1
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Smith J, Hans V, Yacyshyn E, Rouhi A, Oliver M. Systemic lupus erythematosus presenting with atypical hemolytic uremic syndrome: a case report and review of the literature. Rheumatol Int 2024; 44:2213-2225. [PMID: 38502235 DOI: 10.1007/s00296-024-05558-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/09/2024] [Indexed: 03/21/2024]
Abstract
Systemic lupus erythematosus (SLE) can present with a diverse array of hematologic manifestations, among which atypical hemolytic uremic syndrome (aHUS) is a rare entity. SLE-triggered aHUS has significant morbidity and mortality without timely intervention, yet its frequency remains uncertain and optimal strategies for complement-directed therapies are largely expert-driven. We performed a comprehensive literature review and present a case of a 23-year-old female newly diagnosed with SLE/class IV lupus nephritis who developed aHUS that rapidly responded to the C5 antagonist, eculizumab. Review of the current literature identified forty-nine published cases of SLE with concurrent aHUS and revealed a predilection for aHUS in younger SLE patients, concurrent presentation with lupus nephritis, anti-dsDNA positivity, and complement system abnormalities. Over seventy percent of cases used eculizumab as complement-directed therapy with a trend towards faster time to improvement in laboratory parameters, though reported outcomes were highly variable. Early recognition of aHUS in SLE is pivotal in guiding appropriate therapeutic interventions, and prompt initiation of eculizumab may reduce the potential morbidity associated with plasmapheresis and additional immunosuppression. While eculizumab showcases promising results, its optimal timing and duration remain elusive. An understanding of a patients' complement genetics could aid management strategies, and ongoing research into complement-targeted therapies offers promising avenues for both SLE and aHUS treatment.
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Affiliation(s)
- Justin Smith
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada.
| | - Varinder Hans
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Elaine Yacyshyn
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Azin Rouhi
- Department of Medicine, University of Alberta, 8-130 Clinical Sciences Building, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - Monika Oliver
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, Canada
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2
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Hagopian G, Yazdanpanah O, Tran MH, Lee L. Successful application of eculizumab in typical haemolytic uraemic syndrome. BMJ Case Rep 2024; 17:e256449. [PMID: 39179258 DOI: 10.1136/bcr-2023-256449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024] Open
Abstract
A woman in her 40s with no medical history presented on hospital day #0 with 3 days of epigastric pain, nausea, vomiting and bloody diarrhoea. Initial blood work demonstrated acute kidney injury with metabolic acidosis with an elevated anion gap, thrombocytopenia, an elevated lactate dehydrogenase, and an undetectable haptoglobin. She was quickly diagnosed with haemolytic uraemic syndrome from Shiga toxin-producing O157:H7 Escherichia coli Her microangiopathic haemolytic anaemia and renal failure progressively worsened and only improved after the initiation of eculizumab, a monoclonal antibody directed against complement component C5. We report a case of Shiga toxin-producing E. coli-haemolytic uraemia syndrome with a complement-mediated component.
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Affiliation(s)
- Garo Hagopian
- Internal Medicine, University of California Irvine Medical Center, Orange, California, USA
| | - Omid Yazdanpanah
- Hematology/Oncology, University of California Irvine Medical Center, Orange, California, USA
| | - Minh-Ha Tran
- Pathology, University of California Irvine Medical Center, Orange, California, USA
| | - Lisa Lee
- Hematology/Oncology, University of California Irvine Medical Center, Orange, California, USA
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3
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Bendapudi PK, Nazeen S, Ryu J, Söylemez O, Robbins A, Rouaisnel B, O’Neil JK, Pokhriyal R, Yang M, Colling M, Pasko B, Bouzinier M, Tomczak L, Collier L, Barrios D, Ram S, Toth-Petroczy A, Krier J, Fieg E, Dzik WH, Hudspeth JC, Pozdnyakova O, Nardi V, Knight J, Maas R, Sunyaev S, Losman JA. Low-frequency inherited complement receptor variants are associated with purpura fulminans. Blood 2024; 143:1032-1044. [PMID: 38096369 PMCID: PMC10950473 DOI: 10.1182/blood.2023021231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/15/2023] [Indexed: 03/16/2024] Open
Abstract
ABSTRACT Extreme disease phenotypes can provide key insights into the pathophysiology of common conditions, but studying such cases is challenging due to their rarity and the limited statistical power of existing methods. Herein, we used a novel approach to pathway-based mutational burden testing, the rare variant trend test (RVTT), to investigate genetic risk factors for an extreme form of sepsis-induced coagulopathy, infectious purpura fulminans (PF). In addition to prospective patient sample collection, we electronically screened over 10.4 million medical records from 4 large hospital systems and identified historical cases of PF for which archived specimens were available to perform germline whole-exome sequencing. We found a significantly increased burden of low-frequency, putatively function-altering variants in the complement system in patients with PF compared with unselected patients with sepsis (P = .01). A multivariable logistic regression analysis found that the number of complement system variants per patient was independently associated with PF after controlling for age, sex, and disease acuity (P = .01). Functional characterization of PF-associated variants in the immunomodulatory complement receptors CR3 and CR4 revealed that they result in partial or complete loss of anti-inflammatory CR3 function and/or gain of proinflammatory CR4 function. Taken together, these findings suggest that inherited defects in CR3 and CR4 predispose to the maladaptive hyperinflammation that characterizes severe sepsis with coagulopathy.
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Affiliation(s)
- Pavan K. Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sumaiya Nazeen
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Justine Ryu
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Onuralp Söylemez
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Alissa Robbins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Betty Rouaisnel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jillian K. O’Neil
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ruchika Pokhriyal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Moua Yang
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Meaghan Colling
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bryce Pasko
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Michael Bouzinier
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Lindsay Tomczak
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
| | - Lindsay Collier
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
| | - David Barrios
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA
| | - Agnes Toth-Petroczy
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel Krier
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Elizabeth Fieg
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Walter H. Dzik
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - James C. Hudspeth
- Department of Medicine, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
| | - Olga Pozdnyakova
- Harvard Medical School, Boston, MA
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Valentina Nardi
- Harvard Medical School, Boston, MA
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - James Knight
- Yale Center for Genome Analysis, Yale University, New Haven, CT
| | - Richard Maas
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Shamil Sunyaev
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Julie-Aurore Losman
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women’s Hospital, Boston, MA
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Shukla S, Sekar A, Naik S, Rathi M, Sharma A, Nada R, Kohli HS, Ramachandran R. ANCA-Associated Vasculitis with Systemic Thrombotic Microangiopathy: A Review of Literature. Indian J Nephrol 2024; 34:155-161. [PMID: 38681020 PMCID: PMC11044693 DOI: 10.4103/ijn.ijn_376_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/01/2023] [Indexed: 05/01/2024] Open
Abstract
Introduction Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) rarely coexist with systemic thrombotic microangiopathy (TMA).The TMA can be in the form of either hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). This review explores the clinical characteristics, histopathological findings, treatment options, and outcomes in patients presenting as AAV with coexisting HUS/TTP. Methods We conducted a search on the PubMed database and additional searches from January 1998 to September 2022 using the following terms: "ANCA", "Antineutrophil cytoplasmic antibody", "thrombotic thrombocytopenic purpura", "TTP", "thrombotic microangiopathy", "haemolytic uremic syndrome", and "HUS". We excluded articles that described renal-limited TMA. Two authors independently reviewed the full texts and extracted all critical data from the included case reports. Finally, we included 15 cases for this review. Hematological remission and kidney recovery in the form of independence from dialysis was assessed. Results The median age of the patients was 61 years and a majority of them were females (66.7%). Myeloperoxidase (MPO)-ANCA positivity (66.67%) was more common than proteinase 3 (PR3)-ANCA positivity (33.33%). All patients had laboratory parameters consistent with systemic TMA (HUS or TTP), and only six (out of 11) cases showed histological features of renal TMA. Ten had crescentic glomerulonephritis, and two had advanced degrees of chronicity in histology. Eighty-six percent of cases had hematological remission, and sixty percent of cases became dialysis-independent after treatment. Conclusion In conclusion, kidney outcome was worse in patients who manifested both AAV and systemic TMA. A paucity of literature regarding this diagnostic quandary calls for avid reporting of such cases.
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Affiliation(s)
- Shubham Shukla
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sachin Naik
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir S. Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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5
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Dimopoulos K, Tripodi A, Goetze JP. Laboratory investigation and diagnosis of thrombotic thrombocytopenic purpura. Crit Rev Clin Lab Sci 2023; 60:625-639. [PMID: 37452521 DOI: 10.1080/10408363.2023.2232039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/04/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and potentially fatal disease for which rapid diagnosis is crucial for patient outcomes. Deficient activity (< 10%) of the liver enzyme, ADAMTS13, is the pathophysiological hallmark of TTP, and measurement of the enzyme activity can establish the diagnosis of TTP with high accuracy. Thus, along with the clinical history, appropriate laboratory assessment of a suspected case of TTP is essential for diagnosis and treatment. Here, we present a review of the available laboratory tests that can assist clinicians in establishing the diagnosis of TTP, with special focus on ADAMTS13 assays, including the measurement of the antigen and activity, and detection of autoantibodies to ADAMTS13.
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Affiliation(s)
- Konstantinos Dimopoulos
- Department of Clinical Biochemistry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Armando Tripodi
- IRCCS Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health, Copenhagen University, Copenhagen, Denmark
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Tseng MH, Lin SH, Tsai JD, Wu MS, Tsai IJ, Chen YC, Chang MC, Chou WC, Chiou YH, Huang CC. Atypical hemolytic uremic syndrome: Consensus of diagnosis and treatment in Taiwan. J Formos Med Assoc 2023; 122:366-375. [PMID: 36323601 DOI: 10.1016/j.jfma.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/03/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury, is a rare but life-threatening systemic disorder caused by the dysregulation of the complement pathway. Current advances in molecular analysis and pathogenesis have facilitated the establishment of diagnosis and development of effective complement blockade. Based on this recent consensus, we provide suggestions regarding the diagnosis and management of aHUS in Taiwan. The diagnosis of aHUS is made by the presence of TMA with normal ADAMTS13 activity without known secondary causes. Although only 60% of patients with aHUS have mutations in genes involving the compliment and coagulation systems, molecular analysis is suggestive for helping establish diagnosis, clarifying the underlying pathophysiology, guiding the treatment decision-making, predicting the prognosis, and deciding renal transplantation. Complement blockade, anti-C5 monoclonal antibody, is the first-line therapy for patients with aHUS. Plasma therapy should be considered for removing autoantibody in patients with atypical HUS caused by anti-CFH or complement inhibitor is unavailable.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taipei, Taiwan
| | - Yeu-Chin Chen
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Chih Chang
- Division of Hematology/Oncology, Department of Internal Medicine, MacKay Children's Hospital, Taipei, Taiwan
| | - Wen-Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
| | - Chiu-Ching Huang
- Division of Nephrology and the Kidney Institute, Department of Internal Medicine, China Medical University and Hospital, Taichung, Taiwan.
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7
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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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8
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Azad F, Miranda CJ, Amin A, Hadwani R, Gravina M. Eculizumab in the Treatment of Gemcitabine-Induced Atypical Hemolytic Uremic Syndrome. Cureus 2023; 15:e35874. [PMID: 37033542 PMCID: PMC10078131 DOI: 10.7759/cureus.35874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/09/2023] Open
Abstract
Gemcitabine-induced hemolytic uremic syndrome is an often-missed condition. We present a case outlining the successful management of a patient with metastatic cholangiocarcinoma treated with gemcitabine who subsequently developed hemolytic uremic syndrome. Early recognition and stopping gemcitabine are essential in this patient population. Complement inhibitors have been used, and our patient improved on eculizumab therapy.
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9
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Cammett TJ, Garlo K, Millman EE, Rice K, Toste CM, Faas SJ. Exploratory Prognostic Biomarkers of Complement-Mediated Thrombotic Microangiopathy (CM-TMA) in Adults with Atypical Hemolytic Uremic Syndrome (aHUS): Analysis of a Phase III Study of Ravulizumab. Mol Diagn Ther 2023; 27:61-74. [PMID: 36329366 DOI: 10.1007/s40291-022-00620-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinically validated biomarkers for monitoring of patients with complement-mediated thrombotic microangiopathy (CM-TMA) including atypical hemolytic uremic syndrome (aHUS) are unavailable. Improved characterization of biomarkers in patients with aHUS may inform treatment and monitoring for patients with CM-TMA. METHODS This analysis used data collected from 55/56 (98.2 %) adult patients with aHUS enrolled in the global Phase III study of ravulizumab (NCT02949128). Baseline (pre-treatment) patient serum, plasma and urine biomarker levels were compared with the maximum observed levels in normal donors and evaluated for associations with pre-treatment plasma exchange/infusion and dialysis status. Biomarkers were also assessed for associations with key clinical measures at baseline and with changes at 26 and 52 weeks from treatment initiation via linear regression analyses. RESULTS Complement-specific urine levels (factor Ba and sC5b-9) were elevated in >85 % of patients and are significantly associated with pre-treatment kidney dysfunction. Baseline levels of other evaluated biomarkers were elevated in >70 % of patients with aHUS, except for plasma sC5b-9 and serum sVCAM-1. Lower levels of urine complement markers at baseline are significantly associated with improvements in total urine protein and estimated glomerular filtration rate at 26 and 52 weeks of treatment. Clinical assessment of complement activation by a receiver operating characteristic analysis of Ba and sC5b-9 was more sensitive and specific in urine matrix than plasma. CONCLUSION This analysis identified a set of biomarkers that may show utility in the prognosis of CM-TMA, including their potential for measuring and predicting response to anti-C5 therapy. Further studies are required to enhance patient risk stratification and improve management of these vulnerable patients. CLINICAL TRIALS REGISTRATION NCT02949128, ClinicalTrials.gov.
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Affiliation(s)
| | | | | | - Kara Rice
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | - Susan J Faas
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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10
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Spring J, Munshi L. Hematology Emergencies in Critically Ill Adults. Chest 2022; 161:1285-1296. [DOI: 10.1016/j.chest.2021.12.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/14/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
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11
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Abou‐Ismail MY, Kapoor S, Citla Sridhar D, Nayak L, Ahuja S. Thrombotic microangiopathies: An illustrated review. Res Pract Thromb Haemost 2022; 6:e12708. [PMID: 35615754 PMCID: PMC9027164 DOI: 10.1002/rth2.12708] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 11/11/2022] Open
Abstract
The thrombotic microangiopathies (TMAs) are a heterogenous group of disorders with distinct pathophysiologies that cause occlusive microvascular or macrovascular thrombosis, and are characterized by microangiopathic hemolytic anemia, thrombocytopenia, and/or end-organ ischemia. TMAs are associated with significant morbidity and mortality, and data on the management of certain TMAs are often lacking. The nomenclature, classification, and management of various TMAs is constantly evolving as we learn more about these rare syndromes. Thorough clinical and laboratory evaluation is essential to distinguish various TMAs and arrive at an accurate diagnosis, which is key for appropriate management. In this illustrated review, we focus on thrombotic thrombocytopenic purpura (TTP), Shiga toxin-associated hemolytic uremic syndrome, complement-mediated hemolytic uremic syndrome, hematopoietic cell transplant-associated TMA, and drug-induced TMA, and describe their incidence, pathophysiology, diagnosis, and management. We also highlight emerging complement-directed therapies under investigation for the management of complement-mediated TMAs.
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Affiliation(s)
- Mouhamed Yazan Abou‐Ismail
- Division of Hematology and Hematologic Malignancies Department of Internal Medicine University of Utah Health Sciences Center Salt Lake City Utah USA
| | - Sargam Kapoor
- Department of Hematology & Oncology Alaska Native Medical Center Anchorage Alaska USA
| | - Divyaswathi Citla Sridhar
- Department of Pediatric Hematology & Oncology University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Lalitha Nayak
- Department of Hematology & Oncology University Hospitals Cleveland Medical Center Cleveland Ohio USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology University Hospitals Rainbow Babies and Children’s Hospital Cleveland Ohio USA
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12
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Formeck CL, Manrique-Caballero CL, Gómez H, Kellum JA. Uncommon Causes of Acute Kidney Injury. Crit Care Clin 2022; 38:317-347. [DOI: 10.1016/j.ccc.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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13
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Kumar S, Bhagia G, Kaae J. A Rare Case of Atypical Hemolytic Uremia Syndrome Triggered by Influenza Vaccination. Cureus 2022; 14:e23577. [PMID: 35494971 PMCID: PMC9045680 DOI: 10.7759/cureus.23577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/08/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) occurs in patients with defective alternative complement pathways, making them susceptible to thrombotic microangiopathy (thrombocytopenia, intravascular hemolysis, and renal failure), and is usually triggered by infectious agents. Influenza and Streptococcus pneumonia are known triggers for aHUS. However, influenza vaccination triggering aHUS is rarely reported. We present a 30-year-old male who presented with chills, abdominal discomfort, and night sweats after receiving the influenza vaccine. The patient had thrombocytopenia, elevated creatinine, blood urea nitrogen, liver enzymes, and bilirubin with schistocytes with peripheral smear. ADAMTS13 activity was normal so the patient was diagnosed with aHUS. The patient improved with eculizumab and was ultimately found to have a mutation in CD46, which made him susceptible to aHUS. This case shows patients with dysregulated alternative complement pathways may be predisposed to develop aHUS after receiving influenza vaccination.
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Cortes C, Desler C, Mazzoli A, Chen JY, Ferreira VP. The role of properdin and Factor H in disease. Adv Immunol 2022; 153:1-90. [PMID: 35469595 DOI: 10.1016/bs.ai.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The complement system consists of three pathways (alternative, classical, and lectin) that play a fundamental role in immunity and homeostasis. The multifunctional role of the complement system includes direct lysis of pathogens, tagging pathogens for phagocytosis, promotion of inflammatory responses to control infection, regulation of adaptive cellular immune responses, and removal of apoptotic/dead cells and immune complexes from circulation. A tight regulation of the complement system is essential to avoid unwanted complement-mediated damage to the host. This regulation is ensured by a set of proteins called complement regulatory proteins. Deficiencies or malfunction of these regulatory proteins may lead to pro-thrombotic hematological diseases, renal and ocular diseases, and autoimmune diseases, among others. This review focuses on the importance of two complement regulatory proteins of the alternative pathway, Factor H and properdin, and their role in human diseases with an emphasis on: (a) characterizing the main mechanism of action of Factor H and properdin in regulating the complement system and protecting the host from complement-mediated attack, (b) describing the dysregulation of the alternative pathway as a result of deficiencies, or mutations, in Factor H and properdin, (c) outlining the clinical findings, management and treatment of diseases associated with mutations and deficiencies in Factor H, and (d) defining the unwanted and inadequate functioning of properdin in disease, through a discussion of various experimental research findings utilizing in vitro, mouse and human models.
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Affiliation(s)
- Claudio Cortes
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, United States.
| | - Caroline Desler
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Amanda Mazzoli
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Jin Y Chen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States.
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Atypical hemolytic uremic syndrome: when pregnancy leads to lifelong dialysis: a case report and literature review. Cardiovasc Endocrinol Metab 2021; 10:225-230. [PMID: 34765894 PMCID: PMC8575437 DOI: 10.1097/xce.0000000000000247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/09/2021] [Indexed: 01/07/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS), a challenging disorder, commonly caused by inherited defects or regulatory processes of the complement alternative pathway. There are multiple causes, including pregnancy. Pregnancy provokes life-threatening episodes, preeclampsia, hemolysis elevated liver enzymes low platelets, microangiopathic hemolytic anemia (MAHA) and end-stage renal disease. Additionally, complement dysregulation and, with aHUS, affects fetal and maternal outcomes. Pregnancy-associated aHUS results in a poor prognosis with irreversible renal damage. Likewise, it is imperative to know that MAHA can provoke endothelial disruption, destruction of red cells and thrombocytopenia. We present a case of a young 18-year-old woman with MAHA and aHUS, requiring emergent cesarean section at 34 weeks of gestation and hemodialysis, secondary to complications from a recent pregnancy. Elevated blood pressure readings, rising creatinine levels, as well as her mother being on dialysis after pregnancy raised suspicion for thrombotic microangiopathy and aHUS. She was subsequently managed with plasma exchange, steroids, eculizumab and hemodialysis. Thus, plasma exchange should be initiated, with pending additional workup. Upon a definitive diagnosis of aHUS, eculizumab would be warranted to mitigate immune dysregulation. Understanding thrombotic microangiopathies diagnosis, and recognizing concomitant consequences, is vital. Having better insights into endothelial injuries can prevent unfortunate outcomes.
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Abstract
PURPOSE OF REVIEW To discuss the crosstalk between the complement system and hemostatic factors (coagulation cascade, platelet, endothelium, and Von Willebrand Factor), and the consequences of this interaction under physiologic and pathologic conditions. RECENT FINDINGS The complement and coagulation systems are comprised of serine proteases and are genetically related. In addition to the common ancestral genes, the complement system and hemostasis interact directly, through protein-protein interactions, and indirectly, on the surface of platelets and endothelial cells. The close interaction between the complement system and hemostatic factors is manifested both in physiologic and pathologic conditions, such as in the inflammatory response to thrombosis, thrombosis at the inflamed area, and thrombotic complications of complement disorders. SUMMARY The interaction between the complement system and hemostasis is vital for homeostasis and the protective response of the host to tissue injury, but also results in the pathogenesis of several thrombotic and inflammatory disorders.
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Gunay E, Ozan M, Kaya S, Ocal E, Kutlu Z, Senol A, Danis R, Baysal E, Kalin BS, Dincyurek HD, Demir C. Pregnancy-related atypical hemolytic uremic syndrome with renal, cardiac and obstetric complications and a satisfactory recovery: a case report. Ren Fail 2021; 43:460-462. [PMID: 33657972 PMCID: PMC7935114 DOI: 10.1080/0886022x.2021.1893187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Emrah Gunay
- Department of Nephrology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Mahsum Ozan
- Department of Internal Medicine, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Seyhmus Kaya
- Department of Pathology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Ece Ocal
- Department of Perinatology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Zeynep Kutlu
- Department of Internal Medicine, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Ayhan Senol
- Department of Interventional Radiology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Ramazan Danis
- Department of Nephrology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Erkan Baysal
- Department of Cardiology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Burhan Sami Kalin
- Department of Intensive Care, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Huseyin Derya Dincyurek
- Department of Haematology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Cengiz Demir
- Department of Haematology, Health Sciences University of Turkey, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
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Darwin A, Malpica L, Dhanoa J, Hashmi H. Carfilzomib-induced atypical haemolytic uraemic syndrome: a diagnostic challenge and therapeutic success. BMJ Case Rep 2021; 14:14/2/e239091. [PMID: 33637496 PMCID: PMC7919563 DOI: 10.1136/bcr-2020-239091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Haemolytic uraemic syndrome (HUS) is a thrombotic microangiopathy (TMA) that presents with renal insufficiency, thrombocytopaenia and microangiopathic haemolytic anaemia. Typical HUS is associated with Shiga toxin while atypical HUS (aHUS) is due to overactivation of the alternative complement pathway. aHUS has numerous causes, including drugs, with rare reports of carfilzomib, a proteasome inhibitor used in multiple myeloma, as causative agent. Cases vary in presentation, presenting a diagnostic challenge. Historically, TMAs were treated with plasma exchange. aHUS, however, is considered refractory to plasma exchange and best treated with eculizumab, a monoclonal antibody targeting C5, a terminal complement protein. We report a patient with history of multiple myeloma who presented with headaches, elevated blood pressure, petechiae, ecchymosis and haemolytic anaemia. His condition was determined to be carfilzomib-induced aHUS and he was successfully treated with eculizumab. Early detection and treatment of drug-induced aHUS is vital in reducing morbidity and mortality related to the condition.
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Affiliation(s)
- Alicia Darwin
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Leonger Malpica
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jugraj Dhanoa
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Hamza Hashmi
- Department of Blood & Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA .,Department of Hematology Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
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Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
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Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Tso ACY, Sum CLL, Ong KH. Reference range for ADAMTS13 antigen, activity and anti-ADAMTS13 antibody in the healthy adult Singapore population. Singapore Med J 2020; 63:214-218. [PMID: 32588586 DOI: 10.11622/smedj.2020093] [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: 11/18/2022]
Abstract
INTRODUCTION ADAMTS13 (A disintegrin-like and metalloproteinase with a thrombospondin type 1 motif, member 13) plays a fundamental role in the regulation of haemostasis and thrombosis. Its deficiency leads to an accumulation of ultra-large von Willebrand multimers, inducing spontaneous platelet aggregation, thrombosis in the microvasculature and thrombotic thrombocytopenic purpura (TTP), a condition with 90% mortality when left untreated. Promptly quantifying ADAMTS13 antigen, activity and autoantibody has a crucial role in the diagnosis and management of TTP and can help differentiate from other thrombotic microangiopathies (TMAs). Reference ranges for ADAMTS13 are generally derived from Caucasian patients. Given that polymorphism in the ADAMTS13 gene can be associated with variable ADAMTS13 levels, we aimed to establish the first reference range in Singapore and provide a crucial laboratory test for institutions here and elsewhere. METHODS 150 healthy voluntary donors (75 men, 75 women), aged 21-60 years, with an ethnic mix mirroring Singapore's population profile, were recruited. ADAMTS13 antigen, activity and autoantibody levels were measured using the fluorescent resonance energy transfer-vWF73 and enzyme-linked immunosorbent assay methodologies. RESULTS Levels (activity, 0.65-1.79 IU/mL; antigen, 0.36-1.17 IU/mL; autoantibody, 1.4-12.5 U/mL) were not statistically different between the genders and various age groups. CONCLUSION TTP and TMAs are encountered in a wide range of specialties. The availability of new assays in Singapore will aid clinicians in the timely management of these conditions. Standardising reference ranges established for Singapore, against World Health Organization standards, allows the harmonisation of measurements between laboratories and for future research collaborations.
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Affiliation(s)
| | | | - Kiat Hoe Ong
- Department of Haematology, Tan Tock Seng Hospital, Singapore
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21
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Sun RX, Xu J, Zhu HD, Yu XZ, Yang J. Clinical presentation and management of acquired thrombotic thrombocytopenic purpura: A case series of 55 patients. Ther Apher Dial 2020; 25:118-123. [PMID: 32306556 DOI: 10.1111/1744-9987.13502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 01/18/2023]
Abstract
The aim of this study was to explore the clinical characteristics and treatment of acquired thrombotic thrombocytopenic purpura (TTP). The clinical manifestations, laboratory findings, differential diagnoses, therapeutic methods, and prognosis of 55 patients with acquired TTP were retrospectively analyzed. Among the 55 TTP patients, 17 were males and 38 were females, with a mean age of 40 ± 15 years. Twenty-one patients had the Triad syndrome, which included neurological syndromes, microangiopathic hemolytic anemia, and thrombocytopenia. Twenty-three patients had the Quinary syndrome, which included fever, microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, and neurological symptoms. Twenty-eight patients received the measurement for a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity and 23 patients had <10% of the normal range. ADAMTS13 inhibitor was tested in 20 patients and was positive in 18 patients. Both ADAMTS13 activity and ADAMTS13 inhibitor were examined in 20 patients and 90% of the patients showed double positive results. The treatment methods included plasma exchange, glucocorticoids, rituximab, immunosuppressants, and intravenous immunoglobulin. Thirty-three patients survived, and 22 patients died. Plasma exchange improved the remission rate from 16.7% to 65.3% (P = .022). The combined immunosuppressive therapy based on plasma exchange and glucocorticoids raised the remission rate from 43.8% to 75.8%. Most of acquired TTP patients had the Triad syndrome or the Quinary syndrome. A high proportion of TTP patients had ADAMTS13 activity reduction and ADAMTS13 inhibitor positivity. Plasma exchange and immunosuppressive therapy may improve the prognosis of this disease.
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Affiliation(s)
- Rui-Xue Sun
- Department of Emergency, Peking Union Medical College Hospital, Beijing, China
| | - Jun Xu
- Department of Emergency, Peking Union Medical College Hospital, Beijing, China
| | - Hua-Dong Zhu
- Department of Emergency, Peking Union Medical College Hospital, Beijing, China
| | - Xue-Zhong Yu
- Department of Emergency, Peking Union Medical College Hospital, Beijing, China
| | - Jing Yang
- Department of Emergency, Peking Union Medical College Hospital, Beijing, China
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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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Manrique-Caballero CL, Peerapornratana S, Formeck C, Del Rio-Pertuz G, Gomez Danies H, Kellum JA. Typical and Atypical Hemolytic Uremic Syndrome in the Critically Ill. Crit Care Clin 2020; 36:333-356. [PMID: 32172817 DOI: 10.1016/j.ccc.2019.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hemolytic uremic syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome have a similar clinical presentation. Diagnostic needs to be prompt to decrease mortality, because identifying the different disorders can help to tailor specific, effective therapies. However, diagnosis is challenging and morbidity and mortality remain high, especially in the critically ill population. Development of clinical prediction scores and rapid diagnostic tests for hemolytic uremic syndrome based on mechanistic knowledge are needed to facilitate early diagnosis and assign timely specific treatments to patients with hemolytic uremic syndrome variants.
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Affiliation(s)
- Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand; Department of Laboratory Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand
| | - Cassandra Formeck
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 3, Pittsburgh, PA 15224, USA
| | - Gaspar Del Rio-Pertuz
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Hernando Gomez Danies
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA.
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Joseph A, Cointe A, Mariani Kurkdjian P, Rafat C, Hertig A. Shiga Toxin-Associated Hemolytic Uremic Syndrome: A Narrative Review. Toxins (Basel) 2020; 12:E67. [PMID: 31973203 PMCID: PMC7076748 DOI: 10.3390/toxins12020067] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 01/28/2023] Open
Abstract
The severity of human infection by one of the many Shiga toxin-producing Escherichia coli (STEC) is determined by a number of factors: the bacterial genome, the capacity of human societies to prevent foodborne epidemics, the medical condition of infected patients (in particular their hydration status, often compromised by severe diarrhea), and by our capacity to devise new therapeutic approaches, most specifically to combat the bacterial virulence factors, as opposed to our current strategies that essentially aim to palliate organ deficiencies. The last major outbreak in 2011 in Germany, which killed more than 50 people in Europe, was evidence that an effective treatment was still lacking. Herein, we review the current knowledge of STEC virulence, how societies organize the prevention of human disease, and how physicians treat (and, hopefully, will treat) its potentially fatal complications. In particular, we focus on STEC-induced hemolytic and uremic syndrome (HUS), where the intrusion of toxins inside endothelial cells results in massive cell death, activation of the coagulation within capillaries, and eventually organ failure.
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Affiliation(s)
- Adrien Joseph
- Department of Nephrology, AP-HP, Hôpital Tenon, F-75020 Paris, France; (A.J.); (C.R.)
| | - Aurélie Cointe
- Department of Microbiology, AP-HP, Hôpital Robert Debré, F-75019 Paris, France; (A.C.); (P.M.K.)
| | | | - Cédric Rafat
- Department of Nephrology, AP-HP, Hôpital Tenon, F-75020 Paris, France; (A.J.); (C.R.)
| | - Alexandre Hertig
- Department of Renal Transplantation, Sorbonne Université, AP-HP, Hôpital Pitié Salpêtrière, F-75013 Paris, France
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Lee H, Kang E, Kang HG, Kim YH, Kim JS, Kim HJ, Moon KC, Ban TH, Oh SW, Jo SK, Cho H, Choi BS, Hong J, Cheong HI, Oh D. Consensus regarding diagnosis and management of atypical hemolytic uremic syndrome. Korean J Intern Med 2020; 35:25-40. [PMID: 31935318 PMCID: PMC6960041 DOI: 10.3904/kjim.2019.388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/04/2019] [Indexed: 12/13/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is defined by specific clinical characteristics, including microangiopathic hemolytic anemia, thrombocytopenia, and pathologic evidence of endothelial cell damage, as well as the resulting ischemic end-organ injuries. A variety of clinical scenarios have features of TMA, including infection, pregnancy, malignancy, autoimmune disease, and medications. These overlapping manifestations hamper differential diagnosis of the underlying pathogenesis, despite recent advances in understanding the mechanisms of several types of TMA syndrome. Atypical hemolytic uremic syndrome (aHUS) is caused by a genetic or acquired defect in regulation of the alternative complement pathway. It is important to consider the possibility of aHUS in all patients who exhibit TMA with triggering conditions because of the incomplete genetic penetrance of aHUS. Therapeutic strategies for aHUS are based on functional restoration of the complement system. Eculizumab, a monoclonal antibody against the terminal complement component 5 inhibitor, yields good outcomes that include prevention of organ damage and premature death. However, there remain unresolved challenges in terms of treatment duration, cost, and infectious complications. A consensus regarding diagnosis and management of TMA syndrome would enhance understanding of the disease and enable treatment decision-making.
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Affiliation(s)
- Hajeong Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunjeong Kang
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Sang Kyung Jo
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Junshik Hong
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hae Il Cheong
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Doyeun Oh
- Department of Internal Medicine, CHA University School of Medicine, Seongnam, Korea
- Correspondence to Doyeun Oh, M.D. Department of Internal Medicine, CHA University School of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea Tel: +82-31-780-5217, Fax: +82-31-780-5221, E-mail:
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Joseph A, Rafat C, Zafrani L, Mariani-Kurkdjian P, Veyradier A, Hertig A, Rondeau E, Mariotte E, Azoulay E. Early Differentiation of Shiga Toxin-Associated Hemolytic Uremic Syndrome in Critically Ill Adults With Thrombotic Microangiopathy Syndromes. Crit Care Med 2019; 46:e904-e911. [PMID: 29979220 DOI: 10.1097/ccm.0000000000003292] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Thrombotic microangiopathy syndromes are a heterogeneous group of severe diseases that often require ICU admission. Prompt initiation of targeted therapies is required for atypical hemolytic uremic syndrome and thrombotic thrombocytopenic purpura, whereas there is no specific consensus therapy for Shiga toxin-associated hemolytic uremic syndrome. We sought to compare the characteristics of Shiga toxin-associated hemolytic uremic syndrome, atypical hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura patients at admission in the ICU to allow early differentiation of Shiga toxin-associated hemolytic uremic syndrome from other thrombotic microangiopathy syndromes and help to tailor initial treatment. DESIGN Retrospective cohort study. SETTING Two ICUs part of the French reference center for thrombotic microangiopathy syndromes. PATIENTS Adult patients presenting with features of thrombotic microangiopathy syndromes. Other causes than Shiga toxin-associated hemolytic uremic syndrome, atypical hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From September 2003 to January 2017, 236 thrombotic microangiopathy syndrome patients were admitted, including 12 Shiga toxin-associated hemolytic uremic syndrome, 21 atypical hemolytic uremic syndrome, and 91 thrombotic thrombocytopenic purpura. Shiga toxin-associated hemolytic uremic syndrome patients were older than other thrombotic microangiopathy syndromes patients (64 yr [interquartile range, 50-72 yr] vs 42 yr [31-54 yr]; p = 0.007) and presented with more frequent digestive symptoms (92% vs 42%; p < 0.001), especially nonbloody diarrhea and vomiting. Biologically, Shiga toxin-associated hemolytic uremic syndrome patients displayed higher fibrinogen (490 mg/dL [460-540 mg/dL] vs 320 mg/dL [240-410 mg/dL]; p = 0.003) and creatinine levels (2.59 mg/dL [2.12-3.42 mg/dL] vs 1.26 mg/dL [0.61-1.90 mg/dL]; p < 0.001), and less marked anemia (hemoglobin level, 9.7 g/dL [8.7-11.9 g/dL] vs 7.7 g/dL [6.3-9.1 g/dL]; p < 0.001). Forty-two percent (n = 5) required renal replacement therapy, and 83% (n = 10) were treated with plasma exchange before the distinction from other thrombotic microangiopathy syndromes could be made. CONCLUSIONS Adult Shiga toxin-associated hemolytic uremic syndrome patients are older, present more frequently with digestive symptoms and display higher hemoglobin and fibrinogen levels than other thrombotic microangiopathy syndromes. However, overlap across the three thrombotic microangiopathy syndromes remains substantial, putting forward the need to implement early plasma therapy until thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome can be ruled out.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Cédric Rafat
- Department of Renal Intensive Care and Transplantation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Paris, France.,French Reference Center for Thrombotic MicroAngiopathies, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,French Reference Center for Thrombotic MicroAngiopathies, Paris, France.,Paris Diderot Sorbonne University, Paris, France
| | - Patricia Mariani-Kurkdjian
- National Associated Reference Laboratory for Escherichia coli, Microbiology Department, Hôpital Robert-Debré, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic MicroAngiopathies, Paris, France.,Paris Diderot Sorbonne University, Paris, France.,Hematology Department and Research Unit EA3518, Institute of Hematology, Hôpital Lariboisière-Fernand Widal, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexandre Hertig
- Department of Renal Intensive Care and Transplantation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Paris, France.,French Reference Center for Thrombotic MicroAngiopathies, Paris, France.,Sorbonne Universités, UPMC Université Paris 6, Paris, France
| | - Eric Rondeau
- Department of Renal Intensive Care and Transplantation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Paris, France.,French Reference Center for Thrombotic MicroAngiopathies, Paris, France.,Sorbonne Universités, UPMC Université Paris 6, Paris, France
| | - Eric Mariotte
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,French Reference Center for Thrombotic MicroAngiopathies, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,French Reference Center for Thrombotic MicroAngiopathies, Paris, France.,Paris Diderot Sorbonne University, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS) INSERM, Paris, France
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Formeck C, Swiatecka-Urban A. Extra-renal manifestations of atypical hemolytic uremic syndrome. Pediatr Nephrol 2019; 34:1337-1348. [PMID: 30109445 PMCID: PMC8627279 DOI: 10.1007/s00467-018-4039-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 01/31/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare and complex disease resulting from abnormal alternative complement activation with a wide range of clinical presentations. Extra-renal manifestations of aHUS can involve many organ systems, including the peripheral and central nervous, gastrointestinal, cardiovascular, integumentary, pulmonary, as well as the eye. While some of these extra-renal manifestations occur in the acute phase of aHUS, some can also occur as long-term sequelae of unopposed complement activation. Extra-renal symptoms are observed in approximately 20% of patients with aHUS, with the incidence of specific organ system complications ranging from a few case reports to 50% of described patients. Careful monitoring for extra-renal involvement is critical in patients with aHUS, as prompt evaluation and management may decrease the risk of high morbidity and mortality associated with aHUS.
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Affiliation(s)
- Cassandra Formeck
- Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Agnieszka Swiatecka-Urban
- Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Outcomes of Kidney Transplant Patients with Atypical Hemolytic Uremic Syndrome Treated with Eculizumab: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:jcm8070919. [PMID: 31252541 PMCID: PMC6679118 DOI: 10.3390/jcm8070919] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/16/2019] [Accepted: 06/26/2019] [Indexed: 12/19/2022] Open
Abstract
Background: Kidney transplantation in patients with atypical hemolytic uremic syndrome (aHUS) is frequently complicated by recurrence, resulting in thrombotic microangiopathy in the renal allograft and graft loss. We aimed to assess the use of eculizumab in the prevention and treatment of aHUS recurrence after kidney transplantation. Methods: Databases (MEDLINE, EMBASE and Cochrane Database) were searched through February 2019. Studies that reported outcomes of adult kidney transplant recipients with aHUS treated with eculizumab were included. Estimated incidence rates from the individual studies were extracted and combined using random-effects, generic inverse variance method of DerSimonian and Laird. Protocol for this systematic review has been registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018089438). Results: Eighteen studies (13 cohort studies and five case series) consisting of 380 adult kidney transplant patients with aHUS who received eculizumab for prevention and treatment of post-transplant aHUS recurrence were included in the analysis. Among patients who received prophylactic eculizumab, the pooled estimated incidence rates of recurrent thrombotic microangiopathy (TMA) after transplantation and allograft loss due to TMA were 6.3% (95%CI: 2.8–13.4%, I2 = 0%) and 5.5% (95%CI: 2.9–10.0%, I2 = 0%), respectively. Among those who received eculizumab for treatment of post-transplant aHUS recurrence, the pooled estimated rates of allograft loss due to TMA was 22.5% (95%CI: 13.6–34.8%, I2 = 6%). When the meta-analysis was restricted to only cohort studies with data on genetic mutations associated with aHUS, the pooled estimated incidence of allograft loss due to TMA was 22.6% (95%CI: 13.2–36.0%, I2 = 10%). We found no significant publication bias assessed by the funnel plots and Egger’s regression asymmetry test (p > 0.05 for all analyses). Conclusions: This study summarizes the outcomes observed with use of eculizumab for prevention and treatment of aHUS recurrence in kidney transplantation. Our results suggest a possible role for anti-C5 antibody therapy in the prevention and management of recurrent aHUS.
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Fernández-Zarzoso M, Gómez-Seguí I, de la Rubia J. Therapeutic plasma exchange: Review of current indications. Transfus Apher Sci 2019; 58:247-253. [DOI: 10.1016/j.transci.2019.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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30
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Atypical and secondary hemolytic uremic syndromes have a distinct presentation and no common genetic risk factors. Kidney Int 2019; 95:1443-1452. [DOI: 10.1016/j.kint.2019.01.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/01/2019] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
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31
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Atypical Hemolytic Uremic Syndrome With the p.Ile1157Thr C3 Mutation Successfully Treated With Plasma Exchange and Eculizumab: A Case Report. Crit Care Explor 2019; 1:e0008. [PMID: 32166254 PMCID: PMC7063875 DOI: 10.1097/cce.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. To describe a case of atypical hemolytic uremic syndrome induced by influenza A infection with the p.Ile1157Thr C3 mutation.
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32
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Neave L, Gale DP, Cheesman S, Shah R, Scully M. Atypical haemolytic uraemic syndrome in the eculizumab era: presentation, response to treatment and evaluation of an eculizumab withdrawal strategy. Br J Haematol 2019; 186:113-124. [PMID: 30916388 DOI: 10.1111/bjh.15899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/05/2019] [Indexed: 12/11/2022]
Abstract
The complement inhibitor, eculizumab, has revolutionised the management of atypical haemolytic uraemic syndrome (aHUS), although the optimum treatment duration is debated. Twenty-two cases of acute aHUS managed with eculizumab were retrospectively reviewed, including outcomes after eculizumab withdrawal. Although 41% had an associated complement genetic abnormality, mutation status did not affect severity of clinical presentation. Sixty-four percent required renal replacement acutely, with a high incidence of nephrotic range proteinuria (47%). Eculizumab followed a median of 6 days of plasma exchange. After a median duration of therapy of 11 weeks (range 1-227), haematological recovery was seen in 100%, while 81% achieved at least partial renal recovery (median increase in estimated glomerular filtration rate (eGFR) 49 ml/min/1·73 m2 ). At median duration of follow-up of 85 weeks (range 4-255), 54·5% had eGFR ≥ 60 ml/min/1·73 m2 , 27% had CKD, 14% were on dialysis, and 4·5% had died. Eculizumab was withdrawn in 59% (13/22) cases following complete haematological and renal recovery. Three of these 13 patients (23%) subsequently relapsed, with defined triggers in 2/3, but all made a full recovery with rapid resumption of eculizumab. There was a significant association between higher presenting creatinine and poorer renal outcomes. A strategy of eculizumab withdrawal in selected cases is both safe and cost effective.
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Affiliation(s)
- Lucy Neave
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Daniel P Gale
- UCL Centre for Nephrology, University College London, London, UK
| | - Simon Cheesman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Raakhee Shah
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie Scully
- Department of Haematology, UCLH, Cardiometabolic programme- NIHR UCLH/UCL BRC, London, UK
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34
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Thrombotic microangiopathy in a patient with eosinophilic granulomatosis with polyangiitis: case-based review. Rheumatol Int 2018; 39:359-365. [PMID: 30554307 DOI: 10.1007/s00296-018-4228-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
The correct diagnosis, classification and therapeutic management of thrombotic microangiopathies (TMA) continue to be a challenge for the clinician. We report a rare case of eosinophilic granulomatosis with polyangiitis (EGPA) as a trigger for complement-mediated TMA in a 57-year-old man who was successfully treated with corticoids, cyclophosphamide and therapeutic plasma exchange. Additionally, we review few other cases reported in the literature and the pathophysiological pathway of association between TMA and EGPA. We found that the mutual relationships between the inflammation triggered by vasculitis, the exacerbated complement activation, together with hypereosinophilia and endothelial damage seem to be the key in explaining the connection between both entities. We suggest that an understanding of the multi-causal nature of TMAs is crucial for the correct diagnosis and treatment of these patients.
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35
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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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36
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Romero S, Sempere A, Gómez-Seguí I, Román E, Moret A, Jannone R, Moreno I, Mendizábal S, Espí J, Peris A, Carbonell R, Cervera J, Pemán J, Bonanad S, de la Rubia J, Jarque I. Guía práctica de tratamiento urgente de la microangiopatía trombótica. Med Clin (Barc) 2018. [DOI: 10.1016/j.medcli.2018.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Intern Med J 2018; 48:624-636. [DOI: 10.1111/imj.13804] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C. Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J. Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y. Kausman
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology; Monash Health; Melbourne Victoria Australia
- School of Clinical Sciences, Monash Health; Monash University; Melbourne Victoria Australia
| | - Peter D. Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology; Monash Health; Melbourne Victoria Australia
| | - Nicole M. Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D. Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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38
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Fox LC, Cohney SJ, Kausman JY, Shortt J, Hughes PD, Wood EM, Isbel NM, de Malmanche T, Durkan A, Hissaria P, Blombery P, Barbour TD. Consensus opinion on diagnosis and management of thrombotic microangiopathy in Australia and New Zealand. Nephrology (Carlton) 2018; 23:507-517. [DOI: 10.1111/nep.13234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lucy C Fox
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Solomon J Cohney
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
| | - Joshua Y Kausman
- Department of Nephrology and Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Victoria Australia
- Department of Paediatrics; University of Melbourne; Melbourne Victoria Australia
| | - Jake Shortt
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
- School of Clinical Sciences; Monash Health, Monash University; Melbourne Victoria Australia
| | - Peter D Hughes
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Monash Haematology, Monash Health, Monash University; Melbourne Victoria Australia
| | - Nicole M Isbel
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Theo de Malmanche
- New South Wales Health Pathology, Immunology; Newcastle New South Wales Australia
| | - Anne Durkan
- Department of Nephrology; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Pravin Hissaria
- Department of Immunology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Piers Blombery
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Thomas D Barbour
- Department of Medicine; University of Melbourne; Melbourne Victoria Australia
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
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Abstract
Atypical hemolytic uremic syndrome is a rare life-threatening disease of unregulated complement activation. Untreated, the prognosis is generally poor; more than one-half of patients die or develop end-stage renal disease within 1 year. Atypical hemolytic uremic syndrome is characterized by thrombotic microangiopathy with evidence of hemolysis, thrombocytopenia, and renal impairment. This systemic disease affects the kidneys, brain, heart, lungs, gastrointestinal tract, pancreas, and skin. Acquired and genetic abnormalities of complement regulation may be identified in approximately 70% of patients. Plasma therapy is generally ineffective. Eculizumab blocks terminal complement activation, prevents complement-mediated organ damage, and is currently recommended as front-line therapy.
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40
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Tekgündüz E, Yılmaz M, Erkurt MA, Kiki I, Kaya AH, Kaynar L, Alacacioglu I, Cetin G, Ozarslan I, Kuku I, Sincan G, Salim O, Namdaroglu S, Karakus A, Karakus V, Altuntas F, Sari I, Ozet G, Aydogdu I, Okan V, Kaya E, Yildirim R, Yildizhan E, Ozgur G, Ozcebe OI, Payzin B, Akpinar S, Demirkan F. A multicenter experience of thrombotic microangiopathies in Turkey: The Turkish Hematology Research and Education Group (ThREG)-TMA01 study. Transfus Apher Sci 2018; 57:27-30. [PMID: 29503132 DOI: 10.1016/j.transci.2018.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Thrombotic microangiopathies (TMAs) are rare, but life-threatening disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia (MAHAT) associated with multiorgan dysfunction as a result of microvascular thrombosis and tissue ischemia. The differentiation of the etiology is of utmost importance as the pathophysiological basis will dictate the choice of appropriate treatment. We retrospectively evaluated 154 (99 females and 55 males) patients who received therapeutic plasma exchange (TPE) due to a presumptive diagnosis of TMA, who had serum ADAMTS13 activity/anti-ADAMTS13 antibody analysis at the time of hospital admission. The median age of the study cohort was 36 (14-84). 67 (43.5%), 32 (20.8%), 27 (17.5%) and 28 (18.2%) patients were diagnosed as thrombotic thrombocytopenic purpura (TTP), infection/complement-associated hemolytic uremic syndrome (IA/CA-HUS), secondary TMA and TMA-not otherwise specified (TMA-NOS), respectively. Patients received a median of 18 (1-75) plasma volume exchanges for 14 (153) days. 81 (52.6%) patients received concomitant steroid therapy with TPE. Treatment responses could be evaluated in 137 patients. 90 patients (65.7%) achieved clinical remission following TPE, while 47 (34.3%) patients had non-responsive disease. 25 (18.2%) non-responsive patients died during follow-up. Our study present real-life data on the distribution and follow-up of patients with TMAs who were referred to therapeutic apheresis centers for the application of TPE.
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Affiliation(s)
- Emre Tekgündüz
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey.
| | - Mehmet Yılmaz
- Gaziantep University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Mehmet Ali Erkurt
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Ilhami Kiki
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Ali Hakan Kaya
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Leylagul Kaynar
- Erciyes University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Inci Alacacioglu
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
| | - Guven Cetin
- Bezmialem University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Istanbul, Turkey
| | - Ibrahim Ozarslan
- Gaziantep University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Gaziantep, Turkey
| | - Irfan Kuku
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Gulden Sincan
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Ozan Salim
- Akdeniz University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Antalya, Turkey
| | - Sinem Namdaroglu
- Bozyaka Education and Research Hospital, Hematology Clinic, Izmir, Turkey
| | - Abdullah Karakus
- Dicle University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Diyarbakir, Turkey
| | - Volkan Karakus
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Mugla, Turkey
| | - Fevzi Altuntas
- Ankara Oncology Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Ismail Sari
- Pamukkale University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Denizli, Turkey
| | - Gulsum Ozet
- Ankara Numune Education and Research Hospital, Hematology and BMT Clinic, Ankara, Turkey
| | - Ismet Aydogdu
- Celal Bayar University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Manisa, Turkey
| | - Vahap Okan
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Emin Kaya
- Inonu University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Malatya, Turkey
| | - Rahsan Yildirim
- Erzurum University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Erzurum, Turkey
| | - Esra Yildizhan
- Erciyes University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Kayseri, Turkey
| | - Gokhan Ozgur
- Gulhane Military Medical Academy University, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Osman Ilhami Ozcebe
- Hacettepe University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ankara, Turkey
| | - Bahriye Payzin
- Katip Celebi University, Ataturk Training and Research Hospital, Hematology Clinic, Izmir, Turkey
| | - Seval Akpinar
- Sisli Hamidiye Etfal Education and Research Hospital, Hematology Clinic, Istanbul, Turkey
| | - Fatih Demirkan
- Dokuz Eylul University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Izmir, Turkey
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41
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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: 63] [Impact Index Per Article: 10.5] [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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42
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Winters JL. Plasma exchange in thrombotic microangiopathies (TMAs) other than thrombotic thrombocytopenic purpura (TTP). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:632-638. [PMID: 29222314 PMCID: PMC6142547 DOI: 10.1182/asheducation-2017.1.632] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Thrombotic microangiopathies (TMAs) are a diverse group of disorders that are characterized by common clinical and laboratory features. The most commonly thought-of TMA is thrombotic thrombocytopenic purpura (TTP). Because of the marked improvement in patient mortality associated with the use of therapeutic plasma exchange (TPE) in TTP, this therapy has been applied to all of the TMAs. The issue, however, is that the pathophysiology varies and in many instances may represent a disorder of the endothelium and not the blood; in some cases, the pathophysiology is unknown. The use of TPE is further obscured by a lack of strong supporting literature on its use, with most consisting of case series and case reports; controlled or randomized controlled trials are lacking. Evidence supporting the use of TPE in the treatment of TMAs (other than TTP and TMA-complement mediated) is lacking, and therefore its role is uncertain. With the greater availability of genetic testing for mutations involving complement regulatory genes and complement pathway components, there seems to be a percentage of TMA cases, other than TMA-complement mediated, in which complement pathway mutations are involved in some patients. The ability of TPE to remove abnormal complement pathway components and replace them with normal components may support its use in some patients with TMAs other than TTP and TMA-complement mediated.
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Affiliation(s)
- Jeffrey L Winters
- Therapeutic Apheresis Treatment Unit, Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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43
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Gosain R, Gill A, Fuqua J, Volz LH, Kessans Knable MR, Bycroft R, Seger S, Gosain R, Rios JA, Chao JH. Gemcitabine and carfilzomib induced thrombotic microangiopathy: eculizumab as a life-saving treatment. Clin Case Rep 2017; 5:1926-1930. [PMID: 29225827 PMCID: PMC5715608 DOI: 10.1002/ccr3.1214] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/21/2017] [Accepted: 09/05/2017] [Indexed: 12/31/2022] Open
Abstract
Drug‐induced aHUS is rare; however, early diagnosis is vital to reduce morbidity and mortality. With confirmation of the diagnosis, eculizumab appears to be a viable treatment option to suppress the pro‐inflammatory surge. Furthermore, adverse side effects of medications such as carfilzomib and gemcitabine should be considered in the appropriate settings.
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Affiliation(s)
- Rahul Gosain
- Division of Hematology and Medical Oncology James Graham Brown Cancer Center University of Louisville School of Medicine Louisville Kentucky
| | - Amitoj Gill
- Division of Hematology and Medical Oncology James Graham Brown Cancer Center University of Louisville School of Medicine Louisville Kentucky
| | - Jacob Fuqua
- Department of Medicine University of Louisville School of Medicine Louisville Kentucky
| | - Lesley H Volz
- Department of Pharmacy James Graham Brown Cancer Center University of Louisville Louisville Kentucky
| | - Mika R Kessans Knable
- Department of Pharmacy James Graham Brown Cancer Center University of Louisville Louisville Kentucky
| | - Ryan Bycroft
- Department of Pharmacy James Graham Brown Cancer Center University of Louisville Louisville Kentucky
| | - Sarah Seger
- Department of Pharmacy James Graham Brown Cancer Center University of Louisville Louisville Kentucky
| | - Rohit Gosain
- Division of Hematology and Medical Oncology Roswell Park Cancer Institute Buffalo New York
| | - Jorge A Rios
- Division of Hematology and Medical Oncology The Mark H. Zangmeister Cancer Center Columbus Ohio
| | - Ju-Hsien Chao
- Division of Hematology and Medical Oncology Texas Transplant Physician Group - Methodist Physicians San Antonio Texas
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44
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Al-Shaghana M, Bentall A, Jesky MD, Lester W, Lipkin G. Early eculizumab use in atypical haemolytic uraemic syndrome in a Jehovah’s Witness refusing blood products. Oxf Med Case Reports 2017. [PMID: 28638625 PMCID: PMC5471596 DOI: 10.1093/omcr/omx025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- May Al-Shaghana
- Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Bentall
- Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
- Correspondence address. Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK. Tel: +44-121-371-2000; Fax: +44-121-371-5858. E-mail:
| | - Mark D. Jesky
- Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - William Lester
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Graham Lipkin
- Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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45
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Shanmugalingam R, Hsu D, Makris A. Pregnancy-induced atypical haemolytic uremic syndrome: A new era with eculizumab. Obstet Med 2017; 11:28-31. [PMID: 29636811 DOI: 10.1177/1753495x17704563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/12/2017] [Indexed: 11/15/2022] Open
Abstract
Pregnancy is a well-recognised trigger of atypical haemolytic syndrome (P-aHUS) and often occurs in the post-partum period. Similar to atypical haemolytic uremic syndrome, it carries a poor prognosis with high morbidity particularly in the form of renal failure. Early recognition and intervention is crucial in its management particularly with the recent availability of eculizumab, a humanized monoclonal antibody to complement component C5, which has demonstrated drastic improvement in prognosis. The issue, however, is arriving at a timely diagnosis given the considerable amount of overlap in the clinical and biochemical manifestation of P-aHUS, HELLP syndrome (haemolysis, elevated liver enzyme and low platelet count) and other hypertensive disorders of pregnancy. We present a case report and literature review that highlights the clinical conundrum of arriving at the diagnosis. We also highlight the importance of early management of P-aHUS with eculizumab and its impact on improving morbidity.
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Affiliation(s)
- Renuka Shanmugalingam
- Department of Renal Medicine, Liverpool Hospital, NSW, Australia.,School of Medicine, Western Sydney University, NSW, Australia
| | - Danny Hsu
- Department of Haematology, Liverpool Hospital, NSW, Australia
| | - Angela Makris
- Department of Renal Medicine, Liverpool Hospital, NSW, Australia.,School of Medicine, Western Sydney University, NSW, Australia.,University of New South Wales, NSW, Australia
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46
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Ipe TS, Lim J, Reyes MA, Ero M, Leveque C, Lewis B, Kain J. An extremely rare splice site mutation in the gene encoding complement factor I in a patient with atypical hemolytic uremic syndrome. J Clin Apher 2017; 32:584-588. [PMID: 28455885 DOI: 10.1002/jca.21549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/03/2017] [Accepted: 04/04/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney failure. The disease is difficult to diagnose due to its similarity with other hematologic disorders, such as thrombotic thrombocytopenic purpura (TTP). However, genetic mutations are found in 50-70% of patients with aHUS and can be useful in its diagnosis. STUDY DESIGN AND METHODS A 40-year-old male presented to our hospital with acute kidney injury, evidenced by high creatinine levels (8.3 mg/dL) and kidney biopsy results. The patient was preliminarily diagnosed with TTP and therapeutic plasma exchange (TPE) was initiated. After four treatments, TPE was discontinued due to lack of ADAMTS13 activity and inhibitor assay results that were not consistent with TTP, improved hematologic laboratory results, and aHUS genetic testing results. RESULTS Next-generation sequencing showed a rare mutation at a splice site in the gene encoding complement factor I (CFI). Implication of this mutation in aHUS has not been previously described. Treatment with eculizumab reduced creatinine levels below 4.0 mg/dL, and the patient remained on maintenance dosage of eculizumab (1200 mg/14 days) to prevent aHUS recurrence. CONCLUSION An extremely rare, heterozygous mutation in the gene encoding CFI likely affecting splicing was associated for the first time with aHUS. Sequencing was critical for rapid diagnosis and subsequent timely treatment with eculizumab, which resulted in improved renal function.
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Affiliation(s)
- Tina S Ipe
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Jooeun Lim
- Machaon Diagnostics, Oakland, California
| | - Meredith Anne Reyes
- Department of Pathology and Laboratory Medicine, Baylor College of Medicine, Houston, Texas
| | - Mike Ero
- Machaon Diagnostics, Oakland, California
| | - Christopher Leveque
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | | | - Jamey Kain
- Machaon Diagnostics, Oakland, California
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47
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Azoulay E, Knoebl P, Garnacho-Montero J, Rusinova K, Galstian G, Eggimann P, Abroug F, Benoit D, von Bergwelt-Baildon M, Wendon J, Scully M. Expert Statements on the Standard of Care in Critically Ill Adult Patients With Atypical Hemolytic Uremic Syndrome. Chest 2017; 152:424-434. [PMID: 28442312 DOI: 10.1016/j.chest.2017.03.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/01/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022] Open
Abstract
A typical hemolytic uremic syndrome (aHUS) presents similarly to thrombotic thrombocytopenic purpura (TTP) and other causes or conditions with thrombotic microangiopathy (TMA), such as disseminated intravascular coagulation or sepsis. Similarity in clinical presentation may hinder diagnosis and optimal treatment selection in the urgent setting in the ICU. However, there is currently no consensus on the diagnosis or treatment of aHUS for ICU specialists. This review aims to summarize available data on the diagnosis and treatment strategies of aHUS in the ICU to enhance the understanding of aHUS diagnosis and outcomes in patients managed in the ICU. To this end, a review of the recent literature (January 2009-March 2016) was performed to select the most relevant articles for ICU physicians. Based on the paucity of adult aHUS cases overall and within the ICU, no specific recommendations could be formally graded for the critical care setting. However, we recognize a core set of skills required by intensivists for diagnosing and managing patients with aHUS: recognizing thrombotic microangiopathies, differentiating aHUS from related conditions, recognizing involvement of other organ systems, understanding the pathophysiology of aHUS, knowing the diagnostic workup and relevant outcomes in critically ill patients with aHUS, and knowing the standard of care for patients with aHUS based on available data and guidelines. In conclusion, managing critically ill patients with aHUS requires basic skills that, in the absence of sufficient data from patients treated within the ICU, can be gleaned from an increasingly relevant literature outside the ICU. More data on critically ill patients with aHUS are needed to validate these conclusions within the ICU setting.
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Affiliation(s)
- Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Paris, France.
| | - Paul Knoebl
- Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | | | - Katerina Rusinova
- University Hospital, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | - Fekri Abroug
- Fattouma Bourguiba Teaching Hospital Monastir, Tunisia
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48
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Abstract
Thrombocytopenia is a commonly encountered hematologic problem in inpatient and ambulatory medicine. The many underlying mechanisms of thrombocytopenia include pseudothrombocytopenia, splenic sequestration, and marrow underproduction and destruction. This article presents the known causes of thrombocytopenia, a framework for evaluation, and brief descriptions of management in a case-based format.
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Affiliation(s)
- Eun-Ju Lee
- Division of Hematology, Weill Cornell Medical College, New York, NY, USA
| | - Alfred Ian Lee
- Section of Hematology, Yale Cancer Center, Yale University School of Medicine, 333 Cedar Street, Box 208021, New Haven, CT 06520, USA.
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49
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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50
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Cao M, Ferreiro T, Leite BN, Pita F, Bolaños L, Valdés F, Alonso A, Vázquez E, Mosquera J, Trigás M, Rodríguez S. Two cases of atypical hemolytic uremic syndrome (aHUS) and eosinophilic granulomatosis with polyangiitis (EGPA): a possible relationship. CEN Case Rep 2017; 6:91-97. [PMID: 28509134 DOI: 10.1007/s13730-017-0251-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 02/04/2017] [Indexed: 10/20/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by hemolysis, thrombocytopenia, and renal failure. It is related to genetic mutations of the alternative complement pathway and is difficult to differentiate from other prothrombotic microangiopathies. Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss syndrome, CSS) is a systemic ANCA-associated vasculitis and a hypereosinophilic disorder where eosinophils seem to induce cell apoptosis and necrosis and therefore, vasculitis. Here, we report the case of two CSS patients with a genetic complement disorder consistent with aHUS diagnosis. Both patients showed histologic features that supported the diagnosis of CSS, and a genetic complement study confirmed the suspected aHUS diagnosis. In the case where eculizumab was administered, the global response was excellent. There is very limited understanding of the genetics and epidemiology of both, atypical HUS and EGPA, but considering our two patients we suggest that an etiopathogenic link exists among patients diagnosed with both entities.
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Affiliation(s)
- Mercedes Cao
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain.
| | - Tamara Ferreiro
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Bruna N Leite
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco Pita
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Luis Bolaños
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco Valdés
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Angel Alonso
- Servicio de Nefrología, Hospital Universitario A Coruña, A Coruña, Spain
| | - Eduardo Vázquez
- Servicio de Anatomía Patológica, Hospital Universitario A Coruña, A Coruña, Spain
| | - Juan Mosquera
- Servicio de Anatomía Patológica, Hospital Universitario A Coruña, A Coruña, Spain
| | - María Trigás
- Servicio de Medicina Interna, Hospital Arquitecto Marcide, El Ferrol, A Coruña, Spain
| | - Santiago Rodríguez
- Departamento de Medicina Celular y Molecular, Centro de Investigaciones Biológicas (CSIC), Madrid, Spain
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