A registry of TMA cases managed in Spanish paediatric intensive care units (the MATUCIP Registry) was established with the aim of gaining knowledge on their clinical characteristics, diagnosis and acute-phase treatment. METHODS We conducted a prospective multicentre observational study in 20 paediatric intensive care units (PICUs) in Spain from January 2017 to December 2021 in children aged more than 1 month with TMAs, who were followed up through the discharge from the PICU. RESULTS The sample included 97 patients (51.5% female) with a median age of 2.6 years (interquartile range [IQR], 1.6-5.7). The initial manifestations were gastrointestinal (74.2%), respiratory (14.4%), fever (5.2%), neurologic (3.1%) and other (3.1%). At admission, 75.3% of patients had microangiopathic haemolytic anaemia, 95.9% thrombocytopenia and 94.8% acute kidney injury. Of the total sample, 57.7% of patients received a diagnosis of Shiga toxin-associated haemolytic uraemic syndrome (HUS), 14.4% of Streptococcus pneumoniae-associated HUS, 15.6% of atypical HUS, 10.3% of secondary TMA and 2.1% of thrombotic thrombocytopenic purpura. Eighty-seven patients (89.7%) developed arterial hypertension, and 49.5% gastrointestinal, 22.7% respiratory, 25.8% neurologic and 12.4% cardiac manifestations. Also, 60.8% required renal replacement therapy and 2.1% plasma exchange. Twenty patients received eculizumab. The median PICU stay was 8.5 days (IQR, 5-16.5). Two children died. CONCLUSIONS The MATUCIP registry demonstrates the clinical variability of TMA cases requiring admission to the PICU. Knowledge of the presentation and outcomes of TMAs can facilitate early aetiological diagnosis. This registry can help improve our understanding of the clinical spectrum of these diseases, for which there is a dearth of published data.
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Van Hove S, Werion A, Anantharajah A, Belkhir L, van Dievoet MA, Hantson P. Streptococcus Pneumoniae Bacteremia with Acute Kidney Injury and Transient ADAMTS13 Deficiency. Case Rep Infect Dis 2023; 2023:3283606. [PMID: 37159753 PMCID: PMC10163968 DOI: 10.1155/2023/3283606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/30/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023] Open
Abstract
A 43-year-old woman with a medical history of splenectomy for immune thrombocytopenic purpura was diagnosed with Streptococcus pneumoniae bacteremia. Her initial complaints were fever and more importantly painful extremities that appeared cyanotic. During her hospitalisation, she never developed cardiocirculatory failure but presented acute kidney injury (AKI) with oliguria. Laboratory investigations confirmed AKI with serum creatinine 2.55 mg/dL which peaked at 6.49 mg/dL. There was also evidence for disseminated intravascular coagulation (DIC) with decreased platelet count, low fibrinogen levels, and high D-dimer levels. There were no signs of haemolytic anaemia. The initial ADAMTS13 activity was low (17%) but slowly recovered. Renal function progressively improved with supportive therapy, as opposed to the progressing skin necrosis. The association of DIC and low ADAMTS13 activity may have contributed to the severity of microthrombotic complications, even in the absence of thrombotic microangiopathy as thrombotic thrombocytopenic purpura (TTP) or pneumococcal-associated haemolytic uremic syndrome (pa-HUS).
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Affiliation(s)
- Sam Van Hove
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Alexis Werion
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Neuve, Belgium
| | | | - Leila Belkhir
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Neuve, Belgium
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | | | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain, 1200 Brussels, Belgium
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Boyer O, Niaudet P. Hemolytic-Uremic Syndrome in Children. Pediatr Clin North Am 2022; 69:1181-1197. [PMID: 36880929 DOI: 10.1016/j.pcl.2022.07.006] [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] [Indexed: 11/06/2022]
Abstract
Hemolytic uremic syndrome is characterized by a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Most cases are caused by Shiga-toxin-producing bacteria, especially Escherichia coli. Transmission occurs through ground beef and unpasteurized milk. STEC-HUS is the main cause of acute renal failure in children. Management remains supportive. Immediate outcome is most often. Atypical HUS represents about 5% of cases, has a relapsing course with more than half of the patients progressing to end-stage kidney failure. Most cases are due to variants in complement regulators of the alternative pathway. Complement inhibitors, such as eculizumab, have considerably improved the prognosis.
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Affiliation(s)
- Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France; Néphrologie Pédiatrique, Hôpital Necker, 149 Rue de Sèvres, Paris 75015, France
| | - Patrick Niaudet
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France.
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9
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Microangiopatías trombóticas en niños críticamente enfermos. Registro español MATUCIP. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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10
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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Thompson GL, Kavanagh D. Diagnosis and treatment of thrombotic microangiopathy. Int J Lab Hematol 2022; 44 Suppl 1:101-113. [PMID: 36074708 PMCID: PMC9544907 DOI: 10.1111/ijlh.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic haemolytic anaemia and end organ damage. TMAs have varying underlying pathophysiology and can therefore present with an array of clinical presentations. Renal involvement is common as the kidney is particularly susceptible to the endothelial damage and microvascular occlusion. TMAs require rapid assessment, diagnosis, and commencement of appropriate treatment due to the high morbidity and mortality associated with them. Ground-breaking research into the pathogenesis of TMAs over the past 20 years has driven the successful development of targeted therapeutics revolutionizing patient outcomes. This review outlines the clinical presentations, pathogenesis, diagnostic tests and treatments for TMAs.
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Affiliation(s)
- Gemma L Thompson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Abstract
The World Health Organization estimates that approximately a quarter of the world's population suffers from anemia, including almost half of preschool-age children. Globally, iron deficiency anemia is the most common cause of anemia. Other important causes of anemia in children are hemoglobinopathies, infection, and other chronic diseases. Anemia is associated with increased morbidity, including neurologic complications, increased risk of low birth weight, infection, and heart failure, as well as increased mortality. When approaching a child with anemia, detailed historical information, particularly diet, environmental exposures, and family history, often yield important clues to the diagnosis. Dysmorphic features on physical examination may indicate syndromic causes of anemia. Diagnostic testing involves a stepwise approach utilizing various laboratory techniques. The increasing availability of genetic testing is providing new mechanistic insights into inherited anemias and allowing diagnosis in many previously undiagnosed cases. Population-based approaches are being taken to address nutritional anemias. Novel pharmacologic agents and advances in gene therapy-based therapeutics have the potential to ameliorate anemia-associated disease and provide treatment strategies even in the most difficult and complex cases.
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Affiliation(s)
- Patrick G Gallagher
- Departments of Pediatrics, Pathology, and Genetics, Yale University School of Medicine, New Haven, CT
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Kumar S, Bhagia G, Kaae J. A Rare Case of Atypical Hemolytic Uremia Syndrome Triggered by Influenza Vaccination. Cureus 2022; 14:e23577. [PMID: 35494971 PMCID: PMC9045680 DOI: 10.7759/cureus.23577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/08/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) occurs in patients with defective alternative complement pathways, making them susceptible to thrombotic microangiopathy (thrombocytopenia, intravascular hemolysis, and renal failure), and is usually triggered by infectious agents. Influenza and Streptococcus pneumonia are known triggers for aHUS. However, influenza vaccination triggering aHUS is rarely reported. We present a 30-year-old male who presented with chills, abdominal discomfort, and night sweats after receiving the influenza vaccine. The patient had thrombocytopenia, elevated creatinine, blood urea nitrogen, liver enzymes, and bilirubin with schistocytes with peripheral smear. ADAMTS13 activity was normal so the patient was diagnosed with aHUS. The patient improved with eculizumab and was ultimately found to have a mutation in CD46, which made him susceptible to aHUS. This case shows patients with dysregulated alternative complement pathways may be predisposed to develop aHUS after receiving influenza vaccination.
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Inoue D, Oda T, Iwama S, Hoshino T, Mukae M, Sakai T, Kojima A, Uchida T, Kojima T, Sugisaki K, Tomiyasu T, Yoshikawa N, Yamada M. Thrombotic microangiopathy with transiently positive direct Coombs test in an adult with poststreptococcal acute glomerulonephritis: a case report. BMC Nephrol 2022; 23:56. [PMID: 35123445 PMCID: PMC8818228 DOI: 10.1186/s12882-022-02684-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background To date, a few case reports have described the association between poststreptococcal acute glomerulonephritis (PSAGN) and hemolytic anemia/thrombocytopenia, both with or without a pathology similar to that of thrombotic microangiopathy (TMA). However, the detailed mechanism leading to the complication of TMA in PSAGN patients remains to be clarified. In contrast, infection with neuraminidase-producing Streptococcus pneumoniae is a well-known cause of TMA, and it has been reported that transient positivity of the direct Coombs test is observed in up to 90% of such patients. Case presentation A 44-year-old man was hospitalized for acute nephritic syndrome 3 weeks after developing pharyngitis. PSAGN was suspected owing to a low complement C3, increased antistreptolysin-O and serum creatinine (5.46 mg/dL), and hematuria/proteinuria. The throat antigen test for group A Streptococcus was positive. He developed hemolytic anemia with thrombocytopenia from hospital day 9. TMA was suspected owing to minimal coagulation abnormalities. ADAMTS-13 activity was normal, whereas the direct Coombs test was transiently positive. Renal biopsy demonstrated glomerular endocapillary proliferation without crescents, but with severe tubulitis and peritubular capillaritis on light microscopy. Immunofluorescence demonstrated C3 deposition along the glomerular capillary walls, and many subepithelial humps were observed on electron microscopy. The deposition of nephritis-associated plasmin receptor (NAPlr), a nephritogenic protein of Streptococcus pyogenes, was observed only in glomeruli. Thus, the histological diagnosis was typical PSAGN, but with atypical severe tubulointerstitial lesions. A positive direct Coombs test is often observed in pneumococcal TMA patients, which is attributed to the exposure of Thomsen–Friedenreich (T) antigen by neuraminidase. As Streptococcus pyogenes is one of the neuraminidase-producing bacteria other than Streptococcus pneumoniae, T-antigen exposure was analyzed in the renal tissue of this patient using labelled peanut lectin as a probe, which has strong and specific binding affinity for T-antigen. Exposure of T-antigen was found on tubular epithelial cells and small vessels in the tubulointerstitial area, but not in the glomeruli of this patient. Conclusion These findings suggest that 2 pathogenic proteins of Streptococcus pyogenes, i.e., NAPlr and neuraminidase, induced glomerular lesions of PSAGN and tubulointerstitial inflammation with TMA, respectively, resulting in severe acute kidney injury in this patient.
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15
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Ballermann BJ, Nyström J, Haraldsson B. The Glomerular Endothelium Restricts Albumin Filtration. Front Med (Lausanne) 2021; 8:766689. [PMID: 34912827 PMCID: PMC8667033 DOI: 10.3389/fmed.2021.766689] [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] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/05/2021] [Indexed: 12/29/2022] Open
Abstract
Inflammatory activation and/or dysfunction of the glomerular endothelium triggers proteinuria in many systemic and localized vascular disorders. Among them are the thrombotic microangiopathies, many forms of glomerulonephritis, and acute inflammatory episodes like sepsis and COVID-19 illness. Another example is the chronic endothelial dysfunction that develops in cardiovascular disease and in metabolic disorders like diabetes. While the glomerular endothelium is a porous sieve that filters prodigious amounts of water and small solutes, it also bars the bulk of albumin and large plasma proteins from passing into the glomerular filtrate. This endothelial barrier function is ascribed predominantly to the endothelial glycocalyx with its endothelial surface layer, that together form a relatively thick, mucinous coat composed of glycosaminoglycans, proteoglycans, glycolipids, sialomucins and other glycoproteins, as well as secreted and circulating proteins. The glycocalyx/endothelial surface layer not only covers the glomerular endothelium; it extends into the endothelial fenestrae. Some glycocalyx components span or are attached to the apical endothelial cell plasma membrane and form the formal glycocalyx. Other components, including small proteoglycans and circulating proteins like albumin and orosomucoid, form the endothelial surface layer and are bound to the glycocalyx due to weak intermolecular interactions. Indeed, bound plasma albumin is a major constituent of the endothelial surface layer and contributes to its barrier function. A role for glomerular endothelial cells in the barrier of the glomerular capillary wall to protein filtration has been demonstrated by many elegant studies. However, it can only be fully understood in the context of other components, including the glomerular basement membrane, the podocytes and reabsorption of proteins by tubule epithelial cells. Discovery of the precise mechanisms that lead to glycocalyx/endothelial surface layer disruption within glomerular capillaries will hopefully lead to pharmacological interventions that specifically target this important structure.
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Affiliation(s)
| | - Jenny Nyström
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Börje Haraldsson
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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16
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Wang XL, Du Y, Zhao CG, Wu YB, Yang N, Pei L, Wang LJ, Wang QS. Streptococcal pneumonia-associated hemolytic uremic syndrome treated by T-antibody-negative plasma exchange in children: Two case reports. World J Clin Cases 2021; 9:8164-8170. [PMID: 34621876 PMCID: PMC8462191 DOI: 10.12998/wjcc.v9.i27.8164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/29/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The occurrence of Streptococcus pneumoniae-associated hemolytic uremic syndrome (SP-HUS) is increasing. Thomsen-Friedenreich antigen activation is highly involved in the pathogenesis of SP-HUS, and T-antibody-negative plasma exchange (PE) may be effective in the treatment of severe cases of SP-HUS.
CASE SUMMARY We retrospectively reviewed two pediatric patients with SP-HUS. Both clinical features and laboratory examination results of the children were described. T-antibody-negative PE was performed in both cases. Both children made a full recovery after repeated PE and remained well at a 2 year follow-up.
CONCLUSION Streptococcal pneumonia continues to be an uncommon but important cause of HUS. The successful treatment of the presented cases suggests that T-antibody-negative PE may benefit patients with SP-HUS.
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Affiliation(s)
- Xiu-Li Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yue Du
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Cheng-Guang Zhao
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yu-Bin Wu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Ni Yang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Liang Pei
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Li-Jie Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Qiu-Shi Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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17
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Complement C5 inhibition protects against hemolytic anemia and acute kidney injury in anthrax peptidoglycan-induced sepsis in baboons. Proc Natl Acad Sci U S A 2021; 118:2104347118. [PMID: 34507997 DOI: 10.1073/pnas.2104347118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 01/20/2023] Open
Abstract
Late-stage anthrax infections are characterized by dysregulated immune responses and hematogenous spread of Bacillus anthracis, leading to extreme bacteremia, sepsis, multiple organ failure, and, ultimately, death. Despite the bacterium being nonhemolytic, some fulminant anthrax patients develop a secondary atypical hemolytic uremic syndrome (aHUS) through unknown mechanisms. We recapitulated the pathology in baboons challenged with cell wall peptidoglycan (PGN), a polymeric, pathogen-associated molecular pattern responsible for the hemostatic dysregulation in anthrax sepsis. Similar to aHUS anthrax patients, PGN induces an initial hematocrit elevation followed by progressive hemolytic anemia and associated renal failure. Etiologically, PGN induces erythrolysis through direct excessive activation of all three complement pathways. Blunting terminal complement activation with a C5 neutralizing peptide prevented the progressive deposition of membrane attack complexes on red blood cells (RBC) and subsequent intravascular hemolysis, heme cytotoxicity, and acute kidney injury. Importantly, C5 neutralization did not prevent immune recognition of PGN and shifted the systemic inflammatory responses, consistent with improved survival in sepsis. Whereas PGN-induced hemostatic dysregulation was unchanged, C5 inhibition augmented fibrinolysis and improved the thromboischemic resolution. Overall, our study identifies PGN-driven complement activation as the pathologic mechanism underlying hemolytic anemia in anthrax and likely other gram-positive infections in which PGN is abundantly represented. Neutralization of terminal complement reactions reduces the hemolytic uremic pathology induced by PGN and could alleviate heme cytotoxicity and its associated kidney failure in gram-positive infections.
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18
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Streptococcus Pneumoniae-Associated Hemolytic Uremic Syndrome in the Era of Pneumococcal Vaccine. Pathogens 2021; 10:pathogens10060727. [PMID: 34207609 PMCID: PMC8227211 DOI: 10.3390/pathogens10060727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 01/09/2023] Open
Abstract
Streptococcus pneumoniae-associated hemolytic uremic syndrome (Sp-HUS) is a serious complication of invasive pneumococcal disease that is associated with increased mortality in the acute phase and morbidity in the long term. Recently, Sp-HUS definition has undergone revision and cases are categorized as definite, probable, and possible, based on less invasive serological investigations that evaluate Thomsen-Friedenreich crypt antigen (T-antigen) activation. In comparison to the pre-vaccine era, Sp-HUS incidence seems to be decreasing after the introduction of 7-serotype valence and 13-serotype valence pneumococcal vaccines in 2000 and 2010, respectively. However, Sp-HUS cases continue to occur secondary to vaccine failure and emergence of non-vaccine/replacement serotypes. No single hypothesis elucidates the molecular basis for Sp-HUS occurrence, although pneumococcal neuraminidase production and formation of T-antigen antibody complexes on susceptible endothelial and red blood cells continues to remain the most acceptable explanation. Management of Sp-HUS patients remains supportive in nature and better outcomes are being reported secondary to earlier recognition, better diagnostic tools and improved medical care. Recently, the addition of eculizumab therapy in the management of Sp-HUS for control of dysregulated complement activity has demonstrated good outcomes, although randomized clinical trials are awaited. A sustained pneumococcal vaccination program and vigilance for replacement serotypes will be the key for persistent reduction in Sp-HUS cases worldwide.
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19
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Balkanci UB, Sas DJ, Demirel N. An unusual case of necrotizing pneumonia presenting with acute kidney injury. Pediatr Pulmonol 2021; 56:1257-1258. [PMID: 33316145 DOI: 10.1002/ppul.25177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 11/12/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Ugur B Balkanci
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David J Sas
- Division of Pediatric Nephrology and Hypertetnsion, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nadir Demirel
- Division of Pediatric Pulmonology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
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20
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McFarlane PA, Bitzan M, Broome C, Baran D, Garland J, Girard LP, Grewal K, Lapeyraque AL, Patriquin CJ, Pavenski K, Licht C. Making the Correct Diagnosis in Thrombotic Microangiopathy: A Narrative Review. Can J Kidney Health Dis 2021; 8:20543581211008707. [PMID: 33996107 PMCID: PMC8072824 DOI: 10.1177/20543581211008707] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
Purpose of review: Thrombotic microangiopathy (TMA) is suspected in patients presenting with thrombocytopenia and evidence of a microangiopathic hemolytic anemia. Patients with TMA can be critically ill, so rapid and accurate identification of the underlying etiology is essential. Due to better insights into pathophysiology and causes of TMA, we can now categorize TMAs as thrombotic thrombocytopenic purpura, postinfectious (mainly Shiga toxin-producing Escherichia coli–induced) hemolytic uremic syndrome (HUS), TMA associated with a coexisting condition, or atypical HUS (aHUS). We recognized an unmet need in the medical community to guide the timely and accurate identification of TMA, the selection of tests to clarify its etiology, and the sequence of steps to initiate treatment. Sources of information: Key published studies relevant to the identification, classification, and treatment of TMAs in children or adults. These studies were obtained through literature searches conducted with PubMed or based on the prior knowledge of the authors. Methods: This review is the result of a consultation process that reflects the consensus of experts from Canada, the United States, and the United Arab Emirates. The members represent individuals who are clinicians, researchers, and teachers in pediatric and adult medicine from the fields of hematology, nephrology, and laboratory medicine. Authors, through an iterative review process identified and synthesized information from relevant published studies. Key findings: Thrombotic thrombocytopenic purpura occurs in the setting of insufficient activity of the von Willebrand factor protease known as ADAMTS13. Shiga toxin-producing Escherichia coli–induced hemolytic uremic syndrome, also known as “typical” HUS, is caused by gastrointestinal infections with bacteria that produce Shiga toxin (initially called verocytotoxin). A variety of clinical conditions or drug exposures can trigger TMA. Finally, aHUS occurs in the setting of inherited or acquired abnormalities in the alternative complement pathway leading to dysregulated complement activation, often following a triggering event such as an infection. It is possible to break the process of etiological diagnosis of TMA into 2 distinct steps. The first covers the initial presentation and diagnostic workup, including the processes of identifying the presence of TMA, appropriate initial tests and referrals, and empiric treatments when appropriate. The second step involves confirming the etiological diagnosis and moving to definitive treatment. For many forms of TMA, the ultimate response to therapies and the outcome of the patient depends on the rapid and accurate identification of the presence of TMA and then a standardized approach to seeking the etiological diagnosis. We present a structured approach to identifying the presence of TMA and steps to identifying the etiology including standardized lab panels. We emphasize the importance of early consultation with appropriate specialists in hematology and nephrology, as well as identification of whether the patient requires plasma exchange. Clinicians should consider appropriate empiric therapies while following the steps we have recommended toward definitive etiologic diagnosis and management of the TMA. Limitations: The evidence base for our recommendations consists of small clinical studies, case reports, and case series. They are generally not controlled or randomized and do not lend themselves to a stricter guideline-based methodology or a Grading of Recommendations Assessment, Development and Evaluation (GRADE)-based approach.
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Affiliation(s)
- Philip A McFarlane
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Martin Bitzan
- Division of Nephrology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.,Kidney Centre of Excellence, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Catherine Broome
- Division of Hematology, Lombardi Cancer Center, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Dana Baran
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Hospital Centre, Montreal, QC, Canada
| | - Jocelyn Garland
- Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | | | - Kuljit Grewal
- Division of Hematology, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Anne-Laure Lapeyraque
- Division of Nephrology, Sainte-Justine Hospital Center, Montreal University, Montreal, QC, USA
| | - Christopher Jordan Patriquin
- Division of Medical Oncology & Hematology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
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21
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Gómez Delgado I, Corvillo F, Nozal P, Arjona E, Madrid Á, Melgosa M, Bravo J, Szilágyi Á, Csuka D, Veszeli N, Prohászka Z, Sánchez-Corral P. Complement Genetic Variants and FH Desialylation in S. pneumoniae-Haemolytic Uraemic Syndrome. Front Immunol 2021; 12:641656. [PMID: 33777036 PMCID: PMC7991904 DOI: 10.3389/fimmu.2021.641656] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
Haemolytic Uraemic Syndrome associated with Streptococcus pneumoniae infections (SP-HUS) is a clinically well-known entity that generally affects infants, and could have a worse prognosis than HUS associated to E. coli infections. It has been assumed that complement genetic variants associated with primary atypical HUS cases (aHUS) do not contribute to SP-HUS, which is solely attributed to the action of the pneumococcal neuraminidase on the host cellular surfaces. We previously identified complement pathogenic variants and risk polymorphisms in a few Hungarian SP-HUS patients, and have now extended these studies to a cohort of 13 Spanish SP-HUS patients. Five patients presented rare complement variants of unknown significance, but the frequency of the risk haplotypes in the CFH-CFHR3-CFHR1 region was similar to the observed in aHUS. Moreover, we observed desialylation of Factor H (FH) and the FH-Related proteins in plasma samples from 2 Spanish and 4 Hungarian SP-HUS patients. To analyze the functional relevance of this finding, we compared the ability of native and "in vitro" desialylated FH in: (a) binding to C3b-coated microtiter plates; (b) proteolysis of fluid-phase and surface-bound C3b by Factor I; (c) dissociation of surface bound-C3bBb convertase; (d) haemolytic assays on sheep erythrocytes. We found that desialylated FH had reduced capacity to control complement activation on sheep erythrocytes, suggesting a role for FH sialic acids on binding to cellular surfaces. We conclude that aHUS-risk variants in the CFH-CFHR3-CFHR1 region could also contribute to disease-predisposition to SP-HUS, and that transient desialylation of complement FH by the pneumococcal neuraminidase may have a role in disease pathogenesis.
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Affiliation(s)
- Irene Gómez Delgado
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Fernando Corvillo
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
- Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Pilar Nozal
- Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
- Immunology Unit, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Emilia Arjona
- Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
- Department of Cellular and Molecular Medicine, Margarita Salas Center for Biological Research, Madrid, Spain
| | - Álvaro Madrid
- Pediatric Nephrology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marta Melgosa
- Pediatric Nephrology Unit, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Juan Bravo
- Pediatric Nephrology Unit, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Ágnes Szilágyi
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Dorottya Csuka
- Research Group for Immunology and Haematology, Semmelweis University- Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Nóra Veszeli
- Research Group for Immunology and Haematology, Semmelweis University- Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Zoltán Prohászka
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Pilar Sánchez-Corral
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
- Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
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22
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Markic J, Polic B, Kovacevic T, Rogulj M, Ardalic TC. Pediatric Pneumococcal Hemolytic Uremic Syndrome Treated with Sequence Tandem Therapeutic Plasma Exchange and Continuous Venovenous Hemodiafiltration: A Case Report. JOURNAL OF CHILD SCIENCE 2020. [DOI: 10.1055/s-0040-1721450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractHemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Approximately 5% of HUS cases are associated with Streptococcus pneumoniae infections (pHUS). Treatment includes supportive care with appropriate antimicrobial therapy, fluid and blood product resuscitation, and renal replacement therapy. We presented a case of a 22-month-old previously healthy girl, who was hospitalized at University Hospital of Split. Left-sided pneumonia and sepsis caused by S. pneumoniae were confirmed. The course of illness was complicated with development of pHUS. Since the pathogenesis of pHUS is only partially understood, the treatment remains controversial. Our patient was successfully treated with daily sequence tandem continuous venovenous hemodiafiltration and therapeutic plasma exchange with albumins, along with other supportive measures. Therefore, in our opinion, plasmapheresis should be considered as a part of standard treatment of children with pHUS. Additionally, the incidence of pHUS appears to be increasing. S. pneumoniae is a particularly important among pediatric pathogens and it can cause wide spectrum of illnesses. Therefore, due to the significant burden of invasive pneumococcal disease, pneumococcal vaccination should be encouraged.
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Affiliation(s)
- Josko Markic
- Department of Pediatrics, University Hospital of Split, Split, Croatia
- Department of Pediatrics, University of Split School of Medicine, Split, Croatia
| | - Branka Polic
- Department of Pediatrics, University Hospital of Split, Split, Croatia
- Department of Pediatrics, University of Split School of Medicine, Split, Croatia
| | - Tanja Kovacevic
- Department of Pediatrics, University Hospital of Split, Split, Croatia
| | - Marijana Rogulj
- Department of Pediatrics, University Hospital of Split, Split, Croatia
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23
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Scobell RR, Kaplan BS, Copelovitch L. New insights into the pathogenesis of Streptococcus pneumoniae-associated hemolytic uremic syndrome. Pediatr Nephrol 2020; 35:1585-1591. [PMID: 31515631 DOI: 10.1007/s00467-019-04342-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/19/2019] [Accepted: 08/24/2019] [Indexed: 12/20/2022]
Abstract
The purpose of this review is to describe Streptococcus pneumoniae-associated hemolytic uremic syndrome (P-HUS) with emphasis on new insights into the pathophysiology and management over the past 10 years. Even though awareness of this clinico-pathological entity has increased, it likely remains under-recognized. Recent observations indicate that although neuraminidase activity and exposure of the T-antigen are necessary for development of P-HUS, they are not sufficient; activation of the alternate pathway of complement may also contribute. It is unclear, however, whether or not eculizumab and/or plasmapheresis are of value.
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Affiliation(s)
- Rebecca R Scobell
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Bernard S Kaplan
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Lawrence Copelovitch
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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24
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Rose MA, Barker M, Liese J, Adams O, Ankermann T, Baumann U, Brinkmann F, Bruns R, Dahlheim M, Ewig S, Forster J, Hofmann G, Kemen C, Lück C, Nadal D, Nüßlein T, Regamey N, Riedler J, Schmidt S, Schwerk N, Seidenberg J, Tenenbaum T, Trapp S, van der Linden M. [Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]. Pneumologie 2020; 74:515-544. [PMID: 32823360 DOI: 10.1055/a-1139-5132] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.
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Affiliation(s)
- M A Rose
- Fachbereich Medizin, Johann-Wolfgang-Goethe-Universität Frankfurt/Main und Zentrum für Kinder- und Jugendmedizin, Klinikum St. Georg Leipzig
| | - M Barker
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Emil von Behring, Berlin
| | - J Liese
- Kinderklinik und Poliklinik, Universitätsklinikum an der Julius-Maximilians-Universität Würzburg, Würzburg
| | - O Adams
- Institut für Virologie, Universitätsklinikum Düsseldorf
| | - T Ankermann
- Klinik für Kinder- und Jugendmedizin 1, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - U Baumann
- Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover
| | - F Brinkmann
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Ruhr-Universität Bochum
| | - R Bruns
- Zentrum für Kinder- und Jugendmedizin, Ernst-Moritz-Arndt-Universität Greifswald
| | - M Dahlheim
- Praxis für Kinderpneumologie und Allergologie, Mannheim
| | - S Ewig
- Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Bochum/Herne
| | - J Forster
- Kinderabteilung St. Hedwig, St. Josefskrankenhaus , Freiburg und Merzhausen
| | | | - C Kemen
- Katholisches Kinderkrankenhaus Wilhelmstift, Hamburg
| | - C Lück
- Institut für Medizinische Mikrobiologie und Hygiene, Technische Universität Dresden
| | - D Nadal
- Kinderspital Zürich, Schweiz
| | - T Nüßlein
- Klinik für Kinder- und Jugendmedizin, Gemeinschaftsklinikum Mittelrhein, Koblenz
| | - N Regamey
- Pädiatrische Pneumologie, Kinderspital Luzern, Schweiz
| | - J Riedler
- Kinder- und Jugendmedizin, Kardinal Schwarzenberg'sches Krankenhaus, Schwarzach, Österreich
| | - S Schmidt
- Zentrum für Kinder- und Jugendmedizin, Ernst-Moritz-Arndt-Universität Greifswald
| | - N Schwerk
- Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover
| | - J Seidenberg
- Klinik für pädiatrische Pneumologie und Allergologie, Neonatologie, Intensivmedizin und Kinderkardiologie, Klinikum Oldenburg
| | - T Tenenbaum
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Mannheim
| | | | - M van der Linden
- Institut für Medizinische Mikrobiologie, Universitätsklinikum Aachen
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25
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Manrique-Caballero CL, Peerapornratana S, Formeck C, Del Rio-Pertuz G, Gomez Danies H, Kellum JA. Typical and Atypical Hemolytic Uremic Syndrome in the Critically Ill. Crit Care Clin 2020; 36:333-356. [PMID: 32172817 DOI: 10.1016/j.ccc.2019.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hemolytic uremic syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome have a similar clinical presentation. Diagnostic needs to be prompt to decrease mortality, because identifying the different disorders can help to tailor specific, effective therapies. However, diagnosis is challenging and morbidity and mortality remain high, especially in the critically ill population. Development of clinical prediction scores and rapid diagnostic tests for hemolytic uremic syndrome based on mechanistic knowledge are needed to facilitate early diagnosis and assign timely specific treatments to patients with hemolytic uremic syndrome variants.
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Affiliation(s)
- Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand; Department of Laboratory Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand
| | - Cassandra Formeck
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 3, Pittsburgh, PA 15224, USA
| | - Gaspar Del Rio-Pertuz
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Hernando Gomez Danies
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA.
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26
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Joseph A, Cointe A, Mariani Kurkdjian P, Rafat C, Hertig A. Shiga Toxin-Associated Hemolytic Uremic Syndrome: A Narrative Review. Toxins (Basel) 2020; 12:E67. [PMID: 31973203 PMCID: PMC7076748 DOI: 10.3390/toxins12020067] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 01/28/2023] Open
Abstract
The severity of human infection by one of the many Shiga toxin-producing Escherichia coli (STEC) is determined by a number of factors: the bacterial genome, the capacity of human societies to prevent foodborne epidemics, the medical condition of infected patients (in particular their hydration status, often compromised by severe diarrhea), and by our capacity to devise new therapeutic approaches, most specifically to combat the bacterial virulence factors, as opposed to our current strategies that essentially aim to palliate organ deficiencies. The last major outbreak in 2011 in Germany, which killed more than 50 people in Europe, was evidence that an effective treatment was still lacking. Herein, we review the current knowledge of STEC virulence, how societies organize the prevention of human disease, and how physicians treat (and, hopefully, will treat) its potentially fatal complications. In particular, we focus on STEC-induced hemolytic and uremic syndrome (HUS), where the intrusion of toxins inside endothelial cells results in massive cell death, activation of the coagulation within capillaries, and eventually organ failure.
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Affiliation(s)
- Adrien Joseph
- Department of Nephrology, AP-HP, Hôpital Tenon, F-75020 Paris, France; (A.J.); (C.R.)
| | - Aurélie Cointe
- Department of Microbiology, AP-HP, Hôpital Robert Debré, F-75019 Paris, France; (A.C.); (P.M.K.)
| | | | - Cédric Rafat
- Department of Nephrology, AP-HP, Hôpital Tenon, F-75020 Paris, France; (A.J.); (C.R.)
| | - Alexandre Hertig
- Department of Renal Transplantation, Sorbonne Université, AP-HP, Hôpital Pitié Salpêtrière, F-75013 Paris, France
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27
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Guerra OJL, Rodríguez RSG, Camacho WJM, Ortiz JEP, Camacho MAM. HEMOLYTIC UREMIC SYNDROME ASSOCIATED WITH STREPTOCOCCUS PNEUMONIAE IN PEDIATRICS: A CASE SERIES. ACTA ACUST UNITED AC 2019; 38:e2018065. [PMID: 31778402 PMCID: PMC6909244 DOI: 10.1590/1984-0462/2020/38/2018065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/08/2018] [Indexed: 12/20/2022]
Abstract
Objective: To describe a case series of four (4) patients with hemolytic uremic syndrome due to Streptococcus pneumoniae in a level four complexity institution in the city of Bogotá, D.C., Colombia. Cases description: We describe cases of four patients who presented respiratory symptoms and fever. All four patients were in regular conditions on hospital admission, after which they required intensive care and ventilatory support. Upon admission, three cases showed evidence of pleuropulmonary complication. Penicillin-sensitive Streptococcus pneumoniae was isolated in all cases. All patients presented anemia, severe thrombocytopenia, schistocytes on peripheral blood smear, and hyperazotemia. They required blood transfusion and renal replacement therapy during their hospitalization. The patients were diagnosed with hemolytic uremic syndrome due to S. pneumoniae. Three of the four patients had a progressive recovery of the renal function and were discharged after an average of 36 days of hospital stay. The remaining patient had two amputations in the extremities due to thrombotic vascular complications and was discharged after 99 days of hospital stay, requiring hemodialysis every other day. Comments: Hemolytic uremic syndrome due to Streptococcus pneumoniae is a rare but severe complication of invasive pneumococcal disease. Complicated pneumonia is the main condition associated with this entity. It is noteworthy the short period in which these cases were presented, considering the low annual incidence of the disease.
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 766] [Impact Index Per Article: 153.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Pneumococcal-related Hemolytic Uremic Syndrome in the United Kingdom: National Surveillance, 2006-2016. Pediatr Infect Dis J 2019; 38:e254-e259. [PMID: 31232894 DOI: 10.1097/inf.0000000000002368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND children <5 years of age since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in 2006 and its replacement with the 13-valent pneumococcal conjugate vaccine (PCV13) in 2010 in the United Kingdom. METHODS Public Health England conducts enhanced national surveillance of invasive pneumococcal disease in England. Confirmed invasive pneumococcal disease cases diagnosed between September 1, 2006, and March 31, 2016, with hemolytic uremic syndrome reported as a complication were included in the analysis. RESULTS There were 54 cases of pHUS during the surveillance period, with a median age of 17 months. The incidence of pHUS was 0.25/100,000 during the PCV7 period and 0.08/100,000 during the PCV13 period (incidence rate ratio: 0.31; 95% confidence interval: 0.16-0.57; P < 0.0001). Twelve children (22%) had an underlying comorbidity before disease onset. Overall, 31 (57%) presented with lower respiratory tract infection, 14 (25%) with meningitis, 8 (15%) with bacteremia and 1 (2%) with septic arthritis. An empyema was reported in 26/31 children (84%) with lower respiratory tract infection and cerebral abscess in 5/14 children (36%) with meningitis. The main responsible serotypes were 19A (n = 20), 3 (n = 6), 7F (n = 5) and 33F (n = 4). Eight children (15%) died, including 6 with meningitis. CONCLUSIONS pHUS continues to be associated with significant morbidity and mortality. The incidence of pHUS was significantly lower after PCV13 replaced PCV7 in the childhood immunization program. Currently, most cases are due to non-PCV13 serotypes.
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Abstract
The thrombotic microangiopathies (TMAs) are a group of diseases characterised by microangiopathic haemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. Traditionally, TMAs have been classified as either thrombotic thrombocytopenic purpura (TTP) or haemolytic uremic syndrome (HUS) based on the clinical presentation, with neurological involvement predominating in the former and acute kidney injury in the latter. However, as our understanding of the pathogenesis of these conditions has increased, it has become clear that this is an over-simplification; there is significant overlap in the clinical presentation of TTP and HUS, there are different forms of HUS, and TMAs can occur in other, diverse clinical scenarios. This review will discuss recent developments in the diagnosis of HUS, focusing on the different forms of HUS and how to diagnose and manage these potentially life-threatening diseases.
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Affiliation(s)
- Neil S Sheerin
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Emily Glover
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
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31
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Kumar G, Bitzan M. Practical diagnostic approach and management of children presenting with hemolytic uremic syndrome. Nephrol Dial Transplant 2019; 35:2054-2058. [PMID: 33275761 DOI: 10.1093/ndt/gfz138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gurinder Kumar
- Division of Pediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Martin Bitzan
- Kidney Centre of Excellence, Al Jalila Children's Hospital, Al Jadaf, Dubai, United Arab Emirates
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32
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Bagga A, Khandelwal P, Mishra K, Thergaonkar R, Vasudevan A, Sharma J, Patnaik SK, Sinha A, Sethi S, Hari P, Dragon-Durey MA. Hemolytic uremic syndrome in a developing country: Consensus guidelines. Pediatr Nephrol 2019; 34:1465-1482. [PMID: 30989342 DOI: 10.1007/s00467-019-04233-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/06/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is a leading cause of acute kidney injury in children. Although international guidelines emphasize comprehensive evaluation and treatment with eculizumab, access to diagnostic and therapeutic facilities is limited in most developing countries. The burden of Shiga toxin-associated HUS in India is unclear; school-going children show high prevalence of anti-factor H (FH) antibodies. The aim of the consensus meeting was to formulate guidelines for the diagnosis and management of HUS in children, specific to the needs of the country. METHODS Four workgroups performed literature review and graded research studies addressing (i) investigations, biopsy, genetics, and differential diagnosis; (ii) Shiga toxin, pneumococcal, and infection-associated HUS; (iii) atypical HUS; and (iv) complement blockade. Consensus statements developed by the workgroups were discussed during a consensus meeting in March 2017. RESULTS An algorithm for classification and evaluation was developed. The management of Shiga toxin-associated HUS is supportive; prompt plasma exchanges (PEX) is the chief therapy in patients with atypical HUS. Experts recommend that patients with anti-FH-associated HUS be managed with a combination of PEX and immunosuppressive medications. Indications for eculizumab include incomplete remission with plasma therapy, life-threatening features, complications of PEX or vascular access, inherited defects in complement regulation, and recurrence of HUS in allografts. Priorities for capacity building in regional and national laboratories are highlighted. CONCLUSIONS Limited diagnostic capabilities and lack of access to eculizumab prevent the implementation of international guidelines for HUS in most developing countries. We propose practice guidelines for India, which will perhaps be applicable to other developing countries.
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Affiliation(s)
- Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Ranjeet Thergaonkar
- Department of Pediatrics, Indian Naval Hospital Ship, Kalyani, Visakhapatnam, India
| | - Anil Vasudevan
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | - Saroj Kumar Patnaik
- Department of Pediatrics, Army Hospital Research & Referral, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sidharth Sethi
- Department of Nephrology, Medanta Hospital, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Marie-Agnes Dragon-Durey
- Laboratory of Immunology, Hopital Europeen Georges Pompidou, INSERM UMRS 1138, Paris Descartes University, Paris, France
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Iba T, Watanabe E, Umemura Y, Wada T, Hayashida K, Kushimoto S, Wada H. Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. J Intensive Care 2019; 7:32. [PMID: 31139417 PMCID: PMC6528221 DOI: 10.1186/s40560-019-0387-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a common complication in sepsis. Since DIC not only promotes organ dysfunction but also is a strong prognostic factor, its diagnosis at the earliest possible timing is important. Thrombocytopenia is often present in patients with DIC but can also occur in a number of other critical conditions. Of note, many of the rare thrombocytopenic diseases require prompt diagnoses and specific treatments. To differentiate these diseases correctly, the phenotypic expressions must be considered and the different disease pathophysiologies must be understood. There are three major players in the background characteristics of thrombocytopenia: platelets, the coagulation system, and vascular endothelial cells. For example, the activation of coagulation is at the core of the pathogenesis of sepsis-associated DIC, while platelet aggregation is the essential mechanism in thrombotic thrombocytopenic purpura and endothelial damage is the hallmark of hemolytic uremic syndrome. Though each of the three players is important in all thrombocytopenic diseases, one of the three dominant players typically establishes the individual features of each disease. In this review, we introduce the pathogeneses, symptoms, diagnostic measures, and recent therapeutic advances for the major diseases that should be immediately differentiated from DIC in sepsis.
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Affiliation(s)
- Toshiaki Iba
- 1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Eizo Watanabe
- 2Department of General Medical Science Graduate School of Medicine Chiba University, Chiba, Japan.,Department of Emergency and Critical Care Medicine Eastern Chiba Medical Center, Chiba, Japan
| | - Yutaka Umemura
- 4Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeshi Wada
- 5Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kei Hayashida
- 6Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Shigeki Kushimoto
- 7Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Hideo Wada
- 8Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan
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Meinel C, Spartà G, Dahse HM, Hörhold F, König R, Westermann M, Coldewey SM, Cseresnyés Z, Figge MT, Hammerschmidt S, Skerka C, Zipfel PF. Streptococcus pneumoniae From Patients With Hemolytic Uremic Syndrome Binds Human Plasminogen via the Surface Protein PspC and Uses Plasmin to Damage Human Endothelial Cells. J Infect Dis 2019; 217:358-370. [PMID: 28968817 DOI: 10.1093/infdis/jix305] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Pneumococcal hemolytic uremic syndrome (HUS) in children is caused by infections with Streptococcus pneumoniae. Because endothelial cell damage is a hallmark of HUS, we studied how HUS-inducing pneumococci derived from infant HUS patients during the acute phase disrupt the endothelial layer. HUS pneumococci efficiently bound human plasminogen. These clinical isolates of HUS pneumococci efficiently bound human plasminogen via the bacterial surface proteins Tuf and PspC. When activated to plasmin at the bacterial surface, the active protease degraded fibrinogen and cleaved C3b. Here, we show that PspC is a pneumococcal plasminogen receptor and that plasmin generated on the surface of HUS pneumococci damages endothelial cells, causing endothelial retraction and exposure of the underlying matrix. Thus, HUS pneumococci damage endothelial cells in the blood vessels and disturb local complement homeostasis. Thereby, HUS pneumococci promote a thrombogenic state that drives HUS pathology.
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Affiliation(s)
- Christian Meinel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany
| | - Giuseppina Spartà
- Klinik für Kinder- und Jugendmedizin, Kantonsspital Winterthur, Switzerland
| | - Hans-Martin Dahse
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany
| | - Franziska Hörhold
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany.,Associated Group of Network Modeling, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute.,Center for Sepsis Control and Care
| | - Rainer König
- Associated Group of Network Modeling, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute.,Center for Sepsis Control and Care
| | | | - Sina M Coldewey
- Center for Sepsis Control and Care.,Department of Anesthesiology and Intensive Care Medicine.,Septomics Research Center.,Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena
| | - Zoltán Cseresnyés
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena.,Friedrich Schiller University, Jena, Germany
| | - Marc Thilo Figge
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena.,Friedrich Schiller University, Jena, Germany
| | - Sven Hammerschmidt
- Department Genetics of Microorganisms, Interfaculty Institute for Genetics and Functional Genomics, Ernst Moritz Arndt University, Greifswald
| | - Christine Skerka
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany
| | - Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany.,Center for Sepsis Control and Care.,Friedrich Schiller University, Jena, Germany
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36
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Key L, Hijano DR, Arnold SR. A Toddler With Fever, Melena, and Renal Failure. Clin Pediatr (Phila) 2019; 58:367-370. [PMID: 30501507 DOI: 10.1177/0009922818816505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Logan Key
- University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - Sandra R Arnold
- University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
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37
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Abstract
Hemolytic uremic syndrome (HUS) is the clinical triad of thrombocytopenia, anemia, and acute kidney injury. Classically associated with enterocolitis from Shiga toxin-producing Escherichia coli, HUS is also associated with Streptococcus pneumoniae infections; genetic dysregulation of the alternative complement pathway or coagulation cascade; and, rarely, a hereditary disorder of cobalamin C metabolism. These share a common final pathway of a prothrombotic and proinflammatory state on the endothelial cell surface, with fibrin and platelet deposition. Much work has been done to distinguish between the different mechanisms of disease, thereby informing the optimal therapeutic interventions for each entity.
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Affiliation(s)
- Ellen M Cody
- Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 158, Aurora, CO 80045, USA
| | - Bradley P Dixon
- Departments of Pediatrics & Medicine, University of Colorado School of Medicine, 12631 E. 17th Avenue, Aurora, CO 80045, USA.
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38
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Ishiguro T, Kojima A, Shimizu T, Mita N, Kuroiwa S, Takayanagi N. Combined hemophagocytic syndrome and thrombotic microangiopathy due to mixed infection with influenza virus and pneumococcal pneumonia. Clin Case Rep 2019; 7:131-134. [PMID: 30656026 PMCID: PMC6333073 DOI: 10.1002/ccr3.1842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/22/2018] [Accepted: 09/11/2018] [Indexed: 11/06/2022] Open
Abstract
Development of hemophagocytic syndrome and thrombotic microangiopathy due to community-acquired pneumonia is rare, but delayed management of these complications can lead to a poor prognosis. Infection by both Streptococcus pneumoniae and influenza virus can cause these complications; thus, physicians should pay attention to them when treating influenza-associated pneumococcal pneumonia.
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Affiliation(s)
- Takashi Ishiguro
- Department of Respiratory MedicineSaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Ayako Kojima
- Department of Respiratory MedicineSaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Taisuke Shimizu
- Department of NephrologySaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Norikatsu Mita
- Department of AnesthesiologySaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Seiichiro Kuroiwa
- Department of Clinical EngineeringSaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Noboru Takayanagi
- Department of Respiratory MedicineSaitama Cardiovascular and Respiratory CenterSaitamaJapan
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39
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Smirnova TV, Sheludchenko VM, Kozlovskaya NL, Kazaryan EE, Andzhelova DV, Sherstneva LV, Velieva IA, Kuchieva AM, Akaeva MI. [Ocular thrombotic microangiopathy in atypical hemolytic-uremic syndrome (a clinical case study)]. Vestn Oftalmol 2018; 134:215-226. [PMID: 30499520 DOI: 10.17116/oftalma2018134051215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The article presents a clinical observation of ocular thrombotic microangiopathy in atypical hemolytic-uremic syndrome - a rare genetic disease characterized by systemic thrombosis caused by uncontrolled activation of alternative complement pathway. A typical manifestation of this ocular lesion in this disease is bilateral Purtscher-like retinopathy. Timely diagnostics of atypical hemolytic-uremic syndrome, including ophthalmologic examination, determines the early start of a highly effective pathogenetic therapy with complement inhibitor eculizumab.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - V M Sheludchenko
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - N L Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - E E Kazaryan
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - D V Andzhelova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - L V Sherstneva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - I A Velieva
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - A M Kuchieva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - M I Akaeva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
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40
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Hemolytic-uremic syndrome after Escherichia coli urinary tract infection in humans: systematic review of the literature. J Nephrol 2018; 31:919-924. [PMID: 30328581 DOI: 10.1007/s40620-018-0543-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/29/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intestinal infections caused by a shigatoxin-positive Escherichia coli (mostly of the serogroups O26, O45, O103, O111, O121, O145 and especially O157) are a common cause of hemolytic-uremic syndrome. Hemolytic-uremic syndrome was first linked with an E. coli urinary tract infection 40 years ago. METHODS We conducted a systematic review of the literature addressing the association between E. coli urinary tract infection and hemolytic-uremic syndrome. RESULTS For the final analysis, we retained 23 original reports published since 1979. Five unselected pediatric case series addressed the possible occurrence of hemolytic-uremic syndrome after an acute symptomatic E. coli urinary tract infection among 266 cases and found the mentioned association in 8 (3.0%) cases. We also found 28 individual cases (17 females and 11 males) of hemolytic-uremic syndrome preceded by an E. coli urinary tract infection: 16 children aged from 2 days to 6.0 years and 12 adults aged from 22 to 75 years. Testing for shigatoxin, performed in 19 cases, was positive in 15 cases. E. coli serotyping was performed in 18 cases: testing for serotype O157, O103 and O145 was positive in one, one and two cases, respectively, while testing for serotype O26, O45, O111 and O121 was always negative. CONCLUSIONS Hemolytic-uremic syndrome rarely occurs after an acute E. coli urinary tract infection. It affects both children and adults and is mostly caused by germs that are shigatoxin-positive.
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Lawrence J, Gwee A, Quinlan C. Pneumococcal haemolytic uraemic syndrome in the postvaccine era. Arch Dis Child 2018; 103:957-961. [PMID: 29674516 DOI: 10.1136/archdischild-2017-313923] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/06/2018] [Accepted: 03/30/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Pneumococcal infection is a leading cause of haemolytic uraemic syndrome (HUS) and is potentially vaccine preventable. Published data suggest high mortality and poor renal outcomes. The introduction of the 7-valent pneumococcal conjugate vaccine (PCV) has seen the emergence of disease caused by non-vaccine strains, particularly 19A. We sought to describe serotype prevalence and outcomes, particularly after the introduction of the 13-valent PCV. DESIGN AND SETTING We performed a retrospective chart review, using hospital medical records to identify cases of HUS in a tertiary paediatric hospital in Australia over a 20-year period (January 1997-December 2016). Associated pneumococcal infection was identified, and serotype data were categorised according to vaccine era: prevaccine (January 1997-December 2004), PCV7 (January 2005-June 2011) and PCV13 (July 2011-December 2016). RESULTS We identified 66 cases of HUS. Pneumococcal infection was proven in 11 cases, representing 4% (1/26) of cases prior to the introduction of PCV7, 20% (3/15) in the PCV7 era and 28% (7/25) in the PCV13 era. Subtype 19A was the most prevalent pneumococcal serotype (6/11). All four patients who received PCV7 were infected with a non-vaccine serotype. Four of the five patients who received PCV13 were classed as vaccine failures. Median follow-up was 14 (range 1-108) months. Chronic kidney disease was the most common complication (4/7). We observed no mortality, neurological sequelae or progression to end-stage kidney disease. CONCLUSIONS Serotype 19A is most commonly associated with pneumococcal HUS, despite the introduction of the 13-valent vaccine. Chronic kidney disease is a significant complication of pneumococcal HUS.
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Affiliation(s)
- Jolie Lawrence
- Department of Nephrology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Amanda Gwee
- Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Kidney Development, Disease and Regeneration, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Catherine Quinlan
- Department of Nephrology, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Kidney Development, Disease and Regeneration, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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42
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Plautz WE, Raval JS, Dyer MR, Rollins-Raval MA, Zuckerbraun BS, Neal MD. ADAMTS13: origins, applications, and prospects. Transfusion 2018; 58:2453-2462. [PMID: 30208220 DOI: 10.1111/trf.14804] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
ADAMTS13 is an enzyme that acts by cleaving prothrombotic von Willebrand factor (VWF) multimers from the vasculature in a highly regulated manner. In pathologic states such as thrombotic thrombocytopenic purpura (TTP) and other thrombotic microangiopathies (TMAs), VWF can bind to the endothelium and form large multimers. As the anchored VWF chains grow, they provide a greater surface area to bind circulating platelets (PLTs), generating unique thrombi that characterize TTP. This results in microvasculature thrombosis, obstruction of blood flow, and ultimately end-organ damage. Initial presentations of TTP usually occur in an acute manner, typically developing due to an autoimmune response toward, or less commonly a congenital deficiency of, ADAMTS13. Triggers for TMAs that can be associated with ADAMTS13 deficiency, including TTP, have been linked to events that place a burden on hemostatic regulation, such as major trauma and pregnancy. The treatment plan for cases of suspected TTP consists of emergent therapeutic plasma exchange that is continued on a daily basis until normalization of PLT counts. However, a subset of these patients does not respond favorably to standard therapies. These patients necessitate a better understanding of their diseases for the advancement of future therapeutic options. Given ADAMTS13's key role in the cleavage of VWF and the prevention of PLT-rich thrombi within the microvasculature, future treatments may include anti-VWF therapeutics, recombinant ADAMTS13 infusions, and ADAMTS13 expression via gene therapy.
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Affiliation(s)
- William E Plautz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jay S Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Mitchell R Dyer
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marian A Rollins-Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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43
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Complement depletion and Coombs positivity in pneumococcal hemolytic uremic syndrome (pnHUS). Case series and plea to revisit an old pathogenetic concept. Int J Med Microbiol 2018; 308:1096-1104. [PMID: 30177469 DOI: 10.1016/j.ijmm.2018.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 12/27/2022] Open
Abstract
Hemolytic uremic syndrome is a rare complication of invasive pneumococcal infection (pnHUS). Its pathogenesis is poorly understood, and treatment remains controversial. The emerging role of complement in various forms of HUS warrants a new look at this "old" disease. We performed a retrospective analysis of clinical and laboratory features of three sequential cases of pnHUS since 2008 associated with pneumonia/pleural empyema, two due to Streptococcus pneumoniae serotype 19 A. Profound depletion of complement C3 (and less of C4) was observed in two patients. One patient was Coombs test positive. Her red blood cells (RBCs) strongly agglutinated with blood group compatible donor serum at 0 °C, but not at 37 °C. All three patients were treated with hemodialysis, concentrated RBCs, and platelets. Patient 2 received frozen plasma for hepatic failure with coagulation factor depletion. Intravenous immunoglobulin infusion, intended to neutralize pneumococcal neuraminidase in patient 3, was associated with rapid normalization of platelets and cessation of hemolysis. Two patients recovered without sequelae or disease recurrence. Patient 2 died within 2½ days of admission due to complicating Pseudomonas aeruginosa sepsis and multiorgan failure. Our observations suggest that pnHUS can be associated with dramatic, transient complement consumption early in the course of the disease, probably via the alternative pathway. A critical review of the literature and the reported cases argue against the postulated pathological role of preformed antibodies against the neuraminidase-exposed Thomsen-Friedenreich neoantigen (T antigen) in pnHUS. The improved understanding of complement regulation and bacterial strategies of complement evasion allows to propose a testable, new pathogenetic model of pnHUS. This model shifts emphasis from the action of natural anti-T antibodies toward impaired Complement Factor H (CFH) binding and function on desialylated membranes. Removal of neuraminic acid residues converts (protected) self to non-self surfaces that supports membrane attack complex (MAC) assembly. Complement activation is potentially exacerbated by decreased CFH availability following tight CFH binding to pneumococcal evasion proteins and/or by the presence of genetic variants of complement regulator proteins. Detailed clinical and experimental investigations are warranted to better understand the role of unregulated complement activation in pnHUS. Instead of avoidance of plasma, a new, integrated model is evolving, which may include short-term therapeutic complement blockade, particularly where genetic or functional APC dysregulation is suspected, in addition to bacterial elimination and, potentially, neuraminidase neutralization.
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44
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Janapatla RP, Chen CL, Hsu MH, Liao WT, Chiu CH. Immunization with pneumococcal neuraminidases NanA, NanB and NanC to generate neutralizing antibodies and to increase survival in mice. J Med Microbiol 2018; 67:709-723. [PMID: 29557769 DOI: 10.1099/jmm.0.000724] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose. Pneumococcal virulence protein-based vaccines can provide serotype-independent protection against pneumococcal infections. Many studies, including clinical observational studies on Thomsen-Friedenrich antigen exposure and haemolytic uremic syndrome, defined the role of neuraminidases NanA, NanB and NanC in host-pneumococcus interaction. Since neuraminidases are major virulence proteins, they are potential targets for both vaccines and small molecule inhibitors. Here we explored the utility of three neuraminidases as protein vaccine antigens to generate neutralizing antibodies and to increase survival following pneumococcal infections.Methodology. Rabbits and mice were immunized subcutaneously with enzymatically active recombinant NanA, NanB and NanC as individual or a combination of the three neuraminidases. Antisera titres were determined by ELISA. Neuraminidase activity inhibition by antiserum was tested by peanut lectin and flow cytometry. Clinical isolates with serotype 3, 6B, 14, 15B, 19A and 23F were used to infect immunized mice by tail vein injection.Results/Key findings. Presence of high levels of IgG antibodies in antisera against NanA, NanB and NanC indicates that all of the three neuraminidases are immunogenic vaccine antigens. To generate potent NanA neutralizing antibodies, both lectin and catalytic domains are essential, whereas for NanB and NanC a single lectin domain is sufficient. Immunization with triple neuraminidases increased the survival of mice when intravenously challenged with clinical isolates of serotype 3 (40 %), 6B (60 %), 15B (60 %), 19A (40 %) and 23F (30 %).Conclusion. We recommend the inclusion of three pneumococcal neuraminidases in future protein vaccine formulations to prevent invasive pneumococcal infection caused by various serotypes.
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Affiliation(s)
| | - Chyi-Liang Chen
- Molecular Infectious Diseases Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Mei-Hua Hsu
- Molecular Infectious Diseases Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Wan-Ting Liao
- Molecular Infectious Diseases Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Cheng-Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC.,Molecular Infectious Diseases Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
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45
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Abrams CM, Hijano DR, Bagga B. Abdominal Pain in the Setting of Atypical Hemolytic Uremic Syndrome Caused by Streptococcus pneumoniae Pneumonia. Glob Pediatr Health 2018; 5:2333794X18762866. [PMID: 29552602 PMCID: PMC5846901 DOI: 10.1177/2333794x18762866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 01/31/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Christina M Abrams
- University of Tennessee Health Sciences Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - Bindiya Bagga
- University of Tennessee Health Sciences Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
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46
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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47
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Bitzan M, Zieg J. Influenza-associated thrombotic microangiopathies. Pediatr Nephrol 2018; 33:2009-2025. [PMID: 28884355 PMCID: PMC6153504 DOI: 10.1007/s00467-017-3783-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/11/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022]
Abstract
Thrombotic microangiopathy (TMA) refers to phenotypically similar disorders, including hemolytic uremic syndromes (HUS) and thrombotic thrombocytopenic purpura (TTP). This review explores the role of the influenza virus as trigger of HUS or TTP. We conducted a literature survey in PubMed and Google Scholar using HUS, TTP, TMA, and influenza as keywords, and extracted and analyzed reported epidemiological and clinical data. We identified 25 cases of influenza-associated TMA. Five additional cases were linked to influenza vaccination and analyzed separately. Influenza A was found in 83%, 10 out of 25 during the 2009 A(H1N1) pandemic. Two patients had bona fide TTP with ADAMTS13 activity <10%. Median age was 15 years (range 0.5-68 years), two thirds were male. Oligoanuria was documented in 81% and neurological involvement in 40% of patients. Serum C3 was reduced in 5 out of 14 patients (36%); Coombs test was negative in 7 out of 7 and elevated fibrin/fibrinogen degradation products were documented in 6 out of 8 patients. Pathogenic complement gene mutations were found in 7 out of 8 patients tested (C3, MCP, or MCP combined with CFB or clusterin). Twenty out of 24 patients recovered completely, but 3 died (12%). Ten of the surviving patients underwent plasma exchange (PLEX) therapy, 5 plasma infusions. Influenza-mediated HUS or TTP is rare. A sizable proportion of tested patients demonstrated mutations associated with alternative pathway of complement dysregulation that was uncovered by this infection. Further research is warranted targeting the roles of viral neuraminidase, enhanced virus-induced complement activation and/or ADAMTS13 antibodies, and rational treatment approaches.
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Affiliation(s)
- Martin Bitzan
- Division of Nephrology, The Montreal Children's Hospital, McGill University Health Centre, 1001, boul. Décarie-Room B RC.6651, Montréal, QC, H4A 3J1, Canada.
| | - Jakub Zieg
- 0000 0004 1937 116Xgrid.4491.8Department of Pediatric Nephrology, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
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48
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Winters JL. Plasma exchange in thrombotic microangiopathies (TMAs) other than thrombotic thrombocytopenic purpura (TTP). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:632-638. [PMID: 29222314 PMCID: PMC6142547 DOI: 10.1182/asheducation-2017.1.632] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Thrombotic microangiopathies (TMAs) are a diverse group of disorders that are characterized by common clinical and laboratory features. The most commonly thought-of TMA is thrombotic thrombocytopenic purpura (TTP). Because of the marked improvement in patient mortality associated with the use of therapeutic plasma exchange (TPE) in TTP, this therapy has been applied to all of the TMAs. The issue, however, is that the pathophysiology varies and in many instances may represent a disorder of the endothelium and not the blood; in some cases, the pathophysiology is unknown. The use of TPE is further obscured by a lack of strong supporting literature on its use, with most consisting of case series and case reports; controlled or randomized controlled trials are lacking. Evidence supporting the use of TPE in the treatment of TMAs (other than TTP and TMA-complement mediated) is lacking, and therefore its role is uncertain. With the greater availability of genetic testing for mutations involving complement regulatory genes and complement pathway components, there seems to be a percentage of TMA cases, other than TMA-complement mediated, in which complement pathway mutations are involved in some patients. The ability of TPE to remove abnormal complement pathway components and replace them with normal components may support its use in some patients with TMAs other than TTP and TMA-complement mediated.
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Affiliation(s)
- Jeffrey L Winters
- Therapeutic Apheresis Treatment Unit, Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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49
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Rafat C, Coppo P, Fakhouri F, Frémeaux-Bacchi V, Loirat C, Zuber J, Rondeau E. Syndromes hémolytiques et urémiques (SHU) et syndromes de microangiopathie thrombotique apparentés : traitement et pronostic. Rev Med Interne 2017; 38:833-839. [DOI: 10.1016/j.revmed.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/26/2017] [Accepted: 07/24/2017] [Indexed: 10/18/2022]
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50
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Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C. Haemolytic uraemic syndrome. Lancet 2017; 390:681-696. [PMID: 28242109 DOI: 10.1016/s0140-6736(17)30062-4] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
Haemolytic uraemic syndrome is a form of thrombotic microangiopathy affecting predominantly the kidney and characterised by a triad of thrombocytopenia, mechanical haemolytic anaemia, and acute kidney injury. The term encompasses several disorders: shiga toxin-induced and pneumococcus-induced haemolytic uraemic syndrome, haemolytic uraemic syndrome associated with complement dysregulation or mutation of diacylglycerol kinase ɛ, haemolytic uraemic syndrome related to cobalamin C defect, and haemolytic uraemic syndrome secondary to a heterogeneous group of causes (infections, drugs, cancer, and systemic diseases). In the past two decades, experimental, genetic, and clinical studies have helped to decipher the pathophysiology of these various forms of haemolytic uraemic syndrome and undoubtedly improved diagnostic approaches. Moreover, a specific mechanism-based treatment has been made available for patients affected by atypical haemolytic uraemic syndrome due to complement dysregulation. Such treatment is, however, still absent for several other disease types, including shiga toxin-induced haemolytic uraemic syndrome.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, and INSERM UMR S1064, Nantes, France
| | - Julien Zuber
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology and Renal Transplantation, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, and INSERM UMR S1138, Complément et Maladies, Centre de Recherche des Cordeliers, Paris, France
| | - Chantal Loirat
- Assistance Publique-Hôpitaux de Paris, Department of Pediatric Nephrology, Hôpital Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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