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Avila Bernabeu AI, Cavero Escribano T, Cao Vilarino M. Atypical Hemolytic Uremic Syndrome: New Challenges in the Complement Blockage Era. Nephron Clin Pract 2020; 144:537-549. [PMID: 32950988 DOI: 10.1159/000508920] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare cause of thrombotic microangiopathy (TMA), characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and multisystem end organ involvement, most commonly affecting the kidney. Diagnosis is clinical, after exclusion of other TMA causes. Primary aHUS arises from genetic abnormalities, resulting in uncontrolled complement activity, while a variety of clinical scenarios cause secondary aHUS, including infection, pregnancy, malignancy, autoimmune disease, and medications. They can also induce a temporary complement deregulation with an overlap between both scenarios, which can make differential diagnosis difficult. Primary aHUS can be sporadic or familial and is associated with a high rate of progression to ESRD. Many aHUS patients relapse in the native or transplanted kidneys, leading to kidney failure. The introduction of eculizumab has changed the prognosis of aHUS, by inducing hematologic remission, improving or stabilizing kidney functions, and preventing graft failure. The early institution of appropriate therapy can prevent multiorgan damage, so is essential to recognize and differentiate the TMA syndromes. Eculizumab is considered now the first-line treatment, and it is recommended lifelong therapy. However, the high cost of therapy has led to make efforts to develop precise complement functional and genetic studies that help physicians to determine the appropriate duration of eculizumab therapy. Nowadays, more studies are needed to select candidates to adjustment of therapy.
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Lavrishcheva YV, Yakovenko AA, Kudlai DA. [The experience of using the Russian biosimilar of the original drug eculizumab for the treatment of patients with atypical hemolytic-uremic syndrome]. TERAPEVT ARKH 2020; 92:76-80. [PMID: 33346497 DOI: 10.26442/00403660.2020.06.000649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 02/08/2023]
Abstract
Atypical hemolytic-uremic syndrome (aHUS) is a chronic systemic disease of a genetic nature, which is based on uncontrolled activation of the alternative complement pathway, leading to generalized thrombosis in the vessels of the microvasculature (complement-mediated thrombotic microangiopathy). To date, therapy with eculizumab is the most effective and pathogenetically substantiated method of treating patients with ASH. Using the example of three clinical cases of patients with a verified diagnosis of aHUS, the high efficiency and safety of the worlds first bioanalogue of eculizumab in the treatment of adult patients with aHUS (complement-mediated thrombotic microangiopathy) was demonstrated.
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Affiliation(s)
| | - A A Yakovenko
- Pavlov First Saint Petersburg State Medical University
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Hermel M, Hermel D, Azam S, Shinbane J, Sarcon A, Jones E, Mehta A, Grazette L, Liebman H, Weitz I. Acute dilated cardiomyopathy in the setting of catastrophic antiphospholipid syndrome and thrombotic microangiopathy: A case series and review. EJHAEM 2020; 1:44-50. [PMID: 35847716 PMCID: PMC9175940 DOI: 10.1002/jha2.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/25/2022]
Abstract
Catastrophic antiphospholipid antibody syndrome (CAPS) is a rare form of antiphospholipid syndrome, an autoimmune condition characterized by vascular thromboses, pregnancy loss, and antiphospholipid (aPL) antibodies. Diagnosis of CAPS relies on thrombosis of at least three different organs systems over 1 week, histopathological evidence of small vessel occlusion, and high aPL antibody titers. In a subset of precipitating circumstances, activation or disruption of endothelial cells in the microvasculature may occur along with cardiomyopathy. We present two cases of CAPS‐associated dilated cardiomyopathy at our institution, focusing on disease management, pathophysiology, and treatment. These patients were of Southeastern Asian descent, raising the possibility of genetic polymorphisms contributing to the development of cardiomyopathy. Both met CAPS criteria and both demonstrated clinicopathologic thrombotic microangiopathy (TMA) and complement activation and developed severe dilated cardiomyopathy with shock. Complement activation plays an important role in the development of CAPS and may be important in the pathogenesis of CAPS‐associated cardiomyopathy. Clinical suspicion for TMA as a pathophysiologic mechanism of unexplained heart failure in CAPS is important and increased awareness of cardiac side effects is necessary so that early treatment can be initiated to halt further cardiac and systemic complications.
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Affiliation(s)
- Melody Hermel
- Department of MedicineKeck School of MedicineUniversity of Southern California Los Angeles California
| | - David Hermel
- Department of MedicineKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Saif Azam
- Department of MedicineKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Jerold Shinbane
- Department of CardiologyKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Annahita Sarcon
- Department of CardiologyKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Erika Jones
- Department of CardiologyKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Arjun Mehta
- Department of PathologyKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Luanda Grazette
- Department of CardiologyKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Howard Liebman
- Jane Anne Nohl Division of HematologyKeck School of MedicineUniversity of Southern California Los Angeles California
| | - Ilene Weitz
- Jane Anne Nohl Division of HematologyKeck School of MedicineUniversity of Southern California Los Angeles California
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Campbell CM, Cassol C, Cataland SR, Kahwash R. Atypical haemolytic uraemic syndrome: a case report of a rare cause of reversible cardiomyopathy. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 32352052 DOI: 10.1093/ehjcr/ytaa050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/10/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022]
Abstract
Background Atypical haemolytic uraemic syndrome (aHUS) is a life-threatening, genetic disease of complement-mediated thrombotic microangiopathy that typically presents as anaemia, thrombocytopenia, and renal failure. Cardiomyopathy is seen in up to 10% of aHUS cases, but the aetiology is not well-understood. Case summary A 63-year-old man recently was diagnosed with a thrombotic microangiopathy most consistent with aHUS by renal biopsy after presentation with acute renal failure requiring haemodialysis. He was started on therapy with complement inhibitor, eculizumab. Six weeks after diagnosis, he presented with progressive dyspnoea on exertion and chest pain. An echocardiogram demonstrated an acute drop in left ventricular ejection fraction to 20-25% with global hypokinesis. Left heart catheterization showed moderate, non-obstructive coronary artery disease. Cardiac magnetic resonance imaging demonstrated diffuse myocardial oedema. Endomyocardial biopsy revealed an arteriole with obliterative changes and a few possible fragmented red blood cells suggestive of thrombotic microangiopathy. There was no biopsy evidence of immune complex deposition or myocarditis. He was treated for heart failure and was maintained on eculizumab. On repeat echocardiogram 3 months later, the patient had complete recovery of his ejection fraction (60-65%). Discussion In this report, we describe complete recovery of aHUS-associated heart failure with eculizumab therapy and demonstrate for the first time that the aetiology of aHUS-associated heart failure is likely an acute thrombotic microangiopathy involving small intramyocardial arterioles, as demonstrated by cardiac biopsy.
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Affiliation(s)
- Courtney M Campbell
- Division of Cardiovascular Medicine, Department of Internal Medicine, Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH 43210, USA
| | - Clarissa Cassol
- Department of Pathology, The Ohio State University Wexner Medical Center, 129 Hamilton Hall, 1645 Neil Ave, Columbus, OH 43210, USA
| | - Spero R Cataland
- Division of Hematology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, B302 Starling Loving Hall, 320 West 10th Ave, Columbus, OH 43210, USA
| | - Rami Kahwash
- Division of Cardiovascular Medicine, Department of Internal Medicine, Davis Heart & Lung Research Institute, The Ohio State University Wexner Medical Center, 473 W 12th Ave, Suite 200, Columbus, OH 43210, USA
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Haskin O, Falush Y, Davidovits M. Is eculizumab indicated in patients with atypical hemolytic uremic syndrome already on prolonged dialysis? A case report and review of the literature. Pediatr Nephrol 2019; 34:2601-2604. [PMID: 31520126 DOI: 10.1007/s00467-019-04341-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/10/2019] [Accepted: 08/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Eculizumab has caused a revolution in the treatment and prognosis of atypical hemolytic uremic syndrome. Early initiation of treatment is recommended to increase chances of renal recovery. CASE-DIAGNOSIS/TREATMENT We describe a boy with atypical hemolytic uremic syndrome who started eculizumab therapy after being on dialysis for 4.5 months, with complete anuria. With treatment, he was weaned off dialysis. CONCLUSION We review the evidence in the literature and discuss the possible mechanism by which eculizumab induces renal recovery even in patients already on prolonged dialysis. This case report highlights the importance of a treatment trial with eculizumab, even in patients already on prolonged dialysis.
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Affiliation(s)
- Orly Haskin
- Department of Pediatric Nephrolgy, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yafa Falush
- Department of Pediatric Nephrolgy, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah Tikva, Israel
| | - Miriam Davidovits
- Department of Pediatric Nephrolgy, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Borkar D, Schutt C, Verghese P. Renal Recovery Years After Initial Diagnosis of Hemolytic Uremic Syndrome. Clin Pediatr (Phila) 2018; 57:861-864. [PMID: 28931327 DOI: 10.1177/0009922817732621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Deeksha Borkar
- 1 University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Christina Schutt
- 2 Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Priya Verghese
- 1 University of Minnesota Medical Center, Minneapolis, MN, USA
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Kozlovskaya NL, Korotchaeva YV, Bobrova LA. Adverse outcomes in obstetric-atypical haemolytic uraemic syndrome: a case series analysis. J Matern Fetal Neonatal Med 2018; 32:2853-2859. [PMID: 29606012 DOI: 10.1080/14767058.2018.1450381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective: The aim of this case series is to raise awareness of obstetric-related atypical haemolytic uraemic syndrome (aHUS) amongst obstetricians and gynaecologists. Study design: Data from 20 consecutive patients, aged 19-38, with obstetric-aHUS manifestation during or immediately after pregnancy are reported. Patients were diagnosed and treatment was initiated between 2012 and 2016. Results: Presentation of aHUS was mainly preceded by preeclampsia and/or haemolysis, elevated liver enzymes and low platelet count syndrome, other obstetric complications, or by diarrhoea. Thrombotic microangiopathy (TMA) was evident in all patients with signs of microangiopathic haemolysis (sharp decline in haemoglobin; mean 67 g/L), elevated lactate dehydrogenase (LDH; mean 2953.1 U/L), schistocytosis, thrombocytopenia (mean platelet count 52.5 × 109/µL), and acute kidney injury (AKI) (hypercreatininaemia, mean 456.4 µmol/L; oliguria or anuria). The majority of patients (80%) initially presented with arterial hypertension. Diagnosis of obstetric-aHUS was complicated, as multiple organs were affected. Time taken to make the diagnosis of aHUS delayed the initiation of fresh-frozen plasma infusions and plasma exchange (80% of patients) and subsequent eculizumab treatment (40% of patients). Maternal mortality was high (35%) as was foetal mortality (25%). Conclusions: Obstetric-aHUS is a serious condition characterized by multiple organ failure (MOF) and a high mortality rate. Presentation of obstetric-aHUS is preceded by various precipitating factors, suggesting pregnancy complications, and not the pregnancy per se, often induce aHUS in women with a genetic predisposition to its development. A delay in the correct diagnosis and initiation of the most effective treatment can have serious consequences, reinforcing the need to raise awareness of obstetric-aHUS.
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Affiliation(s)
- Natalia L Kozlovskaya
- a Department of Internal Medicine and Occupational Medicine , I.M. Sechenov First Moscow State Medical University , Moscow , Russia
| | - Yulia V Korotchaeva
- a Department of Internal Medicine and Occupational Medicine , I.M. Sechenov First Moscow State Medical University , Moscow , Russia
| | - Larisa A Bobrova
- a Department of Internal Medicine and Occupational Medicine , I.M. Sechenov First Moscow State Medical University , Moscow , Russia
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Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C. Haemolytic uraemic syndrome. Lancet 2017; 390:681-696. [PMID: 28242109 DOI: 10.1016/s0140-6736(17)30062-4] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
Haemolytic uraemic syndrome is a form of thrombotic microangiopathy affecting predominantly the kidney and characterised by a triad of thrombocytopenia, mechanical haemolytic anaemia, and acute kidney injury. The term encompasses several disorders: shiga toxin-induced and pneumococcus-induced haemolytic uraemic syndrome, haemolytic uraemic syndrome associated with complement dysregulation or mutation of diacylglycerol kinase ɛ, haemolytic uraemic syndrome related to cobalamin C defect, and haemolytic uraemic syndrome secondary to a heterogeneous group of causes (infections, drugs, cancer, and systemic diseases). In the past two decades, experimental, genetic, and clinical studies have helped to decipher the pathophysiology of these various forms of haemolytic uraemic syndrome and undoubtedly improved diagnostic approaches. Moreover, a specific mechanism-based treatment has been made available for patients affected by atypical haemolytic uraemic syndrome due to complement dysregulation. Such treatment is, however, still absent for several other disease types, including shiga toxin-induced haemolytic uraemic syndrome.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, and INSERM UMR S1064, Nantes, France
| | - Julien Zuber
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology and Renal Transplantation, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, and INSERM UMR S1138, Complément et Maladies, Centre de Recherche des Cordeliers, Paris, France
| | - Chantal Loirat
- Assistance Publique-Hôpitaux de Paris, Department of Pediatric Nephrology, Hôpital Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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Davis LS, Reimold AM. Research and therapeutics-traditional and emerging therapies in systemic lupus erythematosus. Rheumatology (Oxford) 2017; 56:i100-i113. [PMID: 28375452 DOI: 10.1093/rheumatology/kew417] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 12/21/2022] Open
Abstract
This review summarizes traditional and emerging therapies for SLE. Evidence suggests that the heterogeneity of SLE is a crucial aspect contributing to the failure of large clinical trials for new targeted therapies. A clearer understanding of the mechanisms driving disease pathogenesis combined with recent advances in medical science are predicted to enable accelerated progress towards improved SLE diagnosis and personalized approaches to treatment.
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Affiliation(s)
- Laurie S Davis
- Rheumatic Diseases Division, Department of Internal Medicine, University of Texas Southwestern Medical Center
| | - Andreas M Reimold
- Rheumatic Diseases Division, Department of Internal Medicine, University of Texas Southwestern Medical Center.,Dallas VA Medical Center, Dallas, TX, USA
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Alonso Valente R, García Rodríguez GE, García Marcote Y, Fidalgo Díaz M, Becerra Mosquera V, Novoa García D, Cordal Martínez T, Díaz Rodríguez C. Discontinuation of Peritoneal Dialysis after Late Initiation of Eculizumab in a Case of Familial Atypical Hemolytic-Uremic Syndrome: A Case Report. Case Rep Nephrol Dial 2017; 7:18-25. [PMID: 28612003 PMCID: PMC5465702 DOI: 10.1159/000457950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/23/2017] [Indexed: 11/19/2022] Open
Abstract
Background Atypical hemolytic-uremic syndrome is caused by a thrombotic microangiopathy and manifests itself with hemolytic anemia, thrombocytopenia, and organ ischemia. Its etiology is a mutation affecting the genes encoding for proteins of the complement system. Early treatment with eculizumab (8.6 months from the moment of presentation), a humanized monoclonal antibody against complement, is shown to be effective in controlling symptoms and reversing organ damage. We present a patient with a mutation not previously described in the literature. Late treatment with eculizumab resulted in a good therapeutic response, eliminating the need for peritoneal dialysis. Case Presentation A 34-year-old woman showed symptoms and laboratory findings consistent with atypical hemolytic-uremic syndrome. Genetic analysis revealed an unusual mutation of the complement regulatory gene not seen previously. Due to unavailability of eculizumab at the time of presentation, conventional treatment was started with poor response. Late initiation of eculizumab resulted in discontinuation of peritoneal dialysis and yielded a good and sustained clinical response. Conclusions This case shows that eculizumab treatment for patients with atypical hemolytic-uremic syndrome, even when initiated many months after beginning on dialysis, might offer substantial benefits and improve the patients’ quality of life.
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Affiliation(s)
- Rafael Alonso Valente
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Yanina García Marcote
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Fidalgo Díaz
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Vanesa Becerra Mosquera
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Daniel Novoa García
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Teresa Cordal Martínez
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Cándido Díaz Rodríguez
- Nephrology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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