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Konopásek P, Zieg J. Eculizumab use in patients with pneumococcal-associated hemolytic uremic syndrome and kidney outcomes. Pediatr Nephrol 2023; 38:4209-4215. [PMID: 37306721 PMCID: PMC10584715 DOI: 10.1007/s00467-023-06037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/05/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Streptococcus pneumoniae-associated hemolytic uremic syndrome (P-HUS) is a rare and severe disease. Only a few reports have been published about eculizumab use in P-HUS. METHODS We analyzed demographic, clinical, and laboratory data of patients with P-HUS from our center. RESULTS The cohort consisted of 4 females and 3 males. All patients had pneumonia. Four were given eculizumab (days 1-3). The eculizumab group required a shorter duration of dialysis and mechanical ventilation (medians 20 vs. 28.5 and 30 vs 38.5 days, respectively) compared with the non-eculizumab group, but this was still much longer than normally reported; the thrombocytopenia resolution was similar in both groups (medians 10 vs. 8 days). Chronic kidney disease (CKD) was correlated with the duration of dialysis and mechanical ventilation duration at 1 year (r = 0.797, P = 0.032 and r = 0.765, P = 0.045) and last follow-up (r = 0.807, P = 0.028 and r = 0.814, P = 0.026, respectively); our scoring system showed even stronger correlations (r = 0.872, P = 0.011 and r = 0.901, P = 0.0057, respectively). The eculizumab group showed slightly better 1-year and last follow-up CKD stage (2.75 vs. 3, P = 0.879 and 2.5 vs. 3.67, P = 0.517). CONCLUSIONS Despite the fact that the eculizumab group showed better outcomes, eculizumab does not seem to improve the course of P-HUS compared with previous reports. Kidney outcomes are strongly correlated with the duration of dialysis and mechanical ventilation duration. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Patrik Konopásek
- Department of Pediatric Nephrology, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic.
- Pediatrická Klinika 2. LF UK and FN v Motole, V Úvalu 84, Prague 5, 15006, Czech Republic.
| | - Jakub Zieg
- Department of Pediatric Nephrology, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
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2
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Kuok CI, Hsu MLN, Lai SHF, Wong KNK, Chan WKY. Acute Kidney Injury and Hemolytic Uremic Syndrome in Severe Pneumococcal Pneumonia—A Retrospective Analysis in Pediatric Intensive Care Unit. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1759528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Abstract
Objectives: This study aimed to evaluate the prevalence of acute kidney injury (AKI) and hemolytic uremic syndrome (HUS) in severe pediatric pneumonia due to Streptococcus pneumoniae and to identify factors associated with AKI and HUS in these patients.
Methods: We retrospectively analyzed pediatric patients who were admitted to our pediatric intensive care unit due to severe pneumococcal pneumonia between 2013 and 2019.
Results: Forty-two patients with a median age of 4.3 years were included. Among these patients, 14 (33.3%) developed AKI, including seven (16.7%) stage 1, two (4.8%) stage 2, and five (11.9%) stage 3 AKI. Features of HUS were present in all of the patients with stage 3 AKI, and four required renal replacement therapy (RRT), with a median duration of 10.5 days (range 3 to 16 days). All patients with HUS required mechanical ventilation and inotropic supports. Patients with lower leukocyte and platelet counts, serum sodium and bicarbonate levels, positive urine dipstick (heme or protein ≥ 2 + ), and presence of bacteremia were associated with stage 2 and 3 AKI.
Conclusions: Pediatricians should be aware of the relatively high prevalence of kidney involvement in severe pneumococcal pneumonia, with one-third having AKI and 11.9% developing HUS. Majority (80%) of HUS patients required RRT. Positive urine dipstick, serum sodium, and bicarbonate at presentation, which can be measured in point-of-care tests, may potentially be useful as quick tests to stratify the risks of moderate-to-severe AKI.
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Affiliation(s)
- Chon In Kuok
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong SAR
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3
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Streptococcus Pneumoniae-Associated Hemolytic Uremic Syndrome in the Era of Pneumococcal Vaccine. Pathogens 2021; 10:pathogens10060727. [PMID: 34207609 PMCID: PMC8227211 DOI: 10.3390/pathogens10060727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 01/09/2023] Open
Abstract
Streptococcus pneumoniae-associated hemolytic uremic syndrome (Sp-HUS) is a serious complication of invasive pneumococcal disease that is associated with increased mortality in the acute phase and morbidity in the long term. Recently, Sp-HUS definition has undergone revision and cases are categorized as definite, probable, and possible, based on less invasive serological investigations that evaluate Thomsen-Friedenreich crypt antigen (T-antigen) activation. In comparison to the pre-vaccine era, Sp-HUS incidence seems to be decreasing after the introduction of 7-serotype valence and 13-serotype valence pneumococcal vaccines in 2000 and 2010, respectively. However, Sp-HUS cases continue to occur secondary to vaccine failure and emergence of non-vaccine/replacement serotypes. No single hypothesis elucidates the molecular basis for Sp-HUS occurrence, although pneumococcal neuraminidase production and formation of T-antigen antibody complexes on susceptible endothelial and red blood cells continues to remain the most acceptable explanation. Management of Sp-HUS patients remains supportive in nature and better outcomes are being reported secondary to earlier recognition, better diagnostic tools and improved medical care. Recently, the addition of eculizumab therapy in the management of Sp-HUS for control of dysregulated complement activity has demonstrated good outcomes, although randomized clinical trials are awaited. A sustained pneumococcal vaccination program and vigilance for replacement serotypes will be the key for persistent reduction in Sp-HUS cases worldwide.
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Guerra OJL, Rodríguez RSG, Camacho WJM, Ortiz JEP, Camacho MAM. HEMOLYTIC UREMIC SYNDROME ASSOCIATED WITH STREPTOCOCCUS PNEUMONIAE IN PEDIATRICS: A CASE SERIES. ACTA ACUST UNITED AC 2019; 38:e2018065. [PMID: 31778402 PMCID: PMC6909244 DOI: 10.1590/1984-0462/2020/38/2018065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/08/2018] [Indexed: 12/20/2022]
Abstract
Objective: To describe a case series of four (4) patients with hemolytic uremic syndrome due to Streptococcus pneumoniae in a level four complexity institution in the city of Bogotá, D.C., Colombia. Cases description: We describe cases of four patients who presented respiratory symptoms and fever. All four patients were in regular conditions on hospital admission, after which they required intensive care and ventilatory support. Upon admission, three cases showed evidence of pleuropulmonary complication. Penicillin-sensitive Streptococcus pneumoniae was isolated in all cases. All patients presented anemia, severe thrombocytopenia, schistocytes on peripheral blood smear, and hyperazotemia. They required blood transfusion and renal replacement therapy during their hospitalization. The patients were diagnosed with hemolytic uremic syndrome due to S. pneumoniae. Three of the four patients had a progressive recovery of the renal function and were discharged after an average of 36 days of hospital stay. The remaining patient had two amputations in the extremities due to thrombotic vascular complications and was discharged after 99 days of hospital stay, requiring hemodialysis every other day. Comments: Hemolytic uremic syndrome due to Streptococcus pneumoniae is a rare but severe complication of invasive pneumococcal disease. Complicated pneumonia is the main condition associated with this entity. It is noteworthy the short period in which these cases were presented, considering the low annual incidence of the disease.
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5
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Ishiguro T, Kojima A, Shimizu T, Mita N, Kuroiwa S, Takayanagi N. Combined hemophagocytic syndrome and thrombotic microangiopathy due to mixed infection with influenza virus and pneumococcal pneumonia. Clin Case Rep 2019; 7:131-134. [PMID: 30656026 PMCID: PMC6333073 DOI: 10.1002/ccr3.1842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/22/2018] [Accepted: 09/11/2018] [Indexed: 11/06/2022] Open
Abstract
Development of hemophagocytic syndrome and thrombotic microangiopathy due to community-acquired pneumonia is rare, but delayed management of these complications can lead to a poor prognosis. Infection by both Streptococcus pneumoniae and influenza virus can cause these complications; thus, physicians should pay attention to them when treating influenza-associated pneumococcal pneumonia.
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Affiliation(s)
- Takashi Ishiguro
- Department of Respiratory MedicineSaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Ayako Kojima
- Department of Respiratory MedicineSaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Taisuke Shimizu
- Department of NephrologySaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Norikatsu Mita
- Department of AnesthesiologySaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Seiichiro Kuroiwa
- Department of Clinical EngineeringSaitama Cardiovascular and Respiratory CenterSaitamaJapan
| | - Noboru Takayanagi
- Department of Respiratory MedicineSaitama Cardiovascular and Respiratory CenterSaitamaJapan
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6
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Lawrence J, Gwee A, Quinlan C. Pneumococcal haemolytic uraemic syndrome in the postvaccine era. Arch Dis Child 2018; 103:957-961. [PMID: 29674516 DOI: 10.1136/archdischild-2017-313923] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 03/06/2018] [Accepted: 03/30/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Pneumococcal infection is a leading cause of haemolytic uraemic syndrome (HUS) and is potentially vaccine preventable. Published data suggest high mortality and poor renal outcomes. The introduction of the 7-valent pneumococcal conjugate vaccine (PCV) has seen the emergence of disease caused by non-vaccine strains, particularly 19A. We sought to describe serotype prevalence and outcomes, particularly after the introduction of the 13-valent PCV. DESIGN AND SETTING We performed a retrospective chart review, using hospital medical records to identify cases of HUS in a tertiary paediatric hospital in Australia over a 20-year period (January 1997-December 2016). Associated pneumococcal infection was identified, and serotype data were categorised according to vaccine era: prevaccine (January 1997-December 2004), PCV7 (January 2005-June 2011) and PCV13 (July 2011-December 2016). RESULTS We identified 66 cases of HUS. Pneumococcal infection was proven in 11 cases, representing 4% (1/26) of cases prior to the introduction of PCV7, 20% (3/15) in the PCV7 era and 28% (7/25) in the PCV13 era. Subtype 19A was the most prevalent pneumococcal serotype (6/11). All four patients who received PCV7 were infected with a non-vaccine serotype. Four of the five patients who received PCV13 were classed as vaccine failures. Median follow-up was 14 (range 1-108) months. Chronic kidney disease was the most common complication (4/7). We observed no mortality, neurological sequelae or progression to end-stage kidney disease. CONCLUSIONS Serotype 19A is most commonly associated with pneumococcal HUS, despite the introduction of the 13-valent vaccine. Chronic kidney disease is a significant complication of pneumococcal HUS.
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Affiliation(s)
- Jolie Lawrence
- Department of Nephrology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Amanda Gwee
- Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Kidney Development, Disease and Regeneration, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Catherine Quinlan
- Department of Nephrology, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Kidney Development, Disease and Regeneration, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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7
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Complement depletion and Coombs positivity in pneumococcal hemolytic uremic syndrome (pnHUS). Case series and plea to revisit an old pathogenetic concept. Int J Med Microbiol 2018; 308:1096-1104. [PMID: 30177469 DOI: 10.1016/j.ijmm.2018.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 12/27/2022] Open
Abstract
Hemolytic uremic syndrome is a rare complication of invasive pneumococcal infection (pnHUS). Its pathogenesis is poorly understood, and treatment remains controversial. The emerging role of complement in various forms of HUS warrants a new look at this "old" disease. We performed a retrospective analysis of clinical and laboratory features of three sequential cases of pnHUS since 2008 associated with pneumonia/pleural empyema, two due to Streptococcus pneumoniae serotype 19 A. Profound depletion of complement C3 (and less of C4) was observed in two patients. One patient was Coombs test positive. Her red blood cells (RBCs) strongly agglutinated with blood group compatible donor serum at 0 °C, but not at 37 °C. All three patients were treated with hemodialysis, concentrated RBCs, and platelets. Patient 2 received frozen plasma for hepatic failure with coagulation factor depletion. Intravenous immunoglobulin infusion, intended to neutralize pneumococcal neuraminidase in patient 3, was associated with rapid normalization of platelets and cessation of hemolysis. Two patients recovered without sequelae or disease recurrence. Patient 2 died within 2½ days of admission due to complicating Pseudomonas aeruginosa sepsis and multiorgan failure. Our observations suggest that pnHUS can be associated with dramatic, transient complement consumption early in the course of the disease, probably via the alternative pathway. A critical review of the literature and the reported cases argue against the postulated pathological role of preformed antibodies against the neuraminidase-exposed Thomsen-Friedenreich neoantigen (T antigen) in pnHUS. The improved understanding of complement regulation and bacterial strategies of complement evasion allows to propose a testable, new pathogenetic model of pnHUS. This model shifts emphasis from the action of natural anti-T antibodies toward impaired Complement Factor H (CFH) binding and function on desialylated membranes. Removal of neuraminic acid residues converts (protected) self to non-self surfaces that supports membrane attack complex (MAC) assembly. Complement activation is potentially exacerbated by decreased CFH availability following tight CFH binding to pneumococcal evasion proteins and/or by the presence of genetic variants of complement regulator proteins. Detailed clinical and experimental investigations are warranted to better understand the role of unregulated complement activation in pnHUS. Instead of avoidance of plasma, a new, integrated model is evolving, which may include short-term therapeutic complement blockade, particularly where genetic or functional APC dysregulation is suspected, in addition to bacterial elimination and, potentially, neuraminidase neutralization.
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Bommer M, Wölfle-Guter M, Bohl S, Kuchenbauer F. The Differential Diagnosis and Treatment of Thrombotic Microangiopathies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:327-334. [PMID: 29875054 PMCID: PMC5997890 DOI: 10.3238/arztebl.2018.0327] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 09/04/2017] [Accepted: 02/14/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombotic microangiopathies are rare, life-threatening diseaseswhose care involves physicians from multiple specialties. The past five years haveseen major advances in our understanding of the pathophysiology, classification,and treatment of these conditions. Their timely diagnosis and prompt treatment cansave lives. METHODS This review is based on pertinent articles published up to 17 December2017 that were retrieved by a selective search of the National Library of Medicine'sPubMed database employing the terms "thrombotic microangiopathy," "thromboticthrombocytopenic purpura," "hemolytic-uremic syndrome," "drug-induced TMA," and"EHEC-HUS." RESULTS The classic types of thrombotic microangiopathy are thrombotic thrombo -cytopenic purpura (TTP) and typical hemolytic-uremic syndrome (HUS), also knownas enterohemorrhagic Escherichia coli-associated HUS (EHEC-HUS). There are anumber of further types from which these must be differentiated. The key test,beyond a basic hematological evaluation including a peripheral blood smear, ismeasurement of the blood level of the protease that splits von Willebrand factor,which is designated ADAMTS13 (a disintegrin and metalloprotease with thrombo -spondin type 1 motif, member 13). The quantitative determination of ADAMTS13, ofADAMTS13 activity, and of the ADAMTS13 inhibitor serves to differentiate TTP fromother types of thrombotic microangiopathy. As TTP requires urgent treatment,plasmapheresis should be begun as soon as TTP is suspected on the basis of afinding of hemolysis with schistocytes and thrombocytopenia. The treatment shouldbe altered as indicated once the laboratory findings become available. CONCLUSION Rapid differential diagnosis is needed in order to determine the specifictype of thrombotic microangiopathy that is present, because only patients with TTPand only a very small percentage of those with atypical hemolytic-uremic syndrome(aHUS) can benefit from plasmapheresis. The establishment of a nationwideregistry in Germany with an attached biobank might help reveal yet unknowngenetic predispositions.
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Affiliation(s)
- Martin Bommer
- Department of Hematology, Oncology, Palliative Care and Infectious Diseases, Alb-Fils-Kliniken, Göppingen, Germany; Department of Internal Medicine III, Ulm University, Ulm, Germany
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9
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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10
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Bitzan M, Zieg J. Influenza-associated thrombotic microangiopathies. Pediatr Nephrol 2018; 33:2009-2025. [PMID: 28884355 PMCID: PMC6153504 DOI: 10.1007/s00467-017-3783-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/11/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022]
Abstract
Thrombotic microangiopathy (TMA) refers to phenotypically similar disorders, including hemolytic uremic syndromes (HUS) and thrombotic thrombocytopenic purpura (TTP). This review explores the role of the influenza virus as trigger of HUS or TTP. We conducted a literature survey in PubMed and Google Scholar using HUS, TTP, TMA, and influenza as keywords, and extracted and analyzed reported epidemiological and clinical data. We identified 25 cases of influenza-associated TMA. Five additional cases were linked to influenza vaccination and analyzed separately. Influenza A was found in 83%, 10 out of 25 during the 2009 A(H1N1) pandemic. Two patients had bona fide TTP with ADAMTS13 activity <10%. Median age was 15 years (range 0.5-68 years), two thirds were male. Oligoanuria was documented in 81% and neurological involvement in 40% of patients. Serum C3 was reduced in 5 out of 14 patients (36%); Coombs test was negative in 7 out of 7 and elevated fibrin/fibrinogen degradation products were documented in 6 out of 8 patients. Pathogenic complement gene mutations were found in 7 out of 8 patients tested (C3, MCP, or MCP combined with CFB or clusterin). Twenty out of 24 patients recovered completely, but 3 died (12%). Ten of the surviving patients underwent plasma exchange (PLEX) therapy, 5 plasma infusions. Influenza-mediated HUS or TTP is rare. A sizable proportion of tested patients demonstrated mutations associated with alternative pathway of complement dysregulation that was uncovered by this infection. Further research is warranted targeting the roles of viral neuraminidase, enhanced virus-induced complement activation and/or ADAMTS13 antibodies, and rational treatment approaches.
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Affiliation(s)
- Martin Bitzan
- Division of Nephrology, The Montreal Children's Hospital, McGill University Health Centre, 1001, boul. Décarie-Room B RC.6651, Montréal, QC, H4A 3J1, Canada.
| | - Jakub Zieg
- 0000 0004 1937 116Xgrid.4491.8Department of Pediatric Nephrology, 2nd Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
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11
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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12
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Åkesson A, Zetterberg E, Klintman J. At the Cross Section of Thrombotic Microangiopathy and Atypical Hemolytic Uremic Syndrome: A Narrative Review of Differential Diagnostics and a Problematization of Nomenclature. Ther Apher Dial 2017; 21:304-319. [DOI: 10.1111/1744-9987.12535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Alexander Åkesson
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
| | - Eva Zetterberg
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
| | - Jenny Klintman
- Department of Translational Medicine, Faculty of Medicine; Lund University; Sweden
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13
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Abstract
Post-infectious hemolytic uremic syndrome (HUS) is caused by specific pathogens in patients with no identifiable HUS-associated genetic mutation or autoantibody. The majority of episodes is due to infections by Shiga toxin (Stx) producing Escherichia coli (STEC). This chapter reviews the epidemiology and pathogenesis of STEC-HUS, including bacterial-derived factors and host responses. STEC disease is characterized by hematological (microangiopathic hemolytic anemia), renal (acute kidney injury) and extrarenal organ involvement. Clinicians should always strive for an etiological diagnosis through the microbiological or molecular identification of Stx-producing bacteria and Stx or, if negative, serological assays. Treatment of STEC-HUS is supportive; more investigations are needed to evaluate the efficacy of putative preventive and therapeutic measures, such as non-phage-inducing antibiotics, volume expansion and anti-complement agents. The outcome of STEC-HUS is generally favorable, but chronic kidney disease, permanent extrarenal, mainly cerebral complication and death (in less than 5 %) occur and long-term follow-up is recommended. The remainder of this chapter highlights rarer forms of (post-infectious) HUS due to S. dysenteriae, S. pneumoniae, influenza A and HIV and discusses potential interactions between these pathogens and the complement system.
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Affiliation(s)
- Denis F. Geary
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
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14
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Stack M, Price N, Ronaldson J, Prestidge C, Wong W, Kara T. Laparoscopic versus open peritoneal dialysis catheter insertion for the management of pediatric acute kidney injury. Pediatr Nephrol 2016; 31:297-303. [PMID: 26432705 DOI: 10.1007/s00467-015-3221-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 09/01/2015] [Accepted: 09/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute pediatric dialysis is provided by a single center in New Zealand. Most acute dialysis in our center is performed in the under 5 age group. The advantage of using peritoneal dialysis (PD) in these children is the ability to perform continuous renal replacement therapy without always requiring an ICU setting, avoiding central venous access and promoting greater cardiovascular stability. The disadvantage of PD in the acute setting includes the requirement for immediate use and the potential for early leaks due to peritoneal disruption with resulting delayed use and restricted volumes. There is a growing trend toward minimally invasive surgery and the laparoscopic method allows this. Surgeons at this center have been using a laparoscopic technique since 2005. METHODS We performed a 10-year review of acute PD at the Starship Hospital from 2003 to 2013. Data on 102 children who met the criteria were collected. RESULTS These 102 children had 113 acute PD catheters. The two groups were comparable in terms of age and reason for presentation. The median age of the laparoscopic group was 2 years (interquartile range [IQR] 6) and the open group was 3 years (IQR 3.2). The predominant diagnosis for both groups was hemolytic uremic syndrome (HUS) accounting for 71% of laparoscopic cases, and 72% of open cases. The incidence of infection was 0% versus 7% in the laparoscopic versus open approach. Ten percent of patients required further manipulation of the catheter after initial insertion in the laparoscopic group, compared with 11% in the open approach. Conversion to hemodialysis (HD) due to catheter-related complications was seen in 10% of laparoscopic cases and 9% of the open cases. Dialysate fluid leak was noted in 26% in the laparoscopic group compared with 11% in the open group (p = 0.08). Anesthesia time is longer in the laparoscopic group (p = 0.008). CONCLUSION We found no significant differences in complication rates between laparoscopic and open surgical approaches regarding acute PD catheter insertion. We saw a trend in increased leakage with laparoscopic procedures and a significantly longer operative time. We concluded that the laparoscopic approach in the acute situation for emergency dialysis is safe and effective.
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Affiliation(s)
- Maria Stack
- Department of Pediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand
| | - Neil Price
- Department of Pediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
| | - Jane Ronaldson
- Department of Pediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand
| | - Chanel Prestidge
- Department of Pediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand
| | - William Wong
- Department of Pediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand
| | - Tonya Kara
- Department of Pediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand. .,Children's Research Centre, Starship Children's Hospital, Auckland, New Zealand.
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15
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Burin des Roziers N, Chadebech P, Bodivit G, Guinchard E, Bruneel A, Dupré T, Chevret L, Jugie M, Gallon P, Bierling P, Noizat-Pirenne F. Red blood cell Thomsen-Friedenreich antigen expression and galectin-3 plasma concentrations in Streptococcus pneumoniae-associated hemolytic uremic syndrome and hemolytic anemia. Transfusion 2014; 55:1563-71. [PMID: 25556575 DOI: 10.1111/trf.12981] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/30/2014] [Accepted: 11/07/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pneumococcal hemolytic uremic syndrome (P-HUS) is a rare but severe complication of invasive pneumococcal disease (IPD) in young children. Consensual biologic diagnosis criteria are currently lacking. STUDY DESIGN AND METHODS A prospective study was conducted on 10 children with culture-confirmed IPD. Five presented with full-blown P-HUS, three had an incomplete form with hemolytic anemia and mild or no uremia (P-HA), and two had neither HUS nor HA. Thomsen-Friedenreich (T), Th, and Tk cryptantigens and sialic acid expression were determined on red blood cells (RBCs) with peanut (PNA), Glycine soja (SBA), Bandeiraea simplicifolia II, and Maackia amurensis lectins. Plasma concentrations of the major endogenous T-antigen-binding protein, galectin-3 (Gal-3), were analyzed. RESULTS We found that RBCs strongly reacted with PNA and SBA lectins in all P-HUS and P-HA patients. Three P-HUS and three P-HA patients showed also concomitant Tk activation. Direct antiglobulin test (DAT) was positive in three P-HUS (one with anti-C3d and two with anti-IgG) and two P-HA patients (one with anti-C3d and one with anti-IgG). RBCs derived from the two uncomplicated IPD patients reacted with PNA but not with SBA lectin. Gal-3 plasma concentrations were increased in all P-HUS patients. CONCLUSIONS The results indicate high levels of neuraminidase activity and desialylation in both P-HUS and P-HA patients. T-antigen activation is more sensitive than DAT for P-HUS diagnosis. Combining PNA and SBA lectins is needed to improve the specificity of T-antigen activation. High concentrations of Gal-3 in P-HUS patients suggest that Gal-3 may contribute to the pathogenesis of P-HUS.
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Affiliation(s)
| | - Philippe Chadebech
- Etablissement Français du Sang Ile de France, Villejuif, France.,Inserm UMR955, Créteil, France
| | - Gwellaouen Bodivit
- Etablissement Français du Sang Ile de France, Villejuif, France.,Inserm UMR955, Créteil, France
| | | | - Arnaud Bruneel
- Laboratoire de Biochimie Métabolique et Cellulaire, Hôpital Bichat, Paris, France
| | - Thierry Dupré
- Laboratoire de Biochimie Métabolique et Cellulaire, Hôpital Bichat, Paris, France
| | - Laurent Chevret
- Réanimation Pédiatrique, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Myriam Jugie
- Réanimation Chirurgicale Pédiatrique, Hôpital Necker-Enfants Malades, Paris, France
| | - Philippe Gallon
- Etablissement Français du Sang Ile de France, Villejuif, France
| | - Philippe Bierling
- Etablissement Français du Sang Ile de France, Villejuif, France.,Inserm UMR955, Créteil, France
| | - France Noizat-Pirenne
- Etablissement Français du Sang Ile de France, Villejuif, France.,Inserm UMR955, Créteil, France
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Huang ST, Lin CL, Chang YJ, Sher YP, Wu MJ, Shu KH, Sung FC, Kao CH. Pneumococcal pneumonia infection is associated with end-stage renal disease in adult hospitalized patients. Kidney Int 2014; 86:1023-30. [DOI: 10.1038/ki.2014.79] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 01/09/2014] [Accepted: 02/06/2014] [Indexed: 12/27/2022]
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17
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Abstract
BACKGROUND Hemolytic uremic syndrome related to pneumococcal infection (P+HUS) can be difficult to diagnose due to the lack of a specific test and the absence of a consensus for definite diagnostic criteria. METHODS A retrospective study was conducted on the cases that have been considered as P+HUS in the participating centers during the past 10 years. Diagnostic strategy and criteria used for the diagnosis of P+HUS were evaluated and compared with a review of literature data. RESULTS A total of 17 children were studied. Tests ruling out other causes of HUS were performed in 94% of cases. Direct confirmatory tests for P+HUS were done in a minority of cases as Thomsen-Friedenreich antigen testing using lectin assay were done in only 2 patients (11%). Retrospectively, the diagnosis of P+HUS was confirmed in 28% to 89% of cases depending on the already published criteria used. A literature review focused on the last 15 years confirmed these diagnostic difficulties due to variable definition criteria and bring a new light on the potential usefulness of tests used to reveal T activation in this setting. CONCLUSION To date, in a context of suspicion of P+HUS, no precise, practical and consensual strategy exists for T-antigen exposure diagnosis. The T-antigen activation test using peanut lectin might be the most appropriate test for a direct diagnosis of P+HUS. A large prospective study is required to confirm this hypothesis. However, before such data are available, its use could be of help when a suspicion of P+HUS is present given the therapeutic impact of such a diagnosis.
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18
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Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is usually associated with diarrheal illness but can also occur in children with Streptococcus pneumoniae infection (SpHUS), particularly those with complicated pneumonia. Based on recent reports that hospital discharges for complicated pneumococcal pneumonia are increasing in US children, we studied whether discharges for SpHUS might also be increasing. METHODS We used the Kids' Inpatient Database samples from 1997, 2000, 2003, 2006 and 2009 to estimate trends in US hospital discharges of children (0-18 years) for whom diagnosis codes indicated invasive pneumococcal disease, HUS, or both (SpHUS). Univariate and multivariate analyses were based on 2009 discharges. RESULTS During the 5 study years, annual numbers of US hospital discharges for SpHUS approximately doubled (P = 0.025 for linear trend) and cumulatively totaled an estimated 211 discharges. In 2009, SpHUS accounted for 4.6% (95% confidence interval [CI]: 3.0%-6.7%) of HUS discharges, 0.7% (95% CI: 0.5%-1.0%) of invasive pneumococcal disease discharges and 3.0% (95% CI: 2.0%-3.9%) of discharges for complicated pneumococcal pneumonia. Discharges for SpHUS were more likely than those for other invasive pneumococcal disease to occur in children <3 years of age and to incur longer length of stay and greater hospital charges. SpHUS was independently associated with pneumococcal sepsis/bacteremia (age-adjusted odds ratio 3.8; 95% CI: 1.9-7.8) and complicated pneumonia (odds ratio 9.2; 95% CI: 4.1-20.7). CONCLUSIONS SpHUS is an uncommon but severe illness that primarily affects young children and is strongly associated with complicated pneumococcal pneumonia. US hospital stays for SpHUS appear to be increasing along with those for complicated pneumococcal pneumonia.
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19
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Szilágyi A, Kiss N, Bereczki C, Tálosi G, Rácz K, Túri S, Györke Z, Simon E, Horváth E, Kelen K, Reusz GS, Szabó AJ, Tulassay T, Prohászka Z. The role of complement in Streptococcus pneumoniae-associated haemolytic uraemic syndrome. Nephrol Dial Transplant 2013; 28:2237-45. [PMID: 23787556 DOI: 10.1093/ndt/gft198] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Atypical forms of haemolytic uraemic syndrome (aHUS) include HUS caused by defects in the regulation of alternative complement pathway and HUS linked to neuraminidase-producing pathogens, such as Streptococcus pneumoniae. Increasing data support a pathogenic role of neuraminidase in the development of S. pneumoniae-associated haemolytic uraemic syndrome (SP-HUS), but the role of complement has never been clarified in detail. Therefore, we aimed to investigate whether the pathologic complement profile and genetic risk factors of aHUS are present in patients with SP-HUS. METHODS Enrolling five patients with SP-HUS classical and alternative pathway activity, besides C3, C4, factors H, B, I and anti-factor H autoantibody levels were determined. The coding regions of CFH, CFI, CD46 (MCP), THBD, C3 and CFB genes were sequenced and the copy number of CFI, CD46, CFH and related genes were also analyzed. RESULTS We found that in the acute phase samples of SP-HUS patients, complement components C4, C3 and activity of the classical and alternative pathways were decreased, indicating severe activation and complement consumption, but most of these alterations normalized later in remission. Three of the patients carried mutations and risk haplotypes in complement-mediated aHUS associated genes. The identified mutations include a previously published CFI variant (P50A) and two novel ones in CFH (R1149X) and THBD (T44I) genes. CONCLUSIONS Our results suggest that severe complement dysregulation and consumption accompany the progress of invasive pneumococcal disease (IPD)-associated SP-HUS and genetic variations of complement genes may contribute to the development of this complication in a proportion of the affected patients.
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Affiliation(s)
- Agnes Szilágyi
- 3rd Department of Medicine, Research Laboratory, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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20
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Abstract
PURPOSE OF REVIEW Streptococcus pneumoniae associated hemolytic uremic syndrome (SpHUS) is defined by the occurrence of acute hemolytic anemia, thrombocytopenia and acute kidney injury in a patient with a S. pneumoniae infection. We review the pathophysiology, clinical course, treatment and prognosis for SpHUS. We also describe an expanded classification system that uses additional diagnostic criteria to identify more patients with a high likelihood of having SpHUS. RECENT FINDINGS SpHUS often may be underdiagnosed because of overlapping features with disseminated intravascular coagulation (DIC) and the lack of strict diagnostic criteria. The epidemiology has changed with the emergence of different pneumococcal serotypes as newer pneumococcal vaccines have been introduced. SUMMARY SpHUS accounts for 5-15% of all HUS cases. The majority of SpHUS patients have pneumonia and a low mortality rate in contrast to those with meningitis, who have a more severe clinical course. Although the pathogenesis of SpHUS remains unknown, the Thomsen-Friedenreich antigen seems to play a central role. S. pneumoniae produces neuraminidase, thereby exposing the Thomsen-Friedenreich antigen on the surface of cell membranes. Thomsen-Friedenreich antigen exposure can result in hemolysis and direct endothelial injury leading to HUS phenotype. Early identification of these patients is critical so that fresh frozen plasma may be avoided.
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21
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Pollock KG. HUS Surveillance Notes—Sarah’s Story. Emerg Infect Dis 2013; 19:500-1. [DOI: 10.3201/eid1903.ad1903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Radhi M, Carpenter SL. Thrombotic microangiopathies. ISRN HEMATOLOGY 2012; 2012:310596. [PMID: 22888446 PMCID: PMC3410315 DOI: 10.5402/2012/310596] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/10/2012] [Indexed: 01/13/2023]
Abstract
Thrombotic microangiopathy results from thrombotic occlusion of the microvasculature leading to fragmentation of red blood cells, profound thrombocytopenia, and a microangiopathic hemolytic anemia with elevation of lactate dehydrogenase and negative direct Coomb's test. This constellation of clinical and laboratory findings is not due to one disease entity; rather, it represents a variety of underlying diagnoses. Among the major disease entities are TTP/HUS, which can be congenital or acquired, bacterial infections, medications, vascular or endothelial pathology like Kasabach-Merritt phenomenon, and stem cell transplantation. In this paper, we offer a review of some of the major causes of thrombotic microangiopathy.
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Affiliation(s)
- Mohamed Radhi
- Pediatric Hematology/Oncology/Stem Cell Transplant, Children's Mercy Hospital, Kansas City, MO 64108, USA
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Loirat C, Saland J, Bitzan M. Management of hemolytic uremic syndrome. Presse Med 2012; 41:e115-35. [PMID: 22284541 DOI: 10.1016/j.lpm.2011.11.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 12/19/2022] Open
Abstract
2011 has been a special year for hemolytic uremic syndrome (HUS): on the one hand, the dramatic epidemic of Shiga toxin producing E. coli -associated HUS in Germany brought the disease to the attention of the general population, on the other hand it has been the year when eculizumab, the first complement blocker available for clinical practice, was demonstrated as the potential new standard of care for atypical HUS. Here we review the therapeutic options presently available for the various forms of hemolytic uremic syndrome and show how recent knowledge has changed the therapeutic approach and prognosis of atypical HUS.
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Affiliation(s)
- Chantal Loirat
- Assistance publique-Hôpitaux de Paris, Hôpital Robert-Debré, Nephrology Department, 75019 Paris, France.
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