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Hanna RM, Henriksen K, Kalantar-Zadeh K, Ferrey A, Burwick R, Jhaveri KD. Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers. Adv Chronic Kidney Dis 2022; 29:149-160.e1. [PMID: 35817522 DOI: 10.1053/j.ackd.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/11/2022]
Abstract
Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.
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Affiliation(s)
- Ramy M Hanna
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA.
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Kamyar Kalantar-Zadeh
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Antoney Ferrey
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenar D Jhaveri
- Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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Palma LMP, Sridharan M, Sethi S. Complement in Secondary Thrombotic Microangiopathy. Kidney Int Rep 2020; 6:11-23. [PMID: 33102952 PMCID: PMC7575444 DOI: 10.1016/j.ekir.2020.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a condition characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA) with varying degrees of organ damage in the setting of normal international normalized ratio and activated partial thromboplastin time. Complement has been implicated in the etiology of TMA, which are classified as primary TMA when genetic and acquired defects in complement proteins are the primary drivers of TMA (complement-mediated TMA or atypical hemolytic uremic syndrome, aHUS) or secondary TMA, when complement activation occurs in the context of other disease processes, such as infection, malignant hypertension, autoimmune disease, malignancy, transplantation, pregnancy, and drugs. It is important to recognize that this classification is not absolute because genetic variants in complement genes have been identified in patients with secondary TMA, and distinguishing complement/genetic-mediated TMA from secondary causes of TMA can be challenging and lead to potentially harmful delays in treatment. In this review, we focus on data supporting the involvement of complement in aHUS and in secondary forms of TMA associated with malignant hypertension, drugs, autoimmune diseases, pregnancy, and infections. In aHUS, genetic variants in complement genes are found in up to 60% of patients, whereas in the secondary forms, the finding of genetic defects is variable, ranging from almost 60% in TMA associated with malignant hypertension to less than 10% in drug-induced TMA. On the basis of these findings, a new approach to management of TMA is proposed.
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Affiliation(s)
| | - Meera Sridharan
- Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Palomo M, Blasco M, Molina P, Lozano M, Praga M, Torramade-Moix S, Martinez-Sanchez J, Cid J, Escolar G, Carreras E, Paules C, Crispi F, Quintana LF, Poch E, Rodas L, Goma E, Morelle J, Espinosa M, Morales E, Avila A, Cabello V, Ariceta G, Chocron S, Manrique J, Barros X, Martin N, Huerta A, Fraga-Rodriguez GM, Cao M, Martin M, Romera AM, Moreso F, Manonelles A, Gratacos E, Pereira A, Campistol JM, Diaz-Ricart M. Complement Activation and Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2019; 14:1719-1732. [PMID: 31694864 PMCID: PMC6895490 DOI: 10.2215/cjn.05830519] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Atypical hemolytic uremic syndrome is a form of thrombotic microangiopathy caused by dysregulation of the alternative complement pathway. There is evidence showing complement activation in other thrombotic microangiopathies. The aim of this study was to evaluate complement activation in different thrombotic microangiopathies and to monitor treatment response. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Complement activation was assessed by exposing endothelial cells to sera or activated-patient plasma-citrated plasma mixed with a control sera pool (1:1)-to analyze C5b-9 deposits by immunofluorescence. Patients with atypical hemolytic uremic syndrome (n=34) at different stages of the disease, HELLP syndrome (a pregnancy complication characterized by hemolysis, elevated liver enzymes, and low platelet count) or severe preeclampsia (n=10), and malignant hypertension (n=5) were included. RESULTS Acute phase atypical hemolytic uremic syndrome-activated plasma induced an increased C5b-9 deposition on endothelial cells. Standard and lower doses of eculizumab inhibited C5b-9 deposition in all patients with atypical hemolytic uremic syndrome, except in two who showed partial remission and clinical relapse. Significant fibrin formation was observed together with C5b-9 deposition. Results obtained using activated-plasma samples were more marked and reproducible than those obtained with sera. C5b-9 deposition was also increased with samples from patients with HELLP (all cases) and preeclampsia (90%) at disease onset. This increase was sustained in those with HELLP after 40 days, and levels normalized in patients with both HELLP and preeclampsia after 6-9 months. Complement activation in those with malignant hypertension was at control levels. CONCLUSIONS The proposed methodology identifies complement overactivation in patients with atypical hemolytic uremic syndrome at acute phase and in other diseases such as HELLP syndrome and preeclampsia. Moreover, it is sensitive enough to individually assess the efficiency of the C5 inhibition treatment.
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Affiliation(s)
- Marta Palomo
- Josep Carreras Leukaemia Research Institute; .,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Patricia Molina
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Institut Clinic de Malalties Hematologiques i Oncologiques (ICMHO), IDIBAPS, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Sergi Torramade-Moix
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Julia Martinez-Sanchez
- Josep Carreras Leukaemia Research Institute.,Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis, Institut Clinic de Malalties Hematologiques i Oncologiques (ICMHO), IDIBAPS, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Gines Escolar
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute.,Barcelona Endothelium Team, Barcelona, Spain
| | - Cristina Paules
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Fatima Crispi
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Luis F Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Esteban Poch
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain.,Group of nephro-urological diseases and renal transplantation (IDIBAPS), Barcelona, Spain
| | - Lida Rodas
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Emma Goma
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía e Instituto Maimonides de Investigaciones Biológicas de Córdoba (IMIBIC), Córdoba, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain
| | - Ana Avila
- Department of Nephrology and Renal Transplantation, Hospital Universitario Dr Peset, Valencia, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Virgen del Rocio, Sevilla, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Materno-Infantil, Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Sara Chocron
- Department of Pediatric Nephrology, Hospital Materno-Infantil, Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Joaquin Manrique
- Department of Nephrology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitari Josep Trueta, Girona, Spain
| | - Nadia Martin
- Department of Nephrology, Hospital Universitari Josep Trueta, Girona, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | - Gloria M Fraga-Rodriguez
- Department of Pediatric Nephrology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mercedes Cao
- Department of Nephrology, Complejo Hospitalario Universitario A Coruña, Coruña, Spain
| | - Marisa Martin
- Department of Nephrology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Ana Maria Romera
- Department of Nephrology, Hospital General Universitario, Ciudad Real, Spain
| | - Francesc Moreso
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain
| | - Anna Manonelles
- Kidney Transplant Unit, Department of Nephrology, Hospital de Bellvitge, Universitat de Barcelona, Barcelona, Spain; and
| | - Eduard Gratacos
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic de Barcelona and Hospital Sant Joan de Deu), ICGON, IDIBAPS, Universitat de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | | | - Josep M Campistol
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona, Universitat de Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Department of Pathology, Centre de Diagnostic Biomedic (CDB), Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
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6
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Cavero T, Arjona E, Soto K, Caravaca-Fontán F, Rabasco C, Bravo L, de la Cerda F, Martín N, Blasco M, Ávila A, Huerta A, Cabello V, Jarque A, Alcázar C, Fulladosa X, Carbayo J, Anaya S, Cobelo C, Ramos N, Iglesias E, Baltar J, Martínez-Gallardo R, Pérez L, Morales E, González R, Macía M, Draibe J, Pallardó L, Quintana LF, Espinosa M, Barros X, Pereira F, Cao M, Moreno JA, Rodríguez de Córdoba S, Praga M. Severe and malignant hypertension are common in primary atypical hemolytic uremic syndrome. Kidney Int 2019; 96:995-1004. [DOI: 10.1016/j.kint.2019.05.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/12/2019] [Accepted: 05/02/2019] [Indexed: 01/29/2023]
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