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Vonbrunn E, Daniel C. [The complement cascade in renal pathology]. PATHOLOGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00292-024-01320-x. [PMID: 38578365 DOI: 10.1007/s00292-024-01320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/06/2024]
Abstract
The complement cascade comprises a variety of soluble and cell surface proteins and is an important component of the innate immune system. When the cascade is triggered by any of the three activation pathways, the complement system rapidly produces large amounts of protein fragments that are potent mediators of inflammatory, vasoactive, and metabolic responses. All activation pathways lead to the terminal complement cascade with the formation of the membrane attack complex, which lyses cells by forming membrane pores. Although the complement system is essential for pathogen defense and homeostasis, excessive or uncontrolled activation can lead to tissue damage. Recent research shows that the complement system is activated in almost all kidney diseases, even those not traditionally considered immune-mediated. In directly complement-mediated kidney diseases, complement factors or regulators are defective, afunctional or inactivated by antibodies. In many other renal diseases, the complement system is activated secondarily as a result of renal damage and is therefore involved in the pathogenesis of the disease, but is not the trigger. The detection of complement deposits is also used to diagnose kidney disease. This review describes the structure of the complement system and the effects of its dysregulation as a cause and modulator of renal disease.
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Affiliation(s)
- E Vonbrunn
- Abteilung Nephropathologie, Pathologisches Institut, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Krankenhausstr. 8-10, 91054, Erlangen, Deutschland
| | - C Daniel
- Abteilung Nephropathologie, Pathologisches Institut, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Krankenhausstr. 8-10, 91054, Erlangen, Deutschland.
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Catarci S, Zanfini BA, Di Muro M, Capone E, Frassanito L, Santantonio MT, Draisci G. A case report of an atypical haemolytic uremic syndrome in pregnancy: something wicked this way comes. BMC Anesthesiol 2023; 23:94. [PMID: 36977996 PMCID: PMC10045212 DOI: 10.1186/s12871-023-02066-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Atypical Haemolytic Uremic Syndrome is an acute life-threatening condition, characterized by the clinical triad of microangiopathic hemolytic anaemia, thrombocytopenia, kidney injury. Management of pregnants affected by Atypical Haemolytic Uremic Syndrome can be a serious concern for obstetric anesthesiologist in the delivery room and in the intensive care unit. CASE PRESENTATION A 35-year-old primigravida with a monochorionic diamniotic twin pregnancy, presented with an acute haemorrhage due to retained placenta after elective caesarean section and underwent surgical exploration. In the postoperative period, the patient progressively developed hypoxemic respiratory failure and, later on, anaemia, severe thrombocytopenia, and acute kidney injury. A timely diagnosis of Atypical Haemolytic Uremic Syndrome was made. Non-invasive ventilation and high-flow nasal cannula oxygen therapy sessions were initially required. Hypertensive crisis and fluid overload were aggressively treated with a combination of beta and alpha adrenergic blockers (labetalol 0,3 mg/kg/h by continuous intravenous infusion for the first 24 hours, bisoprolol 2,5 mg twice daily for the first 48 hours, doxazosin 2 mg twice daily), central sympatholytics (methyldopa 250 mg twice daily for the first 72 hours, transdermal clonidine 5 mg by the third day), diuretics (furosemide 20 mg three times daily), calcium antagonists (amlodipine 5 mg twice daily). Eculizumab 900 mg was administered via intravenous infusion once per week, attaining hematological and renal remissions. The patient also received several blood transfusion units and anti- meningococcal B, anti-pneumococcal, anti-haemophilus influenzae type B vaccination. Her clinical condition progressively improved, and she was finally discharged from intensive care unit 5 days after admission. CONCLUSIONS The clinical course of this report underlines how crucial it is for the obstetric anaesthesiologist to promptly identify Atypical Haemolytic Uremic Syndrome, since early initiation of eculizumab, together with supportive therapy, has a direct effect on patient outcome.
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Affiliation(s)
- Stefano Catarci
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.
| | - Bruno Antonio Zanfini
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mariangela Di Muro
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Emanuele Capone
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Luciano Frassanito
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Maria Teresa Santantonio
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Gaetano Draisci
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Smith-Jackson K, Harrison RA. Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events. Immunol Rev 2023; 313:298-319. [PMID: 36377667 PMCID: PMC10100418 DOI: 10.1111/imr.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.
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Affiliation(s)
- Kate Smith-Jackson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Faculty of Medical Science, Newcastle University, Newcastle-upon-Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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4
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Wan Z, Li X, Luo X, Wang B, Zhou X, Chen A. The miR-590-3p/CFHR3/STAT3 signaling pathway promotes cell proliferation and metastasis in hepatocellular carcinoma. Aging (Albany NY) 2022; 14:5783-5799. [PMID: 35852862 PMCID: PMC9365569 DOI: 10.18632/aging.204178] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/08/2022] [Indexed: 12/24/2022]
Abstract
Accumulating evidence has indicated that Complement factor H-related 3 (CFHR3) plays an essential role in various diseases. However, the biological functions of CFHR3 in hepatocellular carcinoma (HCC) remain largely unclear. Therefore, we perform a further study on CFHR3 in HCC. In this article, we report the suppressive role of CFHR3 in the proliferation and metastasis of HCC cells. CFHR3 downregulation is closely associated with large (T3-T4) HCC, tumor recurrence, and advanced (stage III-IV) clinical stage, functioning as an independent factor for the prognoses of HCC patients. Knockdown of CFHR3 promotes proliferation, migration, and invasion of HCC cells. Mechanistically, downregulation of CFHR3 is induced by miR-590-3p binding to the 3’ untranslated region (UTR) of CFHR3. CFHR3 downregulation promotes the phosphorylation of STAT3 protein, thereby suppressing p53 expression. The promotional effect upon downregulation of CFHR3 induced by CFHR3 stable knockdown or miR-590-3p on HCC cell malignant phenotypes is attenuated by STAT3 inhibitor, S3I-201. In conclusion, our results reveal that CFHR3 is a protective biomarker for HCC patients, and targeting the miR-590-3p/CFHR3/p-STAT3/p53 signaling axis provides a promising strategy for HCC therapeutics.
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Affiliation(s)
- Zhongzhong Wan
- Institute of Biology and Medicine, College of Life Science and Health, Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, People’s Republic of China
| | - Xingrun Li
- Institute of Biology and Medicine, College of Life Science and Health, Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, People’s Republic of China
| | - Xinru Luo
- Institute of Biology and Medicine, College of Life Science and Health, Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, People’s Republic of China
| | - Bofan Wang
- Institute of Biology and Medicine, College of Life Science and Health, Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, People’s Republic of China
| | - Xiang Zhou
- Institute of Biology and Medicine, College of Life Science and Health, Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, People’s Republic of China
| | - Ao Chen
- Institute of Biology and Medicine, College of Life Science and Health, Wuhan University of Science and Technology, Wuhan 430081, Hubei Province, People’s Republic of China
- State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong 0000, People’s Republic of China
- Department of Pathology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong 0000, People’s Republic of China
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Complement activation and regulation in preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Am J Obstet Gynecol 2022; 226:S1059-S1070. [PMID: 32986992 DOI: 10.1016/j.ajog.2020.09.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/19/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022]
Abstract
The complement system is critical to human health owing to its central role in host defense and innate immunity. During pregnancy, the complement system must be appropriately regulated to allow for immunologic tolerance to the developing fetus and placenta. Although some degree of complement activation can be seen in normal pregnancy, the fetus seems to be protected in part through the placental expression of complement regulatory proteins, which inhibit complement activation at different steps along the complement activation cascade. In women who develop preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome, there is a shift toward increased complement activation and decreased complement regulation. There is an increase in placental deposition of C5b-9, which is the terminal effector of classical, lectin, and alternative complement pathways. C5b-9 deposition stimulates trophoblasts to secrete soluble fms-like tyrosine kinase-1, which sequesters vascular endothelial growth factor and placental growth factor. Pathogenic mutations or deletions in complement regulatory genes, which predispose to increased complement activation, have been detected in women with preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Before the disease, biomarkers of alternative complement pathway activation are increased; during active disease, biomarkers of terminal complement pathway activation are increased. Urinary excretion of C5b-9 is associated with preeclampsia with severe features and distinguishes it from other hypertensive disorders of pregnancy. Taken together, existing data link preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome with increased activation of the terminal complement pathway that, in some cases, may be influenced by genetic alterations in complement regulators. These findings suggest that the inhibition of the terminal complement pathway, possibly through C5 blockade, may be an effective strategy to treat preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome, but this strategy warrants further evaluation in clinical trials.
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Sridharan M, Kluge ML, Go RS, Abraham RS, Moyer AM. Challenges in classification of novel CFH variants in patients with atypical hemolytic uremic syndrome. THROMBOSIS UPDATE 2020. [DOI: 10.1016/j.tru.2020.100002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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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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Amari Chinchilla K, Vijayan M, Taveras Garcia B, Jim B. Complement-Mediated Disorders in Pregnancy. Adv Chronic Kidney Dis 2020; 27:155-164. [PMID: 32553248 DOI: 10.1053/j.ackd.2020.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 12/13/2022]
Abstract
Complement-mediated disorders in pregnancy span a large spectrum and have been implicated in all three complement pathways: classical, lectin, and alternative. Our understanding of these disorders in recent years has advanced due to a better understanding of complement regulatory proteins, such as complement factor H, complement factor I, membrane cofactor protein, and thrombomodulin that particularly affect the alternative complement pathway. Enthusiasm in genotyping for mutations that encode these proteins has allowed us to study the presence of genetic variants which may predispose women to develop conditions such as pregnancy-associated hemolytic uremic syndrome (P-aHUS), thrombotic thrombocytopenic purpura, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP), systemic lupus erythematosus/antiphospholipid syndrome, and peripartum cardiomyopathy. The advent of the anti-C5-antibody eculizumab to quench the complement cascade has already proven in small case series to improve maternal kidney outcomes in complement-mediated obstetric catastrophes such as P-aHUS and HELLP. In this review, we will detail the pathogenesis behind these complement-mediated pregnancy disorders, the role of complement variants in disease phenotype, and the most up-to-date experience with eculizumab in this population.
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9
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Shanmugam SG, Priyathersini N, Muralikrishnan S, Balasubramanian A. Thrombotic thrombocytopenic purpura presenting as recurrent thrombocytopenia in a young female - A case report. Hematol Transfus Cell Ther 2020; 42:376-380. [PMID: 31956090 PMCID: PMC7599268 DOI: 10.1016/j.htct.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/27/2019] [Accepted: 10/17/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sri Gayathri Shanmugam
- Sri Ramachandra Institute of Higher Education and Research SRIHER [DU], Porur, Chennai, India.
| | - Nagarajan Priyathersini
- Sri Ramachandra Institute of Higher Education and Research SRIHER [DU], Porur, Chennai, India
| | - Srikanth Muralikrishnan
- Sri Ramachandra Institute of Higher Education and Research SRIHER [DU], Porur, Chennai, India
| | - Archana Balasubramanian
- Sri Ramachandra Institute of Higher Education and Research SRIHER [DU], Porur, Chennai, India
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Zheng L, Zhang D, Cao W, Song WC, Zheng XL. Synergistic effects of ADAMTS13 deficiency and complement activation in pathogenesis of thrombotic microangiopathy. Blood 2019; 134:1095-1105. [PMID: 31409673 PMCID: PMC6764266 DOI: 10.1182/blood.2019001040] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/02/2019] [Indexed: 12/13/2022] Open
Abstract
Severe deficiency of plasma ADAMTS13 activity is the primary cause of thrombotic thrombocytopenic purpura (TTP) whereas overwhelming activation of complement via an alternative pathway results in atypical hemolytic uremic syndrome (aHUS), the prototypes of thrombotic microangiopathy (TMA). However, clinical and pathogenic distinctions between TTP and aHUS are often quite challenging. Clinical reports have suggested that complement activation may play a role in the development of TTP, which is caused by severe deficiency of plasma ADAMTS13 activity. However, the experimental evidence to support this hypothesis is still lacking. Here, we show that mice with either Adamts13 -/- or a heterozygous mutation of complement factor H (cfh) at amino acid residue of 1206 (ie, cfh W/R ) alone remain asymptomatic despite the presence of occasional microvascular thrombi in various organ tissues. However, mice carrying both Adamts13 -/- and cfh W/R exhibit thrombocytopenia, low haptoglobin, increased fragmentation of erythrocytes in peripheral blood smear, increased plasma levels of lactate dehydrogenase activity, blood urea nitrogen, and creatinine, as well as an increased mortality rate, consistent with the development of TMA. Moreover, mice with a homozygous mutation of cfh (ie, cfh R/R ) with or without Adamts13 -/- developed severe TMA. The mortality rate in mice with Adamts13 -/- cfh R/R was significantly higher than that in mice with cfh R/R alone. Histological and immunohistochemical analyses demonstrated the presence of disseminated platelet-rich thrombi in terminal arterioles and capillaries of major organ tissues in these mice that were either euthanized or died. Together, our results support a synergistic effect of severe ADAMTS13 deficiency and complement activation in pathogenesis of TMA in mice.
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Affiliation(s)
- Liang Zheng
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
| | - Di Zhang
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
| | - Wenjing Cao
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - X Long Zheng
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
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Liu H, Zhang L, Wang P. Complement factor H‑related 3 overexpression affects hepatocellular carcinoma proliferation and apoptosis. Mol Med Rep 2019; 20:2694-2702. [PMID: 31524260 PMCID: PMC6691229 DOI: 10.3892/mmr.2019.10514] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 12/07/2018] [Indexed: 12/14/2022] Open
Abstract
Complement factor H-related 3 (CFHR3) belongs to the human factor H protein family and is associated with various human diseases, including nephropathy, age-related macular degeneration and atypical hemolytic uremic syndrome. However, to the best of our knowledge, the role of CFHR3 in hepatocellular carcinoma (HCC) remains largely unknown. In the present study, reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blot analysis were performed to determine mRNA and protein expression levels of CFHR3 in HCC and normal adjacent tissue. In addition, CFHR3 was overexpressed in Huh-7 cells and cell counting kit-8 assay was used to determine cell viability. Cell proliferation and apoptosis were assessed using flow cytometry, RT-qPCR and western blotting. The results demonstrated that mRNA (2−ΔΔCq) and protein expression levels of CFHR3 were significantly lower in tumor tissue compared with in adjacent tissue. Additionally, CFHR3 overexpression decreased cell viability, inhibited cell proliferation and significantly increased apoptosis. It was also identified that CFHR3 could downregulate the expression of Ki67. The results suggested that CFHR3 induced apoptosis by downregulating the expression of survivin and B cell lymphoma 2, upregulating the expression of Bcl-2-associated X and promoting caspase-3 activity. Western blotting revealed that CFHR3 significantly inhibited the protein expression levels of phosphorylated (p)-phosphoinositide 3-kinase (PI3K), p-protein kinase B (Akt) and p-mammalian target of rapamycin (mTOR). Overexpression of CFHR3 suppressed proliferation and promoted apoptosis of HCC cells by inhibiting the PI3K/Akt/mTOR signaling pathway.
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Affiliation(s)
- Hong Liu
- Department of Hepatology, Yantai Infectious Disease Hospital, Yantai, Shandong 264001, P.R. China
| | - Ligang Zhang
- Department of Hepatology, Yantai Infectious Disease Hospital, Yantai, Shandong 264001, P.R. China
| | - Pengyan Wang
- Department of Research and Education, Yantai Infectious Disease Hospital, Yantai, Shandong 264001, P.R. China
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12
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Affiliation(s)
- Sarosh Rana
- From the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL (S.R.)
| | - Elizabeth Lemoine
- Harvard Medical School, Boston, MA (E.L.)
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (E.L., S.A.K.)
| | - Joey P. Granger
- Department of Physiology, University of Mississippi Medical Center, Jackson (J.P.G.)
| | - S. Ananth Karumanchi
- Departments of Medicine, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (S.A.K.)
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (E.L., S.A.K.)
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13
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Ueda Y, Miwa T, Ito D, Kim H, Sato S, Gullipalli D, Zhou L, Golla M, Song D, Dunaief JL, Palmer MB, Song WC. Differential contribution of C5aR and C5b-9 pathways to renal thrombic microangiopathy and macrovascular thrombosis in mice carrying an atypical hemolytic syndrome-related factor H mutation. Kidney Int 2019; 96:67-79. [PMID: 30910380 PMCID: PMC10084839 DOI: 10.1016/j.kint.2019.01.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 01/24/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a form of thrombotic microangiopathy (TMA) caused by dysregulated complement activation. Clinically, aHUS is effectively treated by an anti-C5 monoclonal antibody (mAb) but whether the disease is mediated by the C5a receptor (C5aR) or C5b-9 pathway, or both, is unknown. Here we address this in a factor H mutant mouse (FHR/R) which developed complement-mediated TMA as well as macrovascular thrombosis caused by an aHUS-related factor H point mutation (mouse W1206R, corresponding to human W1183R). C5 deficiency and anti-C5 mAb treatment blocked all disease manifestations in FHR/R mice. C5aR1 gene deficiency prevented macrovascular thrombosis in various organs but did not improve survival or reduce renal TMA. Conversely, C6 or C9 deficiency significantly improved survival and markedly diminished renal TMA but did not prevent macrovascular thrombosis. Interestingly, as they aged both FHR/R C6-/- and FHR/R C9-/- mice developed glomerular disease reminiscent of C3 glomerulonephritis. Thus, C5aR and C5b-9 pathways drove different aspects of disease in FHR/R mice with the C5aR pathway being responsible for macrovascular thrombosis and chronic inflammatory injury while the C5b-9 pathway caused renal TMA. Our data provide new understanding of the pathogenesis of complement-mediated TMA and macrovascular thrombosis in FHR/R mice and suggest that C5 blockade is more effective for the treatment of aHUS than selectively targeting the C5aR or C5b-9 pathway alone.
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Affiliation(s)
- Yoshiyasu Ueda
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Takashi Miwa
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daisuke Ito
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hangsoo Kim
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sayaka Sato
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Damodar Gullipalli
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lin Zhou
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Madhu Golla
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Delu Song
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua L Dunaief
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew B Palmer
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Abstract
The classical complement system is engrained in the mind of scientists and clinicians as a blood-operative key arm of innate immunity, critically required for the protection against invading pathogens. Recent work, however, has defined a novel and unexpected role for an intracellular complement system-the complosome-in the regulation of key metabolic events that underlie peripheral human T cell survival as well as the induction and cessation of their effector functions. This review summarizes the current knowledge about the emerging vital role of the complosome in T cell metabolism and discusses how viewing the evolution of the complement system from an "unconventional" vantage point could logically account for the development of its metabolic activities.
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Sridharan M, Go RS, Abraham RS, Fervenza FC, Sethi S, Bryant SC, Spears GM, Murray DL, Willrich MAV. Diagnostic Utility of Complement Serology for Atypical Hemolytic Uremic Syndrome. Mayo Clin Proc 2018; 93:1351-1362. [PMID: 30286829 DOI: 10.1016/j.mayocp.2018.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/24/2018] [Accepted: 07/17/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the clinical utility of a 9-analyte complement serology panel (COMS) covering complement function (CH50 and AH50), components (C3, C4), factor B (CFB), factor H, and activation markers (C4d, Bb, and soluble membrane attack complex) for the diagnosis of atypical hemolytic uremic syndrome (aHUS). METHODS Physician orders for COMS from January 19, 2015, through November 4, 2016, were reviewed. Demographic characteristics, patient diagnosis, and laboratory parameters were recorded. RESULTS There were 177 COMS orders for 147 patients. The median patient age was 44.9 years (range, 0.9-88.0 years). Common reasons for ordering COMS included monitoring and diagnosis of C3 glomerulopathy and renal dysfunction and differentiation of aHUS from other thrombotic microangiopathies (TMAs). Forty-four patients had COMS ordered for TMAs: 8 had aHUS and all had 1 or more abnormalities within the alternative pathway of complement. Although the sensitivity of this finding for the diagnosis of aHUS is 100%, the specificity is only 28%, with a positive likelihood ratio of 1.39. Patients with aHUS had lower CH50, C3, and CFB than did those with secondary non-aHUS TMA (all P<.01). A combined CFB of 20.9 mg/dL or less and CH50 of 56% or less led to sensitivity of 75% with increased specificity of 88.9% and a diagnostic odds ratio of 24. CONCLUSION A COMS abnormality should not be interpreted in isolation. In conjunction with clinical presentation, a decrease in both CFB and CH50 may be an important clue to support the diagnosis of aHUS.
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Affiliation(s)
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Sandra C Bryant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Grant M Spears
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Maria A V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
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16
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Salminen A, Vlachopoulou E, Havulinna AS, Tervahartiala T, Sattler W, Lokki ML, Nieminen MS, Perola M, Salomaa V, Sinisalo J, Meri S, Sorsa T, Pussinen PJ. Genetic Variants Contributing to Circulating Matrix Metalloproteinase 8 Levels and Their Association With Cardiovascular Diseases: A Genome-Wide Analysis. ACTA ACUST UNITED AC 2018; 10:CIRCGENETICS.117.001731. [PMID: 29212897 DOI: 10.1161/circgenetics.117.001731] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 09/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Matrix metalloproteinase 8 (MMP-8) is a proinflammatory enzyme expressed mainly by neutrophils. Elevated serum and plasma concentrations of MMP-8 are associated with the risk for and outcome of cardiovascular diseases (CVDs). The origin of circulating MMP-8 is not completely clear. METHODS AND RESULTS We performed a genome-wide association study of serum MMP-8 levels in 2 populations comprising altogether 6049 individuals. Moreover, we studied whether MMP-8-associated variants are linked to increased risk of CVDs and overall mortality in >20 000 subjects. The strongest association with serum MMP-8 was found in locus 1q31.3, containing the gene for complement factor H (lead single nucleotide polymorphism: rs800292; P=2.4×10-35). In functional experiments, activation of the alternative pathway of complement in the carriers of rs800292 minor allele (Ile62 in factor H) led to decreased release of MMP-8 from neutrophils compared with the major allele (Val62 in factor H). Another association was detected in 1q21.3, containing genes S100A8, S100A9, and S100A12 (strongest association: rs1560833; P=5.3×10-15). The minor allele of rs1560833 was inversely associated with CVD (odds ratio [95% confidence interval]: 0.90 [0.82-0.99]; P=0.032) and the time to incident CVD event (hazard ratio [95% confidence interval]: 0.91 [0.84-0.99]; P=0.032) in men but not in women. CONCLUSIONS According to our results, the activation of the alternative pathway of the complement system strongly contributes to serum MMP-8 concentration. Genetic polymorphism in S100A9-S100A12-S100A8 locus affects serum and plasma MMP-8 and shows a suggestive association with the risk of CVDs. Our results show that genetic variation determines a significant portion of circulating MMP-8 concentrations.
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Affiliation(s)
- Aino Salminen
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.).
| | - Efthymia Vlachopoulou
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Aki S Havulinna
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Taina Tervahartiala
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Wolfgang Sattler
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Marja-Liisa Lokki
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Markku S Nieminen
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Markus Perola
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Veikko Salomaa
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Juha Sinisalo
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Seppo Meri
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Timo Sorsa
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
| | - Pirkko J Pussinen
- From the Department of Oral and Maxillofacial Diseases (A.S., T.T., T.S., P.J.P.), Transplantation Laboratory, Medicum (E.V., M.-L.L.), Institute for Molecular Medicine Finland (M.P.), Immunobiology Research Program, Research Programs Unit (S.M.), and Department of Bacteriology and Immunology, Haartman Institute (S.M.), University of Helsinki, Finland; Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Finland (A.S., T.T., T.S., P.J.P.); Division of Periodontology, Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden (A.S., T.S.); Department of Health, National Institute for Health and Welfare, Helsinki, Finland (A.S.H., M.P., V.S.); Institute of Molecular Biology and Biochemistry, Medical University of Graz, Austria (W.S.); and Division of Cardiology, HUCH Heart and Lung Center, Helsinki University Hospital, Finland (M.S.N., J.S.)
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17
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Triebwasser MP, Wu X, Bertram P, Hourcade DE, Nelson DM, Atkinson JP. Timing and mechanism of conceptus demise in a complement regulatory membrane protein deficient mouse. Am J Reprod Immunol 2018; 80:e12997. [PMID: 29924462 PMCID: PMC6160323 DOI: 10.1111/aji.12997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 05/24/2018] [Indexed: 01/01/2023] Open
Abstract
PROBLEM Crry is a widely expressed type 1 transmembrane complement regulatory protein in rodents which protects self-tissue by downregulating C3 activation. Crry-/- concepti produced by Crry+/- × Crry+/- matings are attacked by maternal complement system leading to loss before day 10. The membrane attack complex is not the mediator of this death. We hypothesized that the ability of C3b to engage the alternative pathway's feedback loop relatively unchecked on placental membranes induces the lesion yielding the demise of the Crry-/- mouse. METHOD OF STUDY We investigated the basis of Crry-/- conceptus demise by depleting maternal complement with cobra venom factor and blocking antibodies. We monitored their effects primarily by genotyping and histologic analyses. RESULTS We narrowed the critical period of the complement effect from 6.5 to 8.5 days post-coitus (dpc), which is immediately after the conceptus is exposed to maternal blood. Deposition by 5.5 dpc of maternal C3b on the placental vasculature lacking Crry-/- yielded loss of the conceptus by 8.5 dpc. Fusion of the allantois to the chorion during placental assembly did not occur, fetal vessels originating in the allantois did not infiltrate the chorioallantoic placenta, the chorionic plate failed to develop, and the labyrinthine component of the placenta did not mature. CONCLUSION Our data are most consistent with the deposition of C3b being responsible for the failure of the allantois to fuse to the chorion leading to subsequent conceptus demise.
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Affiliation(s)
- Michael P Triebwasser
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Xiaobo Wu
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Paula Bertram
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Dennis E Hourcade
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Donald Michael Nelson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ultrasound and Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - John P Atkinson
- Department of Medicine, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
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18
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De Novo Atypical Haemolytic Uremic Syndrome after Kidney Transplantation. Case Rep Nephrol 2018; 2018:1727986. [PMID: 29732228 PMCID: PMC5872611 DOI: 10.1155/2018/1727986] [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] [Received: 11/15/2017] [Revised: 01/23/2018] [Accepted: 02/14/2018] [Indexed: 11/29/2022] Open
Abstract
De novo thrombotic microangiopathy (TMA) can occur after kidney transplantation. An abnormality of the alternative pathway of complement must be suspected and searched for, even in presence of a secondary cause. We report the case of a 23-year-old female patient who was transplanted with a kidney from her mother for end-stage renal disease secondary to Hinman syndrome. Early after transplantation, she presented with 2 episodes of severe pyelonephritis, associated with acute kidney dysfunction and biological and histological features of TMA. Investigations of the alternative pathway of the complement system revealed atypical haemolytic uremic syndrome secondary to complement factor I mutation, associated with mutations in CD46 and complement factor H related protein genes. Plasma exchanges followed by eculizumab injections allowed improvement of kidney function without, however, normalization of creatinine.
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19
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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: 56] [Impact Index Per Article: 9.3] [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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20
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Complement and Immunoglobulin Biology Leading to Clinical Translation. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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21
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Blaum BS. The lectin self of complement factor H. Curr Opin Struct Biol 2017; 44:111-118. [DOI: 10.1016/j.sbi.2017.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 01/08/2017] [Accepted: 01/12/2017] [Indexed: 01/15/2023]
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22
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Alfakeeh K, Azar M, Alfadhel M, Abdullah AM, Aloudah N, Alsaad KO. Rare genetic variant in the CFB gene presenting as atypical hemolytic uremic syndrome and immune complex diffuse membranoproliferative glomerulonephritis, with crescents, successfully treated with eculizumab. Pediatr Nephrol 2017; 32:885-891. [PMID: 28210841 DOI: 10.1007/s00467-016-3577-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 12/25/2016] [Accepted: 12/28/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Complement factor B gene (CFB) is an important component of the alternate pathway of complement activation that provides an active subunit that associates with C3b to form the C3 convertase, which is an essential element in complement activation. Among the complement-associated disorders, mutations and pathogenic variants in the CFB gene are relatively rare phenomena. Moreover, mutated CFB affiliation with immune-complex diffuse membranoproliferative glomerulonephritis (IC-MPGN) and atypical hemolytic uremic syndrome (aHUS) are considered a highly rare occurrence. CASE PRESENTATION We describe the clinical presentation, course, and pathological findings in a 7-year-old boy who has confirmed CFB heterozygous variants with pathological features compatible with IC-MPGN. Mutational analysis revealed a heterozygous variant p.Glu566Arg in exon 13 of the CFB gene. The patient did not respond to steroids and mycophenolate mofetil (MMF) therapy but responded clinically and biochemically to eculizumab treatment. This is the first case report of CFB alteration associated with IC-MPGN and aHUS that was successfully treated with eculizumab. CONCLUSIONS Heterozygous variants in the CFB gene can be pathogenic and associated with IC-MPGN and aHUS. Early diagnosis and prompt management can be essential in preventing end-stage renal disease. Eculizumab may provide an effective modality of treatment.
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Affiliation(s)
- Khalid Alfakeeh
- King Saud bin Abdulaziz University for Health Sciences, Nephrology Division, Department of Pediatrics, King Abdulaziz Medical City, MNG-HA, Riyadh, Saudi Arabia. .,Department of Paediatrics, Division of Nephrology, King Abdullah Specialised Children Hospital, Mail Code 1940, King Abdulaziz Medical City, P. O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Mohammed Azar
- King Saud bin Abdulaziz University for Health Sciences, Nephrology Division, Department of Pediatrics, King Abdulaziz Medical City, MNG-HA, Riyadh, Saudi Arabia
| | - Majid Alfadhel
- Genetics Division, Department of Pediatrics, King Abdulaziz Medical City, MNG-HA, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Alsuayri Mansour Abdullah
- King Saud bin Abdulaziz University for Health Sciences, Nephrology Division, Department of Pediatrics, King Abdulaziz Medical City, MNG-HA, Riyadh, Saudi Arabia
| | - Nourah Aloudah
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, MNG-HA, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khaled O Alsaad
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, MNG-HA, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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23
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Liszewski MK, Java A, Schramm EC, Atkinson JP. Complement Dysregulation and Disease: Insights from Contemporary Genetics. ANNUAL REVIEW OF PATHOLOGY 2017; 12:25-52. [PMID: 27959629 PMCID: PMC6020056 DOI: 10.1146/annurev-pathol-012615-044145] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The vertebrate complement system consists of sequentially interacting proteins that provide for a rapid and powerful host defense. Nearly 60 proteins comprise three activation pathways (classical, alternative, and lectin) and a terminal cytolytic pathway common to all. Attesting to its potency, nearly half of the system's components are engaged in its regulation. An emerging theme over the past decade is that variations in these inhibitors predispose to two scourges of modern humans. One, occurring most often in childhood, is a rare but deadly thrombomicroangiopathy called atypical hemolytic uremic syndrome. The other, age-related macular degeneration, is the most common form of blindness in the elderly. Their seemingly unrelated clinical presentations and pathologies share the common theme of overactivity of the complement system's alternative pathway. This review summarizes insights gained from contemporary genetics for understanding how dysregulation of this powerful innate immune system leads to these human diseases.
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Affiliation(s)
- M Kathryn Liszewski
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110;
| | - Anuja Java
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110
| | | | - John P Atkinson
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110;
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Risitano AM, Marotta S. Therapeutic complement inhibition in complement-mediated hemolytic anemias: Past, present and future. Semin Immunol 2016; 28:223-40. [PMID: 27346521 DOI: 10.1016/j.smim.2016.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/24/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
The introduction in the clinic of anti-complement agents represented a major achievement which gave to physicians a novel etiologic treatment for different human diseases. Indeed, the first anti-complement agent eculizumab has changed the treatment paradigm of paroxysmal nocturnal hemoglobinuria (PNH), dramatically impacting its severe clinical course. In addition, eculizumab is the first agent approved for atypical Hemolytic Uremic Syndrome (aHUS), a life-threatening inherited thrombotic microangiopathy. Nevertheless, such remarkable milestone in medicine has brought to the fore additional challenges for the scientific community. Indeed, the list of complement-mediated anemias is not limited to PNH and aHUS, and other human diseases can be considered for anti-complement treatment. They include other thrombotic microangiopathies, as well as some antibody-mediated hemolytic anemias. Furthermore, more than ten years of experience with eculizumab led to a better understanding of the individual steps of the complement cascade involved in the pathophysiology of different human diseases. Based on this, new unmet clinical needs are emerging; a number of different strategies are currently under development to improve current anti-complement treatment, trying to address these specific clinical needs. They include: (i) alternative anti-C5 agents, which may improve the heaviness of eculizumab treatment; (ii) broad-spectrum anti-C3 agents, which may improve the efficacy of anti-C5 treatment by intercepting the complement cascade upstream (i.e., preventing C3-mediated extravascular hemolysis in PNH); (iii) targeted inhibitors of selective complement activating pathways, which may prevent early pathogenic events of specific human diseases (e.g., anti-classical pathway for antibody-mediated anemias, or anti-alternative pathway for PNH and aHUS). Here we briefly summarize the status of art of current and future complement inhibition for different complement-mediated anemias, trying to identify the most promising approaches for each individual disease.
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Affiliation(s)
- Antonio M Risitano
- Hematology, Department of Clinical Medicine and Surgery; Federico II University, Naples, Italy.
| | - Serena Marotta
- Hematology, Department of Clinical Medicine and Surgery; Federico II University, Naples, Italy
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Dalvin LA, Fervenza FC, Sethi S, Pulido JS. Manifestations of Complement-Mediated and Immune Complex-Mediated Membranoproliferative Glomerulonephritis: A Comparative Consecutive Series. Ophthalmology 2016; 123:1588-94. [PMID: 26996341 DOI: 10.1016/j.ophtha.2016.02.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/26/2016] [Accepted: 02/06/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Membranoproliferative glomerulonephritis (MPGN) recently was reclassified to reflect the underlying cause as a complement-mediated and immune complex-mediated disease. This classification is based on renal biopsy immunofluorescence examination, making the former electron-microscopy classification obsolete. In this report, we describe related eye findings in patients with MPGN based on the new classification. DESIGN Retrospective case series. PARTICIPANTS All Mayo Clinic Rochester patients with pathology-confirmed complement- and immune complex-mediated MPGN who had available ophthalmology records from 1997 through 2014 were included in this study. METHODS The medical and pathologic records of patients with MPGN and eye examination results were reviewed from years 1997 through 2014. MAIN OUTCOME MEASURES The number of patients and the number of eyes with MPGN-related pathologic features were examined. Visual acuity also was considered. RESULTS There were 23 patients with complement-mediated MPGN and available eye examination results. Of these, 9 patients (39%) and 17 eyes (37%) had retinal pathologic features that likely were related to the same underlying pathophysiologic process as their renal disease. Five patients (22%) and 6 eyes (13%) had significant vision loss. There were 23 patients with immune complex-mediated MPGN and available eye examination results. Only 2 (9%) of these patients (4 eyes) had retinal pathologic features that potentially could be related to the same underlying pathophysiologic process as their renal disease, and neither had vision loss. CONCLUSIONS Retinal abnormalities are more prominent among patients with complement-mediated MPGN when compared with patients with immune complex-mediated MPGN. It is critical for ophthalmologists to recognize the updated MPGN classification system, and all patients with complement-mediated MPGN require screening eye examinations.
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Affiliation(s)
- Lauren A Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Fernando C Fervenza
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Sanjeev Sethi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jose S Pulido
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Medicine, Mayo Clinic, Rochester, Minnesota.
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Triebwasser MP, Roberson EDO, Yu Y, Schramm EC, Wagner EK, Raychaudhuri S, Seddon JM, Atkinson JP. Rare Variants in the Functional Domains of Complement Factor H Are Associated With Age-Related Macular Degeneration. Invest Ophthalmol Vis Sci 2016; 56:6873-8. [PMID: 26501415 DOI: 10.1167/iovs.15-17432] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Age-related macular degeneration (AMD) has a substantial genetic risk component, as evidenced by the risk from common genetic variants uncovered in the first genome-wide association studies. More recently, it has become apparent that rare genetic variants also play an independent role in AMD risk. We sought to determine if rare variants in complement factor H (CFH) played a role in AMD risk. METHODS We had previously collected DNA from a large population of patients with advanced age-related macular degeneration (A-AMD) and controls for targeted deep sequencing of candidate AMD risk genes. In this analysis, we tested for an increased burden of rare variants in CFH in 1665 cases and 752 controls from this cohort. RESULTS We identified 65 missense, nonsense, or splice-site mutations with a minor allele frequency ≤ 1%. Rare variants with minor allele frequency ≤ 1% (odds ratio [OR] = 1.5, P = 4.4 × 10⁻²), 0.5% (OR = 1.6, P = 2.6 × 10⁻²), and all singletons (OR = 2.3, P = 3.3 × 10⁻²) were enriched in A-AMD cases. Moreover, we observed loss-of-function rare variants (nonsense, splice-site, and loss of a conserved cysteine) in 10 cases and serum levels of FH were decreased in all 5 with an available sample (haploinsufficiency). Further, rare variants in the major functional domains of CFH were increased in cases (OR = 3.2; P = 1.4 × 10⁻³) and the magnitude of the effect correlated with the disruptive nature of the variant, location in an active site, and inversely with minor allele frequency. CONCLUSIONS In this large A-AMD cohort, rare variants in the CFH gene were enriched and tended to be located in functional sites or led to low serum levels. These data, combined with those indicating a similar, but even more striking, increase in rare variants found in CFI, strongly implicate complement activation in A-AMD etiopathogenesis as CFH and CFI interact to inhibit the alternative pathway.
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Affiliation(s)
- Michael P Triebwasser
- Washington University School of Medicine Department of Internal Medicine, Division of Rheumatology, St. Louis, Missouri, United States
| | - Elisha D O Roberson
- Washington University School of Medicine Department of Internal Medicine, Division of Rheumatology, St. Louis, Missouri, United States 2Washington University School of Medicine, Department of Genetics, St. Louis, Missouri, United States
| | - Yi Yu
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, Massachusetts, United States
| | - Elizabeth C Schramm
- Washington University School of Medicine Department of Internal Medicine, Division of Rheumatology, St. Louis, Missouri, United States
| | - Erin K Wagner
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, Massachusetts, United States 4Department of Ophthalmology, Tufts University School of Medicine, Sackler School of Graduate Medical Sciences, Tufts Universi
| | - Soumya Raychaudhuri
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, Massachusetts, United States 4Department of Ophthalmology, Tufts University School of Medicine, Sackler School of Graduate Medical Sciences, Tufts Universi
| | - Johanna M Seddon
- Ophthalmic Epidemiology and Genetics Service, New England Eye Center, Tufts Medical Center, Boston, Massachusetts, United States 4Department of Ophthalmology, Tufts University School of Medicine, Sackler School of Graduate Medical Sciences, Tufts Universi
| | - John P Atkinson
- Washington University School of Medicine Department of Internal Medicine, Division of Rheumatology, St. Louis, Missouri, United States
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Dalvin LA, Fervenza FC, Sethi S, Pulido JS. SHEDDING LIGHT ON FUNDUS DRUSEN ASSOCIATED WITH MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS: BREAKING STEREOTYPES OF TYPES I, II, AND III. Retin Cases Brief Rep 2016; 10:72-8. [PMID: 26110522 DOI: 10.1097/icb.0000000000000164] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE Membranoproliferative glomerulonephritis (MPGN) classification has been changed from purely anatomic to molecular. This report describes two cases of MPGN with associated drusen that exemplify the importance of this change and the need for ophthalmologists to understand it. METHODS The medical and pathologic records of two patients with MPGN and drusen were examined. RESULTS Two patients with MPGN and risk-associated alleles of complement factor H were found to have drusen. In one case, the process led to severe visual impairment. Based on anatomic classification, one patient had MPGN Type I and the other had MPGN Type III. However, both patients had renal biopsy findings classic for C3 glomerulonephritis and the same genetic abnormality (risk-associated alleles of complement factor H). CONCLUSION The association of MPGN and drusen needs to be reevaluated. Previously only recognized in association with Type II MPGN, drusen have been demonstrated in 2 patients with C3 glomerulonephritis in this report. These drusen are likely the result of complement pathway abnormalities. The authors propose a new nomenclature in the ophthalmic literature to classify pathology as immune complex-mediated or complement-mediated rather than solely by the electron microscopy findings. This nomenclature will better characterize the underlying genetic abnormalities and pathophysiology of these disease processes.
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Affiliation(s)
- Lauren A Dalvin
- Departments of *Ophthalmology †Nephrology and Hypertension ‡Anatomic Pathology, and §Molecular Medicine, Mayo Clinic, Rochester, MN
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Gibbins KJ, Ware Branch D. Pre-eclampsia as a manifestation of antiphospholipid syndrome: assessing the current status. Lupus 2015; 23:1229-31. [PMID: 25228712 DOI: 10.1177/0961203314531347] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The presence of antiphospholipid antibodies is considered a risk factor for pre-eclampsia. Two meta-analyses and a number of case-control and cohort studies have found associations between pre-eclampsia and lupus anticoagulant, anticardiolipin, and/or anti-β2 glycoprotein I. However, existing literature is inconsistent, with varying severity of pre-eclampsia phenotype examined, differing aPL titer cutoffs used to define positive status, and an overwhelming lack of repeat confirmatory aPL testing. This calls into question the link between aPLs and pre-eclampsia, or at least makes it less well defined. There is evidence for a mechanistic pathway between aPLs and adverse pregnancy outcomes (APOs) including pre-eclampsia via the complement pathway. Complement appears to be overactive in pregnancies affected by APOs. A mouse model has show that the fetal wastage caused by treatment with human aPLs can be salvaged by either creating genetic knockouts along the complement, TNF-alpha, and tissue factor pathways or be treating mice with monoclonal antibodies blocking key complement factors. Thus, this is worth further investigation to clarify the likely association of aPLs and pre-eclampsia in humans, as well is to further evaluate the interaction with complement in human pregnancies.
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Affiliation(s)
- K J Gibbins
- University of Utah Health Sciences Center and Intermountain Healthcare Salt Lake City, UT, USA
| | - D Ware Branch
- University of Utah Health Sciences Center and Intermountain Healthcare Salt Lake City, UT, USA
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Successful eculizumab treatment of recurrent postpartum atypical hemolytic uremic syndrome after kidney transplantation. Clin Nephrol Case Stud 2015; 3:8-13. [PMID: 29043127 PMCID: PMC5438012 DOI: 10.5414/cncs108491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 03/27/2015] [Indexed: 12/03/2022] Open
Abstract
Postpartum atypical hemolytic uremic syndrome (aHUS) is a rare disorder associated with poor maternal and fetal outcomes. We describe a case of severe postpartum aHUS with recurrence in a kidney allograft after a second pregnancy. The patient had initially presented age 28 years with aHUS that developed after her first delivery. In spite of treatment with plasma exchange, she developed end-stage renal disease (ESRD) requiring years of hemodialysis before receiving a kidney transplant from a living unrelated donor. Two years later, she became pregnant again and at 26 weeks gestation she presented to our hospital with hypertension and proteinuria. Within 48 hours of delivery she developed hemolytic anemia, thrombocytopenia, and oliguric acute kidney injury (AKI) culminating in the need for dialysis. There was no response to therapeutic plasma exchange (TPE). However, treatment with eculizumab led to prompt, successful resolution of hemolysis, thrombocytopenia, and AKI. Three months after therapy was stopped, her disease relapsed causing renal failure again requiring dialysis. At that time, an allograft biopsy revealed severe thrombotic microangiopathy (TMA). Eculizumab was resumed without plasma exchange leading to resolution of aHUS and return of kidney function. Now, her baby is nearly 2 years old. She remains on maintenance eculizumab therapy 1,200 mg every 2 weeks without dialysis. She has excellent renal function with creatinine of 1.2 mg/dL, eGFR 52 mL/min/1.73 m, and proteinuria 0.35 g/day. She will likely be on eculizumab for the remainder of her life.
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Risitano AM. Current and Future Pharmacologic Complement Inhibitors. Hematol Oncol Clin North Am 2015; 29:561-82. [DOI: 10.1016/j.hoc.2015.01.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ernst LM, Rand CM, Bao R, Andrade J, Linn RL, Minturn L, Zhang C, Kang W, Weese-Mayer DE. Stillbirth: Genome-wide copy number variation profiling in archived placental umbilical cord samples with pathologic and clinical correlation. Placenta 2015; 36:783-9. [PMID: 26094028 DOI: 10.1016/j.placenta.2015.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/30/2015] [Accepted: 04/25/2015] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Stillbirth remains a devastating health issue with 26,000 stillbirths occurring annually in the United States. Formalin-fixed, paraffin-embedded (FFPE) umbilical cord samples are available for many stillbirths. Our aim was to validate the use of these samples in identifying genetic variations in stillbirth through microarray analysis. METHODS This is a retrospective case-control study from a single institution of stillbirths ≥ 23 weeks gestational age and control liveborn infants. Fetal genomic DNA was extracted from FFPE umbilical cord samples of stillborn and control placentas, and genotyping was performed using the Illumina HumanOmniExpresss-12v1 Beadchip. Array results were verified with qPCR. RESULTS 31 case-specific CNVs (17 deletions and 14 amplifications) with an average size of 294 kb for amplifications and 74 kb for deletions were identified among 94 FFPE samples (86 cases; 8 controls). In total 38 (44%) of the stillbirth samples had a CNV detected. Validation of a subset of microarray findings with qPCR confirmed deletions on 1p (2 cases), 11q (4 cases) and amplifications on 18 (1 case). Placental underperfusion changes were seen in stillborns with deletions on 1p, a region containing complement regulatory genes which have been shown to play a role in preeclampsia. DISCUSSION This study validated the use of archived FFPE umbilical cord samples for genome-wide copy number profiling in stillbirths, and demonstrates specific CNV deletions and amplifications. Microarray analysis in an expanded cohort of stillbirth FFPE samples has the potential to identify biomarkers involved in stillbirth pathogenesis.
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Affiliation(s)
- L M Ernst
- Northwestern University, Feinberg School of Medicine, Department of Pathology, USA.
| | - C M Rand
- Ann & Robert H. Lurie Children's Hospital of Chicago, Center for Autonomic Medicine in Pediatrics (CAMP) and Stanley Manne Children's Research Institute, USA
| | - R Bao
- University of Chicago, Center for Research Informatics, USA
| | - J Andrade
- University of Chicago, Center for Research Informatics, USA
| | - R L Linn
- Northwestern University, Feinberg School of Medicine, Department of Pathology, USA
| | - L Minturn
- Northwestern University, Feinberg School of Medicine, Department of Pathology, USA
| | - C Zhang
- University of Chicago, Center for Research Informatics, USA
| | - W Kang
- University of Chicago, Center for Research Informatics, USA
| | - D E Weese-Mayer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Center for Autonomic Medicine in Pediatrics (CAMP) and Stanley Manne Children's Research Institute, USA; Northwestern University, Feinberg School of Medicine, Department of Pediatrics, USA
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Java A, Edwards A, Rossi A, Pandey R, Gaut J, Delos Santos R, Miller B, Klein C, Brennan D. Cytomegalovirus-induced thrombotic microangiopathy after renal transplant successfully treated with eculizumab: case report and review of the literature. Transpl Int 2015; 28:1121-5. [PMID: 25864519 DOI: 10.1111/tri.12582] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/09/2015] [Accepted: 04/07/2015] [Indexed: 01/28/2023]
Abstract
De novo thrombotic microangiopathy (TMA) after renal transplant is rare. Cytomegalovirus (CMV)-related post-transplant TMA has only been reported in 6 cases. We report an unusual case of a 75-year-old woman who developed de novo TMA in association with CMV viremia. The recurrence of TMA with CMV viremia, the resolution with treatment for CMV, and the lack of correlation with a calcineurin inhibitor (CNI) in our case support CMV as the cause of the TMA. What is unique is that the use of eculizumab without plasmapheresis led to prompt improvement in renal function. After a failure to identify a genetic cause for TMA and the clear association with CMV, eculizumab was discontinued. This case provides insight into the pathogenesis and novel treatment of de novo TMA, highlights the beneficial effects of complement inhibitors in this disease, and shows that they can be safely discontinued once the inciting etiology is addressed.
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Affiliation(s)
- Anuja Java
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Angelina Edwards
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ana Rossi
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Richa Pandey
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Joseph Gaut
- Department of Pathology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rowena Delos Santos
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Brent Miller
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christina Klein
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Brennan
- Department of Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
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Abstract
First identified in human serum in the late 19th century as a 'complement' to antibodies in mediating bacterial lysis, the complement system emerged more than a billion years ago probably as the first humoral immune system. The contemporary complement system consists of nearly 60 proteins in three activation pathways (classical, alternative and lectin) and a terminal cytolytic pathway common to all. Modern molecular biology and genetics have not only led to further elucidation of the structure of complement system components, but have also revealed function-altering rare variants and common polymorphisms, particularly in regulators of the alternative pathway, that predispose to human disease by creating 'hyperinflammatory complement phenotypes'. To treat these 'complementopathies', a monoclonal antibody against the initiator of the membrane attack complex, C5, has received approval for use. Additional therapeutic reagents are on the horizon.
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Affiliation(s)
- M K Liszewski
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - J P Atkinson
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Wong EKS, Kavanagh D. Anticomplement C5 therapy with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome. Transl Res 2015; 165:306-20. [PMID: 25468487 DOI: 10.1016/j.trsl.2014.10.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 10/15/2014] [Accepted: 10/16/2014] [Indexed: 12/28/2022]
Abstract
The complement inhibitor eculizumab is a humanized monoclonal antibody against C5. It was developed to specifically target cleavage of C5 thus preventing release of C5a and activation of the terminal pathway. Paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) are 2 diseases with distinctly different underlying molecular mechanisms. In PNH, progeny of hematopoietic stem cells that harbor somatic mutations lead to a population of peripheral blood cells that are deficient in complement regulators resulting in hemolysis and thrombosis. In aHUS, germline mutations in complement proteins or their regulators fail to protect the glomerular endothelium from complement activation resulting in thrombotic microangiopathy and renal failure. Critical to the development of either disease is activation of the terminal complement pathway. Understanding this step has led to the study of eculizumab as a treatment for these diseases. In clinical trials, eculizumab is proven to be effective and safe in PNH and aHUS.
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Affiliation(s)
- Edwin K S Wong
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom.
| | - David Kavanagh
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
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Boisson B, Quartier P, Casanova JL. Immunological loss-of-function due to genetic gain-of-function in humans: autosomal dominance of the third kind. Curr Opin Immunol 2015; 32:90-105. [PMID: 25645939 PMCID: PMC4364384 DOI: 10.1016/j.coi.2015.01.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/06/2015] [Accepted: 01/12/2015] [Indexed: 12/29/2022]
Abstract
All the human primary immunodeficiencies (PIDs) recognized as such in the 1950s were Mendelian traits and, whether autosomal or X-linked, displayed recessive inheritance. The first autosomal dominant (AD) PID, hereditary angioedema, was recognized in 1963. However, since the first identification of autosomal recessive (AR), X-linked recessive (XR) and AD PID-causing genes in 1985 (ADA; severe combined immunodeficiency), 1986 (CYBB, chronic granulomatous disease) and 1989 (SERPING1; hereditary angioedema), respectively, the number of genetically defined AD PIDs has increased more rapidly than that of any other type of PID. AD PIDs now account for 61 of the 260 known conditions (23%). All known AR PIDs are caused by alleles with some loss-of-function (LOF). A single XR PID is caused by gain-of-function (GOF) mutations (WASP-related neutropenia, 2001). In contrast, only 44 of 61 AD defects are caused by LOF alleles, which exert dominance by haploinsufficiency or negative dominance. Since 2003, up to 17 AD disorders of the third kind, due to GOF alleles, have been described. Remarkably, six of the 17 genes concerned also harbor monoallelic (STAT3), biallelic (C3, CFB, CARD11, PIK3R1) or both monoallelic and biallelic (STAT1) LOF alleles in patients with other clinical phenotypes. Most heterozygous GOF alleles result in auto-inflammation, auto-immunity, or both, with a wide range of immunological and clinical forms. Some also underlie infections and, fewer, allergies, by impairing or enhancing immunity to non-self. Malignancies are also rare. The enormous diversity of immunological and clinical phenotypes is thought provoking and mirrors the diversity and pleiotropy of the underlying genotypes. These experiments of nature provide a unique insight into the quantitative regulation of human immunity.
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Affiliation(s)
- Bertrand Boisson
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Pierre Quartier
- Paris Descartes University, Imagine Institute, Paris 75015, France
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital for Sick Children, Paris 75015, France
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
- Paris Descartes University, Imagine Institute, Paris 75015, France
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital for Sick Children, Paris 75015, France
- Howard Hughes Medical Institute, New York, NY 10065, USA
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris 75015, France
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Watson R, Wearmouth E, McLoughlin AC, Jackson A, Ward S, Bertram P, Bennaceur K, Barker CE, Pappworth IY, Kavanagh D, Lea SM, Atkinson JP, Goodship THJ, Marchbank KJ. Autoantibodies to CD59, CD55, CD46 or CD35 are not associated with atypical haemolytic uraemic syndrome (aHUS). Mol Immunol 2015; 63:287-96. [PMID: 25150608 PMCID: PMC4452024 DOI: 10.1016/j.molimm.2014.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 07/16/2014] [Indexed: 01/31/2023]
Abstract
Autoantibody formation against Factor H (FH) is found in 7-10% of patients who are diagnosed with atypical haemolytic uraemic syndrome (aHUS). These autoantibodies predominately target the C-terminal cell binding recognition domain of FH and are associated with absence of FHR1. Additional autoantibodies have also been identified in association with aHUS, for example autoantibodies to Factor I. Based on this, and that there are genetic mutations in other complement regulators and activators associated with aHUS, we hypothesised that other complement regulator proteins, particularly surface bound regulators in the kidney, might be the target for autoantibody formation in aHUS. Therefore, we assayed serum derived from 89 patients in the Newcastle aHUS cohort for the presence of autoantibodies to CD46 (membrane cofactor protein, MCP), CD55 (decay accelerating factor, DAF), CD35 (complement receptor type 1, CR1; TP10) and CD59. We also assayed 100 healthy blood donors to establish the normal levels of reactivity towards these proteins in the general population. Recombinant proteins CD46 and CD55 (purified from Escherichia coli) as well as soluble CR1 (CD35) and oligomeric C4BP-CD59 (purified from eukaryotic cell media) were used in ELISA to detect high responders. False positive results were established though Western blot and flow cytometric analysis. After excluding false positive responders to bacterial proteins in the CD46 and CD55 preparations, and responses to blood group antigens in CD35, we found no significant level of patient serum IgG reactivity with CD46, CD55, CD35 or CD59 above that detected in the normal population. These results suggest that membrane anchored complement regulators are not a target for autoantibody generation in aHUS.
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Affiliation(s)
- Rachael Watson
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Emma Wearmouth
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Amy-Claire McLoughlin
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Arthur Jackson
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Sophie Ward
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Paula Bertram
- Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Karim Bennaceur
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Catriona E Barker
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Isabel Y Pappworth
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - David Kavanagh
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Susan M Lea
- Sir William Dunn School of Pathology, University of Oxford, UK
| | - John P Atkinson
- Division of Rheumatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy H J Goodship
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Kevin J Marchbank
- Institutes of Cellular and Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK.
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37
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Vogel CW, Finnegan PW, Fritzinger DC. Humanized cobra venom factor: Structure, activity, and therapeutic efficacy in preclinical disease models. Mol Immunol 2014; 61:191-203. [DOI: 10.1016/j.molimm.2014.06.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 10/25/2022]
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38
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Cai L, Zhu J, Yin D, Chen L, Jin P, Ma F. Identification and characterization of complement factor H in Branchiostoma belcheri. Gene 2014; 553:42-8. [PMID: 25281822 DOI: 10.1016/j.gene.2014.09.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 09/22/2014] [Accepted: 09/27/2014] [Indexed: 10/24/2022]
Abstract
Complement factor H (CFH) is an essential regulator of the complement system and plays very important roles in animal innate immunity. Although the complement system of amphioxus has been extensively studied, the expression in amphioxus and evolution of CFH gene remain unknown. In this study, we identified and characterized an amphioxus (Branchiostoma belcheri) CFH gene (designated as AmphiCFH). Our results showed that the full-length cDNA of AmphiCFH gene consists of 1295 bp nucleotides containing an 855 bp open reading frame (ORF) that was predicted to encode a 284 amino acid protein. The putative AmphiCFH protein possessed the characteristic of the CFH protein family, including typical CCP (complement control protein) domain. Real-time PCR analysis showed that the AmphiCFH was ubiquitously and differentially expressed in five investigated tissues (intestine, gills, notochord, muscles, and hepatic cecum). The expression level of the AmphiCFH gene was induced upon lipopolysaccharide stimulation, indicating that the AmphiCFH gene might be involved in innate immunity. In addition, phylogenetic analysis showed that the AmphiCFH gene was located between that of invertebrates and vertebrates, suggesting that the AmphiCFH gene is a member of the CFH gene family. In conclusion, our findings provided an insight into animal innate immunity and evolution of the CFH gene family.
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Affiliation(s)
- Lu Cai
- Laboratory for Comparative Genomics and Bioinformatics & Jiangsu Key Laboratory for Biodiversity and Biotechnology, College of Life Science, Nanjing Normal University, Nanjing 210046, PR China
| | - Jiu Zhu
- Laboratory for Comparative Genomics and Bioinformatics & Jiangsu Key Laboratory for Biodiversity and Biotechnology, College of Life Science, Nanjing Normal University, Nanjing 210046, PR China
| | - Denghua Yin
- Laboratory for Comparative Genomics and Bioinformatics & Jiangsu Key Laboratory for Biodiversity and Biotechnology, College of Life Science, Nanjing Normal University, Nanjing 210046, PR China
| | - Liming Chen
- The Key Laboratory of Developmental Genes and Human Disease, Ministry of Education, Institute of Life Science, Southeast University, Nanjing 210009, PR China
| | - Ping Jin
- Laboratory for Comparative Genomics and Bioinformatics & Jiangsu Key Laboratory for Biodiversity and Biotechnology, College of Life Science, Nanjing Normal University, Nanjing 210046, PR China.
| | - Fei Ma
- Laboratory for Comparative Genomics and Bioinformatics & Jiangsu Key Laboratory for Biodiversity and Biotechnology, College of Life Science, Nanjing Normal University, Nanjing 210046, PR China.
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39
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Schramm EC, Clark SJ, Triebwasser MP, Raychaudhuri S, Seddon J, Atkinson JP. Genetic variants in the complement system predisposing to age-related macular degeneration: a review. Mol Immunol 2014; 61:118-125. [PMID: 25034031 DOI: 10.1016/j.molimm.2014.06.032] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 06/20/2014] [Accepted: 06/23/2014] [Indexed: 01/09/2023]
Abstract
Age-related macular degeneration (AMD) is a major cause of visual impairment in the western world. It is characterized by the presence of lipoproteinaceous deposits (drusen) in the inner layers of the retina. Immunohistochemistry studies identified deposition of complement proteins in the drusen as well as in the choroid. In the last decade, genetic studies have linked both common and rare variants in genes of the complement system to increased risk of development of AMD. Here, we review the variants described to date and discuss the functional implications of dysregulation of the alternative pathway of complement in AMD.
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Affiliation(s)
- Elizabeth C Schramm
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Simon J Clark
- Centre for Hearing & Vision Research, Institute of Human Development, University of Manchester, Oxford Road, Manchester M13 9PT, UK
| | - Michael P Triebwasser
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Soumya Raychaudhuri
- Divisions of Rheumatology and Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Partners Center for Personalized Genetic Medicine, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Johanna Seddon
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA.,Ophthalmic Epidemiology and Genetics Service, Tufts Medical Center, Boston, MA
| | - John P Atkinson
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
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40
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Abstract
Hemolytic uremic syndrome (HUS) is a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. The atypical form of HUS is a disease characterized by complement overactivation. Inherited defects in complement genes and acquired autoantibodies against complement regulatory proteins have been described. Incomplete penetrance of mutations in all predisposing genes is reported, suggesting that a precipitating event or trigger is required to unmask the complement regulatory deficiency. The underlying genetic defect predicts the prognosis both in native kidneys and after renal transplantation. The successful trials of the complement inhibitor eculizumab in the treatment of atypical HUS will revolutionize disease management.
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Affiliation(s)
- David Kavanagh
- The Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK.
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41
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Diamante Chiodini B, Davin JC, Corazza F, Khaldi K, Dahan K, Ismaili K, Adams B. Eculizumab in anti-factor h antibodies associated with atypical hemolytic uremic syndrome. Pediatrics 2014; 133:e1764-8. [PMID: 24843055 DOI: 10.1542/peds.2013-1594] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a life-threatening multisystemic condition often leading to end-stage renal failure. It results from an increased activation of the alternative pathway of the complement system due to mutations of genes coding for inhibitors of this pathway or from autoantibodies directed against them. Eculizumab is a monoclonal antibody directed against complement component C5 and inhibiting the activation of the effector limb of the complement system. Its efficacy has already been demonstrated in aHUS. The present article reports for the first time the use of eculizumab in a patient presenting with aHUS associated with circulating anti-complement Factor H autoantibodies and complicated by cardiac and neurologic symptoms. Our observation highlights the efficacy of eculizumab in this form of aHUS not only on renal symptoms but also on the extrarenal symptoms. It also suggests that eculizumab should be used very promptly after aHUS presentation to prevent life-threatening complications and to reduce the risk of chronic disabilities. To obtain a complete inhibition of the effector limb activation, the advised dosage must be respected. After this initial therapy in the autoimmune aHUS form, a long-term immunosuppressive treatment should be considered, to prevent relapses by reducing anti-complement Factor H autoantibody plasma levels.
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Affiliation(s)
| | - Jean-Claude Davin
- Departments of Pediatric Nephrology, andDepartment of Pediatric Nephrology, Emma Children's Hospital-Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Francis Corazza
- Department of Immunology, CHU Brugmann Hospital (ULB), Brussels, Belgium; and
| | - Karim Khaldi
- Pediatric Cardiology, Hôpital Universitaire des Enfants-Reine Fabiola, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Karin Dahan
- Center for Human Genetics, Université Catholique de Louvain, Brussels, Belgium
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42
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Thrombotic microangiopathies. Semin Arthritis Rheum 2014; 43:797-805. [DOI: 10.1016/j.semarthrit.2013.11.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 11/03/2013] [Accepted: 11/07/2013] [Indexed: 12/24/2022]
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43
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Zhang H, Verkman AS. Longitudinally extensive NMO spinal cord pathology produced by passive transfer of NMO-IgG in mice lacking complement inhibitor CD59. J Autoimmun 2014; 53:67-77. [PMID: 24698947 DOI: 10.1016/j.jaut.2014.02.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/21/2014] [Accepted: 02/26/2014] [Indexed: 12/18/2022]
Abstract
Spinal cord pathology with inflammatory, demyelinating lesions spanning three or more vertebral segments is a characteristic feature of neuromyelitis optica (NMO). NMO pathogenesis is thought to involve binding of immunoglobulin G anti-aquaporin-4 autoantibodies (NMO-IgG) to astrocytes, causing complement-dependent cytotoxicity (CDC) and secondary inflammation, demyelination and neuron loss. We investigated the involvement of CD59, a glycophosphoinositol (GPI)-anchored membrane protein on astrocytes that inhibits formation of the terminal C5b-9 membrane attack complex. CD59 inhibition by a neutralizing monoclonal antibody greatly increased NMO-IgG-dependent CDC in murine astrocyte cultures and ex vivo spinal cord slice cultures. Greatly increased NMO pathology was also found in spinal cord slice cultures from CD59 knockout mice, and in vivo following intracerebral injection of NMO-IgG and human complement. Intrathecal injection (at L5-L6) of small amounts of NMO-IgG and human complement in CD59-deficient mice produced robust, longitudinally extensive white matter lesions in lumbar spinal cord. Pathology was most severe at day 2 after injection, showing loss of AQP4 and GFAP, C5b-9 deposition, microglial activation, granulocyte infiltration, and demyelination. Hind limb motor function was remarkably impaired as well. There was partial remyelination and recovery of motor function by day 5. Our results implicate CD59 as an important modulator of the immune response in NMO, and provide a novel animal model of NMO that closely recapitulates human NMO pathology. Up-regulation of CD59 on astrocytes may have therapeutic benefit in NMO.
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Affiliation(s)
- Hua Zhang
- Department of Medicine, University of California, San Francisco, CA, USA; Department of Physiology, University of California, San Francisco, CA, USA
| | - A S Verkman
- Department of Medicine, University of California, San Francisco, CA, USA; Department of Physiology, University of California, San Francisco, CA, USA.
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44
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Ardissino G, Testa S, Possenti I, Tel F, Paglialonga F, Salardi S, Tedeschi S, Belingheri M, Cugno M. Discontinuation of eculizumab maintenance treatment for atypical hemolytic uremic syndrome: a report of 10 cases. Am J Kidney Dis 2014; 64:633-7. [PMID: 24656451 DOI: 10.1053/j.ajkd.2014.01.434] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/14/2014] [Indexed: 02/07/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a life-threatening thrombotic microangiopathy, and as many as 70% of patients with aHUS have mutations in the genes encoding complement regulatory proteins. Eculizumab, a humanized recombinant monoclonal antibody targeting C5, has been used successfully in patients with aHUS since 2009. The standard maintenance treatment requires life-long eculizumab therapy, but the possibility of discontinuation has not yet been tested systematically. We report the safety of discontinuing eculizumab treatment in 10 patients who stopped treatment with the aim of minimizing the risk of adverse reactions, reducing the risk of meningitis, and improving quality of life while also reducing the considerable treatment costs. Disease activity was monitored closely at home by means of urine dipstick testing for hemoglobin. During the cumulative observation period of 95 months, 3 of the 10 patients experienced relapse within 6 weeks of discontinuation, but then immediately resumed treatment and completely recovered. Our experience supports the possibility of discontinuing eculizumab therapy with strict home monitoring for early signs of relapse in patients with aHUS who achieve stable remission.
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Affiliation(s)
- Gianluigi Ardissino
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Sara Testa
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Possenti
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Tel
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Paglialonga
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Salardi
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvana Tedeschi
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Center for HUS Prevention, Control and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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45
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Yamamoto H, Fara AF, Dasgupta P, Kemper C. CD46: the 'multitasker' of complement proteins. Int J Biochem Cell Biol 2013; 45:2808-20. [PMID: 24120647 DOI: 10.1016/j.biocel.2013.09.016] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 09/23/2013] [Accepted: 09/30/2013] [Indexed: 12/12/2022]
Abstract
Complement is undeniably quintessential for innate immunity by detecting and eliminating infectious microorganisms. Recent work, however, highlights an equally profound impact of complement on the induction and regulation of a wide range of immune cells. In particular, the complement regulator CD46 emerges as a key sensor of immune activation and a vital modulator of adaptive immunity. In this review, we summarize the current knowledge of CD46-mediated signalling events and their functional consequences on immune-competent cells with a specific focus on those in CD4(+) T cells. We will also discuss the promises and challenges that potential therapeutic modulation of CD46 may hold and pose.
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Affiliation(s)
- Hidekazu Yamamoto
- Division of Transplant Immunology and Mucosal Biology, MRC Centre for Transplantation, King's College London, Guy's Hospital, London SE1 9RT, UK; The Urology Centre, Guy's and St. Thomas' NHS Foundations Trust, London SE1 9RT, UK
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46
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Feng S, Liang X, Cruz MA, Vu H, Zhou Z, Pemmaraju N, Dong JF, Kroll MH, Afshar-Kharghan V. The interaction between factor H and Von Willebrand factor. PLoS One 2013; 8:e73715. [PMID: 23991205 PMCID: PMC3753316 DOI: 10.1371/journal.pone.0073715] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 07/30/2013] [Indexed: 01/22/2023] Open
Abstract
Complement factor H (fH) is a plasma protein that regulates activation of the alternative pathway, and mutations in fH are associated with a rare form of thrombotic microangiopathy (TMA), known as atypical hemolytic uremic syndrome (aHUS). A more common TMA is thrombotic thrombocytopenic purpura, which is caused by the lack of normal ADAMTS-13-mediated cleavage of von Willebrand factor (VWF). We investigated whether fH interacts with VWF and affects cleavage of VWF. We found that factor H binds to VWF in plasma, to plasma-purified VWF, and to recombinant A1 and A2 domains of VWF as detected by co-immunoprecipitation (co-IP) and surface plasmon resonance assays. Factor H enhanced ADAMTS-13-mediated cleavage of recombinant VWF-A2 as determined by quantifying the cleavage products using Western-blotting, enhanced cleavage of a commercially available fragment of VWF-A2 (FRETS-VWF73) as determined by fluorometric assay, and enhanced cleavage of ultralarge (UL) VWF under flow conditions as determined by cleavage of VWF-platelet strings attached to histamine stimulated endothelial cells. Using recombinant full-length and truncated fH molecules, we found that the presence of the C-terminal half of fH molecule is important for binding to VWF-A2 and for enhancing cleavage of the A2 domain by ADAMTS-13. We conclude that factor H binds to VWF and may modulate cleavage of VWF by ADAMTS-13.
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Affiliation(s)
- Shuju Feng
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Xiaowen Liang
- Institute of Biosciences and Technology, Texas A&M University Health Science Center, Houston, Texas, United States of America
| | - Miguel A. Cruz
- Cardiovascular Research Section, Baylor College of Medicine, Houston, Texas, United States of America
| | - Hangoc Vu
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Zhou Zhou
- Puget Sound Blood Center, Seattle, Washington, United States of America
| | - Naresh Pemmaraju
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Jing-Fei Dong
- Puget Sound Blood Center, Seattle, Washington, United States of America
| | - Michael H. Kroll
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
| | - Vahid Afshar-Kharghan
- Division of Internal Medicine, Benign Hematology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas, United States of America
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47
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Wong EKS, Goodship THJ, Kavanagh D. Complement therapy in atypical haemolytic uraemic syndrome (aHUS). Mol Immunol 2013; 56:199-212. [PMID: 23810412 PMCID: PMC3899040 DOI: 10.1016/j.molimm.2013.05.224] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 05/10/2013] [Indexed: 12/22/2022]
Abstract
Central to the pathogenesis of atypical haemolytic uraemic syndrome (aHUS) is over-activation of the alternative pathway of complement. Inherited defects in complement genes and autoantibodies against complement regulatory proteins have been described. The use of plasma exchange to replace non-functioning complement regulators and hyper-functional complement components in addition to the removal of CFH-autoantibodies made this the ‘gold-standard’ for management of aHUS. In the last 4 years the introduction of the complement inhibitor Eculizumab has revolutionised the management of aHUS. In this review we shall discuss the available literature on treatment strategies to date.
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Affiliation(s)
- Edwin K S Wong
- The Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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48
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Xie L, Nester CM, Reed AI, Zhang Y, Smith RJ, Thomas CP. Tailored eculizumab therapy in the management of complement factor H-mediated atypical hemolytic uremic syndrome in an adult kidney transplant recipient: a case report. Transplant Proc 2013. [PMID: 23195022 DOI: 10.1016/j.transproceed.2012.07.141] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury (AKI) which frequently progresses to end-stage renal disease (ESRD). In 50% of affected patients, mutations in complement regulatory proteins cause inappropriate complement activation with endothelial injury. Complement factor H (CFH) mutations cause 25% of aHUS cases; these patients have an 80% recurrence risk after kidney transplantation. Eculizumab, an anti-C5 antibody, is effective in limiting hemolysis episodes in patients with aHUS, but less is known about preventing recurrence after kidney transplantation. Herein we report the use of prophylactic eculizumab in an adult with aHUS who underwent kidney transplantation. A 31-year-old female presented with aHUS and progressive AKI associated with low complement 3 level leading to ESRD despite plasmapheresis and corticosteroids. She had a heterozygous nonsense mutation in CFH and reduced plasma CFH levels. She was given preoperative plasmapheresis and eculizumab and underwent living unrelated renal transplantation. Postoperatively, eculizumab was dosed to achieve low functional complement 5 levels and low soluble membrane attack complex levels and she has maintained excellent graft function without aHUS recurrence. We propose that eculizumab with titrated dosing should be used in CFH-mediated aHUS patients who are at a high risk of recurrence.
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Affiliation(s)
- L Xie
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA
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49
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Hepatitis C virus infection upregulates CD55 expression on the hepatocyte surface and promotes association with virus particles. J Virol 2013; 87:7902-10. [PMID: 23658447 DOI: 10.1128/jvi.00917-13] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
CD55 limits excessive complement activation on the host cell surface by accelerating the decay of C3 convertases. In this study, we observed that hepatitis C virus (HCV) infection of hepatocytes or HCV core protein expression in transfected hepatocytes upregulated CD55 expression at the mRNA and protein levels. Further analysis suggested that the HCV core protein or full-length (FL) genome enhanced CD55 promoter activity in a luciferase-based assay, which was further augmented in the presence of interleukin-6. Mutation of the CREB or SP-1 binding site on the CD55 promoter impaired HCV core protein-mediated upregulation of CD55. HCV-infected or core protein-transfected Huh7.5 cells displayed greater viability in the presence of CD81 and CD55 antibodies and complement. Biochemical analysis revealed that CD55 was associated with cell culture-grown HCV after purification by sucrose density gradient ultracentrifugation. Consistent with this, a polyclonal antibody to CD55 captured cell culture-grown HCV. Blocking antibodies against CD55 or virus envelope glycoproteins in the presence of normal human serum as a source of complement inhibited HCV infection. The inhibition was enhanced in the presence of both the antibodies and serum complement. Collectively, these results suggest that HCV induces and associates with a negative regulator of the complement pathway, a likely mechanism for immune evasion.
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50
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Risitano AM. Paroxysmal nocturnal hemoglobinuria and other complement-mediated hematological disorders. Immunobiology 2013; 217:1080-7. [PMID: 22964233 DOI: 10.1016/j.imbio.2012.07.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 07/18/2012] [Accepted: 07/18/2012] [Indexed: 11/29/2022]
Abstract
The recent availability of eculizumab as the first complement inhibitor renewed the interest for complement-mediated damage in several human diseases. Paroxysmal nocturnal hemoglobinuria (PNH) may be considered the paradigm a disease caused by complement dysregulation specifically on erythrocytes; in fact, PNH is a clonal, non-malignant, hematological disorder characterized by the expansion of hematopoietic stem cells and progeny mature blood cells which are deficient in some surface proteins, including the two complement regulators CD55 and CD59. As a result, PNH erythrocytes are incapable to modulate on their surface physiologic complement activation, which eventually enables the terminal lytic complement leading to complement-mediated intravascular anemia - the typical clinical hallmark of PNH. In the last decade the anti-C5 monoclonal antibody has been proven effective for the treatment of PNH, resulting in a sustained control of complement-mediated intravascular hemolysis, with a remarkable clinical benefit. Since then, different diseases with a proved or suspected complement-mediated pathophysiology have been considered as candidate for a clinical complement inhibition. At the same time, the growing information on biological changes during eculizumab treatment in PNH have improved our understanding of different steps of the complement system in human diseases, as well as their modulation by current anti-complement treatment. As a result, investigators are currently working on novel strategy of complement inhibition, looking at the second generation of anti-complement agents which hopefully will be able to modulate distinct steps of the complement cascade. Here we review PNH as a disease model, focusing on the observation that led to the development of novel complement modulators; the discussion will be extended to other hemolytic disorders potentially candidate for clinical complement inhibition.
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Affiliation(s)
- Antonio M Risitano
- Department of Biochemistry and Medical Biotechnologies, Federico II University, Naples, Italy.
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