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Shajari A, Zare Ahmadabadi A, Ashrafi MM, Mahdavi T, Mirzaee M, Mohkam M, Sharafian S, Tamiji M, Jamee M. Inborn errors of immunity with kidney and urinary tract disorders: a review. Int Urol Nephrol 2024; 56:1965-1972. [PMID: 38198013 PMCID: PMC11090940 DOI: 10.1007/s11255-023-03907-4] [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: 05/30/2023] [Accepted: 12/02/2023] [Indexed: 01/11/2024]
Abstract
Human inborn errors of immunity (IEIs), previously referred to as primary immunodeficiency disorders (PIDs), are a heterogeneous spectrum of inherited abnormalities of the immune system with different organ involvement. The number of identified IEIs is rapidly increasing, highlighting the non-negligible role of an interdisciplinary approach in clinical diagnosis. Kidney disorders are one of the important comorbidities in some of the affected patients and play a significant role in the diagnosis and course of disease. According to recent studies, 22 types of human IEI with renal manifestations have been identified so far, including immunodeficiency with congenital thrombocytopenia, thymic defects with additional congenital anomalies, complement deficiencies, type 1 interferonopathies, immunity related to non-hematopoietic tissues, congenital neutropenia's, common variable immunodeficiency disorder (CVID) phenotype and immuno-osseous dysplasia. Based on this classification, we herein review IEIs with renal features and explain the genetic defect, inheritance, and type of renal manifestations.
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Affiliation(s)
- Ahmad Shajari
- Department of Pediatric Nephrology, Islamic Azad University of Yazd, Yazd, Iran
| | - Atefe Zare Ahmadabadi
- Immunology and Allergy Department, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Moein Ashrafi
- Immunology and Allergy Department, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tolue Mahdavi
- Department of Allergy and Clinical Immunology, Rasool E Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahbubeh Mirzaee
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Mohkam
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samin Sharafian
- Immunology and Allergy Department, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Tamiji
- Department of Computer Science, Rice University, Houston, TX, USA
| | - Mahnaz Jamee
- Laboratory for Pediatric Immunology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands.
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2
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Gudsoorkar P, Abudayyeh A, Tchakarov A, Hanna R. Onconephrology and Thrombotic Microangiopathy: Looking Beyond the Horizon. Semin Nephrol 2023; 42:151345. [PMID: 37196461 DOI: 10.1016/j.semnephrol.2023.151345] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Thrombotic microangiopathies (TMAs) represent a complex interaction of endothelial and podocyte biology, nephron physiology, complement genetics, and oncologic therapies with host immunology. The complexity of various factors, such as molecular causes, genetic expressions, and immune system mimicking, along with incomplete penetrance, make it difficult to find a straightforward solution. As a result, there may be variations in diagnosis, study, and treatment approaches, and achieving a consensus can be challenging. Here, we review the molecular biology, pharmacology, immunology, molecular genetics, and pathology of the various TMA syndromes in the setting of cancer. Controversies in etiology, nomenclature, and points requiring further clinical, translational, and bench research are discussed. Complement-mediated TMAs, chemotherapy drug-mediated TMAs, TMAs in monoclonal gammopathy, and other TMAs central to onconephrology practice are reviewed in detail. In addition, established and emerging therapies within the US Food and Drug Administration pipeline subsequently are discussed. Finally, a comprehensive review of critical areas of onconephrology clinical practice is presented as practical value to the clinical practitioner and seeds of investigation to be sown among the community of atypical hemolytic uremic syndrome researchers.
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Affiliation(s)
- Prakash Gudsoorkar
- Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, OH
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Amanda Tchakarov
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX
| | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine Medical Center, Orange, CA.
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3
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Thompson GL, Kavanagh D. Diagnosis and treatment of thrombotic microangiopathy. Int J Lab Hematol 2022; 44 Suppl 1:101-113. [PMID: 36074708 PMCID: PMC9544907 DOI: 10.1111/ijlh.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic haemolytic anaemia and end organ damage. TMAs have varying underlying pathophysiology and can therefore present with an array of clinical presentations. Renal involvement is common as the kidney is particularly susceptible to the endothelial damage and microvascular occlusion. TMAs require rapid assessment, diagnosis, and commencement of appropriate treatment due to the high morbidity and mortality associated with them. Ground-breaking research into the pathogenesis of TMAs over the past 20 years has driven the successful development of targeted therapeutics revolutionizing patient outcomes. This review outlines the clinical presentations, pathogenesis, diagnostic tests and treatments for TMAs.
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Affiliation(s)
- Gemma L Thompson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - David Kavanagh
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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4
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Najar H, Tuider L, Kukkar V, Quasem M. Thrombotic Thrombocytopenic Purpura: A Rare Cause of Severe Acute Kidney Injury. Cureus 2022; 14:e24221. [PMID: 35602841 PMCID: PMC9113771 DOI: 10.7759/cureus.24221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a serious and potentially fatal disorder, especially if there is a delay in diagnosis and appropriate treatment. Thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are the two main forms of TMA. Although severe acute kidney injury (AKI) is a common manifestation of TMA, it remains rarely described in reported TTP cases. We present a rare case of TTP in a 76-year-old African American male who presented with severe AKI (stage 3) and uremic symptoms. Early diagnosis and prompt treatment of TTP with plasmapheresis followed by rituximab and caplacizumab were associated with the resolution of the AKI and avoidance of hemodialysis. This case highlights the need to consider TTP as a possible diagnosis even in the setting of severe AKI.
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Liszewski MK, Atkinson JP. Membrane cofactor protein (MCP; CD46): deficiency states and pathogen connections. Curr Opin Immunol 2021; 72:126-134. [PMID: 34004375 PMCID: PMC8123722 DOI: 10.1016/j.coi.2021.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 02/07/2023]
Abstract
Membrane cofactor protein (MCP; CD46), a ubiquitously expressed complement regulatory protein, serves as a cofactor for serine protease factor I to cleave and inactivate C3b and C4b deposited on host cells. However, CD46 also plays roles in human reproduction, autophagy, modulating T cell activation and effector functions and is a member of the newly identified intracellular complement system (complosome). CD46 also is a receptor for 11 pathogens ('pathogen magnet'). While CD46 deficiencies contribute to inflammatory disorders, its overexpression in cancers and role as a receptor for some adenoviruses has led to its targeting by oncolytic agents and adenoviral-based therapeutic vectors, including coronavirus disease of 2019 (COVID-19) vaccines. This review focuses on recent advances in identifying disease-causing CD46 variants and its pathogen connections.
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Affiliation(s)
- M Kathryn Liszewski
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA.
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA.
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6
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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.
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Aradottir SS, Kristoffersson AC, Roumenina LT, Bjerre A, Kashioulis P, Palsson R, Karpman D. Factor D Inhibition Blocks Complement Activation Induced by Mutant Factor B Associated With Atypical Hemolytic Uremic Syndrome and Membranoproliferative Glomerulonephritis. Front Immunol 2021; 12:690821. [PMID: 34177949 PMCID: PMC8222914 DOI: 10.3389/fimmu.2021.690821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/10/2021] [Indexed: 12/30/2022] Open
Abstract
Complement factor B (FB) mutant variants are associated with excessive complement activation in kidney diseases such as atypical hemolytic uremic syndrome (aHUS), C3 glomerulopathy and membranoproliferative glomerulonephritis (MPGN). Patients with aHUS are currently treated with eculizumab while there is no specific treatment for other complement-mediated renal diseases. In this study the phenotype of three FB missense variants, detected in patients with aHUS (D371G and E601K) and MPGN (I242L), was investigated. Patient sera with the D371G and I242L mutations induced hemolysis of sheep erythrocytes. Mutagenesis was performed to study the effect of factor D (FD) inhibition on C3 convertase-induced FB cleavage, complement-mediated hemolysis, and the release of soluble C5b-9 from glomerular endothelial cells. The FD inhibitor danicopan abrogated C3 convertase-associated FB cleavage to the Bb fragment in patient serum, and of the FB constructs, D371G, E601K, I242L, the gain-of-function mutation D279G, and the wild-type construct, in FB-depleted serum. Furthermore, the FD-inhibitor blocked hemolysis induced by the D371G and D279G gain-of-function mutants. In FB-depleted serum the D371G and D279G mutants induced release of C5b-9 from glomerular endothelial cells that was reduced by the FD-inhibitor. These results suggest that FD inhibition can effectively block complement overactivation induced by FB gain-of-function mutations.
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Affiliation(s)
| | | | - Lubka T Roumenina
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Anna Bjerre
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pavlos Kashioulis
- Department of Molecular and Clinical Medicine/Nephrology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Runolfur Palsson
- Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavík, Iceland
| | - Diana Karpman
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
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Outcomes of a clinician-directed protocol for discontinuation of complement inhibition therapy in atypical hemolytic uremic syndrome. Blood Adv 2021; 5:1504-1512. [PMID: 33683339 DOI: 10.1182/bloodadvances.2020003175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022] Open
Abstract
Terminal complement inhibition is the standard of care for atypical hemolytic uremic syndrome (aHUS). The optimal duration of complement inhibition is unknown, although indefinite therapy is common. Here, we present the outcomes of a physician-directed eculizumab discontinuation and monitoring protocol in a prospective cohort of 31 patients that started eculizumab for acute aHUS (and without a history of renal transplant). Twenty-five (80.6%) discontinued eculizumab therapy after a median duration on therapy of 2.37 (interquartile range: 1.06, 9.70) months. Eighteen patients discontinued per protocol and 7 because of nonadherence. Of these, 5 (20%) relapsed; however, relapse rate was higher in the case of nonadherence (42.8%) vs clinician-directed discontinuation and monitoring (11.1%). Four of 5 patients who relapsed were successfully retreated without a decline in renal function. One patient died because of recurrent aHUS and hypertensive emergency in the setting of nonadherence. Nonadherence to therapy (odds ratio, 8.25; 95% confidence interval, 1.02-66.19; P = .047) was associated with relapse, whereas the presence of complement gene variants (odds ratio, 1.39; 95% confidence interval, 0.39-4.87; P = .598) was not significantly associated with relapse. Relapse occurred in 40% (2 of 5) with a CFH or MCP variant, 33.3% (2 of 6) with other complement variants, and 0% (0 of 6) with no variants (P = .217). There was no decline in mean glomerular filtration rate from the date of stopping eculizumab until end of follow-up. In summary, eculizumab discontinuation with close monitoring is safe in most patients, with low rates of aHUS relapse and effective salvage with eculizumab retreatment in the event of recurrence.
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9
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Wijewickrama ES, Gooneratne LV, Gnanathasan A, Gawarammana I, Gunatilake M, Isbister GK. Severe acute kidney injury following Sri Lankan Hypnale spp. envenoming is associated with thrombotic microangiopathy. Clin Toxicol (Phila) 2020; 59:296-302. [PMID: 32870056 DOI: 10.1080/15563650.2020.1810695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
CONTEXT Acute kidney injury (AKI) is the most serious clinical manifestation of the Sri Lankan hump-nosed pit viper (Hypnale spp.) bites. Thrombotic microangiopathy (TMA) is increasingly recognized in association with AKI in cases of Hypnale spp envenomation. We investigated AKI in a cohort of cases of Hypnale envenomation, its association with TMA and the early diagnostic value of common biomarkers for AKI occurring. MATERIALS AND METHODS We conducted a prospective observational study of suspected viper bites and included 103 confirmed cases of Hypnale envenomation, based on venom specific enzyme immunoassay of blood. AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Thrombotic microangiopathy was diagnosed based on thrombocytopenia (platelet count < 150,000 × 103/μL) and microangiopathic haemolytic anaemia (MAHA). We investigated the diagnostic performance of creatinine, platelet count and INR for AKI within 4 h and 8 h post-bite by area under the receiver operator characteristic curve (AUC-ROC). RESULTS Ten patients developed AKI: seven AKI stage 1 and three AKI stage 3. Ten patients (10%) developed thrombocytopaenia while 11 (11%) had MAHA. All three AKI stage 3 had thrombocytopaenia and MAHA fulfilling the criteria for TMA. Two of them presented with oliguria/anuria and all three required haemodialysis. Serum creatinine within 4 h post-bite was the best predictor of AKI with AUC-ROC of 0.83 (95% CI: 0.67-0.99) and was no better within 8 h of the bite. CONCLUSIONS We found that AKI is uncommon in Hypnale spp. envenomation, but an important serious complication. Severe AKI was associated with TMA. A creatinine within 4 h post-bite was the best predictor of AKI.
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Affiliation(s)
- Eranga S Wijewickrama
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Lalindra V Gooneratne
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Ariaranee Gnanathasan
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Indika Gawarammana
- Department of Medicine and South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Mangala Gunatilake
- Department of Physiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia.,South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Abstract
OBJECTIVE To evaluate disease presentation, diagnosis, treatment, and clinical outcomes in pregnancy-associated atypical hemolytic uremic syndrome (aHUS). DATA SOURCES We searched PubMed, MEDLINE, Cochrane Library, ClinicalTrials.gov, Web of Science, EMBASE and Google Scholar, from inception until March 2018. METHODS OF STUDY SELECTION We included English-language articles describing aHUS in pregnancy or postpartum. The diagnosis of aHUS was characterized by hemolysis, thrombocytopenia, and renal failure and was distinguished from typical diarrhea-associated hemolytic uremic syndrome. Patients were excluded if individual data could not be obtained, the diagnosis was unclear, or an alternative etiology was more likely, such as thrombotic thrombocytopenic purpura or Shiga toxin-producing Escherichia coli. Reports were appraised by two reviewers, with disagreements adjudicated by a third reviewer. TABULATION, INTEGRATION, AND RESULTS The search identified 796 articles. After review of titles, abstracts, and full text, we identified 48 reports describing 60 unique cases of pregnancy-associated aHUS, with 66 pregnancies. Twelve cases involved pregnancy in women with known aHUS, and 54 cases involved first-episode pregnancy-associated aHUS. Women with known aHUS, particularly those with baseline creatinine at or above 1.5 mg/dL, had a high rate of adverse pregnancy outcomes. For first-episode pregnancy-associated aHUS, diagnosis most often occurred postpartum (94%), after a cesarean delivery (70%), in nulliparous women (58%). Preceding obstetric complications were common and included fetal death, preeclampsia, and hemorrhage. Diagnosis was usually made clinically, based on the triad of microangiopathic hemolysis, thrombocytopenia, and renal failure. Additional testing included renal biopsy, complement genetic testing, and ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) testing. Treatment modalities included corticosteroids, plasma exchange, dialysis, and eculizumab. More women with first-episode pregnancy-associated aHUS achieved disease remission when treated with eculizumab, compared with those not treated with eculizumab (88% vs 57%, P=.02). CONCLUSION Pregnancy-associated aHUS usually presents in the postpartum period, often after a pregnancy complication, and eculizumab is effective for achieving disease remission. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019129266.
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Goel A, Ramakrishna B, Zachariah U, Sajith KG, Burad DK, Kodiatte TA, Keshava SN, Balasubramanian KA, Elias E, Eapen CE. What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors. Indian J Med Res 2020; 149:468-478. [PMID: 31411170 PMCID: PMC6676844 DOI: 10.4103/ijmr.ijmr_1405_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.
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Affiliation(s)
- Ashish Goel
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Banumathi Ramakrishna
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Uday Zachariah
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - K G Sajith
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Deepak K Burad
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Thomas A Kodiatte
- Department of Pathology, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Shyamkumar N Keshava
- Department of Radio-diagnosis, Division of GI Sciences, Christian Medical College, Vellore, India
| | - K A Balasubramanian
- Department of Wellcome Research Laboratory, Division of GI Sciences, Christian Medical College, Vellore, India
| | - Elwyn Elias
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India; Liver Unit, University Hospitals, Birmingham, UK
| | - C E Eapen
- Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India
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12
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Neave L, Gale DP, Cheesman S, Shah R, Scully M. Atypical haemolytic uraemic syndrome in the eculizumab era: presentation, response to treatment and evaluation of an eculizumab withdrawal strategy. Br J Haematol 2019; 186:113-124. [PMID: 30916388 DOI: 10.1111/bjh.15899] [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] [Received: 11/12/2018] [Accepted: 02/05/2019] [Indexed: 12/11/2022]
Abstract
The complement inhibitor, eculizumab, has revolutionised the management of atypical haemolytic uraemic syndrome (aHUS), although the optimum treatment duration is debated. Twenty-two cases of acute aHUS managed with eculizumab were retrospectively reviewed, including outcomes after eculizumab withdrawal. Although 41% had an associated complement genetic abnormality, mutation status did not affect severity of clinical presentation. Sixty-four percent required renal replacement acutely, with a high incidence of nephrotic range proteinuria (47%). Eculizumab followed a median of 6 days of plasma exchange. After a median duration of therapy of 11 weeks (range 1-227), haematological recovery was seen in 100%, while 81% achieved at least partial renal recovery (median increase in estimated glomerular filtration rate (eGFR) 49 ml/min/1·73 m2 ). At median duration of follow-up of 85 weeks (range 4-255), 54·5% had eGFR ≥ 60 ml/min/1·73 m2 , 27% had CKD, 14% were on dialysis, and 4·5% had died. Eculizumab was withdrawn in 59% (13/22) cases following complete haematological and renal recovery. Three of these 13 patients (23%) subsequently relapsed, with defined triggers in 2/3, but all made a full recovery with rapid resumption of eculizumab. There was a significant association between higher presenting creatinine and poorer renal outcomes. A strategy of eculizumab withdrawal in selected cases is both safe and cost effective.
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Affiliation(s)
- Lucy Neave
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Daniel P Gale
- UCL Centre for Nephrology, University College London, London, UK
| | - Simon Cheesman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Raakhee Shah
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie Scully
- Department of Haematology, UCLH, Cardiometabolic programme- NIHR UCLH/UCL BRC, London, UK
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13
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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.
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14
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Intern Med J 2018; 48:624-636. [DOI: 10.1111/imj.13804] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C. Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J. Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y. Kausman
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology; Monash Health; Melbourne Victoria Australia
- School of Clinical Sciences, Monash Health; Monash University; Melbourne Victoria Australia
| | - Peter D. Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology; Monash Health; Melbourne Victoria Australia
| | - Nicole M. Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D. Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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15
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Nephrology (Carlton) 2018; 23:507-517. [DOI: 10.1111/nep.13234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y Kausman
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
- School of Clinical Sciences; Monash Health, Monash University; Melbourne Victoria Australia
| | - Peter D Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
| | - Nicole M Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology, Immunology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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16
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Gupta M, Feinberg BB, Burwick RM. Thrombotic microangiopathies of pregnancy: Differential diagnosis. Pregnancy Hypertens 2018; 12:29-34. [PMID: 29674195 DOI: 10.1016/j.preghy.2018.02.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/08/2018] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
Abstract
Thrombotic microangiopathy (TMA) disorders are characterized by microangiopathic hemolytic anemia, thrombocytopenia and end-organ injury. In pregnancy and postpartum, TMA is most commonly encountered with HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) or preeclampsia with severe features, but rarely TMA is due to thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS). Due to overlapping clinical and laboratory features, TTP and aHUS are often mistaken for preeclampsia or HELLP. Unfortunately, delays in appropriate diagnosis and treatment may be life-threatening. Our objective is to alert obstetrician-gynecologists, certified nurse midwives, family medicine providers, and subspecialty consultants, to the range of TMA disorders that may occur in and around pregnancy. To do this, we have provided a review of individual disorders that comprise the differential diagnosis of pregnancy TMA, and we have proposed a systematic approach to make an accurate diagnosis with readily available clinical and laboratory data. In complex or critical cases, we recommend a multidisciplinary team approach (e.g., Critical Care, Hematology, Maternal Fetal Medicine, Nephrology) to expedite diagnosis and treatment, which may be life-saving.
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Affiliation(s)
- M Gupta
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - B B Feinberg
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - R M Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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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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18
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Scully M. Thrombocytopenia in hospitalized patients: approach to the patient with thrombotic microangiopathy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:651-659. [PMID: 29222317 PMCID: PMC6142615 DOI: 10.1182/asheducation-2017.1.651] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thrombotic microangiopathies (TMAs), specifically, thrombotic thrombocytopenic purpura (TTP) and complement-mediated hemolytic uremic syndrome (CM-HUS) are acute life-threatening disorders that require prompt consideration, diagnosis, and treatment to improve the high inherent mortality and morbidity. Presentation is with microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) and variable organ symptoms resulting from microvascular thrombi. Neurological and cardiac involvement is most common in TTP and associated with poorer prognosis and primarily renal involvement in CM-HUS. TTP is confirmed by severe ADAMTS13 deficiency (which can be undertaken in real time) and CM-HUS by an abnormality in complement regulators, confirmed by mutational analysis (in 60% to 70% of cases) or the presence of Factor H antibodies (which may not be available for weeks or months). Plasma exchange (PEX) should be started as soon as possible following consideration of these TMAs. Differentiation of the diagnosis requires specific treatment pathways thereafter (immunosuppression primarily for TTP and complement inhibitor therapy for CM-HUS). As the diagnosis is based on MAHAT, there are a number of other medical situations that need to be excluded and these are discussed within the article. Other differentials presenting as TMAs may also be associated with micro- or macrovascular thrombosis, yet are more likely to be due to direct endothelial damage, many of which do not have a clear therapeutic benefit with PEX.
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Affiliation(s)
- Marie Scully
- Department of Haematology, University College London Hospitals NHS Trust, London, United Kingdom
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19
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Fidalgo T, Martinho P, Pinto CS, Oliveira AC, Salvado R, Borràs N, Coucelo M, Manco L, Maia T, Mendes MJ, Del Orbe Barreto R, Corrales I, Vidal F, Ribeiro ML. Combined study of ADAMTS13 and complement genes in the diagnosis of thrombotic microangiopathies using next-generation sequencing. Res Pract Thromb Haemost 2017; 1:69-80. [PMID: 30046676 PMCID: PMC6058207 DOI: 10.1002/rth2.12016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/15/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The 2 main forms of thrombotic microangiopathy (TMA) are thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). Deficiency of ADAMTS13 and dysregulation of the complement pathway result in TTP and aHUS, respectively; however, overlap of their clinical characteristics makes differential diagnosis challenging. OBJECTIVES AND METHODS We aimed to develop a TMA diagnosis workflow based on ADAMTS13 activity and screening of ADAMTS13 and complement genes using a custom next-generation sequencing (NGS) gene panel. PATIENTS For this, from a cohort of 154 Portuguese patients with acute TMA, the genotype-phenotype correlations were analyzed in 7 hereditary TTP (ADAMTS13 activity <10%, no inhibitor), 36 acquired TTP (ADAMTS13 activity <10%, presence of an inhibitor), and in 34 presumable aHUS. RESULTS In total, 37 different rare variants, 8 of which novel (in ADAMTS13,CFH, and CD46), were identified across 7 genes. Thirteen TTP patients were homozygous (n=6), compound heterozygous (n=2), and heterozygous (n=5) for 11 ADAMTS13 variants (6 pathogenic mutations). Among the 34 aHUS patients, 17 were heterozygous for 23 variants in the different complement genes with distinct consequences, ranging from single pathogenic mutations associated with complete disease penetrance to benign variants that cause aHUS only when combined with other variants and/or CFH and CD46 risk haplotypes or CFHR1-3 deletion. CONCLUSIONS Our study provides evidence of the usefulness of the NGS panel as an excellent technology that enables more rapid diagnosis of TMA, and is a valuable asset in clinical practice to discriminate between TTP and aHUS.
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Affiliation(s)
- Teresa Fidalgo
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Patrícia Martinho
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Catarina S. Pinto
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Ana C. Oliveira
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Ramon Salvado
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Nina Borràs
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - Margarida Coucelo
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Licínio Manco
- Research Centre for Anthropology and Health (CIAS), Department of Life SciencesUniversity of CoimbraCoimbraPortugal
| | - Tabita Maia
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - M. João Mendes
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | | | - Irene Corrales
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - Francisco Vidal
- Congenital CoagulopathiesBlood and Tissue BankBarcelonaSpain
- Molecular Diagnosis and TherapyVall d'Hebron Research InstituteUniversitat Autònoma de Barcelona (VHIR‐UAB)BarcelonaSpain
| | - M. Letícia Ribeiro
- Department of Clinical HaematologyCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
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20
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Jamme M, Raimbourg Q, Chauveau D, Seguin A, Presne C, Perez P, Gobert P, Wynckel A, Provôt F, Delmas Y, Mousson C, Servais A, Vrigneaud L, Veyradier A, Rondeau E, Coppo P. Predictive features of chronic kidney disease in atypical haemolytic uremic syndrome. PLoS One 2017; 12:e0177894. [PMID: 28542627 PMCID: PMC5436831 DOI: 10.1371/journal.pone.0177894] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/04/2017] [Indexed: 11/18/2022] Open
Abstract
Chronic kidney disease (CKD) is a frequent and serious complication of atypical haemolytic uremic syndrome (aHUS). We aimed to develop a simple accurate model to predict the risk of renal dysfunction in aHUS based on clinical and biological features available at hospital admission. Renal function at 1-year follow-up, based on an estimated glomerular filtration rate < 60mL/min/1.73m2 as assessed by the Modification of Diet in Renal Disease equation, was used as an indicator of significant CKD. Prospectively collected data from a cohort of 156 aHUS patients who did not receive eculizumab were used to identify predictors of CKD. Covariates associated with renal impairment were identified by multivariate analysis. The model performance was assessed and a scoring system for clinical practice was constructed from the regression coefficient. Multivariate analyses identified three predictors of CKD: a high serum creatinine level, a high mean arterial pressure and a mildly decreased platelet count. The prognostic model had a good discriminative ability (area under the curve = .84). The scoring system ranged from 0 to 5, with corresponding risks of CKD ranging from 18% to 100%. This model accurately predicts development of 1-year CKD in patients with aHUS using clinical and biological features available on admission. After further validation, this model may assist in clinical decision making.
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Affiliation(s)
- Matthieu Jamme
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, AP-HP, Paris, France
| | | | - Dominique Chauveau
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie-immunologie clinique, Hôpital Rangueil, Toulouse, France
| | - Amélie Seguin
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Caen, Normandy, France
| | - Claire Presne
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie - Médecine Interne, Hôpital Sud, Amiens, France
| | - Pierre Perez
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie-Immunologie, Service de Réanimation, CHU Brabois, Nancy, France
| | - Pierre Gobert
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Médecine Interne et Néphrologie, Hôpital Général Henri Duffaut, Avignon, France
| | - Alain Wynckel
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Maison Blanche, Reims, France
| | - François Provôt
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Albert Calmette, Lille, France
| | - Yahsou Delmas
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie-Transplantation-Dialyse, CHU de Bordeaux, Bordeaux, France
| | - Christiane Mousson
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie, Dijon, France
| | - Aude Servais
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Laurence Vrigneaud
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service de Médecine interne, Néphrologie et Médecine vasculaire, Centre hospitalier de Valenciennes, Valenciennes, France
| | - Agnès Veyradier
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France
| | - Eric Rondeau
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, AP-HP, Paris, France
| | - Paul Coppo
- Centre de Reference des Microangiopathies Thrombotiques, Hôpital Saint Antoine, AP-HP, Paris, France
- Service d’Hématologie, Hôpital Saint Antoine, AP-HP, Paris, France
- * E-mail:
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21
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Murine systemic thrombophilia and hemolytic uremic syndrome from a factor H point mutation. Blood 2017; 129:1184-1196. [PMID: 28057640 DOI: 10.1182/blood-2016-07-728253] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/22/2016] [Indexed: 01/07/2023] Open
Abstract
Complement plays a key role in host defense, but its dysregulation can cause autologous tissue injury. Complement activation is normally controlled by regulatory proteins, including factor H (FH) in plasma and membrane cofactor protein (MCP) on the cell surface. Mutations in FH and MCP are linked to atypical hemolytic uremic syndrome, a type of thrombotic microangiopathy (TMA) that causes renal failure. We describe here that disruption of FH function on the cell surface can also lead to disseminated complement-dependent macrovascular thrombosis. By gene targeting, we introduced a point mutation (W1206R) into murine FH that impaired its interaction with host cells but did not affect its plasma complement-regulating activity. Homozygous mutant mice carrying this mutation developed renal TMA as well as systemic thrombophilia involving large blood vessels in multiple organs, including liver, lung, spleen, and kidney. Approximately 30% of mutant mice displayed symptoms of stroke and ischemic retinopathy, and 48% died prematurely. Genetic deficiency of complement C3 and factor D prevented both the systemic thrombophilia and renal TMA phenotypes. These results demonstrate a causal relationship between complement dysregulation and systemic angiopathy and suggest that complement activation may contribute to various human thrombotic disorders involving both the micro- and macrovasculature.
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22
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Afshar-Kharghan V. Atypical hemolytic uremic syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:217-225. [PMID: 27913483 PMCID: PMC6142509 DOI: 10.1182/asheducation-2016.1.217] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) that affects multiple organs and the kidneys in particular. aHUS can be sporadic or familial and is most commonly caused by dysregulation of the alternative complement pathway. The initial attack of aHUS can occur at any age, and is associated with a high rate of progression to end stage renal disease. Many aHUS patients relapse in the native or transplanted kidneys, and require close monitoring and long-term management. Availability of anticomplement therapy has revolutionized the management of aHUS, and can change the natural course of aHUS by inducing hematologic remission, improving or stabilizing kidney functions, and preventing graft failure. As a result, it is important to succeed in the challenging task of differentiating aHUS from other TMAs and initiate adequate treatment early during the course of disease. Considering the high cost of currently available anticomplement therapy, it is important also from a financial point of view to accurately diagnose aHUS early during the course of disease and determine the necessary length of therapy. This highlights the need for development of precise complement functional and genetic studies with rapid turnaround time.
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23
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Eculizumab in children with hemolytic uremic syndrome. Kidney Int 2016; 89:537-8. [PMID: 26880449 DOI: 10.1016/j.kint.2015.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 12/29/2015] [Indexed: 11/22/2022]
Abstract
Greenbaum et al. report the first prospective trial of eculizumab in pediatric atypical hemolytic uremic syndrome. As in adult trials, eculizumab appears effective and no serious safety signals were reported. There is the first suggestion of a dichotomy in response to treatment with a trend toward poorer outcome in those without complement abnormalities. This group, however, had worse renal function at presentation, and it remains to be seen whether this represents true non-response or merely late presentation.
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Ricklin D, Reis ES, Lambris JD. Complement in disease: a defence system turning offensive. Nat Rev Nephrol 2016; 12:383-401. [PMID: 27211870 DOI: 10.1038/nrneph.2016.70] [Citation(s) in RCA: 372] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although the complement system is primarily perceived as a host defence system, a more versatile, yet potentially more harmful side of this innate immune pathway as an inflammatory mediator also exists. The activities that define the ability of the complement system to control microbial threats and eliminate cellular debris - such as sensing molecular danger patterns, generating immediate effectors, and extensively coordinating with other defence pathways - can quickly turn complement from a defence system to an aggressor that drives immune and inflammatory diseases. These host-offensive actions become more pronounced with age and are exacerbated by a variety of genetic factors and autoimmune responses. Complement can also be activated inappropriately, for example in response to biomaterials or transplants. A wealth of research over the past two decades has led to an increasingly finely tuned understanding of complement activation, identified tipping points between physiological and pathological behaviour, and revealed avenues for therapeutic intervention. This Review summarizes our current view of the key activating, regulatory, and effector mechanisms of the complement system, highlighting important crosstalk connections, and, with an emphasis on kidney disease and transplantation, discusses the involvement of complement in clinical conditions and promising therapeutic approaches.
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Affiliation(s)
- Daniel Ricklin
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, 401 Stellar Chance, 422 Curie Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Edimara S Reis
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, 401 Stellar Chance, 422 Curie Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - John D Lambris
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, 401 Stellar Chance, 422 Curie Boulevard, Philadelphia, Pennsylvania 19104, USA
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25
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Keir LS, Langman CB. Complement and the kidney in the setting of Shiga-toxin hemolytic uremic syndrome, organ transplantation, and C3 glomerulonephritis. Transfus Apher Sci 2016; 54:203-11. [PMID: 27156109 DOI: 10.1016/j.transci.2016.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To review the role of complement in glomerular pathologies focusing on thrombotic microangiopathies (TMA) caused by Shiga toxin (Stx) and organ transplantation associated hemolytic uremic syndrome (HUS) as well as C3 glomerulopathy (C3G). METHODS Examination of literature discussing TMA associated with Stx HUS, transplantation related HUS and C3G. RESULTS There is an emerging role for complement biology in the renal glomerulus where its inappropriate over-activation is integral to several diseases. Stx HUS patients show evidence of complement activation and the toxin itself can activate complement and inhibit its normal regulation. However, therapeutic complement blockade has not yet proven effective in all circumstances. This may be partly related to late use and a clinical trial could be warranted. Organ transplantation associated HUS has carried a poor prognosis. While case reports supporting the use of complement inhibition exist, there has not been a formal trial. Complement activation in C3G is established but again treatment with complement inhibition has failed to be uniformly beneficial. Here, too, a clinical trial may help determine which subgroup of patients should be treated with these agents. CONCLUSION Complement plays an important role in the glomerulus but more work is needed to fully understand how it contributes to normal function and pathology. This will help direct appropriate therapy in these diseases.
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Affiliation(s)
- Lindsay S Keir
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Kidney Diseases, The Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Craig B Langman
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Kidney Diseases, The Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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26
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Phillips EH, Westwood JP, Brocklebank V, Wong EKS, Tellez JO, Marchbank KJ, McGuckin S, Gale DP, Connolly J, Goodship THJ, Kavanagh D, Scully MA. The role of ADAMTS-13 activity and complement mutational analysis in differentiating acute thrombotic microangiopathies. J Thromb Haemost 2016; 14:175-85. [PMID: 26559391 PMCID: PMC4737436 DOI: 10.1111/jth.13189] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/25/2015] [Indexed: 01/10/2023]
Abstract
UNLABELLED ESSENTIALS: Molecular diagnostics has improved the differentiation of acute thrombotic microangiopathys (TMAs). Atypical hemolytic uremic syndrome may have features mimicking thrombotic thrombocytopenic purpura. We identified novel complement mutations and a high incidence of CD46, with favorable long term outcomes. Complement mutation analysis in TMA where the diagnosis is unclear and ADAMTS-13 activity is >10%. BACKGROUND Differentiation of acute thrombotic microangiopathy (TMA) at presentation has historically been dependent on clinical parameters. Confirmation of thrombotic thrombocytopenic purpura (TTP) is increasingly reliant on demonstrating deficient ADAMTS-13 activity. The identification of alternative complement pathway abnormalities in atypical hemolytic uremic syndrome (aHUS), along with the proven efficacy of terminal complement inhibitors in treatment, has increased the need for rapid differentiation of TTP from aHUS. OBJECTIVES We describe the clinical phenotype and nature of complement mutations in a cohort of aHUS patients referred as acute TMAs. PATIENTS/METHODS Fourteen consecutive aHUS patients were screened for mutations in C3, CD46, CFH, CFI, and CFB, as well as factor H (FH) antibodies. All aHUS patients had ADAMTS-13 activity > 10%. RESULTS Of 14 aHUS patients, 11 (79%) had platelet counts < 30 × 10(9) /L during the acute phase. Median presenting creatinine level was 295 μmol L(-1) , while five (36%) of 14 presented with a serum creatinine level < 200 μmol L(-1) . Alternative complement pathway mutations were detected in 9 (64%) of 14 patients, including CD46 mutations in five (36%) of 14 patients. Patients were identified with novel mutations in CFB and C3 that have not been previously reported. CONCLUSIONS We demonstrate that diagnostic differentiation based on platelet count and renal function is insufficient to predict an underlying complement mutation in some aHUS cases. Specifically, we demonstrate a high frequency of functionally significant CD46 mutations which may mimic TTP. ADAMTS-13 activity > 10% in a patient with a TMA should necessitate genetic screening for complement abnormalities.
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Affiliation(s)
- E. H. Phillips
- Department of HaematologyUniversity College LondonLondonUK
| | - J. P. Westwood
- Department of HaematologyUniversity College LondonLondonUK
| | - V. Brocklebank
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
| | - E. K. S. Wong
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
| | - J. O. Tellez
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
| | - K. J. Marchbank
- Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUK
| | - S. McGuckin
- Department of HaematologyUniversity College LondonLondonUK
| | - D. P. Gale
- Centre for NephrologyUniversity College LondonLondonUK
| | - J. Connolly
- Department of NephrologyRoyal Free HospitalLondonUK
| | - T. H. J. Goodship
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
| | - D. Kavanagh
- Institute of Genetic MedicineNewcastle UniversityNewcastle upon TyneUK
| | - M. A. Scully
- Cardiometabolic ProgrammeNIHR/University College London Hospitals Biomedical Research CentreLondonUK
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