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Altaf F, Khanzada M, Qasim A, Anto AM, Haider A, Khaja M. Successful Management of Atypical Hemolytic-Uremic Syndrome in Pregnancy Using Eculizumab: A Case Review. Cureus 2024; 16:e57973. [PMID: 38738120 PMCID: PMC11086038 DOI: 10.7759/cureus.57973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Hemolytic-uremic syndrome (HUS) is a rare thrombotic microangiopathy characterized by the triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and acute kidney injury. The disease is pathologically marked by fibrinoid necrosis within renal arterioles and glomerular capillaries. HUS can be categorized into typical variants, often linked to Shiga toxin-producing Escherichia coli (STEC) infection, and atypical variants that stem from dysregulation in the alternative complement pathway. Pregnancy is a recognized predisposing condition for HUS due to the potential reduction in complement regulatory proteins and the possibility of heightened maternal immune response. This report illustrates the case of a 36-year-old woman who, at 36 weeks of gestation, faced a breech presentation and was diagnosed with atypical HUS (aHUS) after placental abruption. Following a cesarean section, she developed complications, including a pelvic hematoma and bilateral hydronephrosis. Despite initial suboptimal response to plasmapheresis, the patient exhibited marked clinical improvement with eculizumab treatment, with no evidence of disease relapse.
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Affiliation(s)
- Faryal Altaf
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Abeer Qasim
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Anandu M Anto
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Asim Haider
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | - Misbahuddin Khaja
- Internal Medicine/Pulmonary Critical Care, Icahn School of Medicine at Mount Sinai, BronxCare Health System, Bronx, USA
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2
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Smith J, Hans V, Yacyshyn E, Rouhi A, Oliver M. Systemic lupus erythematosus presenting with atypical hemolytic uremic syndrome: a case report and review of the literature. Rheumatol Int 2024:10.1007/s00296-024-05558-9. [PMID: 38502235 DOI: 10.1007/s00296-024-05558-9] [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: 01/07/2024] [Accepted: 02/09/2024] [Indexed: 03/21/2024]
Abstract
Systemic lupus erythematosus (SLE) can present with a diverse array of hematologic manifestations, among which atypical hemolytic uremic syndrome (aHUS) is a rare entity. SLE-triggered aHUS has significant morbidity and mortality without timely intervention, yet its frequency remains uncertain and optimal strategies for complement-directed therapies are largely expert-driven. We performed a comprehensive literature review and present a case of a 23-year-old female newly diagnosed with SLE/class IV lupus nephritis who developed aHUS that rapidly responded to the C5 antagonist, eculizumab. Review of the current literature identified forty-nine published cases of SLE with concurrent aHUS and revealed a predilection for aHUS in younger SLE patients, concurrent presentation with lupus nephritis, anti-dsDNA positivity, and complement system abnormalities. Over seventy percent of cases used eculizumab as complement-directed therapy with a trend towards faster time to improvement in laboratory parameters, though reported outcomes were highly variable. Early recognition of aHUS in SLE is pivotal in guiding appropriate therapeutic interventions, and prompt initiation of eculizumab may reduce the potential morbidity associated with plasmapheresis and additional immunosuppression. While eculizumab showcases promising results, its optimal timing and duration remain elusive. An understanding of a patients' complement genetics could aid management strategies, and ongoing research into complement-targeted therapies offers promising avenues for both SLE and aHUS treatment.
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Affiliation(s)
- Justin Smith
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada.
| | - Varinder Hans
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Elaine Yacyshyn
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Azin Rouhi
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Monika Oliver
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, Canada
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3
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Xiao MT, Ellsworth CR, Qin X. Emerging role of complement in COVID-19 and other respiratory virus diseases. Cell Mol Life Sci 2024; 81:94. [PMID: 38368584 PMCID: PMC10874912 DOI: 10.1007/s00018-024-05157-8] [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: 09/29/2023] [Revised: 01/03/2024] [Accepted: 02/03/2024] [Indexed: 02/19/2024]
Abstract
The complement system, a key component of innate immunity, provides the first line of defense against bacterial infection; however, the COVID-19 pandemic has revealed that it may also engender severe complications in the context of viral respiratory disease. Here, we review the mechanisms of complement activation and regulation and explore their roles in both protecting against infection and exacerbating disease. We discuss emerging evidence related to complement-targeted therapeutics in COVID-19 and compare the role of the complement in other respiratory viral diseases like influenza and respiratory syncytial virus. We review recent mechanistic studies and animal models that can be used for further investigation. Novel knockout studies are proposed to better understand the nuances of the activation of the complement system in respiratory viral diseases.
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Affiliation(s)
- Mark T Xiao
- Division of Comparative Pathology, Tulane National Primate Research Center, Health Sciences Campus, 18703 Three Rivers Road, Covington, LA, 70433, USA
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Calder R Ellsworth
- Division of Comparative Pathology, Tulane National Primate Research Center, Health Sciences Campus, 18703 Three Rivers Road, Covington, LA, 70433, USA
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Xuebin Qin
- Division of Comparative Pathology, Tulane National Primate Research Center, Health Sciences Campus, 18703 Three Rivers Road, Covington, LA, 70433, USA.
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
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4
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Maus M, López-Polo V, Mateo L, Lafarga M, Aguilera M, De Lama E, Meyer K, Sola A, Lopez-Martinez C, López-Alonso I, Guasch-Piqueras M, Hernandez-Gonzalez F, Chaib S, Rovira M, Sanchez M, Faner R, Agusti A, Diéguez-Hurtado R, Ortega S, Manonelles A, Engelhardt S, Monteiro F, Stephan-Otto Attolini C, Prats N, Albaiceta G, Cruzado JM, Serrano M. Iron accumulation drives fibrosis, senescence and the senescence-associated secretory phenotype. Nat Metab 2023; 5:2111-2130. [PMID: 38097808 PMCID: PMC10730403 DOI: 10.1038/s42255-023-00928-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/11/2023] [Indexed: 12/21/2023]
Abstract
Fibrogenesis is part of a normal protective response to tissue injury that can become irreversible and progressive, leading to fatal diseases. Senescent cells are a main driver of fibrotic diseases through their secretome, known as senescence-associated secretory phenotype (SASP). Here, we report that cellular senescence, and multiple types of fibrotic diseases in mice and humans are characterized by the accumulation of iron. We show that vascular and hemolytic injuries are efficient in triggering iron accumulation, which in turn can cause senescence and promote fibrosis. Notably, we find that senescent cells persistently accumulate iron, even when the surge of extracellular iron has subdued. Indeed, under normal conditions of extracellular iron, cells exposed to different types of senescence-inducing insults accumulate abundant ferritin-bound iron, mostly within lysosomes, and present high levels of labile iron, which fuels the generation of reactive oxygen species and the SASP. Finally, we demonstrate that detection of iron by magnetic resonance imaging might allow non-invasive assessment of fibrotic burden in the kidneys of mice and in patients with renal fibrosis. Our findings suggest that iron accumulation plays a central role in senescence and fibrosis, even when the initiating events may be independent of iron, and identify iron metabolism as a potential therapeutic target for senescence-associated diseases.
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Grants
- SAF2017-82613-R "la Caixa" Foundation (Caixa Foundation)
- of M. Serrano was funded by the IRB and “laCaixa” Foundation, and by grants from the Spanish Ministry of Science co-funded by the European Regional Development Fund (ERDF) (SAF2017-82613-R), European Research Council (ERC-2014-AdG/669622), and grant RETOS COLABORACION RTC2019-007125-1 from MCIN/AEI, and Secretaria d'Universitats i Recerca del Departament d'Empresa i Coneixement of Catalonia (Grup de Recerca consolidat 2017 SGR 282)
- M.M. received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement (No 794744) and from the Spanish Ministry of Science and Innovation (MCIN) (RYC2020-030652-I /AEI /10.13039/501100011033)
- V.L.P. was recipient of a predoctoral contract from Spanish Ministry of Education (FPU-18/05917).
- K.M. was recipient of fellowships from the German Cardiac, the German Research Foundation, and a postdoctoral contract Juan de la Cierva from the MCIN.
- F.H.G. was supported by the PhD4MD Collaborative Research Training Programme for Medical Doctors (IRB Barcelona/Hospital Clinic/IDIBAPS).
- M. Sanchez was funded by grants PID2021-122436OB-I00 from MCIN/ AEI /10.13039/501100011033 / FEDER, UE, and RETOS COLABORACION RTC2019-007074-1 from MCIN/AEI /10.13039/501100011033.
- G.A. was funded by Instituto de Salud Carlos III through project PI 20/01360, FEDER funds.
- J.M.C was funded by Instituto de Salud Carlos III through projects PI18/00910 and PI21/00931 (Co-funded by European Regional Development Fund. ERDF, a way to build Europe), and thanks CERCA Programme / Generalitat de Catalunya for institutional support.
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Affiliation(s)
- Mate Maus
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain.
- Vall d'Hebron Institute of Oncology, Barcelona, Spain.
| | - Vanessa López-Polo
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Lidia Mateo
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Miguel Lafarga
- Departamento de Anatomía y Biología Celular, Universidad de Cantabria-IDIVAL, Santander, Spain
| | - Mònica Aguilera
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Eugenia De Lama
- Radiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kathleen Meyer
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Altos Labs, Cambridge Institute of Science, Cambridge, UK
| | - Anna Sola
- Nephrology and Renal Transplantation Research Group. Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Cecilia Lopez-Martinez
- Departamento de Biología Funcional, Instituto Universitario de Oncología del principado de Asturias, Universidad de Oviedo, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos. Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Ines López-Alonso
- Departamento de Morfología y Biología Celular, Universidad de Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | | | - Fernanda Hernandez-Gonzalez
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Department of Pulmonary Medicine, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Selim Chaib
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Miguel Rovira
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Mayka Sanchez
- Iron Metabolism: Regulation and Diseases Group, Department of Basic Sciences, Universitat Internacional de Catalunya (UIC), Sant Cugat del Vallès, Spain
| | - Rosa Faner
- Biomedicine Department, University of Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Alvar Agusti
- Universitat de Barcelona, Institut Respiratori, Hospital Clinic, IDIBAPS, CIBERES, Barcelona, Spain
| | - Rodrigo Diéguez-Hurtado
- Deparment of Tissue Morphogenesis, Max Planck Institute for Molecular Biomedicine, Münster, Germany
| | - Sagrario Ortega
- Transgenics Unit, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - Anna Manonelles
- Nephrology and Renal Transplantation Research Group. Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Stefan Engelhardt
- Institute of Pharmacology and Toxicology, Technical University of Munich (TUM), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Freddy Monteiro
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Camille Stephan-Otto Attolini
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Neus Prats
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Guillermo Albaiceta
- Departamento de Biología Funcional, Instituto Universitario de Oncología del principado de Asturias, Universidad de Oviedo, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos. Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep M Cruzado
- Nephrology and Renal Transplantation Research Group. Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Serrano
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona, Spain.
- Altos Labs, Cambridge Institute of Science, Cambridge, UK.
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
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5
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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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6
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Muacevic A, Adler JR, Viveiros C, S. Santos M, Esteves J. Monoclonal Gammopathy of Renal Significance and Thrombotic Microangiopathy: A Case Report. Cureus 2022; 14:e32753. [PMID: 36686103 PMCID: PMC9851652 DOI: 10.7759/cureus.32753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of pathologies that includes all kidney disorders related to a monoclonal protein in patients without diagnostic criteria for B-cell malignancies. There are multiple MGRS-associated kidney disorders, and more are still being discovered, which makes this diagnosis challenging. The relationship between monoclonal gammopathies and thrombotic microangiopathy (TMA) is of growing interest in literature. This article describes the case of a patient with newly diagnosed MGRS, presenting with rapidly progressing kidney failure and with histologic characteristics of TMA. The patient progressed to end-stage renal disease (ESRD) despite treatment with plasmapheresis and clone-directed therapy, as is currently advised in the literature. Although rare, the association between these two entities should not be unnoticed because of patients' renal and vital prognosis.
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7
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Poddighe D, Demirkaya E, Sazonov V, Romano M. Mycoplasma pneumoniae Infections and Primary Immune Deficiencies. Int J Clin Pract 2022; 2022:6343818. [PMID: 35855053 PMCID: PMC9286979 DOI: 10.1155/2022/6343818] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
Mycoplasma pneumoniae (M. pneumoniae) is one of the leading causes of community-acquired pneumonia in children and is also implicated in a variety of reactive extrapulmonary diseases. Recurrent and/or severe respiratory infections are one of the most frequent manifestations of several types of primary immunodeficiency. Here, we reviewed the medical literature to assess the potential relevance of M. pneumoniae in the infections observed in children affected with combined, humoral, and innate primary immune deficiencies. M. pneumoniae does not result to be epidemiologically prevalent as a cause of pneumonia in children affected by primary immunodeficiencies, but this infection can have a persistent or severe course in this category of patients. Indeed, the active search of M. pneumoniae could be useful and appropriate especially in children with humoral immune deficiencies. Indeed, most cases of M. pneumoniae infection in primary immunodeficiencies are described in patients affected by a/hypo-gammaglobulinemia.
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Affiliation(s)
- Dimitri Poddighe
- Department of Medicine, Nazarbayev University School of Medicine (Nur-Sultan), Nur-Sultan, Kazakhstan
- Clinical Academic Department of Pediatrics, National Research Center of Mother and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
| | - Erkan Demirkaya
- Division of Pediatric Rheumatology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Canada
| | - Vitaliy Sazonov
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (Nur-Sultan), Nur-Sultan, Kazakhstan
| | - Micol Romano
- Division of Pediatric Rheumatology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Canada
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8
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Atypical hemolytic uremic syndrome: when pregnancy leads to lifelong dialysis: a case report and literature review. Cardiovasc Endocrinol Metab 2021; 10:225-230. [PMID: 34765894 PMCID: PMC8575437 DOI: 10.1097/xce.0000000000000247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/09/2021] [Indexed: 01/07/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS), a challenging disorder, commonly caused by inherited defects or regulatory processes of the complement alternative pathway. There are multiple causes, including pregnancy. Pregnancy provokes life-threatening episodes, preeclampsia, hemolysis elevated liver enzymes low platelets, microangiopathic hemolytic anemia (MAHA) and end-stage renal disease. Additionally, complement dysregulation and, with aHUS, affects fetal and maternal outcomes. Pregnancy-associated aHUS results in a poor prognosis with irreversible renal damage. Likewise, it is imperative to know that MAHA can provoke endothelial disruption, destruction of red cells and thrombocytopenia. We present a case of a young 18-year-old woman with MAHA and aHUS, requiring emergent cesarean section at 34 weeks of gestation and hemodialysis, secondary to complications from a recent pregnancy. Elevated blood pressure readings, rising creatinine levels, as well as her mother being on dialysis after pregnancy raised suspicion for thrombotic microangiopathy and aHUS. She was subsequently managed with plasma exchange, steroids, eculizumab and hemodialysis. Thus, plasma exchange should be initiated, with pending additional workup. Upon a definitive diagnosis of aHUS, eculizumab would be warranted to mitigate immune dysregulation. Understanding thrombotic microangiopathies diagnosis, and recognizing concomitant consequences, is vital. Having better insights into endothelial injuries can prevent unfortunate outcomes.
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9
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Sangeetha G, Jayaraj J, Ganesan S, Puttagunta S. Atypical haemolytic uraemic syndrome: a case of rare genetic mutation. BMJ Case Rep 2021; 14:14/7/e244190. [PMID: 34330731 PMCID: PMC8327850 DOI: 10.1136/bcr-2021-244190] [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: 11/03/2022] Open
Abstract
Complement-mediated kidney disease has been an evolving area in the field of nephrology. Atypical haemolytic uraemic syndrome (aHUS) is a rare thrombotic microangiopathy that affects multiple organs, particularly kidneys. The disease is characterised by a triad of haemolytic anaemia, thrombocytopenia and acute kidney injury (AKI). aHUS is most commonly caused by dysregulation of alternative complement pathway. In contrast to shiga toxin-associated haemolytic uraemic syndrome, diarrheal prodrome is usually absent in children with aHUS. We report a 2-year, 9-month-old boy who presented with acute dysentery and AKI. He had an unusual prolonged course of illness with hypocomplementaemia; hence, genetic testing was performed. He had a storming course in the hospital and succumbed to complications of the disease. Genetic study revealed digenic mutation in Complement Factor I and C3 Therefore, it is important to differentiate aHUS from other thrombotic microangiopathies to improve the outcome.
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Affiliation(s)
- Geminiganesan Sangeetha
- Department of Paediatric Nephrology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Jaippreetha Jayaraj
- Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Swathi Ganesan
- Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Sreeapoorva Puttagunta
- Department of Paediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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10
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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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Alshaer W, Zureigat H, Al Karaki A, Al-Kadash A, Gharaibeh L, Hatmal MM, Aljabali AAA, Awidi A. siRNA: Mechanism of action, challenges, and therapeutic approaches. Eur J Pharmacol 2021; 905:174178. [PMID: 34044011 DOI: 10.1016/j.ejphar.2021.174178] [Citation(s) in RCA: 137] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 11/19/2022]
Abstract
Owing to specific and compelling gene silencing, RNA interference (RNAi) is expected to become an essential approach in treating a variety of infectious, hemato-oncological, cardiovascular, and neurodegenerative conditions. The mechanism of action of small interfering RNA (siRNA) is based on post-transcriptional gene silencing. siRNA molecules are usually specific and efficient in the knockdown of disease-related genes. However, they are characterized by low cellular uptake and are susceptible to nuclease-mediated degradation. Therefore, siRNAs require a carrier for their protection and efficient delivery into target cells. The current review highlights the siRNA-based mechanism of action, challanges, and recent advances in clinical applications.
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Affiliation(s)
- Walhan Alshaer
- Cell Therapy Center, The University of Jordan, Amman, 11942, Jordan.
| | - Hadil Zureigat
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Arwa Al Karaki
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | | | - Lobna Gharaibeh
- Faculty of Pharmacy, Al-Ahliyya Amman University, Amman, 19328, Jordan
| | - Ma'mon M Hatmal
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, The Hashemite University, Zarqa 13133, Jordan
| | - Alaa A A Aljabali
- Faculty of Pharmacy, Department of Pharmaceutical Sciences, Yarmouk University, Irbid, 21163, Jordan
| | - Abdalla Awidi
- Cell Therapy Center, The University of Jordan, Amman, 11942, Jordan; Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan; Department of Hematology and Oncology, Jordan University Hospital, The University of Jordan, Amman, 11942, Jordan.
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12
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Chong WH, Saha BK. Relationship Between Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the Etiology of Acute Kidney Injury (AKI). Am J Med Sci 2021; 361:287-296. [PMID: 33358501 PMCID: PMC7590839 DOI: 10.1016/j.amjms.2020.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Since it was first recognized in December 2019, it has resulted in the ongoing worldwide pandemic. Although acute hypoxic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) are the main features of the disease, the involvement of other organs needs to be explored. There has been a growing concern regarding the association between acute kidney injury (AKI) and poor outcomes in SARS-CoV-2 patients. Based on current observational data, AKI is the 2nd most common cause of morbidity and mortality behind ARDS in SARS-CoV-2 patients. Angiotensin-converting enzyme 2 (ACE2) receptor has been shown to be the cornerstone of SARS-CoV-2 infection and possibly plays a significant role in the occurrence of renal injury. The pathogenesis of AKI is likely multifactorial that involves not only direct viral invasion but also dysregulated immune response in the form of cytokine storm, ischemia to kidneys, hypercoagulable state, and rhabdomyolysis, among others. We performed a literature search of the Pubmed and Google Scholar database from 1996 to 2020 using the following keywords: severe acute respiratory syndrome coronavirus 2, coronavirus disease 2019, angiotensin-converting enzyme 2 receptor, and acute kidney injury to find the most pertinent and highest-quality of evidence. Any cited references were reviewed to identify relevant literature. The purpose of this review is to discuss, explore, and summarize the relationship between AKI in SARS-CoV-2 patients, with a focus on its epidemiology, association with ACE2 receptors, and pathophysiology of AKI.
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Affiliation(s)
- Woon H Chong
- Department of Pulmonary and Critical Care Medicine; Albany Medical Center, Albany, New York, USA.
| | - Biplab K Saha
- Department of Pulmonary and Critical Care; Ozarks Medical Center, West Plains, Missouri, USA
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13
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Detsika MG, Lianos EA. Regulation of Complement Activation by Heme Oxygenase-1 (HO-1) in Kidney Injury. Antioxidants (Basel) 2021; 10:antiox10010060. [PMID: 33418934 PMCID: PMC7825075 DOI: 10.3390/antiox10010060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/31/2020] [Accepted: 01/01/2021] [Indexed: 12/20/2022] Open
Abstract
Heme oxygenase is a cytoprotective enzyme with strong antioxidant and anti-apoptotic properties. Its cytoprotective role is mainly attributed to its enzymatic activity, which involves the degradation of heme to biliverdin with simultaneous release of carbon monoxide (CO). Recent studies uncovered a new cytoprotective role for heme oxygenase-1 (HO-1) by identifying a regulatory role on the complement control protein decay-accelerating factor. This is a key complement regulatory protein preventing dysregulation or overactivation of complement cascades that can cause kidney injury. Cell-specific targeting of HO-1 induction may, therefore, be a novel approach to attenuate complement-dependent forms of kidney disease.
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Affiliation(s)
- Maria G. Detsika
- First Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M. Simou Laboratories, National & Kapodistrian University of Athens, Medical School, Evangelismos Hospital, 10675 Athens, Greece
- Correspondence: ; Tel.: +30-210-723552; Fax: +30-210-7239127
| | - Elias A. Lianos
- Thorax Foundation, Research Center of Intensive Care and Emergency Thoracic Medicine, 10675 Athens, Greece;
- Veterans Affairs Medical Center and Virginia Tech, Carilion School of Medicine, 1970 Roanoke Blvd, Salem, VA 24153, USA
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Gain-of-function mutation in complement C2 protein identified in a patient with aHUS. J Allergy Clin Immunol 2020; 146:916-919.e11. [PMID: 32113979 DOI: 10.1016/j.jaci.2020.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 11/21/2022]
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15
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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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St-Pierre F, Pawar AS, Kumar R. 63-Year-Old Woman With Abdominal Pain and Thrombocytopenia. Mayo Clin Proc 2019; 94:2122-2126. [PMID: 31585585 DOI: 10.1016/j.mayocp.2019.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Frederique St-Pierre
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Aditya S Pawar
- Resident in Nephrology, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Rajiv Kumar
- Advisor to residents and Consultant in Nephrology, Mayo Clinic, Rochester, MN.
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Aigner C, Schmidt A, Gaggl M, Sunder-Plassmann G. An updated classification of thrombotic microangiopathies and treatment of complement gene variant-mediated thrombotic microangiopathy. Clin Kidney J 2019; 12:333-337. [PMID: 31198225 PMCID: PMC6543965 DOI: 10.1093/ckj/sfz040] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Indexed: 12/21/2022] Open
Abstract
Conditions presenting with signs of thrombotic microangiopathies (TMAs) comprise a wide spectrum of different diseases. While pathological hallmarks are thrombosis of arterioles and capillaries, clinical signs are mechanical haemolysis, thrombocytopenia and acute renal injury or neurological manifestations. The current classification of various syndromes of TMA is heterogeneous and often does not take the underlying pathophysiology into consideration. Therefore we propose a simplified classification based on the aetiology of different syndromes leading to TMA. We propose to categorize different TMA syndromes in hereditary and acquired forms and classify them based on the genetic background or underlying conditions. Of course, this classification is not always distinctly applicable in each case and from time to time reassessment of the established diagnosis is strongly recommended. The recommended treatment of TMA in the past was plasma exchange (PE). However, recently, the terminal complement inhibitor eculizumab became commercially available and has shown promising results in different open-label studies and case series. In our centre, first-line therapy is PE; however, patients are instantly switched to complement inhibitory therapy in case of treatment failure or intolerance.
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Affiliation(s)
- Christof Aigner
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Alice Schmidt
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Martina Gaggl
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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18
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Ashoor IF, Dharnidharka VR. Non-immunologic allograft loss in pediatric kidney transplant recipients. Pediatr Nephrol 2019; 34:211-222. [PMID: 29480356 DOI: 10.1007/s00467-018-3908-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 01/13/2023]
Abstract
Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.
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Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70130, USA.
| | - Vikas R Dharnidharka
- Washington University and St. Louis Children's Hospital, 600 South Euclid Ave, St. Louis, MO, 63110, USA
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Feitz WJC, van de Kar NCAJ, Orth-Höller D, van den Heuvel LPJW, Licht C. The genetics of atypical hemolytic uremic syndrome. MEDIZINISCHE GENETIK : MITTEILUNGSBLATT DES BERUFSVERBANDES MEDIZINISCHE GENETIK E.V 2018. [PMID: 30930551 DOI: 10.1007/s11825-018-0216-0)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a disorder characterized by thrombocytopenia and microangiopathic hemolytic anemia due to endothelial injury. aHUS is felt to be caused by defective complement regulation due to underlying genetic mutations in complement regulators or activators, most often of the alternative pathway. Mutations causing aHUS can be subdivided into two groups, loss of function mutations (affecting factor H, factor H-related proteins, membrane co-factor protein, and factor I), and gain of function mutations (affecting factor B and C3). As more information becomes available on the relationship between specific mutations and clinical outcome, complete genetic workup of aHUS patients becomes more and more important. In this review, we will discuss the genetic background of aHUS, the role of complement for aHUS pathogenesis, and the different groups of specific mutations known to be involved in the pathogenesis of aHUS.
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Affiliation(s)
- Wouter J C Feitz
- 1Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands.,2Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nicole C A J van de Kar
- 1Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Dorothea Orth-Höller
- 3Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lambert P J W van den Heuvel
- 1Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands.,4Department of Development and Regeneration, Department of Pediatric Nephrology, KU Leuven, Leuven, Belgium
| | - Christoph Licht
- 2Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,5Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada.,6Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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20
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Feitz WJC, van de Kar NCAJ, Orth-Höller D, van den Heuvel LPJW, Licht C. The genetics of atypical hemolytic uremic syndrome. MED GENET-BERLIN 2018; 30:400-409. [PMID: 30930551 PMCID: PMC6404389 DOI: 10.1007/s11825-018-0216-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a disorder characterized by thrombocytopenia and microangiopathic hemolytic anemia due to endothelial injury. aHUS is felt to be caused by defective complement regulation due to underlying genetic mutations in complement regulators or activators, most often of the alternative pathway. Mutations causing aHUS can be subdivided into two groups, loss of function mutations (affecting factor H, factor H-related proteins, membrane co-factor protein, and factor I), and gain of function mutations (affecting factor B and C3). As more information becomes available on the relationship between specific mutations and clinical outcome, complete genetic workup of aHUS patients becomes more and more important. In this review, we will discuss the genetic background of aHUS, the role of complement for aHUS pathogenesis, and the different groups of specific mutations known to be involved in the pathogenesis of aHUS.
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Affiliation(s)
- Wouter J C Feitz
- 1Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands.,2Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nicole C A J van de Kar
- 1Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Dorothea Orth-Höller
- 3Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lambert P J W van den Heuvel
- 1Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands.,4Department of Development and Regeneration, Department of Pediatric Nephrology, KU Leuven, Leuven, Belgium
| | - Christoph Licht
- 2Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,5Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada.,6Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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21
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van Hoeve K, Vandermeulen C, Van Ranst M, Levtchenko E, van den Heuvel L, Mekahli D. Occurrence of atypical HUS associated with influenza B. Eur J Pediatr 2017; 176:449-454. [PMID: 28110418 DOI: 10.1007/s00431-017-2856-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 12/29/2016] [Accepted: 01/10/2017] [Indexed: 12/27/2022]
Abstract
UNLABELLED Hemolytic uremic syndrome (HUS) is a disease characterized by thrombotic microangiopathy with a triad of non-immune hemolytic anemia, thrombocytopenia, and renal impairment. Approximately 10% of cases of HUS are classified as atypical (aHUS). While today many genetically forms of aHUS pathology are known, only about 50% of carriers precipitate the disease. The reason remains unclear, and triggering events like intercurrent infections have been postulated. In rare cases, influenza A is the known trigger of aHUS; however, no cases of influenza B have been reported. CONCLUSION We describe for the first time that influenza B strain as a trigger for aHUS in children with primary hereditary forms. We also showed in our three cases that immunization appears to be safe; however, this needs to be confirmed in a larger cohort. What is Known: • Known triggers of aHUS are infectious specimen. • Influenza A-associated aHUS cases are rarely published. What is New: • aHUS can be triggered by influenza B virus infection. • Influenza vaccination of patients with aHUS appears safe.
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Affiliation(s)
- Karen van Hoeve
- Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Corinne Vandermeulen
- University Vaccinology Center, KU Leuven - University of Leuven, 3000, Leuven, Belgium
| | - Marc Van Ranst
- Department of Microbiology and Immunology, KU Leuven - Rega Institute, 3000, Leuven, Belgium
| | - Elena Levtchenko
- Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Laboratory of Pediatrics, KU Leuven - University of Leuven, 3000, Leuven, Belgium
| | | | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Laboratory of Pediatrics, KU Leuven - University of Leuven, 3000, Leuven, Belgium
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22
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Okumi M, Tanabe K. Prevention and treatment of atypical haemolytic uremic syndrome after kidney transplantation. Nephrology (Carlton) 2017; 21 Suppl 1:9-13. [PMID: 26988663 DOI: 10.1111/nep.12776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Atypical haemolytic uraemic syndrome is a rare disorder characterized by an over-activated, dysregulated alternative complement pathway due to genetic mutation and environmental triggers. Atypical haemolytic uraemic syndrome is a serious, life-threatening disease characterized by thrombotic microangiopathy, which causes haemolytic anaemia, thrombocytopaenia, and acute renal failure. Since recurrences of atypical haemolytic uraemic syndrome frequently lead to end-stage kidney disease even in renal allografts, kidney transplantation for patients with end-stage kidney disease secondary to atypical haemolytic uraemic syndrome has long been contraindicated. However, over the past several years, advancements in the management of atypical haemolytic uraemic syndrome have allowed successful kidney transplantation in these patients. The key factor of this success is eculizumab, a humanized anti-C5 monoclonal antibody, which inhibits terminal membrane-attack complex formation and thrombotic microangiopathy progression. In the setting of kidney transplantation, there are different possible triggers of post-transplant atypical haemolytic uraemic syndrome recurrence, such as brain-death related injury, ischaemia-reperfusion injury, infections, the use of immunosuppressive drugs, and rejection. Principal strategies are to prevent endothelial damage that could potentially activate alternative complement pathway activation and subsequently lead to atypical haemolytic uraemic syndrome recurrence in kidney allograft. Published data shows that prophylactic eculizumab therapy is highly effective for the prevention of post-transplant atypical haemolytic uraemic syndrome recurrence, and prompt treatment with eculizumab as soon as recurrence is diagnosed is important to maintain renal allograft function. Further study to determine the optimal dosing and duration of prophylactic therapy and treatment of post-transplant atypical haemolytic uraemic syndrome recurrence is needed.
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Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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23
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Dolcemascolo V, Vivarelli M, Colucci M, Diomedi-Camassei F, Piras R, Alberti M, Emma F. Nephrotic-Range Proteinuria and Peripheral Edema in a Child: Not Only Idiopathic Nephrotic Syndrome. Case Rep Nephrol Dial 2016; 6:120-127. [PMID: 27904864 PMCID: PMC5121544 DOI: 10.1159/000449423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/25/2016] [Indexed: 01/16/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is defined by the simultaneous occurrence of hemolytic anemia, thrombocytopenia, and acute kidney injury due to thrombotic microangiopathy (TMA) mainly occurring in renal and cerebral microvessels. Although the most common cause of HUS in children is Shiga toxin-producing Escherichia coli, atypical forms in which Shiga toxin is not the trigger may occur. Research over the last few years has shown that complement dysregulation secondary to mutations of genes coding for proteins involved in the regulation of the alternative pathway of complement account for most forms of atypical HUS (aHUS). Among these, thrombomodulin (THBD) gene mutations, representing 3–5% of all alternative pathway complement component abnormalities, correlate with early disease onset and rapid evolution to end-stage renal failure. aHUS onset is generally sudden, but occasionally the only manifestations of renal TMA are arterial hypertension, proteinuria, and a progressive increase in serum creatinine. Nephrotic syndrome at disease onset is exceptional. We describe the case of an adolescent female who presented with peripheral edema due to nephrotic-range proteinuria with bioptic evidence of TMA. Study of the alternative complement pathway showed a heterozygous missense THBD gene mutation (P501L variant) consistent with aHUS diagnosis. One year later she developed clinical signs of hemolytic anemia. Eculizumab, an anti-C5 monoclonal antibody, was started with rapid improvement. This case report highlights the phenotypic variability in aHUS due to THBD gene mutation. Early diagnosis by renal biopsy followed by genetic screening is required to optimize management in such a rare disease with a severe prognosis.
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Affiliation(s)
- Valentina Dolcemascolo
- Division of Pediatrics, Department of Clinical and Experimental Medical Sciences, University Hospital of Udine, Udine, Italy
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manuela Colucci
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Rossella Piras
- Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, IRCCS, Bergamo, Italy
| | - Marta Alberti
- Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, IRCCS, Bergamo, Italy
| | - Francesco Emma
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Novikov P, Kozlovskaya N, Moiseev S, Shilov E, Bobkova I, Schreiber A, Tsvetkov D, Gollasch M, Mah N, El Amrani K, Kurtz A. Therapeutic Complement Targeting in ANCA-Associated Vasculitides and Thrombotic Microangiopathy. Biomed Hub 2016; 1:1-11. [PMID: 31988889 PMCID: PMC6945915 DOI: 10.1159/000453106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/26/2016] [Indexed: 11/19/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of systemic autoimmune disorders characterized by necrotizing inflammation of medium-to-small vessels, a relative paucity of immune deposits, and an association with detectable circulating ANCAs. AAVs include granulomatosis with polyangiitis (renamed from Wegener's granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Until recently, AAVs have not been viewed as complement-mediated disorders. However, recent findings predominantly from animal studies demonstrated a crucial role of the complement system in the pathogenesis of AAVs. Complement activation or defects in its regulation have been described in an increasing number of acquired or genetically driven forms of thrombotic microangiopathy. Coinciding with this expanding spectrum of complement-mediated diseases, the question arises as to which AAV patients might benefit from a complement-targeted therapy. Therapies directed against the complement system point to the necessity of a genetic workup of genes of complement components and regulators in patients with AAV. Genetic testing together with pluripotent stem cells and bioinformatics tools may broaden our approach to the treatment of patients with aggressive forms of AAV.
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Affiliation(s)
- Pavel Novikov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Sergey Moiseev
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Eugene Shilov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Irina Bobkova
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Adrian Schreiber
- Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine at the Charité and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Nephrology and Intensive Care Medicine, Campus Virchow, Berlin, Germany
| | - Dmitry Tsvetkov
- Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine at the Charité and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Nephrology and Intensive Care Medicine, Campus Virchow, Berlin, Germany
| | - Maik Gollasch
- Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine at the Charité and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- Nephrology and Intensive Care Medicine, Campus Virchow, Berlin, Germany
- Koch Metchnikoff Forum, Section Nephrology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nancy Mah
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Khadija El Amrani
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Kurtz
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
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25
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Abstract
PURPOSE OF REVIEW Neonatal proteinuria and hematuria while not common can have potentially devastating consequences if left undiagnosed and untreated. It is important to distinguish between inherited and acquired causes of proteinuria to initiate appropriate and timely treatment. With regards to hematuria, it is critical to identify true hematuria from pseudo-hematuria to balance between thorough investigation and unnecessary laboratory work up. This review provides an overview of the common causes of hematuria and proteinuria in a neonate. RECENT FINDINGS The identification of genetic mutations in nephrotic syndrome has improved our understanding of the role of various proteins that play an important role in maintaining the glomerular filtration barrier. With the advancement in our ability to provide care for extreme premature neonates, the incidence of acute kidney injury has increased in these neonates along with proteinuria and hematuria. SUMMARY Persistent proteinuria after neonatal acute kidney injury would be of interest in regards to the risk of developing future chronic kidney disease and hypertension.
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Lee JM, Park YS, Lee JH, Park SJ, Shin JI, Park YH, Yoo KH, Cho MH, Kim SY, Kim SH, Namgoong MK, Lee SJ, Lee JH, Cho HY, Han KH, Kang HG, Ha IS, Bae JS, Kim NKD, Park WY, Cheong HI. Atypical hemolytic uremic syndrome: Korean pediatric series. Pediatr Int 2015; 57:431-8. [PMID: 25443527 DOI: 10.1111/ped.12549] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare disease with a genetic predisposition. Few studies have evaluated the disease in the Asian population. We studied a Korean pediatric cohort to delineate the clinical characteristics and genotypes. METHODS A multicenter cohort of 51 Korean children with aHUS was screened for mutations using targeted exome sequencing covering 46 complement related genes. Anti-complement-factor-H autoantibody (anti-CFH) titers were measured. Multiplex ligation-dependent probe amplification assay was performed to detect deletions in the complement factor-H related protein genes (CFHR) in the patients as well as in 100 healthy Korean controls. We grouped the patients according to etiology and compared the clinical features using Mann-Whitney U-test and chi-squared test. RESULTS Fifteen patients (group A, 29.7%) had anti-CFH, and mutations were detected in 11 (group B, 21.6%), including one with combined mutations. The remaining 25 (group C, 49.0%) were negative for both. The prevalence of anti-CFH was higher than the worldwide level. Group A had a higher onset age than group B, although the difference was not significant. Group B had the worst renal outcome. Gene frequencies of homozygous CFHR1 deletion were 73.3%, 2.7% and 1% in group A, group B + C and the control, respectively. CONCLUSIONS The incidence of anti-CFH in the present Korean aHUS cohort was high. Clinical outcomes largely conformed to the previous reports. Although the sample size was limited, this cohort provides a reassessment of clinicogenetic features of aHUS in Korean children.
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Affiliation(s)
- Jiwon M Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Se Jin Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University, Seoul, Korea
| | - Yong-Hoon Park
- Department of Pediatrics, Yeungnam University College of Medicine, Daegu, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University Hospital, Daegu, Korea
| | - Su-Young Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Mee Kyung Namgoong
- Department of Pediatrics, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Seung Joo Lee
- Department of Pediatrics, Ehwa University Mokdong Hospital, Seoul, Korea
| | - Jun Ho Lee
- Department of Pediatrics, Bundang CHA Hospital, Seongnam, Korea
| | - Hee Yeon Cho
- Department of Pediatrics, Samsung Medical Center, Seoul, Korea
| | - Kyoung Hee Han
- Department of Pediatrics, Jeju University Hospital, Jeju, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jun-Seok Bae
- Samsung Genome Institute, Samsung Medical Center, Seoul, Korea.,Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Nayoung K D Kim
- Samsung Genome Institute, Samsung Medical Center, Seoul, Korea
| | - Woong-Yang Park
- Samsung Genome Institute, Samsung Medical Center, Seoul, Korea.,Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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27
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Alasfar S, Alachkar N. Atypical hemolytic uremic syndrome post-kidney transplantation: two case reports and review of the literature. Front Med (Lausanne) 2014; 1:52. [PMID: 25593925 PMCID: PMC4292050 DOI: 10.3389/fmed.2014.00052] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 11/29/2014] [Indexed: 01/09/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disorder characterized by over-activation and dysregulation of the alternative complement pathway. Its estimated prevalence is 1–2 per million. The disease is characterized by thrombotic microangiopathy, which causes anemia, thrombocytopenia, and acute renal failure. aHUS has more severe course compared to typical (infection-induced) HUS and is frequently characterized by relapses that leads to end stage renal disease. For a long time, kidney transplantation for these patients was contraindicated because of high rate of recurrence and subsequent renal graft loss. The post-kidney transplantation recurrence rate largely depends on the pathogenetic mechanisms involved. However, over the past several years, advancements in the understanding and therapeutics of aHUS have allowed successful kidney transplantation in these patients. Eculizumab, which is a complement C5 antibody that inhibits complement factor 5a and subsequent formation of the membrane-attack complex, has been used in prevention and treatment of post-transplant aHUS recurrence. In this paper, we present two new cases of aHUS patients who underwent successful kidney transplantation in our center with the use of prophylactic and maintenance eculizumab therapy that have not been published before. The purpose of reporting these two cases is to emphasize the importance of using eculizumab as a prophylactic therapy to prevent aHUS recurrence post-transplant in high-risk patients. We will also review the current understanding of the genetics of aHUS, the pathogenesis of its recurrence after kidney transplantation, and strategies for prevention and treatment of post-transplant aHUS recurrence.
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Affiliation(s)
- Sami Alasfar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Nada Alachkar
- Department of Medicine, Division of Nephrology, The Johns Hopkins University School of Medicine , Baltimore, MD , USA
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28
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Are complement deficiencies really rare? Overview on prevalence, clinical importance and modern diagnostic approach. Mol Immunol 2014; 61:110-7. [DOI: 10.1016/j.molimm.2014.06.030] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 06/18/2014] [Accepted: 06/23/2014] [Indexed: 01/18/2023]
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30
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Rathbone J, Kaltenthaler E, Richards A, Tappenden P, Bessey A, Cantrell A. A systematic review of eculizumab for atypical haemolytic uraemic syndrome (aHUS). BMJ Open 2013; 3:e003573. [PMID: 24189082 PMCID: PMC3822313 DOI: 10.1136/bmjopen-2013-003573] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine the efficacy and safety of eculizumab for patients with atypical haemolytic uraemic syndrome (aHUS), compared with current treatment options. DESIGN A systematic review was performed according to the general principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All study designs were included, except case histories. PARTICIPANTS All patients diagnosed with aHUS were included; no age restrictions were used. INTERVENTIONS Eculizumab compared with current treatment options. IDENTIFICATION OF STUDIES 12 databases were searched. Additional searches were performed through the Food and Drug Administration (FDA) and the Electronic Medicines Compendium websites, Google internet searches and contacting clinical experts. Reference lists of relevant articles were checked for additional studies. RESULTS 2 small, uncontrolled prospective multinational, multicentre studies and one small uncontrolled multinational, multicentre retrospective study were included. No meta-analyses were performed. Compared with baseline measures, thrombotic microangiopathy event-free status was achieved in 84% of patients in the prospective studies. Adverse events, as documented by enrolling investigators were frequent, with upper-respiratory tract infection affecting a third of patients. No deaths or episodes of meningitis or meningococcal septicaemia occurred in the prospective studies. Results of the study extension phases up to 114 weeks indicate that the benefits of the treatment are sustained. CONCLUSIONS Eculizumab is clinically effective for the treatment of aHUS. Further research is needed to evaluate eculizumab, ideally using patient-related clinical outcomes. If randomised studies are not feasible, study investigators should ensure that the threat of bias is minimised in future studies of eculizumab with respect to the reporting of patient recruitment and selection.
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Affiliation(s)
- John Rathbone
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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