1
|
Tan YC, Teo ECY, Ng HJ. A Rare Case of Atypical Hemolytic Uremic Syndrome (aHUS) Precipitated by Dengue and the Treatment Landscape in Singapore. Cureus 2024; 16:e58731. [PMID: 38779250 PMCID: PMC11110694 DOI: 10.7759/cureus.58731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease caused by uncontrolled complement activation due to complement dysregulation. It is often triggered by precipitating events such as infections, inflammation, pregnancy, or medications. Dengue, an endemic viral infection in Southeast Asia, can activate the complement pathway, thereby triggering aHUS in genetically susceptible individuals. Here, we present the case of a 33-year-old male who presented with Dengue fever and subsequently developed aHUS. Plasma exchange (PLEX) successfully normalized his neurological status and hematological parameters. Although his renal function improved, it failed to normalize. Eculizumab, a monoclonal antibody that inhibits C5, was administered for a total of six months. The treatment was successfully discontinued without evidence of relapse after six months of follow-up. This case report demonstrates the safety of discontinuing eculizumab in patients who do not possess pathogenic mutations or variants in complement factors.
Collapse
Affiliation(s)
- Yan Chin Tan
- Haematology, Sengkang General Hospital, Sengkang, SGP
| | | | - Heng Joo Ng
- Haematology, Singapore General Hospital, Bukit Merah, SGP
| |
Collapse
|
2
|
Cordero L, Cavero T, Gutiérrez E, Trujillo H, Sandino J, Auñón P, Rivero M, Morales E. Rational use of eculizumab in secondary atypical hemolytic uremic syndrome. Front Immunol 2024; 14:1310469. [PMID: 38274833 PMCID: PMC10808527 DOI: 10.3389/fimmu.2023.1310469] [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: 10/09/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background Secondary atypical hemolytic uremic syndrome (secondary aHUS) is a heterogeneous group of thrombotic microangiopathies (TMA) associated with various underlying conditions. Unlike primary aHUS, there is still no hard evidence on the efficacy of complement blockade in secondary aHUS, since the two main series that investigated this subject showed discrepant results. Our work aims to reassess the efficacy of eculizumab in treating secondary aHUS. Methods Observational, retrospective, single-center study, in which we analyzed the hematological and renal evolution of 23 patients diagnosed with secondary aHUS who received treatment with eculizumab and compared them with a control cohort of 14 patients. Complete renal response was defined as the recovery of renal function before the event, partial renal response as a recovery of 50% of lost glomerular filtration rate, and hematological response as normalization of hemoglobin and platelets. Results We found no statistically significant differences in baseline characteristics or disease severity between both groups. After a median of 5 doses of eculizumab, the group of patients who received complement blockade presented a significant difference in renal response (complete in 52.3% of patients and partial in 23.8%) compared to the control cohort (complete response 14.3% and partial of 14.3%). Rates of hematological remission were similar in both groups (90.9% in the eculizumab cohort and 85.7% in the control cohort). Conclusion Early and short-term use of eculizumab in patients with secondary aHUS could be an effective and safe therapeutic option, assuring better renal recovery compared to patients who do not receive complement blockade.
Collapse
Affiliation(s)
- Lucía Cordero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Cavero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Eduardo Gutiérrez
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Hernando Trujillo
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Justo Sandino
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Auñón
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Rivero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Enrique Morales
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| |
Collapse
|
3
|
Tang ZC, Hui H, Shi C, Chen X. New findings in preventing recurrence and improving renal function in AHUS patients after renal transplantation treated with eculizumab: a systemic review and meta-analyses. Ren Fail 2023; 45:2231264. [PMID: 37563792 PMCID: PMC10424606 DOI: 10.1080/0886022x.2023.2231264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/24/2023] [Accepted: 04/22/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The long-term mortality of kidney transplantation patients with atypical hemolytic uremic syndrome remains high, and the efficacy of the main treatment eculizumab is still controversial. OBJECTIVE A comprehensive systematic review and meta-analysis of clinical trials using eculizumab in renal transplant patients with atypical hemolytic uremic syndrome was conducted to evaluate the efficacy of this therapy and its impact on renal function. METHODS A comprehensive systematic search was conducted across multiple reputable databases, including Ovid (MEDLINE, EMBASE), PubMed, and the Cochrane Library (since database inception), to identify relevant studies exploring the use of eculizumab in patients with atypical hemolytic uremic kidney transplantation. Various renal function parameters, such as dialysis, rejection, glomerular filtration rate, serum creatinine, lactate dehydrogenase, and platelet count, along with patient relapse rates, were extracted and summarized using a combination of robust statistical methods, including fixed effects, random effects, and general inverse variance methods. RESULT Eighteen trials with 618 subjects were analyzed. Our analysis suggests that the use of eculizumab is associated with a reduced likelihood of AHUS recurrence (odds ratio (OR) = 0.05, 95% CI: 0.00-0.13), as well as a significant reduction in the need for dialysis (odds ratio (OR) = 0.13, 95% CI: 0.01-0.32). Additionally, eculizumab treatment led to lower serum creatinine levels (mean differences (MD) = 126.931μmoI/L, 95% CI: 115.572μmoI/L-138.290μmoI/L) and an improved glomerular filtration rate (mean differences (MD) = 59.571 ml/min, 95% CI: 57.876 ml/min-61.266 mL/min). Our results also indicate that the use of eculizumab reduces the likelihood of rejection (odds ratio (OR) = 0.09, 95% CI: 0.01-0.22). Furthermore, the drug was effective in improving platelet counts (×10∧9/L) (mean differences (MD) = 163.421, 95% CI: 46.998-279.844) and lactate dehydrogenase levels (mean differences (MD) = 336.608 U/L, 95% CI: 164.816 U/L-508.399 U/L). CONCLUSIONS Based on the meta-analysis, treatment with eculizumab can reduce dialysis rates and improve patients' quality of life by enhancing renal function.
Collapse
Affiliation(s)
| | - Huang Hui
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Chunru Shi
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Xiangmei Chen
- Renal Medicine Department, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
4
|
Jelicic I, Kovacic V, Luketin M, Mikacic M, Skaro DB. Atypical HUS with multiple complement system mutations triggered by synthetic psychoactive drug abuse: a case report. J Nephrol 2023; 36:2371-2373. [PMID: 37145269 PMCID: PMC10161151 DOI: 10.1007/s40620-023-01646-4] [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: 02/27/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Abstract
Atypical hemolytic uremic syndrome is a rare disorder with an estimated annual incidence of about two cases per million in the adult population. It is caused by the overactivation of the alternative pathway of the complement system. The disease can be triggered by many factors, including pregnancy, viral diseases, and sepsis; approximately 30% of atypical hemolytic uremic syndrome cases are caused by unknown processes. We present a case of a patient with C3-complement system mutations and aHUS triggered by the use of a new synthetic psychoactive drug.
Collapse
Affiliation(s)
- Ivo Jelicic
- Internal Medicine Department, Nephrology and Haemodialysis Division, School of Medicine, University Hospital of Split, University of Split, 21000, Split, Croatia
| | - Vedran Kovacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, School of Medicine, University Hospital of Split, University of Split, Spinciceva 1, 21000, Split, Croatia.
| | - Mirko Luketin
- Internal Medicine Department, Nephrology and Haemodialysis Division, School of Medicine, University Hospital of Split, University of Split, 21000, Split, Croatia
| | - Marijana Mikacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, School of Medicine, University Hospital of Split, University of Split, Spinciceva 1, 21000, Split, Croatia
| | - Dijana Boric Skaro
- Internal Medicine Department, Nephrology and Haemodialysis Division, School of Medicine, University Hospital of Split, University of Split, 21000, Split, Croatia
| |
Collapse
|
5
|
Ariceta G. Pharmacological and clinical profile of ravulizumab 100 mg/mL formulation for paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Expert Rev Clin Pharmacol 2023; 16:401-410. [PMID: 37128905 DOI: 10.1080/17512433.2023.2209317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are two rare and severe conditions caused by chronic complement (C') system dysregulation. Treatment with eculizumab, a recombinant, humanized monoclonal antibody against complement C5, changed the natural history of both diseases inducing remission and improving patient outcome. Ravulizumab, a new long-acting next-generation C5 inhibitor has been recently approved for treatment of PNH and aHUS. AREAS COVERED Main characteristics of ravulizumab are described: composition, dosing, efficacy and safety profile. Further, an overview of seminal studies and clinical trials using ravulizumab to treat PNH and aHUS in children and adults is detailed. Literature review was performed using the following key words: paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and ravulizumab. EXPERT OPINION Ravulizumab profile to treat PNH and aHUS is equivalent to eculizumab in efficacy and safety but allows extended dosing interval to every 4-8 weeks based on patient weight, and requires reduced infusion time. Less travels to infusion centers and medical visits and decreasing job and school absences, significantly increases patient and families' QoL, while reducing cost. Further infusion time is reduced Ravulizumab will possibly become the treatment of choice for patients with PNH and aHUS on chronic C5 inhibition.
Collapse
Affiliation(s)
- Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron. Universitat Autonoma Barcelona, Spain
| |
Collapse
|
6
|
Tseng MH, Lin SH, Tsai JD, Wu MS, Tsai IJ, Chen YC, Chang MC, Chou WC, Chiou YH, Huang CC. Atypical hemolytic uremic syndrome: Consensus of diagnosis and treatment in Taiwan. J Formos Med Assoc 2023; 122:366-375. [PMID: 36323601 DOI: 10.1016/j.jfma.2022.10.006] [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: 07/05/2022] [Revised: 09/03/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, is a rare but life-threatening systemic disorder caused by the dysregulation of the complement pathway. Current advances in molecular analysis and pathogenesis have facilitated the establishment of diagnosis and development of effective complement blockade. Based on this recent consensus, we provide suggestions regarding the diagnosis and management of aHUS in Taiwan. The diagnosis of aHUS is made by the presence of TMA with normal ADAMTS13 activity without known secondary causes. Although only 60% of patients with aHUS have mutations in genes involving the compliment and coagulation systems, molecular analysis is suggestive for helping establish diagnosis, clarifying the underlying pathophysiology, guiding the treatment decision-making, predicting the prognosis, and deciding renal transplantation. Complement blockade, anti-C5 monoclonal antibody, is the first-line therapy for patients with aHUS. Plasma therapy should be considered for removing autoantibody in patients with atypical HUS caused by anti-CFH or complement inhibitor is unavailable.
Collapse
Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taipei, Taiwan
| | - Yeu-Chin Chen
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Chih Chang
- Division of Hematology/Oncology, Department of Internal Medicine, MacKay Children's Hospital, Taipei, Taiwan
| | - Wen-Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
| | - Chiu-Ching Huang
- Division of Nephrology and the Kidney Institute, Department of Internal Medicine, China Medical University and Hospital, Taichung, Taiwan.
| |
Collapse
|
7
|
Balwani MR, Pasari AS, Gurjar P, Bhawane A, Bawankule C, Tolani P, Kashiv P, Dubey S, Katekhaye VM. Profile and Post-Kidney Retrieval Outcomes in Asymptomatic Kidney Donors With Genetic Mutations in Complement Factors–Related Genes. Transplant Proc 2023:S0041-1345(23)00105-7. [PMID: 36990884 DOI: 10.1016/j.transproceed.2023.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 02/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare disorder triggered by various stressors. Most of the time, stressors may not be identified in patients with aHUS. The disease may remain quiescent without manifestation throughout life. BACKGROUND To assess the outcome of an asymptomatic carrier of genetic mutations of patients with aHUS who had undergone donor kidney retrieval surgery. METHODS We retrospectively included the patients diagnosed with a genetic abnormality in complement factor H (CHF) or CHF-related (CFHR) genes without manifestation of the aHUS and who had undergone donor kidney retrieval surgery. The data were analyzed with descriptive statistics. RESULTS Among patients who were the kidney recipients from the prospective donors, 6 donors were screened for genetic mutations in CFH and CFHR genes. Four donors showed positive mutation for CFH and CFHR. The mean age was 54.5 years (range, 50-64 years). After over a year since donor kidney retrieval surgery, all prospective mother donors are alive without aHUS activation and with a normal kidney function on a single kidney. CONCLUSION Asymptomatic carriers of genetic mutations in CFH and CFHR can be the prospective donors for their first-degree family member who have active aHUS. A genetic mutation in an asymptomatic donor should not be a contraindication for refuting the prospective donor.
Collapse
|
8
|
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
|
9
|
[Thrombotic microangiopathies in surgical intensive care medicine with special consideration of atypical hemolytic uremic syndrome]. DIE ANAESTHESIOLOGIE 2023; 72:3-12. [PMID: 36454255 PMCID: PMC9713746 DOI: 10.1007/s00101-022-01221-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 12/02/2022]
Abstract
Thrombotic microangiopathies (TMA) are rare diseases, which are defined by the triad microangiopathic hemolytic anemia, thrombocytopenia and organ damage, and are associated with high morbidity and mortality. The recognition of a TMA and the distinction of important differential diagnoses are key factors, particularly in a perioperative context and in routine clinical intensive care. The further differentiation of the different TMA subtypes, such as thrombotic thrombocytopenic purpura (TTP), Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (STEC-HUS) and atypical hemolytic uremic syndrome (aHUS), based on the underlying pathophysiology and the development of new targeted treatment options in recent years have significantly improved the prognosis. A close interdisciplinary cooperation between critical care specialists and specialist disciplines experienced in the treatment of TMA, is essential for a prompt diagnosis and the initiation of the appropriate treatment.
Collapse
|
10
|
Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
Collapse
Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| |
Collapse
|
11
|
Muacevic A, Adler JR, Abdulqader MA, Yolmo D, Shaikh M, Rupasinghe PCD, Patel AA. Trends and Outcomes of Hospitalizations Due to Hemolytic Uremic Syndrome: A National Perspective. Cureus 2022; 14:e32315. [PMID: 36628001 PMCID: PMC9825057 DOI: 10.7759/cureus.32315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is a rare but challenging disease with varying degrees of mortality and prognosis. We aim to evaluate the trends and outcomes of hospitalizations due to HUS by utilizing a large population-based dataset. METHODS We derived a study cohort from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. Our primary outcomes were in-hospital mortality, discharge disposition, and predictors of poor outcomes. We then utilized the Cochran Armitage trend test and multivariable survey logistic regression models to analyze the trends, outcomes, and predictors. RESULTS A total of 8043 hospitalizations ranging from age zero to above 65 years of age occurred due to HUS from 2007-2018. The number of hospitalizations with HUS increased steadily from 528 in 2007 to 800 in 2013, but afterwards, we noticed a steady decline to 620 in 2018. Additionally, trends of in-hospital mortality slowly increased over the study period but we noticed a decline in the rate of discharge to skilled nursing facilities (SNFs). Furthermore, in multivariable regression analysis, predictors of increased mortality in hospitalized HUS patients were advanced age (95%CI: 1.221-1.686; p-value <0.0001) and requirement for dialysis (95%CI: 1.141-4.167; p-value: <0.0001). Advanced age >65 years (OR: 2.599, 95%CI: 1.406-4.803; p-value: 0.0023), as well as comorbidities such as diabetes mellitus and pulmonary circulatory diseases, which are under vascular events (OR: 1.467, 95%CI:1.075-2.000; p-value: 0.0156), were shown to have a higher rate of discharge to SNFs. Moreover, patients needing intravenous immunoglobulin (IVIG) and plasmapheresis had high odds of discharge to SNFs ((OR: 1.99, 95%CI: 1.307-3.03; p-value: 0.0013) and (OR: 5.509, 95%CI: 2.807- 10.809; p-value <0.0001), respectively), as well as smaller hospital bed size and hospital type (OR: 1.849, 95%CI: 1.142-2.993; p-value: 0.012). CONCLUSION In this national representative study, we observed a total decrease in hospitalizations as well as discharge to SNFs; however we saw an increase in inpatient mortality. We also identified multiple predictors significantly associated with increased mortality, some of which are potentially modifiable and can be points of interest for future studies.
Collapse
|
12
|
Two concomitant thrombotic microangiopathies in the background of systemic lupus erythematosus: A case report. Ann Med Surg (Lond) 2022; 81:104541. [PMID: 36147129 PMCID: PMC9486710 DOI: 10.1016/j.amsu.2022.104541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/21/2022] [Accepted: 08/27/2022] [Indexed: 11/21/2022] Open
|
13
|
Kalantari S, Brezzi B, Bracciamà V, Barreca A, Nozza P, Vaisitti T, Amoroso A, Deaglio S, Manganaro M, Porta F, Spada M. Adult-onset CblC deficiency: a challenging diagnosis involving different adult clinical specialists. Orphanet J Rare Dis 2022; 17:33. [PMID: 35109910 PMCID: PMC8812048 DOI: 10.1186/s13023-022-02179-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/16/2022] [Indexed: 12/13/2022] Open
Abstract
Background Methylmalonic aciduria and homocystinuria, CblC type (OMIM #277400) is the most common disorder of cobalamin intracellular metabolism, an autosomal recessive disease, whose biochemical hallmarks are hyperhomocysteinemia, methylmalonic aciduria and low plasma methionine. Despite being a well-recognized disease for pediatricians, there is scarce awareness of its adult presentation. A thorough analysis and discussion of cobalamin C defect presentation in adult patients has never been extensively performed. This article reviews the published data and adds a new case of the latest onset of symptoms ever described for the disease.
Results We present the emblematic case of a 45-year-old male, describing the diagnostic odyssey he ventured through to get to the appropriate treatment and molecular diagnosis. Furthermore, available clinical, biochemical and molecular data from 22 reports on cases and case series were collected, resulting in 45 adult-onset CblC cases, including our own. We describe the onset of the disease in adulthood, encompassing neurological, psychiatric, renal, ophthalmic and thromboembolic symptoms. In all cases treatment with intramuscular hydroxycobalamin was effective in reversing symptoms. From a molecular point of view adult patients are usually compound heterozygous carriers of a truncating and a non-truncating variant in the MMACHC gene. Conclusion Adult onset CblC disease is a rare disorder whose diagnosis can be delayed due to poor awareness regarding its presenting insidious symptoms and biochemical hallmarks. To avoid misdiagnosis, we suggest that adult onset CblC deficiency is acknowledged as a separate entity from pediatric late onset cases, and that the disease is considered in the differential diagnosis in adult patients with atypical hemolytic uremic syndromes and/or slow unexplained decline in renal function and/or idiopathic neuropathies, spinal cord degenerations, ataxias and/or recurrent thrombosis and/or visual field defects, maculopathy and optic disc atrophy. Plasma homocysteine measurement should be the first line for differential diagnosis when the disease is suspected. To further aid diagnosis, it is important that genes belonging to the intracellular cobalamin pathway are included within gene panels routinely tested for atypical hemolytic uremic syndrome and chronic kidney disorders. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02179-y.
Collapse
Affiliation(s)
- Silvia Kalantari
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Brigida Brezzi
- Nephrology and Dialysis Unit, Azienda Ospedaliera "SS. Antonio e Biagio e Cesare Arrigo", Alessandria, Italy
| | | | - Antonella Barreca
- Anatomia e Istologia Patologica, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Paolo Nozza
- S.C. Anatomia e Istologia Patologica, Azienda Ospedaliera "SS. Antonio e Biagio e Cesare Arrigo", Alessandria, Italy
| | - Tiziana Vaisitti
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Biology of Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Silvia Deaglio
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Biology of Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Marco Manganaro
- Nephrology and Dialysis Unit, Azienda Ospedaliera "SS. Antonio e Biagio e Cesare Arrigo", Alessandria, Italy
| | - Francesco Porta
- Department of Pediatrics, Città della Salute e della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy.
| | - Marco Spada
- Department of Pediatrics, Città della Salute e della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy
| |
Collapse
|
14
|
Chandler S, Oliver K, Tan KS, Palamuthusingam D. Should we biopsy? Intern Med J 2021; 51:1359-1360. [PMID: 34423536 DOI: 10.1111/imj.15454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/16/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Shaun Chandler
- Department of Nephrology, Royal Brisbane and Women's Hospital, Metro-North Health Service, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Kimberly Oliver
- Department of Pathology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ken-Soon Tan
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Department of Nephrology, Logan Hospital Metro South Nephrology and Transplant Service, Logan City, Queensland, Australia
| | - Dharmenaan Palamuthusingam
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Nephrology, Logan Hospital Metro South Nephrology and Transplant Service, Logan City, Queensland, Australia
| |
Collapse
|
15
|
How I treat microangiopathic hemolytic anemia in patients with cancer. Blood 2021; 137:1310-1317. [PMID: 33512445 PMCID: PMC8555418 DOI: 10.1182/blood.2019003810] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.
Collapse
|
16
|
Freyer CW, Bange EM, Skuli S, Hsu M, Lin J, Cuker A, Cohen AD, Garfall A. Carfilzomib-Induced Atypical Hemolytic Uremic Syndrome in a Patient With Heterozygous CFHR3/CFHR1 Deletion Treated With Eculizumab. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e845-e849. [PMID: 34366267 DOI: 10.1016/j.clml.2021.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Craig W Freyer
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Erin M Bange
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sarah Skuli
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Miles Hsu
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John Lin
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam D Cohen
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alfred Garfall
- Hospital of the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
17
|
Kar S, Krishnamurthy S, Karunakar P, Maya M, Thangaraj A, Agarwal Y. A rare cause of recurrent acute kidney injury in a 3-year-old girl: Answers. Pediatr Nephrol 2021; 36:2033-2037. [PMID: 33427983 DOI: 10.1007/s00467-020-04885-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/27/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Shrutiprajna Kar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sriram Krishnamurthy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Pediredla Karunakar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Malini Maya
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Abarna Thangaraj
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Yamini Agarwal
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| |
Collapse
|
18
|
Pugh D, O'Sullivan ED, Duthie FA, Masson P, Kavanagh D. Interventions for atypical haemolytic uraemic syndrome. Cochrane Database Syst Rev 2021; 3:CD012862. [PMID: 33783815 PMCID: PMC8078160 DOI: 10.1002/14651858.cd012862.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Atypical haemolytic uraemic syndrome (aHUS) is a rare disorder characterised by thrombocytopenia, microangiopathic haemolytic anaemia, and acute kidney injury. The condition is primarily caused by inherited or acquired dysregulation of complement regulatory proteins with ~40% of those affected aged < 18 years. Historically, kidney failure and death were common outcomes, however, improved understanding of the condition has led to discovery of novel therapies. OBJECTIVES To evaluate the benefits and harms of interventions for aHUS. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies for randomised controlled studies (RCTs) up to 3 September 2020 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. MEDLINE(OVID) 1946 to 27 July 2020 and EMBASE (OVID) 1974 to 27 July 2020 were searched for non-RCTs. SELECTION CRITERIA All randomised and non-randomised clinical trials comparing an intervention with placebo, an intervention with supportive therapy, or two or more interventions for aHUS were included. Given the rare nature of the condition in question, prospective single-arm studies of any intervention for aHUS were also included. DATA COLLECTION AND ANALYSIS Two authors independently extracted pre-specified data from eligible studies and evaluated risk of bias using a newly developed tool based on existing Cochrane criteria. As statistical meta-analysis was not appropriate, qualitative analysis of data was then performed. MAIN RESULTS We included five single-arm studies, all of which evaluated terminal complement inhibition for the treatment of aHUS. Four studies evaluated the short-acting C5 inhibitor eculizumab and one study evaluated the longer-acting C5 inhibitor ravulizumab. All included studies within the review were of non-randomised, single-arm design. Thus, risk of bias is high, and it is challenging to draw firm conclusions from this low-quality evidence. One hundred patients were included within three primary studies evaluating eculizumab, with further data reported from 37 patients in a secondary study. Fifty-eight patients were included in the ravulizumab study. After 26 weeks of eculizumab therapy there were no deaths and a 70% reduction in the number of patients requiring dialysis. Complete thrombotic microangiopathic (TMA) response was observed in 60% of patients at 26 weeks and 65% at two years. After 26 weeks of ravulizumab therapy four patients had died (7%) and complete TMA response was observed in 54% of patients. Substantial improvements were seen in estimated glomerular filtration rate and health-related quality of life in both eculizumab and ravulizumab studies. Serious adverse events occurred in 42% of patients, and meningococcal infection occurred in two patients, both treated with eculizumab. AUTHORS' CONCLUSIONS When compared with historical data, terminal complement inhibition appears to offer favourable outcomes in patients with aHUS, based upon very low-quality evidence drawn from five single-arm studies. It is unlikely that an RCT will be conducted in aHUS and therefore careful consideration of future single-arm data as well as longer term follow-up data will be required to better understand treatment duration, adverse outcomes and risk of disease recurrence associated with terminal complement inhibition.
Collapse
Affiliation(s)
- Dan Pugh
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Eoin D O'Sullivan
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Inflammation Research, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fiona Ai Duthie
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Philip Masson
- Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - David Kavanagh
- Renal Department, Newcastle University/Freeman Hospital, Newcastle Upon Tyne, UK
| |
Collapse
|
19
|
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 273] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
Collapse
|
20
|
Occlusive retinal vasculopathy with macular branch retinal artery occlusion as a leading sign of atypical hemolytic uremic syndrome - a case report. BMC Ophthalmol 2021; 21:65. [PMID: 33516177 PMCID: PMC7847162 DOI: 10.1186/s12886-021-01820-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 01/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemolytic Uremic Syndrome (HUS) is a rare disorder characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure, considered within the group of thrombocytic microangiopathies. Ocular complications in HUS are very rare. Here, we report an adult patient who suffered from acute onset of paracentral scotoma, caused by branch retinal artery occlusion (BRAO), as a leading symptom of atypical HUS. CASE PRESENTATION A 39-year-old healthy male was lately diagnosed with essential hypertension and mild renal impairment. He complained about acute onset of central scotoma in his left eye. Fundus examination revealed marked narrowing of retinal vessels, cotton wool spots and few retinal hemorrhages in both eyes. The patient was diagnosed with bilateral ischemic retinal vasculopathy and acute macular BRAO in his left eye. Workup revealed thrombocytopenia, worsening renal failure. Renal biopsy showed signs of chronic thrombotic microangiopathy. The patient was diagnosed with atypical HUS (aHUS) and started on plasmapheresis, together with eculizumab. As his condition continued to worsen, he was put on renal replacement therapy. Due to a persistent monoclone of IgG1, the patient underwent bone marrow biopsy which revealed Monoclonal Gammopathy of renal significance, triggering a HUS and treatment was initiated accordingly. Two months after initial presentation, the patient developed neovascularization of the optic disc (NVD) in his left eye, and was treated with 3 monthly intravitreal bevacizumab injections with complete regression of the NVD. The patient suffered from myocardial infarction in the later course and was lost for follow-up. He returned 11 months after the last bevacizumab injection because of sudden loss of vision in his left eye caused by a dense vitreous hemorrhage. Biomicroscopy revealed a new NVD in his right eye. The patient underwent panretinal photocoagulation in both eyes with regression of neovascularization. Vision improved and remained 20/20 in both eyes. CONCLUSION We present a case report showing retinal ischemia can be linked with aHUS. As clinal diagnosis might be challenging, physicians should be aware of the rare ocular manifestations of this devastating multi-organ disease. In case of retinal ischemia, panretinal photocoagulation should be initiated soon to avoid blinding complications.
Collapse
|
21
|
Abstract
Objective To report here, case series of women developing acute kidney injury (AKI) in association with hemolytic uremic syndrome (HUS) during pregnancy or within days postpartum. Methods Subjects for the study reported here comprised of a cohort of 49 women referred from OBGYN and diagnosed having AKI and HUS. AKI was defined according to RIFLE criteria and HUS on basis of hematological, biochemical and histological features. All patients had normal size kidneys on ultrasonography and no previous co- morbidity. Results From January 2000 - January 2020, 49 such women were admitted/ referred to this facility. The mean age of these patients was 29.02±5.258 years. Two had HUS during pregnancy while rest during postpartum. Majority of women had more than one insults these include hemorrhages, intrauterine deaths, operative measure (lower segment caesarean section). Renal replacement was required in all women. Complete renal recovery was observed in 14 patients, while one died during acute phase of illness. CKD-V developed in 17 patients, 16 patients lost long term follow up, but were dialysis free till last follow up and one left against medical advice during acute phase of illness. Treatment with plasmapheresis revealed significantly better renal recovery (p value 0.03) in this group of patients. Conclusion AKI with background of Hemolytic Uremic Syndrome (HUS) may remain irreversible in many of these young women. Plasmapheresis should be offered to patients with established diagnosis of HUS.
Collapse
Affiliation(s)
- Rubina Naqvi
- Prof. Dr. Rubina Naqvi Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| |
Collapse
|
22
|
Chao SH, Chang YL, Yen JC, Liao HT, Wu TH, Yu CL, Tsai CY, Chou YC. Efficacy and safety of rituximab in autoimmune and microangiopathic hemolytic anemia: a systematic review and meta-analysis. Exp Hematol Oncol 2020; 9:6. [PMID: 32322437 PMCID: PMC7161265 DOI: 10.1186/s40164-020-00163-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background The efficacy and safety of rituximab (RTX) on hemolytic anemia (HA) is unknown. Therefore we retrospectively analyze the efficacy and safety of RTX in autoimmune hemolytic anemia (AIHA) and microangiopathic hemolytic anemia (MAHA) from the previous literature. Methods Data in clinical trials and observational studies were collected from PubMed, Cochrane, Embase, and Google Scholar until Oct 15, 2018. The efficacy and safety of RTX in patients with AIHA or MAHA were assessed and overall response rates (ORRs), complete response rates (CRRs), adverse events (AEs) and relapse rates (RRs) were extracted if available. A meta-analysis was performed with a random-effects model, estimating mean proportions in all studies, and relative rates in comparative studies. Results After quality assessment, a total of 37 investigations encompassing 1057 patients eligible for meta-analysis were included. Pooled mean proportion of ORR was 0.84 (95% confidence interval [CI] 0.80–0.88), and that of CRR was 0.61 (95% CI 0.49–0.73). Mean AE rate was 0.14 (95% CI 0.10–0.17), and mean RR was 0.21 (95% CI 0.15–0.26). Relative ORR was 1.18 (95% CI 1.02–1.36), and relative CRR was 1.17 (95% CI 0.98–1.39) fold more than the respective non-RTX counter parts. Relative AE rate was 0.77 (95% CI 0.36–1.63), and relative RR was 0.93 (95% CI 0.56–1.55) fold less than the respective non-RTX counter parts. Conclusion RTX is more effective than the treatments without RTX for AIHA and MAHA and is well-tolerated.
Collapse
Affiliation(s)
- Shih-Hsuan Chao
- 1Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Yuh-Lih Chang
- 2Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiin-Cherng Yen
- 1Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Hsien-Tzung Liao
- 3Division of Allergy Immunology & Rheumatology, Taipei Veterans General Hospital, 201 Shih-Pai Rd Sec 2, Taipei, 112 Taiwan
| | - Tsai-Hung Wu
- 4Division of Nephrology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Li Yu
- 5Division of Rheumatology Immunology & Allergy, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Youh Tsai
- 3Division of Allergy Immunology & Rheumatology, Taipei Veterans General Hospital, 201 Shih-Pai Rd Sec 2, Taipei, 112 Taiwan
| | - Yueh-Ching Chou
- 2Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
23
|
Amari Chinchilla K, Vijayan M, Taveras Garcia B, Jim B. Complement-Mediated Disorders in Pregnancy. Adv Chronic Kidney Dis 2020; 27:155-164. [PMID: 32553248 DOI: 10.1053/j.ackd.2020.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 12/13/2022]
Abstract
Complement-mediated disorders in pregnancy span a large spectrum and have been implicated in all three complement pathways: classical, lectin, and alternative. Our understanding of these disorders in recent years has advanced due to a better understanding of complement regulatory proteins, such as complement factor H, complement factor I, membrane cofactor protein, and thrombomodulin that particularly affect the alternative complement pathway. Enthusiasm in genotyping for mutations that encode these proteins has allowed us to study the presence of genetic variants which may predispose women to develop conditions such as pregnancy-associated hemolytic uremic syndrome (P-aHUS), thrombotic thrombocytopenic purpura, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP), systemic lupus erythematosus/antiphospholipid syndrome, and peripartum cardiomyopathy. The advent of the anti-C5-antibody eculizumab to quench the complement cascade has already proven in small case series to improve maternal kidney outcomes in complement-mediated obstetric catastrophes such as P-aHUS and HELLP. In this review, we will detail the pathogenesis behind these complement-mediated pregnancy disorders, the role of complement variants in disease phenotype, and the most up-to-date experience with eculizumab in this population.
Collapse
|
24
|
Manrique-Caballero CL, Peerapornratana S, Formeck C, Del Rio-Pertuz G, Gomez Danies H, Kellum JA. Typical and Atypical Hemolytic Uremic Syndrome in the Critically Ill. Crit Care Clin 2020; 36:333-356. [PMID: 32172817 DOI: 10.1016/j.ccc.2019.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hemolytic uremic syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome have a similar clinical presentation. Diagnostic needs to be prompt to decrease mortality, because identifying the different disorders can help to tailor specific, effective therapies. However, diagnosis is challenging and morbidity and mortality remain high, especially in the critically ill population. Development of clinical prediction scores and rapid diagnostic tests for hemolytic uremic syndrome based on mechanistic knowledge are needed to facilitate early diagnosis and assign timely specific treatments to patients with hemolytic uremic syndrome variants.
Collapse
Affiliation(s)
- Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand; Department of Laboratory Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand
| | - Cassandra Formeck
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 3, Pittsburgh, PA 15224, USA
| | - Gaspar Del Rio-Pertuz
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Hernando Gomez Danies
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA.
| |
Collapse
|
25
|
Knoop M, Haller H, Menne J. [Human genetics in atypical hemolytic uremic syndrome-its role in diagnosis and treatment]. Internist (Berl) 2019; 59:799-804. [PMID: 29995248 DOI: 10.1007/s00108-018-0455-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The atypical hemolytic uremic syndrome (aHUS), one of the three major forms of thrombotic microangiopathy, is characterized by genetic alterations in the area of the complement cascade, which can be detected in 40%-60% of all patients with aHUS. Mutations in over 10 different genes have now been identified. The most frequent and clinically relevant of these are mutations that result in a decreased or absent function of factor H, the formation of hybrid genes, or the formation of autoantibodies against factor H. Although genetics are not required for the diagnosis of aHUS, it is of great importance for the decision on how long to treat with the C5 inhibitor eculizumab. Also, knowledge of genetic alterations is absolutely essential if a living related donor is considered, in order to protect the living donor and recipient from developing aHUS.
Collapse
Affiliation(s)
- M Knoop
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - J Menne
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| |
Collapse
|
26
|
Formeck C, Swiatecka-Urban A. Extra-renal manifestations of atypical hemolytic uremic syndrome. Pediatr Nephrol 2019; 34:1337-1348. [PMID: 30109445 PMCID: PMC8627279 DOI: 10.1007/s00467-018-4039-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 01/31/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare and complex disease resulting from abnormal alternative complement activation with a wide range of clinical presentations. Extra-renal manifestations of aHUS can involve many organ systems, including the peripheral and central nervous, gastrointestinal, cardiovascular, integumentary, pulmonary, as well as the eye. While some of these extra-renal manifestations occur in the acute phase of aHUS, some can also occur as long-term sequelae of unopposed complement activation. Extra-renal symptoms are observed in approximately 20% of patients with aHUS, with the incidence of specific organ system complications ranging from a few case reports to 50% of described patients. Careful monitoring for extra-renal involvement is critical in patients with aHUS, as prompt evaluation and management may decrease the risk of high morbidity and mortality associated with aHUS.
Collapse
Affiliation(s)
- Cassandra Formeck
- Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Agnieszka Swiatecka-Urban
- Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
27
|
Bagga A, Khandelwal P, Mishra K, Thergaonkar R, Vasudevan A, Sharma J, Patnaik SK, Sinha A, Sethi S, Hari P, Dragon-Durey MA. Hemolytic uremic syndrome in a developing country: Consensus guidelines. Pediatr Nephrol 2019; 34:1465-1482. [PMID: 30989342 DOI: 10.1007/s00467-019-04233-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/06/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is a leading cause of acute kidney injury in children. Although international guidelines emphasize comprehensive evaluation and treatment with eculizumab, access to diagnostic and therapeutic facilities is limited in most developing countries. The burden of Shiga toxin-associated HUS in India is unclear; school-going children show high prevalence of anti-factor H (FH) antibodies. The aim of the consensus meeting was to formulate guidelines for the diagnosis and management of HUS in children, specific to the needs of the country. METHODS Four workgroups performed literature review and graded research studies addressing (i) investigations, biopsy, genetics, and differential diagnosis; (ii) Shiga toxin, pneumococcal, and infection-associated HUS; (iii) atypical HUS; and (iv) complement blockade. Consensus statements developed by the workgroups were discussed during a consensus meeting in March 2017. RESULTS An algorithm for classification and evaluation was developed. The management of Shiga toxin-associated HUS is supportive; prompt plasma exchanges (PEX) is the chief therapy in patients with atypical HUS. Experts recommend that patients with anti-FH-associated HUS be managed with a combination of PEX and immunosuppressive medications. Indications for eculizumab include incomplete remission with plasma therapy, life-threatening features, complications of PEX or vascular access, inherited defects in complement regulation, and recurrence of HUS in allografts. Priorities for capacity building in regional and national laboratories are highlighted. CONCLUSIONS Limited diagnostic capabilities and lack of access to eculizumab prevent the implementation of international guidelines for HUS in most developing countries. We propose practice guidelines for India, which will perhaps be applicable to other developing countries.
Collapse
Affiliation(s)
- Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Ranjeet Thergaonkar
- Department of Pediatrics, Indian Naval Hospital Ship, Kalyani, Visakhapatnam, India
| | - Anil Vasudevan
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | - Saroj Kumar Patnaik
- Department of Pediatrics, Army Hospital Research & Referral, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sidharth Sethi
- Department of Nephrology, Medanta Hospital, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Marie-Agnes Dragon-Durey
- Laboratory of Immunology, Hopital Europeen Georges Pompidou, INSERM UMRS 1138, Paris Descartes University, Paris, France
| | | |
Collapse
|
28
|
Ravi R, Balan S, Murlidharan P, Visweswaran K, B V, T U S, R S. Isolated Liver Transplantation: A Worthy Choice for Atypical Hemolytic Syndrome in Resource-Restricted Settings. Kidney Int Rep 2019; 4:1019-1022. [PMID: 31312773 PMCID: PMC6609822 DOI: 10.1016/j.ekir.2019.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/19/2019] [Accepted: 03/11/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ranjani Ravi
- Department of Nephrology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Satish Balan
- Department of Nephrology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Praveen Murlidharan
- Department of Nephrology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Kasi Visweswaran
- Department of Nephrology, Ananthapuri Hospital, Thiruvananthauram, Kerala, India
| | - Venugopal B
- Department of Hepatobiliary and Pancreatic surgery, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Shabeerali T U
- Department of Hepatobiliary and Pancreatic surgery, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Shiraz R
- Department of Hepatobiliary and Pancreatic surgery, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| |
Collapse
|
29
|
Al-Shyoukh A, Younis M, Abughanimeh O, Tahboub M, Hamarshi MS. An Unusual Case of Diffuse Alveolar Hemorrhage as a Clinical Manifestation of Atypical Hemolytic Uremic Syndrome: A Case Report. Cureus 2019; 11:e5059. [PMID: 31516771 PMCID: PMC6721894 DOI: 10.7759/cureus.5059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is a constellation of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury. HUS is subcategorized into primary or secondary HUS. Primary HUS is synonymous with atypical HUS (aHUS) and is attributed to genetic complement deficiency. Diffuse alveolar hemorrhage (DAH) is a serious condition complicating multiple systemic conditions. aHUS presenting as DAH is exceedingly rare. In this case, we present a 75-year-old male patient who presented with generalized weakness, malaise, and hemoptysis. He was found to have hemolytic anemia and thrombocytopenia, with elevated creatinine. Bronchoscopy confirmed DAH. He was started on plasmapheresis with a suboptimal response. aHUS was suspected and the patient was started on eculizumab with subsequent laboratory and clinical improvement. HUS and aHUS can present as DAH. It is very important to recognize both conditions as both are life threatening with high morbidity and mortality.
Collapse
Affiliation(s)
- Ahmad Al-Shyoukh
- Internal Medicine, University of Missouri-Kansas City l Saint Luke's Health System, Kansas City, USA
| | - Moustafa Younis
- Internal Medicine, University of Missouri-Kansas City l Saint Luke's Health System, Kansas City, USA
| | - Omar Abughanimeh
- Internal Medicine, University of Missouri-Kansas City l Saint Luke's Health System, Kansas City, USA
| | - Mohammad Tahboub
- Internal Medicine, University of Missouri-Kansas City l Saint Luke's Health System, Kansas City, USA
| | - Majdi S Hamarshi
- Critical Care, University of Missouri-Kansas City l Saint Luke's Health System, Kansas City, USA
| |
Collapse
|
30
|
Critical Appraisal of International Clinical Practice Guidelines in Kidney Transplantation Using the Appraisal of Guidelines for Research and Education II Tool: A Systematic Review. Transplantation 2019; 102:1419-1439. [PMID: 30124634 DOI: 10.1097/tp.0000000000002255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although clinical practice guidelines (CPGs) are used for the development of local protocols in kidney transplantation (Ktx), the quality of their methodology is variable. This systematic review aimed to critically appraise international CPGs in all aspects of Ktx using the Appraisal of Guidelines for Research and Evaluation II tool. METHODS Clinical Practice Guidelines in Ktx and donation published between 2010 and 2017 were identified from MEDLINE, Embase, National Guideline Clearinghouse, National Health Service and National Institute for Health and Care Excellence Evidence Searches, and the websites of transplant societies. Using Appraisal of Guidelines for Research and Evaluation II, 3 appraisers assessed the quality of CPGs. Interrater reliability was measured using the intraclass correlation coefficient (ICC). RESULTS Searches identified 3168 records, and 115 CPGs were included. The highest scoring Appraisal of Guidelines for Research and Evaluation II domain was "scope and purpose" (80%; range, 30%-100%), followed by "clarity of presentation" (77%; range, 43%-98%), "editorial independence" (52%; range, 0%-94%), "rigor of development" (47%; range 6%-97%) and "stakeholder involvement" (41%; range, 11%-85%). The poorest scoring domain was "applicability" (31%; range, 3%-74%). Most CPGs were recommended for future use either with (63%) or without (18%) modifications. A small number (14%) were not recommended for future use or reviewers (5%) did not agree on recommending the CPG. The overall mean CPG quality score was 4 of 7 (range, 2-7). The mean ICC of 0.74 indicated substantial agreement between reviewers. CONCLUSIONS The quality of international CPGs in Ktx was variable, and most CPGs lacked key aspects of methodological robustness and transparency. Improvements in methodology, patient involvement, and strategies for implementation are required.
Collapse
|
31
|
Chan S, Weinstein AR. Seizure as the Presenting Symptom for Atypical Hemolytic Uremic Syndrome. J Emerg Med 2019; 56:441-443. [PMID: 30826084 DOI: 10.1016/j.jemermed.2018.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/03/2018] [Accepted: 12/24/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a complement-mediated disease manifesting in thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. It has a higher incidence of extrarenal manifestations, including central nervous system findings like seizure or stroke, pancreatitis, and cardiac manifestations. CASE REPORT We present a case of an unimmunized 14-month-old girl presenting with generalized seizure and ultimately diagnosed with aHUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These atypical neurological symptoms can cause the diagnosis to be commonly missed in the emergency department. The etiology of approximately 60% of patients with aHUS can be attributed to genetic mutations in complement regulators including factor H, membrane cofactor protein, factor I, activator factor B, or C3. Although previously treated with plasma transfusion and immunosuppressants, eculizumab is a newer treatment that has been changing prognosis and management of aHUS, but it should be administered within 48 h of symptom onset for best efficacy.
Collapse
Affiliation(s)
- Sandy Chan
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire and Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Adam R Weinstein
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire and Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
32
|
Abstract
Thrombotic microangiopathy (TMA) is a syndrome involving fragmentation haemolysis, thrombocytopenia, and thrombosis. A range of disorders including cancer may have TMA as a clinical manifestation. TMA in cancer may be caused by several mechanisms, including systemic microvascular metastases, but may also be due to extensive bone marrow involvement with cancer or secondary necrosis. Chemotherapeutic agents may also cause associated TMA through a range of different mechanisms. Gemcitabine, platinum-based drugs, mitomycin C, and proteasome inhibitors are known to cause TMA in cancer patients. Transplant-associated TMA (TA-TMA) may affect either solid organ or HSCT patients. TA-TMA remains a difficult complication to address due to its high mortality rate, lack of standard diagnostic criteria, and limited therapeutic options. The challenge of cancer-associated TMA is furthered by the fact that plasma exchange is ineffective in its management.
Collapse
|
33
|
Mukherjee AA, Kandhare AD, Bodhankar SL. Evaluation of health-related quality of life in hemolytic uraemic syndrome patients treated with eculizumab: a systematic evaluation on basis of EMPRO. Ren Fail 2018; 40:107-118. [PMID: 29363392 PMCID: PMC6014301 DOI: 10.1080/0886022x.2018.1427110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/07/2017] [Accepted: 12/14/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hemolytic uraemic syndrome (HUS) is progressive renal failure disease and determination of their quality of life (QoL) on the basis of patient-reported outcomes (PROs) are becoming increasingly important in the economic evaluations for its treatment with eculizumab (ECU). AIM To perform the systematic evaluation of QoL in HUS patients treated with ECU on the basis of Evaluating Measures of Patient Reported Outcomes (EMPRO) tool. MATERIALS AND METHODS A systematic review was conducted in PubMed, EMBASE, the Cochrane Library, CINAHL and Google Scholar till September 2016 by two independent researchers. Each identified instrument was evaluated for its quality of performance by using the EMPRO tool for its overall score and seven attribute specific scores (range 0-100, worst to best). RESULTS Five different PROs instruments were identified from 10 articles (n = 112) which showed eculizumab significantly improves health-related quality of life (HRQOL) in atypical HUS (aHUS) patients. Amongst five instruments viz. EuroQol five dimensions questionnaire (EQ-5 D), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Headache Impact Test-6 (HIT-6), 36-Item Short Form Health Survey (SF-36) and Visual Analogue Scale (VAS), the overall EMPRO score was higher for VAS (73.83) and EQ-5 D (73.81). Whereas, FACIT-F and HIT- 6 were just able to meet the minimal threshold of EMPRO scoring (50.24 and 59.09, respectively). CONCLUSIONS Evidence from present investigation support that eculizumab significantly improves HRQoL in patients with aHUS furthermore, EQ-5 D and VAS instrument should be recommended for assessing HRQoL in them. However, selection of PRO instrument for determination of QoL in HUS entirely depend upon the study requirements.
Collapse
Affiliation(s)
| | - Amit D. Kandhare
- Department of Pharmacology, Poona College of Pharmacy, Pune, India
| | | |
Collapse
|
34
|
Terano C, Ishikura K, Hamada R, Yoshida Y, Kubota W, Okuda Y, Shinozuka S, Harada R, Iyoda S, Fujimura Y, Hamasaki Y, Hataya H, Honda M. Practical issues in using eculizumab for children with atypical haemolytic uraemic syndrome in the acute phase: A review of four patients. Nephrology (Carlton) 2018; 23:539-545. [PMID: 28387984 DOI: 10.1111/nep.13054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 03/14/2017] [Accepted: 04/05/2017] [Indexed: 11/28/2022]
Abstract
AIM Recently eculizumab, a monoclonal antibody to C5, was found to improve the disease course of atypical haemolytic uraemic syndrome (aHUS) and has been recommended as the first line treatment by an international consensus guideline. However, several practical issues in the use of eculizumab for the acute phase of aHUS have yet to be resolved. METHODS Children who received eculizumab with diagnosis of aHUS between March 2010 and December 2015 at Tokyo Metropolitan Children's Medical Center were enrolled. aHUS was diagnosed according to the haemolytic uraemic syndrome (HUS) criteria after excluding Shiga toxin-inducing Escherichia coli (STEC) -associated HUS and thrombocytopaenic purpura. We retrieved and analyzed data from the electronic medical records at our institution. RESULTS We reviewed four patients with suspected aHUS. Eculizumab was discontinued in one patient in whom STEC-HUS was later diagnosed. Treatment was continued in the remaining three patients without recurrence. Practical issues included difficulty in diagnosing aHUS, particularly in the acute phase, risk of infection by encapsulated organisms, especially Neisseria meningitis, and infusion reaction. In addition to issues relating to the acute phase, discontinuing eculizumab in stable patients in the chronic phase must be considered. CONCLUSION Eculizumab, the first line treatment for children with aHUS, is usually effective. However, certain problems associated with its use require caution to be exercised. As clinical information on eculizumab are still very limited, and the rationale for its long-term use has yet to be established, physicians are advised to exercise care when using eculizumab to manage aHUS.
Collapse
Affiliation(s)
- Chikako Terano
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan.,Division of Nephrology and Rheumatology, National Center for Child Health and Development, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Yasuhiro Yoshida
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Japan
| | - Wataru Kubota
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Japan
| | - Shunsuke Shinozuka
- Department of Pediatrics, National Hospital Organization Saitama National Hospital, Japan
| | - Ryoko Harada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Sunao Iyoda
- Department of Bacteriology I, National Institute of Infectious Diseases, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan.,Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Japan
| |
Collapse
|
35
|
Acute kidney injury in a patient with hemolytic anemia and thrombocytopenia. JAAPA 2018; 29:1-4. [PMID: 27787280 DOI: 10.1097/01.jaa.0000496961.12367.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atypical hemolytic uremic syndrome (HUS) is clinically difficult to distinguish from HUS and thrombotic thrombocytopenic purpura. Atypical HUS results from dysregulation of complement activation causing thrombotic microangiopathy affecting multiple organ systems. Atypical HUS is associated with high morbidity and mortality, making early recognition and appropriate therapy necessary to improve patient outcomes.
Collapse
|
36
|
Walsh PR, Johnson S. Treatment and management of children with haemolytic uraemic syndrome. Arch Dis Child 2018; 103:285-291. [PMID: 28899876 DOI: 10.1136/archdischild-2016-311377] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/31/2017] [Accepted: 08/07/2017] [Indexed: 11/03/2022]
Abstract
Haemolytic uraemic syndrome (HUS), comprising microangiopathic haemolytic anaemia, thrombocytopaenia and acute kidney injury, remains the leading cause of paediatric intrinsic acute kidney injury, with peak incidence in children aged under 5 years. HUS most commonly occurs following infection with Shiga toxin-producing Escherichia coli (STEC-HUS). Additionally, HUS can occur as a result of inherited or acquired dysregulation of the alternative complement cascade (atypical HUS or aHUS) and in the setting of invasive pneumococcal infection. The field of HUS has been transformed by the discovery of the central role of complement in aHUS and the dawn of therapeutic complement inhibition. Herein, we address these three major forms of HUS in children, review the latest evidence for their treatment and discuss the management of STEC infection from presentation with bloody diarrhoea, through to development of fulminant HUS.
Collapse
Affiliation(s)
- Patrick R Walsh
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutic Centre, Newcastle upon Tyne, UK
| | - Sally Johnson
- National Renal Complement Therapeutic Centre, Newcastle upon Tyne, UK.,Department of Paediatric Nephrology, Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| |
Collapse
|
37
|
Knöbl P. Treatment of thrombotic microangiopathy with a focus on new treatment options. Hamostaseologie 2018; 33:149-59. [DOI: 10.5482/hamo-13-01-0004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 04/12/2013] [Indexed: 11/05/2022] Open
Abstract
SummaryThe thrombotic microangiopathies (TMA) are a heterogeneous group of disorders, characterized by microangiopathic haemolytic anaemia with red cell fragmentation, thrombocytopenia and signs of organ dysfunction due to disturbed microcirculation. Current laboratory methods can be used to better distinguish some of these entities. Organ dysfunction can be severe and life-threatening, and immediate start of sufficient therapy is necessary to avoid permanent damage or death. The therapeutic options, however, are often limited to symptomatic measures, and are not standardized or based on high scientific evidence. During the preceding years, not only considerable progress has been made in better diagnosis of TMA, but also new therapeutic strategies have been established. Initial treatment still is based on plasma exchange and symptomatic measures to protect organ function. New concepts (immunosuppression, targeted anti-von Willebrand factor or anti-complement therapy, replacement with recombinant enzymes) are discussed in this article.
Collapse
|
38
|
Claes KJ, Massart A, Collard L, Weekers L, Goffin E, Pochet JM, Dahan K, Morelle J, Adams B, Broeders N, Stordeur P, Abramowicz D, Bosmans JL, Van Hoeck K, Janssens P, Pipeleers L, Peeters P, Van Laecke S, Levtchenko E, Sprangers B, van den Heuvel L, Godefroid N, Van de Walle J. Belgian consensus statement on the diagnosis and management of patients with atypical hemolytic uremic syndrome. Acta Clin Belg 2018; 73:80-89. [PMID: 29058539 DOI: 10.1080/17843286.2017.1345185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Kathleen J Claes
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Annick Massart
- Department of Nephrology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Laurent Weekers
- Department of Internal Medicine, Division of Nephrology, ULg, CHU Liège, Liège, Belgium
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Michel Pochet
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Karin Dahan
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institut de Génétique et de Pathologie, IPG, Gosselies, Belgium
| | - Johann Morelle
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Brigitte Adams
- Queen Fabiola Children’s University Hospital, Brussels, Belgium
| | - Nilufer Broeders
- Department of Nephrology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Stordeur
- Immunobiology Clinic, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, University Hospital Antwerp, Antwerp, Belgium
| | | | - Koen Van Hoeck
- Department of Pediatrics, University Hospital Antwerp, Antwerp, Belgium
| | - Peter Janssens
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussels, Brussels, Belgium
| | - Lissa Pipeleers
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussels, Brussels, Belgium
| | - Patrick Peeters
- Department of Nephrology, University Hospital Ghent, Ghent, Belgium
| | | | - Elena Levtchenko
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Nathalie Godefroid
- Pediatric Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Johan Van de Walle
- Department of Pediatric Nephrology, University Hospital Ghent, Ghent, Belgium
| |
Collapse
|
39
|
Kaul A, Vishwakarma K, Bhaduaria DS, Mishra P, Prasad N, Jain M, Thammshetti V, Patel MR, Gupta A, Sharma RK. Early versus late institution of plasma exchange therapy in pregnancy induced thrombotic microangiopathy and its effects on clinical outcomes-A case series. Eur J Obstet Gynecol Reprod Biol 2017; 221:129-134. [PMID: 29288923 DOI: 10.1016/j.ejogrb.2017.12.020] [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: 06/10/2017] [Revised: 12/04/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To look for incidence of pregnancy associated TMA, clinical presentation and impact of early diagnosis and institution of plasma exchange on overall renal outcomes METHODS: -This is a retrospective study among all female patients who presented with acute kidney injury post pregnancy between October 2002 to April 2016 in department of nephrology in a tertiary care hospital in northern India and diagnosed as pregnancy induced TMA. The patient were assessed for duration of onset of renal failure to time of diagnosis of TMA, role of modality of treatment ie plasmpaharesis to outcome. These patients were assessed for complete, partial or no recovery in renal functions at 60 days after admission. RESULTS Patients whose time of onset of renal failure to a correct diagnosis of TMA was ≤15 days and age less than 30 years was also associated with good prognosis. The patients who received plasma exchange and that to within 72 h of admission had more chances of recovery. CONCLUSIONS Early diagnosis of disease and early institution of plasma exchange therapy improves renal outcomes in postpartum TMA.
Collapse
Affiliation(s)
- Anupama Kaul
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India.
| | - Kavita Vishwakarma
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Dharmendra Singh Bhaduaria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Prabhaker Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Venkatesh Thammshetti
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Manas R Patel
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| | - Raj Kumar Sharma
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, India
| |
Collapse
|
40
|
Routine use of clinical exome-based next-generation sequencing for evaluation of patients with thrombotic microangiopathies. Mod Pathol 2017; 30:1739-1747. [PMID: 28752844 PMCID: PMC5716882 DOI: 10.1038/modpathol.2017.90] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023]
Abstract
Next-generation sequencing is increasingly used for clinical evaluation of patients presenting with thrombotic microangiopathies because it allows for simultaneous interrogation of multiple complement and coagulation pathway genes known to be associated with disease. However, the diagnostic yield is undefined in routine clinical practice. Historic studies relied on case-control cohorts, did not apply current guidelines for variant pathogenicity assessment, and used targeted gene enrichment combined with next-generation sequencing. A clinically enhanced exome, targeting ~54 Mb, was sequenced for 73 patients. Variant analysis and interpretation were performed on genes with biological relevance in thrombotic microangiopathy (C3,CD46, CFB, CFH, CFI, DGKE, and THBD). CFHR3-CFHR1 deletion status was also assessed using multiplex ligation-dependent probe amplification. Variants were classified using American College of Medical Genetics and Genomics guidelines. We identified 5 unique novel and 14 unique rare variants in 25% (18/73) of patients, including a total of 5 pathogenic, 4 likely pathogenic, and 15 variants of uncertain clinical significance. Nine patients had homozygous deletions in CFHR3-CFHR1. The diagnostic yield, defined as the presence of a pathogenic variant, likely pathogenic variant or homozygous deletion of CFHR3-CFHR1, was 25% for all patients tested. Variants of uncertain clinical significance were identified in 21% (15/73) of patients.These results illustrate the expected diagnositic yield in the setting of thrombotic microangiopathies through the application of standardized variant interpretation, and highlight the utility of such an approach. Sequencing a clinically enhanced exome to enable targeted, disease-specific variant analysis is a viable approach. The moderate rate of variants of uncertain clinical significance highlights the paucity of data surrounding the variants in our cohort and illustrates the need for expanded variant curation resources to aid in thrombotic microangiopathy-related disease variant classification.
Collapse
|
41
|
Langley K, Chitolie A, Liesner R, Scully M, Machin S, Peyvandi F, Mackie I. Discrepancies between ADAMTS13 activity assays in patients with thrombotic microangiopathies. Thromb Haemost 2017; 109:488-96. [DOI: 10.1160/th12-08-0565] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 12/07/2012] [Indexed: 11/05/2022]
Abstract
SummaryADAMTS13 activity assays are sometimes useful in confirming the clinical diagnosis or to distinguish different thrombotic microangiopathies (TMA). We investigated the commonly used clinical assays for ADAMTS13 activity. 159 samples from normal subjects or acquired TMA patients were studied in collagen binding (CBA), Fret and chromogenic peptide substrate assays. Frozen aliquots of pooled normal plasma gave similar values by CBA, Fret-VWF73 peptide, Fret-VWF86 and chromogenic VWF73 ELISA (chr-VWF73). Two lyophilised commercial calibrants gave lower ADAMTS13 activity by CBA than peptide substrate assays. The addition of solid HEPES to normal plasma caused a significant fall in CBA, but not Fret-VWF73 activity and might partly explain the differences, since lyophilised plasmas are often HEPES buffered. Normal plasmas showed good agreement between CBA and Fret assays, although chr-VWF73 gave slightly higher values. In acquired TMA, there was reasonable agreement between assays for samples with <11% ADAMTS13 activity (83% of samples showed agreement between CBA, Fret-VWF73 and chr-VWF73), but samples with moderate deficiency frequently showed lower CBA levels (only 41–52% agreement). However, there were also some discrepancies among the peptide substrate assays, with Fret-VWF86 sometimes giving slightly higher values than the VWF73 substrate assays. An International reference plasma might improve standardisation, but is not the only problem. It is unclear which assay has greatest clinical utility, this may depend on the nature of the sample. If the activity does not match the clinical picture, an alternative method should be performed. Where therapeutic monitoring is required, the same activity assay should be used throughout.
Collapse
|
42
|
Alternative complement pathway hemolytic assays reveal incomplete complement blockade in patients treated with eculizumab. Clin Immunol 2017. [DOI: 10.1016/j.clim.2017.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
43
|
O'Donoghue KJM, Reed RD, Knight SR, O'Callaghan JM, Ayaz‐Shah AA, Hassan S, Morris PJ, Pengel LHM. Systematic review of clinical practice guidelines in kidney transplantation. BJS Open 2017; 1:97-105. [PMID: 29951611 PMCID: PMC5989947 DOI: 10.1002/bjs5.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/03/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) are widely used to inform the development of protocols for clinical management. Previous work has demonstrated that the quality of CPGs varies widely. This systematic review aimed to determine the quality of CPGs in kidney transplantation in the UK. METHODS CPGs in kidney transplantation published between 2010 and 2017 were identified through searches of MEDLINE, NHS NICE Evidence, and websites of relevant UK societies. Using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool, three appraisers rated the quality of CPGs across six domains, the overall quality of each CPG, and whether it should be recommended for future use. Domain scores were calculated, and inter-rater reliability using the intraclass correlation coefficient (ICC) was reported. RESULTS Thirteen CPGs met the inclusion criteria. The domain 'clarity of presentation' scored highest, followed closely by 'scope and purpose'. The poorest scoring domains were 'applicability' and 'editorial independence'. Editorial independence also had the widest range of scores. Of the 13 CPGs, one was not recommended for future use, seven were recommended for use with modifications, and five for future use with no need for modification. Mean overall CPG quality was 5 (range 3-6) of a maximum score of 7, and mean inter-rater reliability was substantial with an ICC of 0·71. CONCLUSION UK CPGs scored satisfactorily, although with wide variation in how well each domain scored both within and across CPGs. The quality of UK CPGs can still be improved.
Collapse
Affiliation(s)
- K. J. M. O'Donoghue
- Centre for Evidence in Transplantation, Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - R. D. Reed
- University of Alabama at BirminghamComprehensive Transplant InstituteBirmingham, AlabamaUSA
| | - S. R. Knight
- Centre for Evidence in Transplantation, Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Nuffield Department of Surgical SciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - J. M. O'Callaghan
- Centre for Evidence in Transplantation, Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Nuffield Department of Surgical SciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - A. A. Ayaz‐Shah
- Centre for Evidence in Transplantation, Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - S. Hassan
- West London Renal and Transplant Centre, Hammersmith HospitalImperial College Healthcare NHS TrustLondonUK
| | - P. J. Morris
- Centre for Evidence in Transplantation, Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Nuffield Department of Surgical SciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - L. H. M. Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
- Nuffield Department of Surgical SciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| |
Collapse
|
44
|
Gordon CE, Chitalia VC, Sloan JM, Salant DJ, Coleman DL, Quillen K, Ravid K, Francis JM. Thrombotic Microangiopathy: A Multidisciplinary Team Approach. Am J Kidney Dis 2017; 70:715-721. [PMID: 28720207 DOI: 10.1053/j.ajkd.2017.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/14/2017] [Indexed: 12/20/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by the presence of microangiopathic hemolytic anemia and thrombocytopenia along with organ dysfunction, and pathologically, by the presence of microthrombi in multiple microvascular beds. Delays in diagnosis and initiation of therapy are common due to the low incidence, variable presentation, and poor awareness of these diseases, underscoring the need for interdisciplinary approaches to clinical care for TMA. We describe a new approach to improve clinical management via a TMA team that originally stemmed from an Affinity Research Collaborative team focused on thrombosis and hemostasis. The TMA team consists of clinical faculty from different disciplines who together are charged with the responsibility to quickly analyze clinical presentations, guide laboratory testing, and streamline prompt institution of treatment. The TMA team also includes faculty members from a broad range of disciplines collaborating to elucidate the pathogenesis of TMA. To this end, a clinical database and biorepository have been constructed. TMA leaders educate front-line providers from other departments through presentations in various forums across multiple specialties. Facilitated by an Affinity Research Collaborative mechanism, we describe an interdisciplinary team dedicated to improving both clinical care and translational research in TMA.
Collapse
Affiliation(s)
- Craig E Gordon
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Vipul C Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - J Mark Sloan
- Hematology-Oncology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - David J Salant
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - David L Coleman
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Karen Quillen
- Hematology-Oncology Section, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Katya Ravid
- Department of Medicine, Boston University School of Medicine, Boston, MA; Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | - Jean M Francis
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA.
| |
Collapse
|
45
|
Volokhina E, Wijnsma K, van der Molen R, Roeleveld N, van der Velden T, Goertz J, Sweep F, Brüggemann RJ, Wetzels J, van de Kar N, van den Heuvel L. Eculizumab Dosing Regimen in Atypical HUS: Possibilities for Individualized Treatment. Clin Pharmacol Ther 2017; 102:671-678. [DOI: 10.1002/cpt.686] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 01/30/2023]
Affiliation(s)
- E Volokhina
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - K Wijnsma
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - R van der Molen
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - N Roeleveld
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
- Department of Health Evidence; Radboud University Medical Center; Nijmegen The Netherlands
| | - T van der Velden
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - J Goertz
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - F Sweep
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - RJ Brüggemann
- Department of Pharmacy; Radboud University Medical Center; Nijmegen The Netherlands
| | - J Wetzels
- Department of Nephrology; Radboud University Medical Center; Nijmegen The Netherlands
| | - N van de Kar
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - L van den Heuvel
- Department of Pediatric Nephrology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
- Department of Laboratory Medicine; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Pediatrics; University Hospitals Leuven; Leuven Belgium
| |
Collapse
|
46
|
Song D, Liu XR, Chen Z, Xiao HJ, Ding J, Sun SZ, Liu HY, Guo WY, Wang SX, Yu F, Zhao MH. The clinical and laboratory features of Chinese Han anti-factor H autoantibody-associated hemolytic uremic syndrome. Pediatr Nephrol 2017; 32:811-822. [PMID: 28035470 DOI: 10.1007/s00467-016-3562-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-complement factor H (CFH) autoantibody-associated hemolytic uremic syndrome (HUS) is a severe sub-type of HUS. METHODS We assessed the clinical and renal pathological features, circulating complement levels, and genetic background of Chinese pediatric patients with this sub-type of HUS. Thirty-three consecutive patients with acute kidney injury who tested positive for serum anti-CFH autoantibodies were enrolled in this study. RESULTS All of the eight patients who underwent renal biopsies presented with changes typical of thrombotic microangiopathy, especially changes in chronic characteristics. Compared to patients in remission and normal control subjects, patients with acute disease had significantly lower plasma CFH levels and significantly higher plasma complement 3a (C3a), C5a, and terminal complement complex (SC5b-9) levels. The CFH-anti-CFH immunoglobin G (IgG) circulating immunocomplex (CFH-CIC) titers were more closely correlated with CFH plasma levels than anti-CFH IgG levels. Of the 22 patients, four (18%) were homozygous for CFHR3-1Δ and ten were heterozygous for CFHR1 or CFHR3 deletions. Most patients responded well to a combination of plasma and immunosuppressive therapies, with a remission rate of 87%. At the end of the follow-up, nine patients reached the combined end-points, including two with end-stage renal disease and seven with relapses. CONCLUSION Plasma C3a, C5a, and SC5b-9 levels predicted disease activity in anti-CFH autoantibody-associated HUS patients enrolled in this study. These patients responded well to plasma therapy combined with immunosuppression.
Collapse
Affiliation(s)
- Di Song
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Xiao-Rong Liu
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China.
| | - Zhi Chen
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China
| | - Hui-Jie Xiao
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Shu-Zhen Sun
- Department of Pediatrics, Shandong Provincial Hospital affiliated with Shandong University, Jinan, People's Republic of China
| | - Hong-Yan Liu
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Wei-Yi Guo
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China.
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.
- Department of Nephrology, Peking University International Hospital, Beijing, 102206, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
| |
Collapse
|
47
|
Azoulay E, Knoebl P, Garnacho-Montero J, Rusinova K, Galstian G, Eggimann P, Abroug F, Benoit D, von Bergwelt-Baildon M, Wendon J, Scully M. Expert Statements on the Standard of Care in Critically Ill Adult Patients With Atypical Hemolytic Uremic Syndrome. Chest 2017; 152:424-434. [PMID: 28442312 DOI: 10.1016/j.chest.2017.03.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/01/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022] Open
Abstract
A typical hemolytic uremic syndrome (aHUS) presents similarly to thrombotic thrombocytopenic purpura (TTP) and other causes or conditions with thrombotic microangiopathy (TMA), such as disseminated intravascular coagulation or sepsis. Similarity in clinical presentation may hinder diagnosis and optimal treatment selection in the urgent setting in the ICU. However, there is currently no consensus on the diagnosis or treatment of aHUS for ICU specialists. This review aims to summarize available data on the diagnosis and treatment strategies of aHUS in the ICU to enhance the understanding of aHUS diagnosis and outcomes in patients managed in the ICU. To this end, a review of the recent literature (January 2009-March 2016) was performed to select the most relevant articles for ICU physicians. Based on the paucity of adult aHUS cases overall and within the ICU, no specific recommendations could be formally graded for the critical care setting. However, we recognize a core set of skills required by intensivists for diagnosing and managing patients with aHUS: recognizing thrombotic microangiopathies, differentiating aHUS from related conditions, recognizing involvement of other organ systems, understanding the pathophysiology of aHUS, knowing the diagnostic workup and relevant outcomes in critically ill patients with aHUS, and knowing the standard of care for patients with aHUS based on available data and guidelines. In conclusion, managing critically ill patients with aHUS requires basic skills that, in the absence of sufficient data from patients treated within the ICU, can be gleaned from an increasingly relevant literature outside the ICU. More data on critically ill patients with aHUS are needed to validate these conclusions within the ICU setting.
Collapse
Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Paris, France.
| | - Paul Knoebl
- Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | | | - Katerina Rusinova
- University Hospital, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | - Fekri Abroug
- Fattouma Bourguiba Teaching Hospital Monastir, Tunisia
| | | | | | | | | |
Collapse
|
48
|
Adult Post-Kidney Transplant Familial Atypical Hemolytic Uremic Syndrome Successfully Treated With Eculizumab: A Case Report and Literature Review. Am J Ther 2017; 23:e1110-5. [PMID: 25486517 DOI: 10.1097/mjt.0000000000000133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hemolytic uremic syndrome is the triad of nonimmune microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. When not associated with enteric infection, it is classified as atypical hemolytic uremic syndrome (aHUS) and carries a worse outcome with high mortality rate and up to 50% of the survivors will end up with end-stage renal disease. Renal transplant was restricted to a very small percentage of patients due to high recurrence rate posttransplant that approaches 90%. Our case describes a posttransplant adult patient with familial aHUS whom was successfully treated with eculizumab. We also reviewed all other reported cases of adult posttransplant aHUS, both familial and sporadic, which were treated with eculizumab. In summary, eculizumab might expand the utility of renal transplant for patients with end-stage renal disease due to aHUS.
Collapse
|
49
|
Choo SZ, Brown F. Subclinical atypical haemolytic uremic syndrome relapse following discontinuation of eculizumab. Nephrology (Carlton) 2017; 22 Suppl 1:4-6. [DOI: 10.1111/nep.12931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Fiona Brown
- Department of Nephrology; Monash Health; Australia
| |
Collapse
|
50
|
Yamada Y, Abe R, Okano Y, Miyakawa Y. Long-term Eculizumab Treatment Contributes to Recovery from End-stage Renal Disease Caused by Atypical Hemolytic Uremic Syndrome. Intern Med 2017; 56:1085-1088. [PMID: 28458317 PMCID: PMC5478572 DOI: 10.2169/internalmedicine.56.7862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
We experienced a favorable outcome in an adult case of atypical hemolytic uremic syndrome (aHUS) after long-term eculizumab treatment. A 38-year-old Japanese man with a history of central retinal vein occlusion was admitted to our hospital with progressive dyspnea. He was found to have non-immune hemolytic anemia, thrombocytopenia, and acute renal failure two weeks after an episode of the common cold. Plasma exchange was ineffective; therefore, we initiated eculizumab after we excluded other thrombotic microangiopathies. Although long-term peritoneal dialysis was required, we successfully discontinued dialysis 18 months after the onset of aHUS with eculizumab.
Collapse
Affiliation(s)
- Yuji Yamada
- Department of Medicine, Kawasaki Municipal Kawasaki Hospital, Japan
- Department of Medicine, Mount Sinai Beth Israel, USA
| | - Ryohei Abe
- Department of Medicine, Kawasaki Municipal Kawasaki Hospital, Japan
- Division of Hematology, Keio University School of Medicine, Japan
| | - Yutaka Okano
- Department of Medicine, Kawasaki Municipal Kawasaki Hospital, Japan
| | - Yoshitaka Miyakawa
- Department of Medicine, Kawasaki Municipal Kawasaki Hospital, Japan
- Department of General Internal Medicine, Saitama Medical University Hospital, Japan
| |
Collapse
|