1
|
Bouwman HB, Guchelaar HJ. The efficacy and safety of eculizumab in patients and the role of C5 polymorphisms. Drug Discov Today 2024; 29:104134. [PMID: 39111540 DOI: 10.1016/j.drudis.2024.104134] [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: 03/14/2024] [Revised: 07/11/2024] [Accepted: 07/31/2024] [Indexed: 08/13/2024]
Abstract
Eculizumab is an orphan drug with indications for extremely rare autoimmune disorders. It is primarily prescribed for use in patients with paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome; but is also highly effective in the treatment of myasthenia gravis, among others. By binding to the C5 protein in the complement system, eculizumab effectively inhibits cellular hemolysis and autoimmune reactions. Despite this effective treatment, some patients reported no improvement in symptoms. Genetic sequencing revealed three distinct C5 mutations in the non-responders and these polymorphisms appeared to be most prevalent among Japanese, Korean and African populations. Here, we present an overview of the current and potential future applications of eculizumab, as well as the disadvantages of eculizumab treatment in patients with C5 polymorphisms.
Collapse
Affiliation(s)
| | - Henk-Jan Guchelaar
- Clinical Pharmacy and Toxicology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.
| |
Collapse
|
2
|
Ramdas S, Painho T, Vanegas MI, Famili DT, Lim MJ, Jungbluth H. Targeted Treatments for Myasthenia Gravis in Children and Adolescents. Paediatr Drugs 2024:10.1007/s40272-024-00649-3. [PMID: 39198371 DOI: 10.1007/s40272-024-00649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2024] [Indexed: 09/01/2024]
Abstract
Myasthenia gravis (MG) is an antibody-mediated disorder of the neuromuscular junction affecting children and adults. MG is a treatable condition with most patients requiring immunosuppression for disease control and/or remission. Juvenile myasthenia gravis (JMG) is rare in comparison with adult-onset MG but given the same underlying pathophysiology, treatment strategies are similar to those in adults. Until recently, there were only a few randomised controlled trials (RCTs) for MG treatments in adults and none in children, and management strategies were primarily based on expert consensus. In addition, treatment options for refractory MG cases have been severely limited, resulting in poor long-term quality of life in such patients due to the significant disease burden. Recently, there have been several RCTs focussing on novel therapeutic strategies with potentially promising outcomes, suggesting a change in MG management over the coming years and access to more effective and faster-acting drugs for MG patients. This paper will review current and new MG treatments including efgartigimod, eculizumab, rozanolixizumab, ravulizumab, and zilucoplan, with a focus on juvenile myasthenia gravis.
Collapse
Affiliation(s)
- Sithara Ramdas
- Department of Paediatrics, MDUK Neuromuscular Centre, University of Oxford, Oxford, UK
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Teresa Painho
- Department of Paediatrics, MDUK Neuromuscular Centre, University of Oxford, Oxford, UK
- Neurology Unit, Hospital Dona Estefânia, Unidade Local de Saúde São José, Centro Clínico Académico de Lisboa, Lisbon, Portugal
| | - Maria I Vanegas
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Dennis T Famili
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Ming J Lim
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK
- Women and Children's Health, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Evelina London Children's Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, Children's Neurosciences Centre, F02-Becket House, Lambeth Palace Road, London, SE1 7EU, UK.
- Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK.
| |
Collapse
|
3
|
Zhang Z, Liu X, Zhang J, Zhang B. Real-world safety profile of eculizumab: an analysis of FDA adverse event reporting system and systematic review of case reports. Expert Opin Drug Saf 2024:1-7. [PMID: 39140260 DOI: 10.1080/14740338.2024.2392885] [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: 04/22/2024] [Revised: 07/02/2024] [Accepted: 07/05/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Most of the safety data regarding eculizumab came from clinical trials, while its safety information in the real world is still limited. RESEARCH DESIGN AND METHODS The data of eculizumab in the FDA Adverse Event Reporting System (FAERS) database (from the first quarter of 2007 to the first quarter of 2023) was collected and analyzed. The case reports of adverse drug reactions (ADRs) related to eculizumab in PubMed, Embase and Web of Science before May 2023 were systematically reviewed. RESULTS A total of 464 ADRs of eculizumab were identified in the FAERS database. The top five ADRs with the highest proportional reporting ratio (PRR) are total complement activity decreased, extravascular hemolysis, hemoglobinuria, total complement activity increased and breakthrough hemolysis. Fifty-one cases of ADR related to eculizumab were identified from 44 publications. The number of reported cases of eculizumab associated Neisseria gonorrhoeae infection in case reports was observed to be comparable to the number of cases of Neisseria meningitidis infection. CONCLUSIONS Clinicians must pay close attention to the risk of infections in patients receiving eculizumab, including severe N. meningitidis infection and other potentially fatal infections such as N. gonorrhoeae infection. In addition, The possible emergence of new ADRs should be vigilant during clinical medication.
Collapse
Affiliation(s)
- Zhihui Zhang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Liu
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Jinlan Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bo Zhang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
4
|
Martin M, Llorens-Cebria C, León-Román J, Perurena-Prieto J, Perez-Beltran V, Saumell S, Torres IB, Agraz I, Sellarès J, Ramos N, Bestard O, López M, Moreso F, Ariceta G, Soler MJ, Hernandez-Gonzalez M, Jacobs-Cachá C. Ex vivo C5b-9 Deposition Test to Monitor Complement Activity in Clinical and Subclinical Atypical Hemolytic Uremic Syndrome and in Transplantation-Associated Thrombotic Microangiopathy. Kidney Int Rep 2024; 9:2227-2239. [PMID: 39081726 PMCID: PMC11284441 DOI: 10.1016/j.ekir.2024.04.022] [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: 12/14/2023] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a complement system (CS)-mediated ultrarare disease that manifests as thrombotic microangiopathy (TMA) with preferential small kidney vessels involvement. Transient CS activation is also observed in secondary TMA or in patients at risk of developing aHUS. There is no gold standard test to monitor disease activity; however, the ex vivo C5b-9 deposition test seems to be a good approach. Methods We assessed the C5b-9 deposition induced by serum samples of patients with aHUS (n = 8) and with TMA associated with kidney (n = 2), lung (n = 1) or hematopoietic stem cell (HSC) transplantation (HSCT, n = 2) during the acute phase of the disease or in remission. As control for transplant-associated TMA (TA-TMA), we analyzed samples of clinically stable kidney and HSC-transplanted patients without signs of TMA. In addition, we studied 1 child with genetic risk of aHUS during an acute infection. Results In the acute disease phase or in patients with disease activity despite C5 blockade, a significant increase of C5b-9 deposition was detected. In all patients with clinical response to C5 blockade but one, levels of C5b-9 deposition were within the normal range. Finally, we detected increased C5b-9 deposition levels in an asymptomatic child with genetic risk of aHUS when a concomitant otitis episode was ongoing. Conclusion The ex vivo C5b-9 deposition test is an auspicious tool to monitor CS activity in aHUS and TA-TMA. In addition, we demonstrate that the test may be useful to detect subclinical increase of CS activity, which expands the spectrum of patients that would benefit from a better CS activity assessment.
Collapse
Affiliation(s)
- Maria Martin
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Carmen Llorens-Cebria
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan León-Román
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Janire Perurena-Prieto
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Víctor Perez-Beltran
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Silvia Saumell
- Hematology Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irina B. Torres
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Irene Agraz
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Joana Sellarès
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Natàlia Ramos
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Bestard
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Mercedes López
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Francesc Moreso
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Gema Ariceta
- Pediatric Nephrology, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Universitat Autonoma Barcelona, Barcelona, Spain
| | - Maria José Soler
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS2040, RD21/0005/0031), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Hernandez-Gonzalez
- Translational Immunology Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Conxita Jacobs-Cachá
- Nephrology and Transplantation Research Group, Vall d’Hebron Institut de Recerca, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Biochemistry Department, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| |
Collapse
|
5
|
Saxena R, Bushey RT, Campa MJ, Gottlin EB, Guo J, Patz EF, He YW. Promotion of an Antitumor Immune Program by a Tumor-specific, Complement-activating Antibody. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:1589-1601. [PMID: 38558134 DOI: 10.4049/jimmunol.2300728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
Tumor-targeting Abs can be used to initiate an antitumor immune program, which appears essential to achieve a long-term durable clinical response to cancer. We previously identified an anti-complement factor H (CFH) autoantibody associated with patients with early-stage non-small cell lung cancer. We cloned from their peripheral B cells an mAb, GT103, that specifically recognizes CFH on tumor cells. Although the underlying mechanisms are not well defined, GT103 targets a conformationally distinct CFH epitope that is created when CFH is associated with tumor cells, kills tumor cells in vitro, and has potent antitumor activity in vivo. In the effort to better understand how an Ab targeting a tumor epitope can promote an effective antitumor immune response, we used the syngeneic CMT167 lung tumor C57BL/6 mouse model, and we found that murinized GT103 (mGT103) activates complement and enhances antitumor immunity through multiple pathways. It creates a favorable tumor microenvironment by decreasing immunosuppressive regulatory T cells and myeloid-derived suppressor cells, enhances Ag-specific effector T cells, and has an additive antitumor effect with anti-PD-L1 mAb. Furthermore, the immune landscape of tumors from early-stage patients expressing the anti-CFH autoantibody is associated with an immunologically active tumor microenvironment. More broadly, our results using an mAb cloned from autoantibody-expressing B cells provides novel, to our knowledge, mechanistic insights into how a tumor-specific, complement-activating Ab can generate an immune program to kill tumor cells and inhibit tumor growth.
Collapse
Affiliation(s)
- Ruchi Saxena
- Department of Integrative Immunobiology, Duke University School of Medicine, Durham, NC
| | - Ryan T Bushey
- Department of Radiology, Duke University School of Medicine, Durham, NC
| | - Michael J Campa
- Department of Radiology, Duke University School of Medicine, Durham, NC
| | | | - Jian Guo
- Department of Integrative Immunobiology, Duke University School of Medicine, Durham, NC
| | - Edward F Patz
- Department of Radiology, Duke University School of Medicine, Durham, NC
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC
| | - You-Wen He
- Department of Integrative Immunobiology, Duke University School of Medicine, Durham, NC
| |
Collapse
|
6
|
Le Tilly O, Gatault P, Semlali S, Sberro-Soussan R, Passot C, Bertrand D, Desvignes C, Caillard S, Paintaud G, Halimi JM, Ternant D. Eculizumab dose tapering should take into account the nonlinearity of its pharmacokinetics. Br J Clin Pharmacol 2024; 90:1312-1321. [PMID: 38373846 DOI: 10.1111/bcp.16019] [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: 10/18/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/21/2024] Open
Abstract
AIMS Eculizumab is a monoclonal antibody targeting complement protein C5 used in renal diseases. As recommended dosing regimen leads to unnecessarily high concentrations in some patients, tailored dosing therapeutic drug monitoring was proposed to reduce treatment cost. The objectives of the present work were (i) to investigate the target-mediated elimination of eculizumab and (ii) whether a pharmacokinetic model integrating a nonlinear elimination allows a better prediction of eculizumab concentrations than a linear model. METHODS We analysed 377 eculizumab serum concentrations from 44 patients treated for atypical haemolytic uraemic syndrome and C3 glomerulopathy with a population pharmacokinetic approach. Critical concentrations (below which a non-log-linear decline of concentration over time is evidenced) were computed to estimate the relevance of the target-mediated elimination. Simulations of dosing regimens were then performed to predict probabilities of target attainment (i.e. trough >100 mg/L). RESULTS Pharmacokinetics of eculizumab was nonlinear and followed a mixture of first-order (CL = 1.318 mL/day/kg) and Michaelis-Menten elimination (Vmax = 26.07 mg/day, Km = 24.06 mg/L). Volume of distribution (72.39 mL/kg) and clearance were weight-dependent. Critical concentrations (Vmax/CL) ranged from 144.7 to 759.7 mg/L and were inversely related to body weight (P = .013). Nonlinearity was thus noticeable at therapeutic concentrations. Simulations predicted that 1200 mg of eculizumab every 21 days would allow 85% and 76% of patients to maintain a therapeutic exposure, for 50 or 90 kg body weight, respectively. CONCLUSIONS Our study investigates the nonlinear elimination of eculizumab and discusses the importance of accounting for eculizumab target-mediated elimination in therapeutic drug monitoring.
Collapse
Affiliation(s)
- Olivier Le Tilly
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
| | - Philippe Gatault
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Nephrology, Arterial Hypertension, Dialysis and Transplant Department, CHRU Tours, Tours, France
| | | | - Rebecca Sberro-Soussan
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research, Paris, France
| | | | - Dominique Bertrand
- Nephrology Department and Transplantation Center, Rouen University Hospital, Rouen, France
| | - Céline Desvignes
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, Strasbourg University Hospital, Strasbourg, France
| | - Gilles Paintaud
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| | - Jean-Michel Halimi
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Nephrology, Arterial Hypertension, Dialysis and Transplant Department, CHRU Tours, Tours, France
| | - David Ternant
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| |
Collapse
|
7
|
Sonnentag SJ, Dopler A, Kleiner K, Garg BK, Mannes M, Späth N, Akilah A, Höchsmann B, Schrezenmeier H, Anliker M, Boyanapalli R, Huber-Lang M, Schmidt CQ. Triple-fusion protein (TriFu): A potent, targeted, enzyme-like inhibitor of all three complement activation pathways. J Biol Chem 2024; 300:105784. [PMID: 38401844 PMCID: PMC11065761 DOI: 10.1016/j.jbc.2024.105784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024] Open
Abstract
The introduction of a therapeutic anti-C5 antibody into clinical practice in 2007 inspired a surge into the development of complement-targeted therapies. This has led to the recent approval of a C3 inhibitory peptide, an antibody directed against C1s and a full pipeline of several complement inhibitors in preclinical and clinical development. However, no inhibitor is available that efficiently inhibits all three complement initiation pathways and targets host cell surface markers as well as complement opsonins. To overcome this, we engineered a novel fusion protein combining selected domains of the three natural complement regulatory proteins decay accelerating factor, factor H and complement receptor 1. Such a triple fusion complement inhibitor (TriFu) was recombinantly expressed and purified alongside multiple variants and its building blocks. We analyzed these proteins for ligand binding affinity and decay acceleration activity by surface plasmon resonance. Additionally, we tested complement inhibition in several in vitro/ex vivo assays using standard classical and alternative pathway restricted hemolysis assays next to hemolysis assays with paroxysmal nocturnal hemoglobinuria erythrocytes. A novel in vitro model of the alternative pathway disease C3 glomerulopathy was established to evaluate the potential of the inhibitors to stop C3 deposition on endothelial cells. Next to the novel engineered triple fusion variants which inactivate complement convertases in an enzyme-like fashion, stoichiometric complement inhibitors targeting C3, C5, factor B, and factor D were tested as comparators. The triple fusion approach yielded a potent complement inhibitor that efficiently inhibits all three complement initiation pathways while targeting to surface markers.
Collapse
Affiliation(s)
- Sophia J Sonnentag
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Arthur Dopler
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Katharina Kleiner
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | | | - Marco Mannes
- Institute of Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Nadja Späth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Amira Akilah
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Markus Anliker
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | | | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christoph Q Schmidt
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany; Institute of Pharmacy, Biochemical Pharmacy Group, Martin Luther University Halle-Wittenberg, Halle, Germany.
| |
Collapse
|
8
|
Kirschfink M, Frazer-Abel A, Balogh E, Goseberg S, Weiss N, Prohászka Z. External quality assurance program for diagnostic complement laboratories: evaluation of the results of the past seven years. Front Immunol 2024; 15:1368399. [PMID: 38596685 PMCID: PMC11002221 DOI: 10.3389/fimmu.2024.1368399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024] Open
Abstract
Introduction The complement external quality assurance (EQA) program was first organized in 2010 by a group of researchers working in diagnostic complement laboratories. Starting in 2016, INSTAND e.V., a German, non-profit interdisciplinary scientific medical society dedicated to providing expert EQA programs for medical laboratories, started organizing the EQAs for complement diagnostic laboratories together with the same group of experienced scientists and doctors who also work as EQA experts. The aim of the current work is to provide descriptive analysis of the past seven years' complement EQA results and evaluate timeline changes in proficiency testing. Methods Each year, in March and October, blinded samples (normal, pathological) were sent to the participating diagnostic laboratories, where complement parameters were evaluated exactly as in daily routine samples. Since no reference method/target values exist for these parameters, and participants used different units for measurement, the reported results were compared to the stable mean (Algorithm A) of the participants using the same method/measurement units. A reported result was qualified as "passed" if it fell into the 30-50% evaluation/target range around the mean of reported results (depending on the given parameter). Results While the number of participating laboratories has increased in the past years (from around 120 to 347), the number of complement laboratories providing multiple determinations remained mostly unchanged (around 30 worldwide). C3, C4, C1-inhibitor antigen and activity determinations provided the best proficiency results, with >90% passing quotas in the past years, independent of the applied method. Determination of the functional activity of the three activation pathways was good in general, but results showed large variance, especially with the pathological samples. Complement factor C1q and regulators FH and FI are determined by only a few laboratories, with variable outcomes (in general in the 85-90% pass range). Activation products sC5b-9 and Bb were determined in 30 and 10 laboratories, respectively, with typical passing quotas in the 70-90% range, without a clear tendency over the past years. Conclusion With these accumulated data from the past seven years, it is now possible to assess sample-, method-, and evaluation related aspects to further improve proficiency testing and protocolize diagnostic complement determinations.
Collapse
Affiliation(s)
- Michael Kirschfink
- Institute of Immunology, University of Heidelberg, Heidelberg, Germany
- Instand eV, Düsseldorf, Germany
| | | | - Emese Balogh
- Department of Pharmaceutics, Semmelweis University, Budapest, Hungary
| | | | | | - Zoltán Prohászka
- Instand eV, Düsseldorf, Germany
- Department of Internal Medicine and Hematology, Füst György Complement Diagnostic Laboratory, Semmelweis University, Budapest, Hungary
| |
Collapse
|
9
|
Kinoshita K, Maenaka A, Rosales IA, Karadagi A, Tomosugi T, Ayares D, Lederman S, Colvin RB, Kawai T, Pierson RN, Kobayashi T, Cooper DKC. Novel factors potentially initiating acute antibody-mediated rejection in pig kidney xenografts despite an efficient immunosuppressive regimen. Xenotransplantation 2024; 31:e12859. [PMID: 38646924 DOI: 10.1111/xen.12859] [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: 01/31/2024] [Revised: 03/08/2024] [Accepted: 03/28/2024] [Indexed: 04/23/2024]
Abstract
Antibody-mediated rejection (AMR) is a common cause of graft failure after pig-to-nonhuman primate organ transplantation, even when the graft is from a pig with multiple genetic modifications. The specific factors that initiate AMR are often uncertain. We report two cases of pig kidney transplantation into immunosuppressed baboons in which we identify novel factors associated with the initiation of AMR. In the first, membranous nephropathy was the initiating factor that was then associated with the apparent loss of the therapeutic anti-CD154 monoclonal antibody in the urine when severe proteinuria was present. This observation suggests that proteinuria may be associated with the loss of any therapeutic monoclonal antibody, for example, anti-CD154 or eculizumab, in the urine, resulting in xenograft rejection. In the second case, the sequence of events and histopathology tentatively suggested that pyelonephritis may have initiated acute-onset AMR. The association of a urinary infection with graft rejection has been well-documented in ABO-incompatible kidney allotransplantation based on the expression of an antigen on the invading microorganism shared with the kidney graft, generating an immune response to the graft. To our knowledge, these potential initiating factors of AMR in pig xenografts have not been highlighted previously.
Collapse
Affiliation(s)
- Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Karadagi
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Toshihide Tomosugi
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Tatsuo Kawai
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Takaaki Kobayashi
- Department of Transplantation, Aichi Medical University, Nagakute, Japan
| | - David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Parra AP, Ramos N, Perurena-Prieto J, Manrique-Rodríguez S, Climente M, Quintanilla LG, Escolano Á, Miarons M. [Translated article] Pharmacokinetics of eculizumab in adult and pediatric patients with atypical hemolytic uremic syndrome and C3 glomerulopathy. FARMACIA HOSPITALARIA 2024; 48:T16-T22. [PMID: 38057242 DOI: 10.1016/j.farma.2023.09.009] [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: 02/25/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE The objective of the study was to analyze and describe the concentrations of eculizumab and the complement blockade in patients with atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy, and to define a therapeutic margin where there is a high probability of achieving therapeutic efficacy. METHODS Observational, ambispective, and multicenter study that included adult and pediatric patients diagnosed with aHUS and C3 glomerulopathy from September 2020 to October 2022 in 5 hospitals in Spain. Eculizumab was administered at the doses recommended by the data sheet according to the European Medicines Agency (EMA). Pre- and post-dose concentrations of eculizumab were determined, as well as blockade of the classical complement pathway (CH50). Sociodemographic and clinical data were collected, and pharmacokinetic parameters were calculated. To establish the cut-off point for eculizumab concentrations that predicted complement blockade, Receiver Operating Characteristic (ROC) curve analysis was performed. Lastly, the Kruskal-Wallis test was used to contrast the differences in different parameters according to eculizumab concentrations. RESULTS Twenty-five patients were included, 19 adults (76.0%) and 6 pediatrics (24.0%), with median ages of 43.4 (interquartile range (IQR) 35.7-48.8) and 10.1 (IQR 9.6-11.3) years, respectively. Of these, 22 (88.0%) patients were diagnosed with aHUS and 3 (12.0%) with C3 glomerulopathy. A total of 111 eculizumab concentrations were determined. Mean pre- and post-dose concentration values detected during the maintenance phase were 243.8 (SD 240.6) μg/mL and 747.4 (standard deviation (SD) 444.3) μg/mL, respectively. Increased complement blockade was observed at higher pre-dose concentrations (P = .002) and decreased serum creatinine at both higher pre- and post-dose concentrations (P = .001 and P = .017, respectively). Using ROC curves, it was determined that a pre-dose concentration >149.0 μg/mL was optimal to achieve complement blockade, with an AUC of 0.87 (0.78-0.95). Finally, high inter-individual (48.9% variation coefficient (CV)) with low intra-individual variabilities (11.9% CV) in eculizumab clearance were observed. CONCLUSIONS The present study reports supratherapeutic concentrations of eculizumab in patients with aHUS, and defines higher concentrations than those described in the data sheet to achieve blockade, thus encouraging the personalization of treatment with eculizumab.
Collapse
Affiliation(s)
- Alba Pau Parra
- Servicio de Farmacia, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Natalia Ramos
- Servicio de Nefrología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Janire Perurena-Prieto
- Servicio de Inmunología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Monica Climente
- Servicio de Farmacia, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Laura García Quintanilla
- Servicio de Farmacia, Área Sanitaria de Santiago de Compostela e Barbanza (SERGAS), Santiago de Compostela, Galicia, Spain
| | - Ángel Escolano
- Servicio de Farmacia, Hospital Universitario Miguel Servet, Aragón, Spain
| | - Marta Miarons
- Servicio de Farmacia, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| |
Collapse
|
11
|
Pau Parra A, Ramos N, Perurena-Prieto J, Manrique-Rodríguez S, Climente M, García Quintanilla L, Escolano Á, Miarons M. Pharmacokinetics of eculizumab in adult and pediatric patients with atypical hemolytic uremic syndrome and C3 glomerulopathy. FARMACIA HOSPITALARIA 2024; 48:16-22. [PMID: 37612186 DOI: 10.1016/j.farma.2023.07.009] [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: 02/25/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE The objective of the study was to analyze and describe the concentrations of eculizumab and the complement blockade in patients with atypical hemolytic uremic syndrome (aHUS) and C3 glomerulopathy, and to define a therapeutic margin where there is a high probability of achieving therapeutic efficacy. METHODS Observational, ambispective and multicenter study that included adult and pediatric patients diagnosed with aHUS and C3 glomerulopathy from September 2020 to October 2022 in five hospitals in Spain. Eculizumab was administered at the doses recommended by the data sheet according to the European Medicines Agency (EMA). Pre-dose and post-dose concentrations of eculizumab were determined, as well as blockade of the classical complement pathway (CH50). Sociodemographic and clinical data were collected, and pharmacokinetic parameters were calculated. To establish the cut-off point for eculizumab concentrations that predicted complement blockade, Receiver Operating Characteristic (ROC) curve analysis was performed. Lastly, the Kruskal-Wallis test was used to contrast the differences in different parameters according to eculizumab concentrations. RESULTS Twenty-five patients were included, 19 adults (76.0%) and 6 pediatrics (24.0%), with median ages of 43.4 (IQR 35.7-48.8) and 10.1 (IQR 9.6-11.3) years, respectively. Of these, 22 (88.0%) patients were diagnosed with aHUS and 3 (12.0%) with C3 glomerulopathy. A total of 111 eculizumab concentrations were determined. Mean pre-dose and post-dose concentration values detected during the maintenance phase were 243.8 (SD 240.6) μg/mL and 747.4 (SD 444.3) μg/mL, respectively. Increased complement blockade was observed at higher pre-dose concentrations (p=0.002) and decreased serum creatinine at both higher pre- and post-dose concentrations (p=0.001 and p=0.017, respectively). Using ROC curves, it was determined that a pre-dose concentration >149.0 μg/mL was optimal to achieve complement blockade, with an AUC of 0.87 (0.78-0.95). Finally, high inter-individual (48.9% CV) with low intra-individual variabilities (11.9% CV) in eculizumab clearance were observed. CONCLUSIONS The present study reports supratherapeutic concentrations of eculizumab in patients with aHUS, and defines higher concentrations than those described in the data sheet to achieve blockade, thus encouraging the personalization of treatment with eculizumab.
Collapse
Affiliation(s)
- Alba Pau Parra
- Servicio de Farmacia, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, España
| | - Natalia Ramos
- Servicio de Nefrología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, España
| | - Janire Perurena-Prieto
- Servicio de Inmunología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, España
| | | | - Monica Climente
- Servicio de Farmacia, Hospital Universitario Doctor Peset, Valencia, España
| | - Laura García Quintanilla
- Servicio de Farmacia, Área Sanitaria de Santiago de Compostela e Barbanza (SERGAS), Santiago de Compostela, Galicia, España
| | - Ángel Escolano
- Servicio de Farmacia, Hospital Universitario Miguel Servet, Aragón, España
| | - Marta Miarons
- Servicio de Farmacia, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, España.
| |
Collapse
|
12
|
Riedl Khursigara M, Chung E, Tjon J, Noone D, Chami R, Licht C, Teoh CW. Utilizing therapeutic drug monitoring to optimize therapy with eculizumab and mycophenolate mofetil in a child with C3 glomerulonephritis. Pediatr Nephrol 2023; 38:3483-3487. [PMID: 36884075 DOI: 10.1007/s00467-023-05927-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/26/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND C3 glomerulonephritis (C3GN) can be a devastating disease with poor response to immunosuppressive therapy. Complement inhibition with eculizumab has had equivocal results in patients with C3GN. CASE-DIAGNOSIS/TREATMENT We report a case of a 6-year-old boy with C3GN presenting with nephrotic syndrome, severe hypertension and impaired kidney function. He did not respond to initial treatment with prednisone and mycophenolate (mofetil and sodium), and subsequent treatment with standard dosing of eculizumab. Pharmacokinetic studies identified a lack of eculizumab exposure and subsequent intensification of treatment with weekly dosing of eculizumab led to significant clinical improvement: his kidney function normalized, hypertension (weaned off 3 antihypertensive drugs), edema and proteinuria improved. Additionally, exposure to mycophenolic acid (MPA), active metabolite of mycophenolate, determined by area under the concentration-time curve of MPA was low throughout, despite significant dosing escalation. CONCLUSIONS This case report demonstrates that individualized therapy guided by therapeutic drug monitoring might be needed in patients with nephrotic range proteinuria treated with eculizumab and mycophenolate (mofetil and sodium), an important finding that needs to be considered for further treatment trials.
Collapse
Affiliation(s)
| | - Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - James Tjon
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, 555 University Ave, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Rose Chami
- Division of Pathology, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, 555 University Ave, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, 555 University Ave, Toronto, Canada.
- Department of Paediatrics, University of Toronto, Toronto, Canada.
| |
Collapse
|
13
|
Garnier A, Brochard K, Kwon T, Sellier-Leclerc AL, Lahoche A, Launay EA, Nobili F, Caillez M, Taque S, Harambat J, Michel-Bourdat G, Guigonis V, Fila M, Cloarec S, Djamal-Dine D, de Parscaux L, Allard L, Salomon R, Ulinski T, Frémeaux-Bacchi V, Morin C, Olivier-Abbal P, Colineaux H, Auriol F, Arnaud C, Kieffer I, Brusq C. Efficacy and Safety of Eculizumab in Pediatric Patients Affected by Shiga Toxin-Related Hemolytic and Uremic Syndrome: A Randomized, Placebo-Controlled Trial. J Am Soc Nephrol 2023; 34:1561-1573. [PMID: 37303085 PMCID: PMC10482062 DOI: 10.1681/asn.0000000000000182] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/21/2023] [Indexed: 06/13/2023] Open
Abstract
SIGNIFICANCE STATEMENT Shiga toxin-related hemolytic uremic syndrome (STEC-HUS) is a serious condition, characterized by multiorgan thrombotic microangiopathy, mainly affecting children. Renal involvement is severe, with approximately half of patients requiring dialysis. So far, no specific treatment has been proven efficient in STEC-HUS. The use of eculizumab, a monoclonal antibody inhibiting terminal complement complex, has demonstrated remarkable success in atypical hemolytic uremic syndrome, but its use in uncontrolled studies to treat STEC-HUS has yielded inconsistent results. In this Phase 3 randomized, placebo-controlled trial in 100 pediatric patients with STEC-HUS, the findings did not show efficacy of eculizumab during the acute phase of the disease. However, the results indicated a reduction of renal sequelae in eculizumab-treated patients at 1-year follow-up. Larger prospective studies would be needed to further explore eculizumab as a potential treatment. BACKGROUND Shiga toxin-related hemolytic uremic syndrome (STEC-HUS) in children is a severe condition, resulting in approximately 50% of patients requiring RRT. Furthermore, at least 30% of survivors experience kidney sequelae. Recently, activation of the complement alternative pathway has been postulated as a factor in STEC-HUS pathophysiology, leading to compassionate use of eculizumab, a monoclonal antibody inhibiting the terminal complement complex, in affected patients. Given the lack of therapy for STEC-HUS, a controlled study of eculizumab efficacy in treating this condition is a priority. METHODS We conducted a Phase 3 randomized trial of eculizumab in children with STEC-HUS. Patients were randomly assigned in a 1:1 ratio to receive either eculizumab or placebo during 4 weeks. Follow-up lasted for 1 year. The primary end point was RRT duration <48 hours after randomization. Secondary endpoints included hematologic and extrarenal involvement. RESULTS Baseline characteristics were similar among the 100 patients who underwent randomization. The rate of RRT <48 hours did not differ significantly between the two groups (48% in the placebo versus 38% in the eculizumab group; P = 0.31) or in the course of ARF. The two groups also exhibited similar hematologic evolution and extrarenal manifestations of STEC-HUS. The proportion of patients experiencing renal sequelae at 1 year was lower in the eculizumab group than in the placebo group (43.48% and 64.44%, respectively, P = 0.04). No safety concern was reported. CONCLUSIONS In pediatric patients with STEC-HUS, eculizumab treatment does not appear to be associated with improved renal outcome during acute phase of the disease but may reduce long-term kidney sequelae. CLINICAL TRIALS REGISTRATIONS EUDRACT (2014-001169-28) ClinicalTrials.gov ( NCT02205541 ).
Collapse
Affiliation(s)
- Arnaud Garnier
- Department of Pediatric Nephrology, Hôpital des Enfants, CHU Toulouse, Toulouse, France
| | - Karine Brochard
- Department of Pediatric Nephrology, Hôpital des Enfants, CHU Toulouse, Toulouse, France
| | - Theresa Kwon
- Department of Pediatric Nephrology, Hôpital Robert Debré, Paris, France
| | | | - Annie Lahoche
- Department of Pediatric Nephrology, Hôpital Jeanne de Flandre, Lille, France
| | | | - François Nobili
- Department of Pediatric Nephrology, CHU Besançon, Besançon, France
| | - Mathilde Caillez
- Department of Pediatric Nephrology, Hôpital La Timone, Marseille, France
| | - Sophie Taque
- Department of Pediatric Nephrology, CHU Anne de Bretagne, Rennes, France
| | - Jerôme Harambat
- Department of Pediatric Nephrology, CHU Pellegrin, Bordeaux, France
| | | | - Vincent Guigonis
- Department of Pediatric Nephrology, Hôpital de la Mère et de l’Enfant, Limoges, France
| | - Marc Fila
- Department of Pediatric Nephrology, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Sylvie Cloarec
- Department of Pediatric Nephrology, CHRU Clocheville, Tours, France
| | | | - Loïc de Parscaux
- Department of Pediatrics and Genetics, CHU Morvan, Brest, France
| | - Lise Allard
- Department of Pediatric Nephrology, CHU Angers, Angers, France
| | - Rémi Salomon
- Department of Pediatric Nephrology, Hôpital Necker-Enfants Malades, Paris, France
| | - Tim Ulinski
- Department of Pediatric Nephrology, Hôpital Trousseau, Paris, France
| | | | | | | | | | - Françoise Auriol
- Unit of Pediatric Clinical Research, CIC1436, Hôpital des Enfants, CHU Toulouse, Toulouse, France
| | | | - Isabelle Kieffer
- Unit of Pediatric Clinical Research, CIC1436, Hôpital des Enfants, CHU Toulouse, Toulouse, France
| | - Clara Brusq
- Clinical Epidemiology Unit, CHU Toulouse, Toulouse, France
| |
Collapse
|
14
|
ter Avest M, Steenbreker H, Bouwmeester RN, Duineveld C, Wijnsma KL, van den Heuvel LP, Langemeijer SM, Wetzels JF, van de Kar NC, ter Heine R. Proteinuria and Exposure to Eculizumab in Atypical Hemolytic Uremic Syndrome. Clin J Am Soc Nephrol 2023; 18:759-766. [PMID: 36913245 PMCID: PMC10278783 DOI: 10.2215/cjn.0000000000000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/28/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Eculizumab is a monoclonal antibody for the treatment of atypical hemolytic uremic syndrome (aHUS). Kidney damage, a common condition in patients with aHUS, may result in proteinuria. Because proteinuria may affect the pharmacokinetics of therapeutic proteins such as eculizumab, the aim of our study was to investigate the effect of proteinuria on eculizumab pharmacokinetics. METHODS This study was an ancillary study of a previously performed pharmacokinetic-pharmacodynamic study of eculizumab in aHUS. Proteinuria, measured as urinary protein-creatinine ratios (UPCR), was investigated as covariate for eculizumab clearance. Thereafter, we evaluated the effect of proteinuria on the exposure to eculizumab in a simulation study for the initial phase and for a 2-weekly and 3-weekly interval in the maintenance phase. RESULTS The addition of UPCR as a linear covariate on clearance to our base model resulted in a statistically improved fit ( P < 0.001) and reduction of unexplained variability in clearance. From our data, we predicted that in the initial phase, 16% of the adult patients with severe proteinuria (UPCR >3.1 g/g) will have inadequate complement inhibition (classical pathway activity >10%) on day 7 of treatment, compared with 3% of the adult patients without proteinuria. None of the pediatric patients will have inadequate complement inhibition at day 7 of treatment. For the 2- and 3-weekly dosing intervals, we predicted that, respectively, 18% and 49% of the adult patients and, respectively, 19% and 57% of the pediatric patients with persistent severe proteinuria will have inadequate complement inhibition, compared with, respectively, 2% and 13% of the adult patients and, respectively, 4% and 22% of the pediatric patients without proteinuria. CONCLUSIONS Severe proteinuria is associated with a higher risk of underexposure to eculizumab. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER CUREiHUS, Dutch Trial Register, NTR5988/NL5833.
Collapse
Affiliation(s)
- Mendy ter Avest
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hilbert Steenbreker
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Romy N. Bouwmeester
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kioa L. Wijnsma
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lambertus P.W.J. van den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jack F.M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole C.A.J. van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
15
|
Erger F, Aryal RP, Reusch B, Matsumoto Y, Meyer R, Zeng J, Knopp C, Noel M, Muerner L, Wenzel A, Kohl S, Tschernoster N, Rappl G, Rouvet I, Schröder-Braunstein J, Seibert FS, Thiele H, Häusler MG, Weber LT, Büttner-Herold M, Elbracht M, Cummings SF, Altmüller J, Habbig S, Cummings RD, Beck BB. Germline C1GALT1C1 mutation causes a multisystem chaperonopathy. Proc Natl Acad Sci U S A 2023; 120:e2211087120. [PMID: 37216524 PMCID: PMC10235935 DOI: 10.1073/pnas.2211087120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 03/28/2023] [Indexed: 05/24/2023] Open
Abstract
Mutations in genes encoding molecular chaperones can lead to chaperonopathies, but none have so far been identified causing congenital disorders of glycosylation. Here we identified two maternal half-brothers with a novel chaperonopathy, causing impaired protein O-glycosylation. The patients have a decreased activity of T-synthase (C1GALT1), an enzyme that exclusively synthesizes the T-antigen, a ubiquitous O-glycan core structure and precursor for all extended O-glycans. The T-synthase function is dependent on its specific molecular chaperone Cosmc, which is encoded by X-chromosomal C1GALT1C1. Both patients carry the hemizygous variant c.59C>A (p.Ala20Asp; A20D-Cosmc) in C1GALT1C1. They exhibit developmental delay, immunodeficiency, short stature, thrombocytopenia, and acute kidney injury (AKI) resembling atypical hemolytic uremic syndrome. Their heterozygous mother and maternal grandmother show an attenuated phenotype with skewed X-inactivation in blood. AKI in the male patients proved fully responsive to treatment with the complement inhibitor Eculizumab. This germline variant occurs within the transmembrane domain of Cosmc, resulting in dramatically reduced expression of the Cosmc protein. Although A20D-Cosmc is functional, its decreased expression, though in a cell or tissue-specific manner, causes a large reduction of T-synthase protein and activity, which accordingly leads to expression of varied amounts of pathological Tn-antigen (GalNAcα1-O-Ser/Thr/Tyr) on multiple glycoproteins. Transient transfection of patient lymphoblastoid cells with wild-type C1GALT1C1 partially rescued the T-synthase and glycosylation defect. Interestingly, all four affected individuals have high levels of galactose-deficient IgA1 in sera. These results demonstrate that the A20D-Cosmc mutation defines a novel O-glycan chaperonopathy and causes the altered O-glycosylation status in these patients.
Collapse
Affiliation(s)
- Florian Erger
- Institute of Human Genetics, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50931Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
| | - Rajindra P. Aryal
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
| | - Björn Reusch
- Institute of Human Genetics, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50931Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
| | - Yasuyuki Matsumoto
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
| | - Robert Meyer
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, Rheinisch-Westfälische Technische Hochschule Aachen University, 52074Aachen, Germany
| | - Junwei Zeng
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
- Medical Research Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080Guangzhou, China
| | - Cordula Knopp
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, Rheinisch-Westfälische Technische Hochschule Aachen University, 52074Aachen, Germany
| | - Maxence Noel
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
| | - Lukas Muerner
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
- Institute of Pharmacology, University of Bern, 3010Bern, Switzerland
| | - Andrea Wenzel
- Institute of Human Genetics, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50931Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
| | - Stefan Kohl
- Children’s and Adolescents’ Hospital, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50937Cologne, Germany
| | - Nikolai Tschernoster
- Institute of Human Genetics, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50931Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
- Cologne Center for Genomics, University of Cologne, 50931Cologne, Germany
| | - Gunter Rappl
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
| | - Isabelle Rouvet
- Centre de Biotechnologie Cellulaire and CBC BioTec Biobank, Centre de Ressources Biologiques, Hospices Civils de Lyon, 69229Lyon, France
| | | | - Felix S. Seibert
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, 44625Herne, Germany
| | - Holger Thiele
- Cologne Center for Genomics, University of Cologne, 50931Cologne, Germany
| | - Martin G. Häusler
- Division of Neuropediatrics and Social Pediatrics, Department of Pediatrics, Medical Faculty, Rheinisch-Westfälische Technische Hochschule Aachen University, 52074Aachen, Germany
| | - Lutz T. Weber
- Children’s and Adolescents’ Hospital, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50937Cologne, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), 91054Erlangen, Germany
| | - Miriam Elbracht
- Institute for Human Genetics and Genomic Medicine, Medical Faculty, Rheinisch-Westfälische Technische Hochschule Aachen University, 52074Aachen, Germany
| | - Sandra F. Cummings
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
| | - Janine Altmüller
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
- Cologne Center for Genomics, University of Cologne, 50931Cologne, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Core Facility Genomics, 10178Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, 13125Berlin, Germany
| | - Sandra Habbig
- Children’s and Adolescents’ Hospital, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50937Cologne, Germany
| | - Richard D. Cummings
- Division of Surgical Sciences, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA02215
| | - Bodo B. Beck
- Institute of Human Genetics, University Hospital Cologne, Faculty of Medicine, University of Cologne, 50931Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, 50931Cologne, Germany
| |
Collapse
|
16
|
ter Avest M, Bouwmeester RN, Duineveld C, Wijnsma KL, Volokhina EB, van den Heuvel LPWJ, Burger DM, Wetzels JFM, van de Kar NCAJ, ter Heine R. Proposal for individualized dosing of eculizumab in atypical haemolytic uraemic syndrome: patient friendly and cost-effective. Nephrol Dial Transplant 2023; 38:362-371. [PMID: 35238929 PMCID: PMC9923710 DOI: 10.1093/ndt/gfac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Eculizumab is a lifesaving yet expensive drug for atypical haemolytic uraemic syndrome (aHUS). Current guidelines advise a fixed-dosing schedule, which can be suboptimal and inflexible in the individual patient. METHODS We evaluated the pharmacokinetics (PK) and pharmacodynamics (PD) [classical pathway (CP) activity levels] of eculizumab in 48 patients, consisting of 849 time-concentration data and 569 CP activity levels. PK-PD modelling was performed with non-linear mixed-effects modelling. The final model was used to develop improved dosing strategies. RESULTS A PK model with parallel linear and non-linear elimination rates best described the data with the parameter estimates clearance 0.163 L/day, volume of distribution 6.42 L, maximal rate 29.6 mg/day and concentration for 50% of maximum rate 37.9 mg/L. The PK-PD relation between eculizumab concentration and CP activity was described using an inhibitory Emax model with the parameter estimates baseline 101%, maximal inhibitory effect 95.9%, concentration for 50% inhibition 22.0 mg/L and Hill coefficient 5.42. A weight-based loading dose, followed by PK-guided dosing was found to improve treatment. On day 7, we predict 99.95% of the patients to reach the efficacy target (CP activity <10%), compared with 94.75% with standard dosing. Comparable efficacy was predicted during the maintenance phase, while the dosing interval could be prolonged in ∼33% of the population by means of individualized dosing. With a fixed-dose 4-week dosing interval to allow for holidays, treatment costs will increase by 7.1% and we predict 91% of the patients will reach the efficacy target. CONCLUSIONS A patient-friendly individualized dosing strategy of eculizumab has the potential to improve treatment response at reduced costs.
Collapse
Affiliation(s)
- Mendy ter Avest
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Romy N Bouwmeester
- Department of Paediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kioa L Wijnsma
- Department of Paediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Elena B Volokhina
- Department of Paediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lambertus P W J van den Heuvel
- Department of Paediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole C A J van de Kar
- Department of Paediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rob ter Heine
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
17
|
Pharmacological Management of Atypical Hemolytic Uremic Syndrome in Pediatric Patients: Current and Future. Paediatr Drugs 2023; 25:193-202. [PMID: 36637720 PMCID: PMC9839393 DOI: 10.1007/s40272-022-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
Atypical hemolytic uremic syndrome is a thrombotic microangiopathy characterized by hemolysis, thrombocytopenia, and acute kidney injury, usually caused by alternative complement system overactivation due to pathogenic genetic variants or antibodies to components or regulatory factors in this pathway. Previously, a lack of effective treatment for this condition was associated with mortality, end-stage kidney disease, and the risk of disease recurrence after kidney transplantation. Plasma therapy has been used for atypical hemolytic uremic syndrome treatment with inconsistent results. Complement-blocking treatment changed the outcome and prognosis of patients with atypical hemolytic uremic syndrome. Early administration of eculizumab, a monoclonal C5 antibody, leads to improvements in hematologic, kidney, and systemic manifestations in patients with atypical hemolytic uremic syndrome, even with apparent dialysis dependency. Pre- and post-transplant use of eculizumab is effective in the prevention of atypical hemolytic uremic syndrome recurrence. Evidence on eculizumab use in secondary hemolytic uremic syndrome cases is controversial. Recent data favor the restrictive use of eculizumab in carefully selected atypical hemolytic uremic syndrome cases, but close monitoring for relapse after drug discontinuation is emphasized. Prophylaxis for meningococcal infection is important. The long-acting C5 monoclonal antibody ravulizumab is now approved for atypical hemolytic uremic syndrome treatment, enabling a reduction in the dosing frequency and improving the quality of life in patients with atypical hemolytic uremic syndrome. New strategies for additional and novel complement blockage medications in atypical hemolytic uremic syndrome are under investigation.
Collapse
|
18
|
Kolev M, Barbour T, Baver S, Francois C, Deschatelets P. With complements: C3 inhibition in the clinic. Immunol Rev 2023; 313:358-375. [PMID: 36161656 DOI: 10.1111/imr.13138] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
C3 is a key complement protein, located at the nexus of all complement activation pathways. Extracellular, tissue, cell-derived, and intracellular C3 plays critical roles in the immune response that is dysregulated in many diseases, making it an attractive therapeutic target. However, challenges such as very high concentration in blood, increased acute expression, and the elevated risk of infections have historically posed significant challenges in the development of C3-targeted therapeutics. This is further complicated because C3 activation fragments and their receptors trigger a complex network of downstream effects; therefore, a clear understanding of these is needed to provide context for a better understanding of the mechanism of action (MoA) of C3 inhibitors, such as pegcetacoplan. Because of C3's differential upstream position to C5 in the complement cascade, there are mechanistic differences between pegcetacoplan and eculizumab that determine their efficacy in patients with paroxysmal nocturnal hemoglobinuria. In this review, we compare the MoA of pegcetacoplan and eculizumab in paroxysmal nocturnal hemoglobinuria and discuss the complement-mediated disease that might be amenable to C3 inhibition. We further discuss the current state and outlook for C3-targeted therapeutics and provide our perspective on which diseases might be the next success stories in the C3 therapeutics journey.
Collapse
Affiliation(s)
- Martin Kolev
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | - Tara Barbour
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | - Scott Baver
- Apellis Pharmaceuticals, Waltham, Massachusetts, USA
| | | | | |
Collapse
|
19
|
Schmidt CQ, Smith RJH. Protein therapeutics and their lessons: Expect the unexpected when inhibiting the multi-protein cascade of the complement system. Immunol Rev 2023; 313:376-401. [PMID: 36398537 PMCID: PMC9852015 DOI: 10.1111/imr.13164] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Over a century after the discovery of the complement system, the first complement therapeutic was approved for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). It was a long-acting monoclonal antibody (aka 5G1-1, 5G1.1, h5G1.1, and now known as eculizumab) that targets C5, specifically preventing the generation of C5a, a potent anaphylatoxin, and C5b, the first step in the eventual formation of membrane attack complex. The enormous clinical and financial success of eculizumab across four diseases (PNH, atypical hemolytic uremic syndrome (aHUS), myasthenia gravis (MG), and anti-aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorder (NMOSD)) has fueled a surge in complement therapeutics, especially targeting diseases with an underlying complement pathophysiology for which anti-C5 therapy is ineffective. Intensive research has also uncovered challenges that arise from C5 blockade. For example, PNH patients can still face extravascular hemolysis or pharmacodynamic breakthrough of complement suppression during complement-amplifying conditions. These "side" effects of a stoichiometric inhibitor like eculizumab were unexpected and are incompatible with some of our accepted knowledge of the complement cascade. And they are not unique to C5 inhibition. Indeed, "exceptions" to the rules of complement biology abound and have led to unprecedented and surprising insights. In this review, we will describe initial, present and future aspects of protein inhibitors of the complement cascade, highlighting unexpected findings that are redefining some of the mechanistic foundations upon which the complement cascade is organized.
Collapse
Affiliation(s)
- Christoph Q. Schmidt
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany
| | - Richard J. H. Smith
- Departments of Internal Medicine and Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
20
|
Brandwijk RJMGE, Michels MAHM, van Rossum M, de Nooijer AH, Nilsson PH, de Bruin WCC, Toonen EJM. Pitfalls in complement analysis: A systematic literature review of assessing complement activation. Front Immunol 2022; 13:1007102. [PMID: 36330514 PMCID: PMC9623276 DOI: 10.3389/fimmu.2022.1007102] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background The complement system is an essential component of our innate defense and plays a vital role in the pathogenesis of many diseases. Assessment of complement activation is critical in monitoring both disease progression and response to therapy. Complement analysis requires accurate and standardized sampling and assay procedures, which has proven to be challenging. Objective We performed a systematic analysis of the current methods used to assess complement components and reviewed whether the identified studies performed their complement measurements according to the recommended practice regarding pre-analytical sample handling and assay technique. Results are supplemented with own data regarding the assessment of key complement biomarkers to illustrate the importance of accurate sampling and measuring of complement components. Methods A literature search using the Pubmed/MEDLINE database was performed focusing on studies measuring the key complement components C3, C5 and/or their split products and/or the soluble variant of the terminal C5b-9 complement complex (sTCC) in human blood samples that were published between February 2017 and February 2022. The identified studies were reviewed whether they had used the correct sample type and techniques for their analyses. Results A total of 92 out of 376 studies were selected for full-text analysis. Forty-five studies (49%) were identified as using the correct sample type and techniques for their complement analyses, while 25 studies (27%) did not use the correct sample type or technique. For 22 studies (24%), it was not specified which sample type was used. Conclusion A substantial part of the reviewed studies did not use the appropriate sample type for assessing complement activation or did not mention which sample type was used. This deviation from the standardized procedure can lead to misinterpretation of complement biomarker levels and hampers proper comparison of complement measurements between studies. Therefore, this study underlines the necessity of general guidelines for accurate and standardized complement analysis
Collapse
Affiliation(s)
| | - Marloes A. H. M. Michels
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mara van Rossum
- R&D Department, Hycult Biotechnology b.v., Uden, Netherlands
| | - Aline H. de Nooijer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Per H. Nilsson
- Department of Immunology, University of Oslo and Oslo University Hospital Rikshospitalet, Oslo, Norway
- Linnaeus Centre for Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
- Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden
| | | | - Erik J. M. Toonen
- R&D Department, Hycult Biotechnology b.v., Uden, Netherlands
- *Correspondence: Erik J. M. Toonen,
| |
Collapse
|
21
|
Ponce A, Rodríguez-Pintó I, Basauli JM, Espinosa G, Erkan D, Shoenfeld Y, Cervera R. The clinical significance of low complement levels in patients with catastrophic antiphospholipid syndrome: A descriptive analysis of 73 patients from the "Catastrophic antiphospholipid syndrome registry". Lupus 2022; 31:1218-1225. [PMID: 35686348 DOI: 10.1177/09612033221107583] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To explore the prevalence and clinical significance of low complement levels in patients with catastrophic antiphospholipid syndrome (CAPS). METHODS We reviewed data from the "CAPS Registry" on C3 and/or C4 complement plasma protein levels during acute CAPS episodes. Patients were classified into those with low and normal complement levels. Data on clinical presentation, with special focus on thrombotic microangiopathy (TMA) features, diagnosis of systemic lupus erythematosus (SLE), and antiphospholipid antibody (aPL) profile were reviewed. The chi-square exact test was performed to evaluate differences between categorical data. RESULTS The "CAPS Registry" includes 566 patients with a total of 578 episodes of CAPS. Data on complement plasma protein levels was available in 73 episodes from the same number of patients. Low levels of C3 and/or C4 complement plasma proteins were detected in 42 (58%) CAPS episodes. Low complement levels were more common in SLE patients (55% SLE vs. 19% No SLE; p<0.001). The frequencies of clinical TMA (72% vs. 80%; p=0.4) or TMA syndrome (86% vs. 84%, p=0.9), frequency of triple aPL triple positivity (67% vs 33%; p=0.3), or the mortality (35% vs. 31%; p=0.7) were similar between low and normal complement groups. CONCLUSION In our study, low levels of C3 and C4 plasma proteins are detected in 58% episodes of CAPS, which were not associated with clinical presentation including TMA features, aPL triple positivity, or mortality.
Collapse
Affiliation(s)
- Ana Ponce
- Autoimmune Diseases Unit, 16496Hospital de Viladecans, Viladecans, Spain
| | - Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, 58955Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - José M Basauli
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, 26744Sheba Medical Center, Tel-Hashomer, Israel.,Ariel University, Ariel, Israel
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | | |
Collapse
|
22
|
Kulasekararaj A, Glasmacher A, Liu P, Szer J, Araten D, Rauch G, Gwaltney C, Sierra JR, Lee JW. Composite endpoint to evaluate complement inhibition therapy in patients with paroxysmal nocturnal hemoglobinuria. Eur J Haematol Suppl 2022; 108:391-402. [PMID: 35100459 PMCID: PMC9311164 DOI: 10.1111/ejh.13746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/16/2022]
Abstract
This study developed and explored a novel composite endpoint to assess the overall impact that treatment can have on patients living with paroxysmal nocturnal hemoglobinuria (PNH). Candidate composite endpoint variables were selected by a group of experts and included: lactate dehydrogenase levels as a measure of intravascular hemolysis; complete terminal complement inhibition; absence of major adverse vascular events, including thrombosis; absence of any adverse events leading to death or discontinuation of study treatment; transfusion avoidance; and improvements in fatigue‐related quality of life as determined by the Functional Assessment of Chronic Illness Therapy (FACIT)‐Fatigue score. From these variables, a novel composite endpoint was constructed and explored using data collected in the ravulizumab PNH Study 301 (NCT02946463). Thresholds were defined and reported for each candidate variable. Five of the six candidate variables were included in the final composite endpoint; the FACIT‐Fatigue score was excluded. Composite endpoint criterion was defined as patients meeting all five selected individual component thresholds. All patients in the ravulizumab arm achieved complete terminal complement inhibition and a reduction in lactate dehydrogenase levels; 51.2% and 41.3% of patients in the ravulizumab arm and eculizumab arm, respectively, achieved all composite endpoint component thresholds (treatment difference: 9.4%; 95% confidence interval: −3.0, 21.5). The composite endpoint provided a single and simultaneous measurement of overall benefit for patients receiving treatment for PNH. Use of the composite endpoint in future PNH research is recommended to determine clinical benefit, and its use in health technology assessments should be evaluated.
Collapse
Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital, King's College London, and NIHR/Wellcome Trust King's Clinical Research Facility, London, UK
| | - Axel Glasmacher
- AG Life Science Consulting, Alfter, Germany.,Department of Medicine III, University of Bonn, Bonn, Germany
| | - Peng Liu
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Jeff Szer
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - David Araten
- New York University Grossman School of Medicine, New York, New York, USA
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chad Gwaltney
- Gwaltney Consulting, Westerly, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | | | - Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
23
|
Kawano N, Abe T, Ikeda N, Nagahiro Y, Kawano S, Tochigi T, Nakaike T, Yamashita K, Kubo K, Yamanaka A, Terasaka S, Marutsuka K, Mashiba K, Kikuchi I, Shimoda K, Matsumoto M, Ochiai H. Clinical features and outcomes of four atypical hemolytic uremic syndrome cases at a single institution in Miyazaki Prefecture from 2015 to 2019. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although atypical hemolytic uremic syndrome (aHUS) is a life-threatening clinical entity that was characterized by thrombotic microangiopathy (TMA) with the activation of the complement system and the efficient treatment of eculizumab, the clinical features of aHUS have been unclear because of the rare incidence.
Case presentation
We retrospectively analyzed 4 aHUS cases at a single institution during 2015–2019. Here, we presented 4 aHUS cases with renal transplantation (one case), influenza/acute interstitial pneumonia/disseminated intravascular coagulation (two cases), and severe fever with thrombocytopenia syndrome (one case), respectively. Initial clinical symptoms were microangiopathic hemolytic anemia (four cases), renal dysfunction (four cases), thrombocytopenia (four cases), and pulmonary hemorrhage (three cases) consisted with TMA features. Subsequent further examinations ruled out thrombotic thrombocytopenic purpura, Shiga toxin-producing E.coli-induced hemolytic uremic syndrome, and secondary TMA. Taken these findings together, we made the clinical diagnosis of aHUS. Furthermore, all cases also presented the high levels of plasma soluble C5b-9 (871.1 ng/ml, 1144.3 ng/ml, 929.2 ng/ml, and 337.5 ng/ml), suggesting persistent activation of complementary system. Regarding the treatment, plasma exchange (PE) (four cases) and eculizumab (two cases) therapy were administered for aHUS cases. Consequently, case 2 and case 4 were still alive with 768 days and 235 days, respectively. The other two cases were dead at 34 days and 13 days, respectively. Finally, although the previous reported genetic pathogenetic mutations were not detected in our cases, multiple genetic variants of complement factors were detected as CFH (H402Y, E936D), and THBD (A473V) in case 1, CFH (V62I, H402Y, V837I) in case 2, and CFH (H402Y, E 936D) and THBD (A473V) in case 3, CFH (V62I, H402Y, E936D) and THBD (473V) in case 4, respectively.
Conclusions
Because of still high mortality in our study, an urgent diagnosis of aHUS and subsequent immediate treatment including PE and eculizumab should be essential in clinical practice. Furthermore, the multiple genetic variants and the triggers may be related to one of the pathogenesis of aHUS. Thus, we assume that such a case-oriented study would be highly useful to the physicians who directly care for aHUS cases in clinical practice.
Collapse
|
24
|
Bertacchi M, Parvex P, Villard J. Antibody-mediated rejection after kidney transplantation in children; therapy challenges and future potential treatments. Clin Transplant 2022; 36:e14608. [PMID: 35137982 PMCID: PMC9286805 DOI: 10.1111/ctr.14608] [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: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Abstract
Antibody‐mediated rejection (AMR) remains one of the most critical problems in renal transplantation, with a significant impact on patient and graft survival. In the United States, no treatment has received FDA approval jet. Studies about treatments of AMR remain controversial, limited by the absence of a gold standard and the difficulty in creating large, multi‐center studies. These limitations emerge even more in pediatric transplantation because of the limited number of pediatric studies and the occasional use of some therapies with unknown and poorly documented side effects. The lack of recommendations and the unsharp definition of different forms of AMR contribute to the challenging management of the therapy by pediatric nephrologists. In an attempt to help clinicians involved in the care of renal transplanted children affected by an AMR, we rely on the latest recommendations of the Transplantation Society (TTS) for the classification and treatment of AMR to describe treatments available today and potential new treatments with a particular focus on the pediatric population.
Collapse
Affiliation(s)
| | - Paloma Parvex
- Division of Pediatric Nephrology, University Children Hospital of Geneva, Geneva, Switzerland
| | - Jean Villard
- Division of Nephrology, University Hospital of Geneva, Geneva, Switzerland.,Division of Transplantation Immunology, University Hospital of Geneva, Geneva, Switzerland
| |
Collapse
|
25
|
Baskin E, Fidan K, Gulhan B, Gulleroglu K, Canpolat N, Yilmaz A, Parmakiz G, Ozcakar BZ, Ozaltin F, Soylemezoglu O. Eculizumab treatment and discontinuation in pediatric patients with atypical hemolytic uremic syndrome: a multicentric retrospective study. J Nephrol 2022; 35:1213-1222. [DOI: 10.1007/s40620-021-01212-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
|
26
|
Abdelsalam M, Abd El Wahab AM, Nassar MK, Samaan E, Eldeep A, Abdalbary M, Tawfik M, Saleh M, Shemies RS, Sabry A. Kidneys in SARS-CoV-2 Era; a challenge of multiple faces. Ther Apher Dial 2022; 26:552-565. [PMID: 34989119 DOI: 10.1111/1744-9987.13792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION With the evolution of SARS-CoV-2 pandemic, it was believed to be a direct respiratory virus. But, its deleterious effects were observed on different body systems, including kidneys. AIM OF WORK In this review, we tried as much as we can to summarize what has been discussed in the literature about the relation between SARS-CoV-2 infection and kidneys since December, 2019. METHODS Each part of the review was assigned to one or two authors to search for relevant articles in three databases (Pubmed, Scopus and Google scholar) and collected data were summarized and revised by two independent researchers. CONCLUSION The complexity of COVID-19 pandemic and kidney could be attributed to the direct effect of SARS-CoV-2 infection on the kidneys, different clinical presentation, difficulties confronting dialysis patients, restrictions of the organ transplant programs, poor outcomes and bad prognosis in patients with known history of kidney diseases who got infected with SARS-CoV-2. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | | | | | - Emad Samaan
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Ahmed Eldeep
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt.,Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, US
| | - Mona Tawfik
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Marwa Saleh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | | | - Alaa Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| |
Collapse
|
27
|
Benoit SW, Fukuda T, VandenHeuvel K, Witte D, Fuller C, Willis J, Dixon BP, Drake KA. Case Report: Atypical HUS Presenting With Acute Rhabdomyolysis Highlights the Need for Individualized Eculizumab Dosing. Front Pediatr 2022; 10:841051. [PMID: 35281224 PMCID: PMC8906567 DOI: 10.3389/fped.2022.841051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is an ultra-rare orphan disease caused by dysregulated complement activation resulting in thrombotic microangiopathy. Although complement-mediated endothelial injury predominantly affects the renal microvasculature, extra-renal manifestations are present in a significant proportion of patients. While eculizumab has significantly improved the morbidity and mortality of this rare disease, optimizing therapeutic regimens of this highly expensive drug remains an active area of research in the treatment of aHUS. CASE PRESENTATION This report describes the case of a previously healthy 4 year-old male who presented with rhabdomyolysis preceding the development of aHUS with anuric kidney injury requiring dialysis. Clinical stabilization required increased and more frequent eculizumab doses compared with the standardized weight-based guidelines. In the maintenance phase of his disease, pharmacokinetic analysis indicated adequate eculizumab levels could be maintained with an individualized dosing regimen every 3 weeks, as opposed to standard 2 week dosing, confirmed in this patient over a 4 year follow up period. Cost analyses show that weight-based maintenance dosing costs $312,000 per year, while extending the dosing interval to every 3 weeks would cost $208,000, a savings of $104,000 per year, relative to the cost of $72,000 from more frequent eculizumab dosing during his initial hospitalization to suppress his acute disease. CONCLUSION This case exemplifies the potential of severe, multisystem involvement of aHUS presenting with extra-renal manifestations, including rhabdomyolysis as in this case, and highlights the possibility for improved clinical outcomes and higher value care with individualized eculizumab dosing in patients over the course of their disease.
Collapse
Affiliation(s)
- Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Tsuyoshi Fukuda
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Katherine VandenHeuvel
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - David Witte
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Christine Fuller
- University of Cincinnati College of Medicine, Cincinnati, OH, United States.,Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | | | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Keri A Drake
- Division of Pediatric Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
28
|
Frazer-Abel A, Kirschfink M, Prohászka Z. Expanding Horizons in Complement Analysis and Quality Control. Front Immunol 2021; 12:697313. [PMID: 34434189 PMCID: PMC8381195 DOI: 10.3389/fimmu.2021.697313] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/19/2021] [Indexed: 01/09/2023] Open
Abstract
Complement not only plays a key role in host microbial defense but also modulates the adaptive immune response through modification of T- and B-cell reactivity. Moreover, a normally functioning complement system participates in hematopoiesis, reproduction, lipid metabolism, and tissue regeneration. Because of its powerful inflammatory potential, multiple regulatory proteins are needed to prevent potential tissue damage. In clinical practice, dysregulation and overactivation of the complement system are major causes of a variety of inflammatory and autoimmune diseases ranging from nephropathies, age-related macular degeneration (AMD), and systemic lupus erythematosus (SLE) to graft rejection, sepsis, and multi-organ failure. The clinical importance is reflected by the recent development of multiple drugs targeting complement with a broad spectrum of indications. The recognition of the role of complement in diverse diseases and the advent of complement therapeutics has increased the number of laboratories and suppliers entering the field. This has highlighted the need for reliable complement testing. The relatively rapid expansion in complement testing has presented challenges for a previously niche field. This is exemplified by the issue of cross-reactivity of complement-directed antibodies and by the challenges of the poor stability of many of the complement analytes. The complex nature of complement testing and increasing clinical demand has been met in the last decade by efforts to improve the standardization among laboratories. Initiated by the IUIS/ICS Committee for the Standardization and Quality Assessment in Complement Measurements 14 rounds of external quality assessment since 2010 resulted in improvements in the consistency of testing across participating institutions, while extending the global reach of the efforts to more than 200 laboratories in 30 countries. Worldwide trends of assay availability, usage, and analytical performance are summarized based on the past years’ experiences. Progress in complement analysis has been facilitated by the quality assessment and standardization efforts that now allow complement testing to provide a comprehensive insight into deficiencies and the activation state of the system. This in turn enables clinicians to better define disease severity, evolution, and response to therapy.
Collapse
Affiliation(s)
| | | | - Zoltán Prohászka
- Department of Medicine and Hematology, Research Laboratory Semmelweis University, Budapest, Hungary
| |
Collapse
|
29
|
Complement and the prothrombotic state. Blood 2021; 139:1954-1972. [PMID: 34415298 DOI: 10.1182/blood.2020007206] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
In 2007 and 2009 the regulatory approval of the first-in-class complement inhibitor Eculizumab has revolutionized the clinical management of two rare, life-threatening clinical conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). While being completely distinct diseases affecting blood cells and the glomerulus, PNH and aHUS remarkably share several features in their etiology and clinical presentation. An imbalance between complement activation and regulation at host surfaces underlies both diseases precipitating in severe thrombotic events that are largely resistant to anti-coagulant and/or anti-platelet therapies. Inhibition of the common terminal complement pathway by Eculizumab prevents the frequently occurring thrombotic events responsible for the high mortality and morbidity observed in patients not treated with anti-complement therapy. While many in vitro and ex vivo studies elaborate numerous different molecular interactions between complement activation products and hemostasis, this review focuses on the clinical evidence that links these two fields in humans. Several non-infectious conditions with known complement involvement are scrutinized for common patterns concerning a prothrombotic statues and the occurrence of certain complement activation levels. Next to PNH and aHUS, germline encoded CD59 or CD55 deficiency (the latter causing the disease Complement Hyperactivation, Angiopathic thrombosis, and Protein-Losing Enteropathy; CHAPLE), autoimmune hemolytic anemia (AIHA), (catastrophic) anti-phospholipid syndrome (APS, CAPS) and C3 glomerulopathy are considered. Parallels and distinct features among these conditions are discussed against the background of thrombosis, complement activation, and potential complement diagnostic and therapeutic avenues.
Collapse
|
30
|
Complement inhibition at the level of C3 or C5: mechanistic reasons for ongoing terminal pathway activity. Blood 2021; 137:443-455. [PMID: 33507296 DOI: 10.1182/blood.2020005959] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022] Open
Abstract
Blocking the terminal complement pathway with the C5 inhibitor eculizumab has revolutionized the clinical management of several complement-mediated diseases and has boosted the clinical development of new inhibitors. Data on the C3 inhibitor Compstatin and the C5 inhibitors eculizumab and Coversin reported here demonstrate that C3/C5 convertases function differently from prevailing concepts. Stoichiometric C3 inhibition failed to inhibit C5 activation and lytic activity during strong classical pathway activation, demonstrating a "C3 bypass" activation of C5. We show that, instead of C3b, surface-deposited C4b alone can also recruit and prime C5 for consecutive proteolytic activation. Surface-bound C3b and C4b possess similar affinities for C5. By demonstrating that the fluid phase convertase C3bBb is sufficient to cleave C5 as long as C5 is bound on C3b/C4b-decorated surfaces, we show that surface fixation is necessary only for the C3b/C4b opsonins that prime C5 but not for the catalytic convertase unit C3bBb. Of note, at very high C3b densities, we observed membrane attack complex formation in absence of C5-activating enzymes. This is explained by a conformational activation in which C5 adopts a C5b-like conformation when bound to densely C3b-opsonized surfaces. Stoichiometric C5 inhibitors failed to prevent conformational C5 activation, which explains the clinical phenomenon of residual C5 activity documented for different inhibitors of C5. The new insights into the mechanism of C3/C5 convertases provided here have important implications for the development and therapeutic use of complement inhibitors as well as the interpretation of former clinical and preclinical data.
Collapse
|
31
|
Willrich MAV, Braun KMP, Moyer AM, Jeffrey DH, Frazer-Abel A. Complement testing in the clinical laboratory. Crit Rev Clin Lab Sci 2021; 58:447-478. [PMID: 33962553 DOI: 10.1080/10408363.2021.1907297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The complement system is the human's first line of defense against microbial pathogens because of its important housekeeping and infection/inflammation roles. It is composed of a series of soluble and cell-bound proteins that are activated in a cascade effect, similar to the coagulation pathways. There are different pattern recognizing molecules that activate the complement system in response to stimuli or threats, acting through three initiation pathways: classical, lectin, and alternative. All three activation pathways converge at the C3 component and share the terminal pathway. The main outputs of the complement system action are lytic killing of microbes, the release of pro-inflammatory anaphylatoxins, and opsonization of targets. Laboratory testing is relevant in the setting of suspected complement deficiencies, as well as in the emerging number of diseases related to dysregulation (over-activation) of complement. Most common assays measure complement lytic activity and the different complement component concentrations. Specialized testing includes the evaluation of autoantibodies against complement components, activation fragments, and genetic studies. In this review, we cover laboratory testing for complement and the conditions with complement involvement, as well as current challenges in the field.
Collapse
Affiliation(s)
| | - Karin M P Braun
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David H Jeffrey
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ashley Frazer-Abel
- Exsera Biolabs, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
32
|
Eculizumab discontinuation in children and adults with atypical hemolytic-uremic syndrome: a prospective multicenter study. Blood 2021; 137:2438-2449. [PMID: 33270832 DOI: 10.1182/blood.2020009280] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/23/2020] [Indexed: 12/21/2022] Open
Abstract
The optimal duration of eculizumab treatment in patients with atypical hemolytic uremic syndrome (aHUS) remains poorly defined. We conducted a prospective national multicenter open-label study to assess eculizumab discontinuation in children and adults with aHUS. Fifty-five patients (including 19 children) discontinued eculizumab (mean treatment duration, 16.5 months). Twenty-eight patients (51%) had rare variants in complement genes, mostly in MCP (n = 12; 22%), CFH (n = 6; 11%), and CFI (n = 6; 10%). At eculizumab discontinuation, 17 (30%) and 4 patients (7%) had stage 3 and 4 chronic kidney disease, respectively. During follow-up, 13 patients (23%; 6 children and 7 adults) experienced aHUS relapse. In multivariable analysis, female sex and presence of a rare variant in a complement gene were associated with an increased risk of aHUS relapse, whereas requirement for dialysis during a previous episode of acute aHUS was not. In addition, increased sC5b-9 plasma level at eculizumab discontinuation was associated with a higher risk of aHUS relapse in all patients and in the subset of carriers with a complement gene rare variant, both by log-rank test and in multivariable analysis. Of the 13 relapsing patients, all of whom restarted eculizumab, 11 regained their baseline renal function and 2 had a worsening of their preexisting chronic kidney disease, including 1 patient who progressed to end-stage renal disease. A strategy of eculizumab discontinuation in aHUS patients based on complement genetics is reasonable and safe. It improves the management and quality of life of a sizeable proportion of aHUS patients while reducing the cost of treatment. This trial was registered at www.clinicaltrials.gov as #NCT02574403.
Collapse
|
33
|
Budge K, Dellepiane S, Yu SMW, Cravedi P. Complement, a Therapeutic Target in Diabetic Kidney Disease. Front Med (Lausanne) 2021; 7:599236. [PMID: 33553201 PMCID: PMC7858668 DOI: 10.3389/fmed.2020.599236] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/21/2020] [Indexed: 01/15/2023] Open
Abstract
Currently available treatments of diabetic kidney disease (DKD) remain limited despite improved understanding of DKD pathophysiology. The complement system is a central part of innate immunity, but its dysregulated activation is detrimental and results in systemic diseases with overt inflammation. Growing evidence suggests complement activation in DKD. With existent drugs and clinical success of treating other kidney diseases, complement inhibition has emerged as a potential novel therapy to halt the progression of DKD. This article will review DKD, the complement system's role in diabetic and non-diabetic disease, and the potential benefits of complement targeting therapies especially for DKD patients.
Collapse
Affiliation(s)
- Kelly Budge
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sergio Dellepiane
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Samuel Mon-Wei Yu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
34
|
Bouwmeester RN, Ter Avest M, Wijnsma KL, Duineveld C, Ter Heine R, Volokhina EB, Van Den Heuvel LPWJ, Wetzels JFM, van de Kar NCAJ. Case Report: Variable Pharmacokinetic Profile of Eculizumab in an aHUS Patient. Front Immunol 2021; 11:612706. [PMID: 33519821 PMCID: PMC7843372 DOI: 10.3389/fimmu.2020.612706] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/01/2020] [Indexed: 12/31/2022] Open
Abstract
Background With the introduction of eculizumab, a C5-inhibitor, morbidity and mortality improved significantly for patients with atypical hemolytic uremic syndrome (aHUS). In view of the high costs, actual needs of the drug, and increasing evidence in literature, aHUS patients can be treated according to a restrictive eculizumab regimen. We retrospectively analyzed the pharmacokinetic and dynamic parameters of eculizumab in one patient in time, emphasizing various factors which could be taken into account during tapering of treatment. Case Presentation A nowadays 18-year-old male with a severe, frequently relapsing form of atypical HUS due to a hybrid CFH/CFHR1 gene in combination with the homozygous factor H haplotype, required chronic plasma therapy (PT), including periods with plasma infusion, from the age of onset at 5 months until initiation of eculizumab at the age of 11 years. A mild but stable chronic kidney disease (CKD) and 9 years of disease remission enabled prolongation of eculizumab interval. At the age of 15 years, a sudden yet multifactorial progression of chronic kidney disease (CKD) was observed, without any signs of disease recurrence. However, an acquired glomerulocystic disease, a reduced left kidney function, and abnormal abdominal venous system of unknown etiology were found. In addition, after an aHUS relapse, an unexpected increase in intra-patient variability of eculizumab concentrations was seen. Retrospective pharmacokinetic analysis revealed a change in eculizumab clearance, associated with a simultaneous increase in proteinuria. Conclusion High intra-patient variability of eculizumab pharmacokinetics were observed over time, emphasizing the necessity for adequate and continuous therapeutic drug monitoring in aHUS patients. Eculizumab serum trough levels together with complement activation markers (CH50) should be frequently assessed, especially during tapering of drug therapy and/or changing clinical conditions in the patient. In addition, an increase in proteinuria could result in urinary eculizumab loss, indicating that urinary monitoring of eculizumab may be important in aHUS patients with an unexplained decline in serum concentrations.
Collapse
Affiliation(s)
- Romy N Bouwmeester
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mendy Ter Avest
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lambertus P W J Van Den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
35
|
Namatame C, Misu T, Takai Y, Nishiyama S, Nakashima I, Fujihara K, Aoki M. CH50 as a putative biomarker of eculizumab treatment in neuromyelitis optica spectrum disorder. Heliyon 2021; 7:e05899. [PMID: 33490671 PMCID: PMC7809378 DOI: 10.1016/j.heliyon.2021.e05899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/21/2020] [Accepted: 12/30/2020] [Indexed: 12/19/2022] Open
Abstract
Here we report 3 cases of neuromyelitis optica spectrum disorder (NMOSD), who were all treated with eculizumab and could be observed with monitoring serum C3, C4 and 50% hemolytic complement (CH50) before and after the treatment. Serum C3 and C4 were not dramatically changed during the treatment, in contrast serum CH50 level of each patient had diminished and kept under the detection limit after the treatment without clinical worsening, even in the situation of extending dosing. Serum CH50 level is useful to monitor the drug efficacy during eculizumab treatment.
Collapse
Affiliation(s)
- Chihiro Namatame
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tatsuro Misu
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yoshiki Takai
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shuhei Nishiyama
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Ichiro Nakashima
- Department of Neurology, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
| | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| |
Collapse
|
36
|
Passot C, Sberro-Soussan R, Bertrand D, Caillard S, Schvartz B, Domenger C, Contin-Bordes C, Paintaud G, Halimi JM, Ternant D, Gatault P. Feasibility and safety of tailored dosing schedule for eculizumab based on therapeutic drug monitoring: Lessons from a prospective multicentric study. Br J Clin Pharmacol 2020; 87:2236-2246. [PMID: 33118186 DOI: 10.1111/bcp.14627] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/13/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022] Open
Abstract
AIMS Eculizumab is an anti-C5 monoclonal antibody approved for rare diseases including atypical haemolytic-uraemic syndrome. The maintenance phase dosing regimen is identical for all adult patients: 1200 mg every 2 weeks. Recent studies reported an overexposure in many patients when considering a target trough concentration range of 50-100 mg/L. The aim of the present work was to validate the feasibility of therapeutic drug monitoring of eculizumab in atypical haemolytic-uraemic syndrome patients. METHODS We performed a 2-step prospective multicentre study. In the first phase, we developed a pharmacokinetic population model using data from 40 patients and identified patients for whom a 1-week lengthening of interval between infusions would lead to a trough concentration above 100 mg/L. In the second phase, selected patients were allocated a 1-week extension and eculizumab trough concentrations were monitored. RESULTS The model confirmed the previously reported influence of bodyweight on elimination clearance and predicted that 36 (90%) patients would be eligible for interval extension. In the second phase of the study, a 1-week lengthening of interval between infusions was performed in 15 patients whose trough concentration at the next visit was predicted with a Bayesian model to be above 100 mg/L. After interval extension, 10 patients (67%) presented measured trough concentrations over 100 mg/L. No biological or clinical recurrence of disease was observed, even in the 5 patients with concentrations below 100 mg/L in whom the initial dosing regimen was resumed. CONCLUSION Safe eculizumab interval adjustment is feasible with a PK monitoring.
Collapse
Affiliation(s)
- Christophe Passot
- EA7501, University of Tours, France.,Laboratory of Pharmacology-Toxicology, CHRU de Tours, France.,Integrated Center for Oncology, Angers, France
| | - Rebecca Sberro-Soussan
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Sophie Caillard
- Nephrology and Transplant Department, Strasbourg University Hospital, Strasbourg, France
| | | | | | | | - Gilles Paintaud
- EA7501, University of Tours, France.,Laboratory of Pharmacology-Toxicology, CHRU de Tours, France
| | - Jean-Michel Halimi
- EA4245 Transplant Immunology and Inflammation, Université de Tours, Tours, France.,Service de Néphrologie-Hypertension artérielle, Dialyses, Transplantation rénale, CHRU Tours, France
| | - David Ternant
- EA7501, University of Tours, France.,Laboratory of Pharmacology-Toxicology, CHRU de Tours, France
| | - Philippe Gatault
- EA4245 Transplant Immunology and Inflammation, Université de Tours, Tours, France.,Service de Néphrologie-Hypertension artérielle, Dialyses, Transplantation rénale, CHRU Tours, France
| |
Collapse
|
37
|
Ohtani K. Complement-Related Proteins and Their Measurements: The Current Status of Clinical Investigation. Nephron Clin Pract 2020; 144 Suppl 1:7-12. [PMID: 33232963 DOI: 10.1159/000512494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/21/2020] [Indexed: 11/19/2022] Open
Abstract
Complement has been considered to be a factor that protects the host against invading microorganisms during infection. However, in recent years, complement-related protein deficiency has been found to be involved in the onset of various diseases, such as autoimmune and inflammatory diseases. In Japan, C3, C4, and CH50 tests were generally performed only when a complement system examination was necessary and there were not enough examinations for other complement factors. Since the complement system has a very complicated activation pathway, at present, it is not well known which molecule must be measured to understand the pathological condition or pathogenesis in complement-related diseases. Furthermore, since the frequency of complement factor gene alleles also differs depending on race, data from foreign countries cannot be directly applied to Japanese populations. Under these circumstances, the Japanese Association for Complement Research (JACR) has prepared approximately 20 items for complement-related examinations, including the 5 categories of functional analysis, complement factors, complement regulators, activation products, and autoantibodies.
Collapse
Affiliation(s)
- Katsuki Ohtani
- Department of Food Science and Human Wellness, Rakuno Gakuen University, Ebetsu, Japan,
| |
Collapse
|
38
|
Barnum SR, Bubeck D, Schein TN. Soluble Membrane Attack Complex: Biochemistry and Immunobiology. Front Immunol 2020; 11:585108. [PMID: 33240274 PMCID: PMC7683570 DOI: 10.3389/fimmu.2020.585108] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
The soluble membrane attack complex (sMAC, a.k.a., sC5b-9 or TCC) is generated on activation of complement and contains the complement proteins C5b, C6, C7, C8, C9 together with the regulatory proteins clusterin and/or vitronectin. sMAC is a member of the MACPF/cholesterol-dependent-cytolysin superfamily of pore-forming molecules that insert into lipid bilayers and disrupt cellular integrity and function. sMAC is a unique complement activation macromolecule as it is comprised of several different subunits. To date no complement-mediated function has been identified for sMAC. sMAC is present in blood and other body fluids under homeostatic conditions and there is abundant evidence documenting changes in sMAC levels during infection, autoimmune disease and trauma. Despite decades of scientific interest in sMAC, the mechanisms regulating its formation in healthy individuals and its biological functions in both health and disease remain poorly understood. Here, we review the structural differences between sMAC and its membrane counterpart, MAC, and examine sMAC immunobiology with respect to its presence in body fluids in health and disease. Finally, we discuss the diagnostic potential of sMAC for diagnostic and prognostic applications and potential utility as a companion diagnostic.
Collapse
Affiliation(s)
| | - Doryen Bubeck
- Department of Life Sciences, Imperial College London, London, United Kingdom
| | | |
Collapse
|
39
|
Simultaneous quantification of rituximab and eculizumab in human plasma by liquid chromatography-tandem mass spectrometry and comparison with rituximab ELISA kits. Clin Biochem 2020; 87:60-66. [PMID: 33096054 DOI: 10.1016/j.clinbiochem.2020.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/30/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Specific and sensitive analytical techniques to quantify therapeutic monoclonal antibodies (mAbs) are required for therapeutic drug monitoring. The quantification of mAbs has been historically performed using enzyme-linked immunosorbent assays (ELISAs), for which the limitations in terms of specificity have led to the development of alternative analytical strategies. METHODS Here, we describe the validation of a liquid chromatography tandem mass-spectrometry (LC-MS/MS) method for the simultaneous quantification of rituximab (RTX - anti-CD20) and eculizumab (ECU - anti-C5). Sample preparation was based on our previously published method, using protein G purification and trypsin digestion. A new specific peptide for RTX, containing an N-terminal pyroglutamine and a trypsin miss-cleavage, enables better sensitivity, while peptide of ECU was chosen thanks to an in silico trypsin digestion and the Skyline® software. Full-length stable-isotope-labeled adalimumab was added to plasma samples as an internal standard. RTX in 50 human serum samples was quantified by LC-MS/MS and the concentrations obtained compared to those obtained with two commercial ELISA kits (Lisa Tracker® and Promonitor®). RESULTS Calibration curves were linear from 1 to 200 µg.mL-1 for RTX and 5 to 200 µg.mL-1 for ECU, and within-day and between-day accuracy and precision fulfilled Food and Drug Administration validation criteria. Comparison of the LC-MS/MS method with ELISA showed a negligible bias with the Lisa Tracker® kit (4%), but significant bias with the Promonitor® assay (mean underestimation of 69% for the Promonitor® assay). CONCLUSIONS This new LC-MS/MS method allows the simultaneous quantification of RTX and ECU in human samples and could be used for therapeutic drug monitoring.
Collapse
|
40
|
Romano R, Giardino G, Cirillo E, Prencipe R, Pignata C. Complement system network in cell physiology and in human diseases. Int Rev Immunol 2020; 40:159-170. [PMID: 33063546 DOI: 10.1080/08830185.2020.1833877] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The complement system is a multi-functional system representing the first line host defense against pathogens in innate immune response, through three different pathways. Impairment of its function, consisting in deficiency or excessive deregulated activation, may lead to severe systemic infections or autoimmune disorders. These diseases may be inherited or acquired. Despite many diagnostic tools are currently available, ranging from traditional, such as hemolytic or ELISA based assays, to innovative ones, like next generation sequencing techniques, these diseases are often not recognized. As for therapeutic aspects, strategies based on the use of targeted drugs are now widespread. The aim of this review is to present an updated overview of complement system pathophysiology, clinical implications of its dysfunction and to summarize diagnostic and therapeutic approaches.
Collapse
Affiliation(s)
- Roberta Romano
- Department of Translational Medical Sciences - Section of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Giuliana Giardino
- Department of Translational Medical Sciences - Section of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Emilia Cirillo
- Department of Translational Medical Sciences - Section of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Rosaria Prencipe
- Department of Translational Medical Sciences - Section of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences - Section of Pediatrics, Federico II University of Naples, Naples, Italy
| |
Collapse
|
41
|
Pharmacology, Pharmacokinetics and Pharmacodynamics of Eculizumab, and Possibilities for an Individualized Approach to Eculizumab. Clin Pharmacokinet 2020; 58:859-874. [PMID: 30758736 PMCID: PMC6584251 DOI: 10.1007/s40262-019-00742-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Eculizumab is the first drug approved for the treatment of complement-mediated diseases, and current dosage schedules result in large interindividual drug concentrations. This review provides insight into the pharmacokinetic and pharmacodynamic properties of eculizumab, both for reported on-label (paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, generalized myasthenia gravis) and off-label (hematopoietic stem cell transplantation-associated thrombotic microangiopathy) indications. Furthermore, we discuss the potential of therapeutic drug monitoring to individualize treatment and reduce costs.
Collapse
|
42
|
Koelman DLH, Brouwer MC, van de Beek D. Targeting the complement system in bacterial meningitis. Brain 2020; 142:3325-3337. [PMID: 31373605 PMCID: PMC6821383 DOI: 10.1093/brain/awz222] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/15/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022] Open
Abstract
Bacterial meningitis is most commonly caused by Streptococcus pneumoniae and Neisseria meningitidis and continues to pose a major public health threat. Morbidity and mortality of meningitis are driven by an uncontrolled host inflammatory response. This comprehensive update evaluates the role of the complement system in upregulating and maintaining the inflammatory response in bacterial meningitis. Genetic variation studies, complement level measurements in blood and CSF, and experimental work have together led to the identification of anaphylatoxin C5a as a promising treatment target in bacterial meningitis. In animals and patients with pneumococcal meningitis, the accumulation of neutrophils in the CSF was mainly driven by C5-derived chemotactic activity and correlated positively with disease severity and outcome. In murine pneumococcal meningitis, adjunctive treatment with C5 antibodies prevented brain damage and death. Several recently developed therapeutics target C5 conversion, C5a, or its receptor C5aR. Caution is warranted because treatment with C5 antibodies such as eculizumab also inhibits the formation of the membrane attack complex, which may result in decreased meningococcal killing and increased meningococcal disease susceptibility. The use of C5a or C5aR antagonists to specifically target the harmful anaphylatoxins-induced effects, therefore, are most promising and present opportunities for a phase 2 clinical trial.
Collapse
Affiliation(s)
- Diederik L H Koelman
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Meibergdreef 9, AZ, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Meibergdreef 9, AZ, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Meibergdreef 9, AZ, Amsterdam, The Netherlands
| |
Collapse
|
43
|
Brodszki N, Frazer-Abel A, Grumach AS, Kirschfink M, Litzman J, Perez E, Seppänen MRJ, Sullivan KE, Jolles S. European Society for Immunodeficiencies (ESID) and European Reference Network on Rare Primary Immunodeficiency, Autoinflammatory and Autoimmune Diseases (ERN RITA) Complement Guideline: Deficiencies, Diagnosis, and Management. J Clin Immunol 2020; 40:576-591. [PMID: 32064578 PMCID: PMC7253377 DOI: 10.1007/s10875-020-00754-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/20/2020] [Indexed: 12/14/2022]
Abstract
This guideline aims to describe the complement system and the functions of the constituent pathways, with particular focus on primary immunodeficiencies (PIDs) and their diagnosis and management. The complement system is a crucial part of the innate immune system, with multiple membrane-bound and soluble components. There are three distinct enzymatic cascade pathways within the complement system, the classical, alternative and lectin pathways, which converge with the cleavage of central C3. Complement deficiencies account for ~5% of PIDs. The clinical consequences of inherited defects in the complement system are protean and include increased susceptibility to infection, autoimmune diseases (e.g., systemic lupus erythematosus), age-related macular degeneration, renal disorders (e.g., atypical hemolytic uremic syndrome) and angioedema. Modern complement analysis allows an in-depth insight into the functional and molecular basis of nearly all complement deficiencies. However, therapeutic options remain relatively limited for the majority of complement deficiencies with the exception of hereditary angioedema and inhibition of an overactivated complement system in regulation defects. Current management strategies for complement disorders associated with infection include education, family testing, vaccinations, antibiotics and emergency planning.
Collapse
Affiliation(s)
- Nicholas Brodszki
- Department of Pediatrics, Children's Hospital, Skåne University Hospital, Lund, Sweden
| | - Ashley Frazer-Abel
- Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anete S Grumach
- Clinical Immunology, Reference Center on Rare Diseases, University Center Health ABC, Santo Andre, SP, Brazil
| | | | - Jiri Litzman
- Department of Clinical Immunology and Allergology, St Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Elena Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, FL, USA
| | - Mikko R J Seppänen
- Rare Disease Center, Children's Hospital, and Adult Primary Immunodeficiency Outpatient Clinic, Inflammation Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, Cardiff University & University Hospital of Wales, Cardiff, UK.
| |
Collapse
|
44
|
van den Heuvel LP, van de Kar NCAJ, Duineveld C, Sarlea A, van der Velden TJAM, Liebrand WTB, van Kraaij S, Schjalm C, Bouwmeester R, Wetzels JFM, Mollnes TE, Volokhina EB. The complement component C5 is not responsible for the alternative pathway activity in rabbit erythrocyte hemolytic assays during eculizumab treatment. Cell Mol Immunol 2020; 17:653-655. [PMID: 32210393 DOI: 10.1038/s41423-020-0406-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Lambertus P van den Heuvel
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.,Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Andrei Sarlea
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Thea J A M van der Velden
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Wilhelmus T B Liebrand
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Sanne van Kraaij
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Camilla Schjalm
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Romy Bouwmeester
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Tom E Mollnes
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway.,Research Laboratory, Nordland Hospital, Bodø, and K. G. Jebsen TREC, University of Tromsø, Tromsø, Norway.,Center of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elena B Volokhina
- Department of Pediatric Nephrology Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands. .,Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.
| |
Collapse
|
45
|
Complement Component C3 Participates in Early Stages of Niemann-Pick C Mouse Liver Damage. Int J Mol Sci 2020; 21:ijms21062127. [PMID: 32244854 PMCID: PMC7139721 DOI: 10.3390/ijms21062127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 02/07/2023] Open
Abstract
Niemann–Pick type C (NPC), a lysosomal storage disorder, is mainly caused by mutations in the NPC1 gene. Niemann–Pick type C patients and mice show intracellular cholesterol accumulation leading to hepatic failure with increased inflammatory response. The complement cascade, which belongs to the innate immunity response, recognizes danger signals from injured tissues. We aimed to determine whether there is activation of the complement system in the liver of the NPC mouse and to assess the relationship between C3 activation, a final component of the pathway, and NPC liver pathology. Niemann–Pick type C mice showed high levels of C3 staining in the liver which unexpectedly decreased with aging. Using an inducible NPC1 hepatocyte rescue mouse model, we restored NPC1 expression for a short time in young mice. We found C3 positive cells only in non-rescued cells, suggesting that C3 activation in NPC cells is reversible. Then, we studied the effect of C3 ablation on NPC liver damage at two postnatal time points, P56 and P72. Deletion of C3 reduced the presence of hepatic CD68-positive cells at postnatal day 56 and prevented the increase of transaminase levels in the blood of NPC mice. These positive effects were abrogated at P72, indicating that the complement cascade participates only during the early stages of liver damage in NPC mice, and that its inhibition may serve as a new potential therapeutic strategy for the disease.
Collapse
|
46
|
Palomo M, Blasco M, Molina P, Lozano M, Praga M, Torramade-Moix S, Martinez-Sanchez J, Cid J, Escolar G, Carreras E, Paules C, Crispi F, Quintana LF, Poch E, Rodas L, Goma E, Morelle J, Espinosa M, Morales E, Avila A, Cabello V, Ariceta G, Chocron S, Manrique J, Barros X, Martin N, Huerta A, Fraga-Rodriguez GM, Cao M, Martin M, Romera AM, Moreso F, Manonelles A, Gratacos E, Pereira A, Campistol JM, Diaz-Ricart M. Complement Activation and Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2019; 14:1719-1732. [PMID: 31694864 PMCID: PMC6895490 DOI: 10.2215/cjn.05830519] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Atypical hemolytic uremic syndrome is a form of thrombotic microangiopathy caused by dysregulation of the alternative complement pathway. There is evidence showing complement activation in other thrombotic microangiopathies. The aim of this study was to evaluate complement activation in different thrombotic microangiopathies and to monitor treatment response. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Complement activation was assessed by exposing endothelial cells to sera or activated-patient plasma-citrated plasma mixed with a control sera pool (1:1)-to analyze C5b-9 deposits by immunofluorescence. Patients with atypical hemolytic uremic syndrome (n=34) at different stages of the disease, HELLP syndrome (a pregnancy complication characterized by hemolysis, elevated liver enzymes, and low platelet count) or severe preeclampsia (n=10), and malignant hypertension (n=5) were included. RESULTS Acute phase atypical hemolytic uremic syndrome-activated plasma induced an increased C5b-9 deposition on endothelial cells. Standard and lower doses of eculizumab inhibited C5b-9 deposition in all patients with atypical hemolytic uremic syndrome, except in two who showed partial remission and clinical relapse. Significant fibrin formation was observed together with C5b-9 deposition. Results obtained using activated-plasma samples were more marked and reproducible than those obtained with sera. C5b-9 deposition was also increased with samples from patients with HELLP (all cases) and preeclampsia (90%) at disease onset. This increase was sustained in those with HELLP after 40 days, and levels normalized in patients with both HELLP and preeclampsia after 6-9 months. Complement activation in those with malignant hypertension was at control levels. CONCLUSIONS The proposed methodology identifies complement overactivation in patients with atypical hemolytic uremic syndrome at acute phase and in other diseases such as HELLP syndrome and preeclampsia. Moreover, it is sensitive enough to individually assess the efficiency of the C5 inhibition treatment.
Collapse
Affiliation(s)
- Marta Palomo
- Josep Carreras Leukaemia Research Institute; .,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Patricia Molina
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Institut Clinic de Malalties Hematologiques i Oncologiques (ICMHO), IDIBAPS, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Sergi Torramade-Moix
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Julia Martinez-Sanchez
- Josep Carreras Leukaemia Research Institute.,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Institut Clinic de Malalties Hematologiques i Oncologiques (ICMHO), IDIBAPS, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Gines Escolar
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute.,Barcelona Endothelium Team, Barcelona, Spain
| | - Cristina Paules
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Fatima Crispi
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Luis F Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Esteban Poch
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Lida Rodas
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Emma Goma
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía e Instituto Maimonides de Investigaciones Biológicas de Córdoba (IMIBIC), Córdoba, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain
| | - Ana Avila
- Department of Nephrology and Renal Transplantation, Hospital Universitario Dr Peset, Valencia, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Virgen del Rocio, Sevilla, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Materno-Infantil, Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Sara Chocron
- Department of Pediatric Nephrology, Hospital Materno-Infantil, Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Joaquin Manrique
- Department of Nephrology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitari Josep Trueta, Girona, Spain
| | - Nadia Martin
- Department of Nephrology, Hospital Universitari Josep Trueta, Girona, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - Gloria M Fraga-Rodriguez
- Department of Pediatric Nephrology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mercedes Cao
- Department of Nephrology, Complejo Hospitalario Universitario A Coruña, Coruña, Spain
| | - Marisa Martin
- Department of Nephrology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Ana Maria Romera
- Department of Nephrology, Hospital General Universitario, Ciudad Real, Spain
| | - Francesc Moreso
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain
| | - Anna Manonelles
- Kidney Transplant Unit, Department of Nephrology, Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain; and
| | - Eduard Gratacos
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | | | - Josep M Campistol
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| |
Collapse
|
47
|
Patriquin CJ, Kuo KHM. Eculizumab and Beyond: The Past, Present, and Future of Complement Therapeutics. Transfus Med Rev 2019; 33:256-265. [PMID: 31703946 DOI: 10.1016/j.tmrv.2019.09.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/18/2022]
Abstract
Dysregulation of the complement system underlies the pathophysiology of many diseases. Renewed interest in complement occurred with the recognition that its therapeutic inhibition was possible. Terminal complement blockade with the anti-C5 monoclonal antibody eculizumab significantly changed management and clinical outcomes of patients with paroxysmal nocturnal hemoglobinuria, and served as a proof of concept for other complement-mediated diseases. Eculizumab is also approved for atypical hemolytic uremic syndrome and myasthenia gravis. Multiple new disease indications have been identified, and novel complement inhibitors are in various stages of development, with several currently in human trials. Beyond C5, these new drugs block proximal complement, pathway-specific targets, convertase activity, and anaphylatoxin function. Though monoclonal antibodies are still common, peptides, RNAi, and small molecule inhibitors provide the opportunity for different administration routes and schedules. Several challenges still exist or will soon present themselves, including mitigation of infection risk, effective monitoring strategies, and how to choose between therapeutics when more than one is available. In this review, we will describe the lessons learned from the "eculizumab era," present many of the novel therapeutics currently or soon to be in trials, and highlight some of the challenges that will require attention as the field progresses.
Collapse
Affiliation(s)
- Christopher J Patriquin
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada; Divison of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada.
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada; Divison of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
48
|
Fontana F, Alfano G, Bardhushi E, Ligabue G, Giovanella S, Neri I, Cappelli G. Relapse of Atypical Hemolytic Uremic Syndrome During Pregnancy in a Patient on Eculizumab Maintenance Treatment: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1460-1465. [PMID: 31582717 PMCID: PMC6788481 DOI: 10.12659/ajcr.916994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 28 Final Diagnosis: Relapse of atypical hemolytic uremic syndrome during pregnancy Symptoms: Anemia • edema • hemolysis • oliguria Medication: — Clinical Procedure: — Specialty: Nephrology
Collapse
Affiliation(s)
- Francesco Fontana
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Gaetano Alfano
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Ermelinda Bardhushi
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Ligabue
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Giovanella
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Isabella Neri
- Department of Mother-Infant, University of Modena and Reggio Emilia, Modena, Italy
| | - Gianni Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
49
|
Raina R, Grewal MK, Radhakrishnan Y, Tatineni V, DeCoy M, Burke LLG, Bagga A. Optimal management of atypical hemolytic uremic disease: challenges and solutions. Int J Nephrol Renovasc Dis 2019; 12:183-204. [PMID: 31564951 PMCID: PMC6732511 DOI: 10.2147/ijnrd.s215370] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a chronic life threatening condition that arises from genetic abnormalities resulting in uncontrolled complement amplifying activity. The introduction of eculizumab, the humanized monoclonal antibody, has brought about a paradigm shift in the management of aHUS. However, there are many knowledge gaps, diagnostic issues, access and cost issues, and patient or physician challenges associated with the use of this agent. Limited data on the natural history of aHUS along with the underlying genetic mutations make it difficult to predict the relapses and thereby raising concerns about the appropriate duration and monitoring of treatment. In this review, we discuss the safety and efficacy of eculizumab in patients with aHUS and its associated challenges.
Collapse
Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | - Manpreet K Grewal
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | | | - Vineeth Tatineni
- Department of Internal Medicine, Summa Health, Akron City Hospital, Akron, OH, USA
| | - Meredith DeCoy
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Linda LG Burke
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Arvind Bagga
- Division of Paediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
50
|
Schröder-Braunstein J, Kirschfink M. Complement deficiencies and dysregulation: Pathophysiological consequences, modern analysis, and clinical management. Mol Immunol 2019; 114:299-311. [PMID: 31421540 DOI: 10.1016/j.molimm.2019.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/31/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023]
Abstract
Complement defects are associated with an enhanced risk of a broad spectrum of infectious as well as systemic or local inflammatory and thrombotic disorders. Inherited complement deficiencies have been described for virtually all complement components but can be mimicked by autoantibodies, interfering with the activity of specific complement components, convertases or regulators. While being rare, diseases related to complement deficiencies are often severe with a frequent but not exclusive manifestation during childhood. Whereas defects of early components of the classical pathway significantly increase the risk of autoimmune disorders, lack of components of the terminal pathway as well as of properdin are associated with an enhanced susceptibility to meningococcal infections. The impaired synthesis or function of C1 inhibitor results in the development of hereditary angioedema (HAE). Furthermore, complement dysregulation causes renal disorders such as atypical hemolytic uremic syndrome (aHUS) or C3 glomerulopathy (C3G) but also age-related macular degeneration (AMD). While paroxysmal nocturnal hemoglobinuria (PNH) results from the combined deficiency of the regulatory complement proteins CD55 and CD59, which is caused by somatic mutation of a common membrane anchor, isolated CD55 or CD59 deficiency is associated with the CHAPLE syndrome and polyneuropathy, respectively. Here, we provide an overview on clinical disorders related to complement deficiencies or dysregulation and describe diagnostic strategies required for their comprehensive molecular characterization - a prerequisite for informed decisions on the therapeutic management of these disorders.
Collapse
Affiliation(s)
- Jutta Schröder-Braunstein
- University of Heidelberg, Institute of Immunology, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Michael Kirschfink
- University of Heidelberg, Institute of Immunology, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
| |
Collapse
|