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Wijnsma KL, Schijvens AM, Bouwmeester RN, Aarts LAM, van den Heuvel L(BP, Haaxma CA, van de Kar NCAJ. Mutations in Genes Encoding Subunits of the RNA Exosome as a Potential Novel Cause of Thrombotic Microangiopathy. Int J Mol Sci 2024; 25:7604. [PMID: 39062862 PMCID: PMC11277116 DOI: 10.3390/ijms25147604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/06/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Thrombotic microangiopathy (TMA) in association with RNA exosome encoding mutations has only recently been recognized. Here, we present an infant (female) with an EXOSC5 mutation (c.230_232del p.Glu77del) associated with the clinical phenotype known as CABAC syndrome (cerebellar ataxia, brain abnormalities, and cardiac conduction defects), including pontocerebellar hypoplasia, who developed renal TMA. At the age of four months, she presented with signs of septic illness, after which she developed TMA. A stool culture showed rotavirus as a potential trigger. The patient received eculizumab once, alongside supportive treatment, while awaiting diagnostic analysis of TMA, including genetic complement analysis, all of which were negative. Eculizumab was withdrawn and the patient's TMA recovered quickly. A review of the literature identified an additional four patients (age < 1 year) who developed TMA after a viral trigger in the presence of mutations in EXOSC3. The recurrence of TMA in one of these patients with an EXOSC3 mutation while on eculizumab treatment underscores the apparent lack of responsiveness to C5 inhibition. In conclusion, mutations in genes influencing the RNA exosome, like EXOSC3 and EXOSC5, characterized by neurodevelopment and neurodegenerative disorders could potentially lead to TMA in the absence of complement dysregulation. Hence, these patients were likely non-responsive to eculizumab.
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Affiliation(s)
- Kioa L. Wijnsma
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Anne M. Schijvens
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Romy N. Bouwmeester
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Lonneke A. M. Aarts
- Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Lambertus (Bert) P. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
| | - Charlotte A. Haaxma
- Department of Pediatric Neurology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands (R.N.B.); (L.P.v.d.H.); (N.C.A.J.v.d.K.)
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Blasco M, Guillén-Olmos E, Diaz-Ricart M, Palomo M. Complement Mediated Endothelial Damage in Thrombotic Microangiopathies. Front Med (Lausanne) 2022; 9:811504. [PMID: 35547236 PMCID: PMC9082680 DOI: 10.3389/fmed.2022.811504] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
Thrombotic microangiopathies (TMA) constitute a group of different disorders that have a common underlying mechanism: the endothelial damage. These disorders may exhibit different mechanisms of endothelial injury depending on the pathological trigger. However, over the last decades, the potential role of the complement system (CS) has gained prominence in their pathogenesis. This is partly due to the great efficacy of complement-inhibitors in atypical hemolytic syndrome (aHUS), a TMA form where the primary defect is an alternative complement pathway dysregulation over endothelial cells (genetic and/or adquired). Complement involvement has also been demonstrated in other forms of TMA, such as thrombotic thrombocytopenic purpura (TTP) and in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (STEC-HUS), as well as in secondary TMAs, in which complement activation occurs in the context of other diseases. However, at present, there is scarce evidence about the efficacy of complement-targeted therapies in these entities. The relationship between complement dysregulation and endothelial damage as the main causes of TMA will be reviewed here. Moreover, the different clinical trials evaluating the use of complement-inhibitors for the treatment of patients suffering from different TMA-associated disorders are summarized, as a clear example of the entry into a new era of personalized medicine in its management.
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Affiliation(s)
- Miquel Blasco
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain.,Institute of Biomedical Research August Pi i Sunyer (IDIPABS), Malalties Nefro-Urològiques i Trasplantament Renal, Barcelona, Spain
| | - Elena Guillén-Olmos
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain
| | - Marta Palomo
- Hematopathology Unit, Department of Pathology, Hospital Clínic of Barcelona, Biomedical Diagnosis Centre (CDB), Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Barcelona Endothelium Team, Barcelona, Spain.,Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
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3
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Feitz WJC, van Setten PA, van der Velden TJAM, Licht C, van den Heuvel LPJW, van de Kar NCAJ. Cell Biological Responses after Shiga Toxin-1 Exposure to Primary Human Glomerular Microvascular Endothelial Cells from Pediatric and Adult Origin. Int J Mol Sci 2021; 22:ijms22115615. [PMID: 34070679 PMCID: PMC8199108 DOI: 10.3390/ijms22115615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/17/2021] [Accepted: 05/22/2021] [Indexed: 01/16/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is characterized by a triad of symptoms consisting of hemolytic anemia, thrombocytopenia and acute renal failure. The most common form of HUS is caused by an infection with Shiga toxin (Stx) producing Escherichia coli bacteria (STEC-HUS), and the kidneys are the major organs affected. The development of HUS after an infection with Stx occurs most frequently in children under the age of 5 years. However, the cause for the higher incidence of STEC-HUS in children compared to adults is still not well understood. Human glomerular microvascular endothelial cells (HGMVECs) isolated and cultured from pediatric and adult kidney tissue were investigated with respect to Stx binding and different cellular responses. Shiga toxin-1 (Stx-1) inhibited protein synthesis in both pediatric and adult HGMVECs in a dose-dependent manner at basal conditions. The preincubation of pediatric and adult HGMVECs for 24 hrs with TNFα resulted in increased Stx binding to the cell surface and a 20-40% increase in protein synthesis inhibition in both age groups. A decreased proliferation of cells was found when a bromodeoxyuridine (BrdU) assay was performed. A trend towards a delay in endothelial wound closure was visible when pediatric and adult HGMVECs were incubated with Stx-1. Although minor differences between pediatric HGMVECs and adult HGMVECs were found in the assays applied in this study, no significant differences were observed. In conclusion, we have demonstrated that in vitro primary HGMVECs isolated from pediatric and adult kidneys do not significantly differ in their cell biological responses to Stx-1.
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Affiliation(s)
- Wouter J. C. Feitz
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Department of Pediatrics, Amalia Children’s Hospital, Radboudumc, 6525 GA Nijmegen, The Netherlands;
| | - Petra A. van Setten
- Department of Pediatrics, Amalia Children’s Hospital, Radboudumc, 6525 GA Nijmegen, The Netherlands;
| | - Thea J. A. M. van der Velden
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
| | - Christoph Licht
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Lambert P. J. W. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
- Department of Development and Regeneration, Department of Pediatric Nephrology, KU, 3000 Leuven, Belgium
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Radboudumc, 6525 GA Nijmegen, The Netherlands; (W.J.C.F.); (T.J.A.M.v.d.V.); (L.P.J.W.v.d.H.)
- Department of Pediatrics, Amalia Children’s Hospital, Radboudumc, 6525 GA Nijmegen, The Netherlands;
- Correspondence: ; Tel.: +31-24-36-14430
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4
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Wu H, Su S, Li L, Zhang L. Atypical hemolytic uremic syndrome and acute tubular necrosis induced by complement factor B gene (CFB) mutation: A case report. Medicine (Baltimore) 2021; 100:e25069. [PMID: 33725982 PMCID: PMC7982152 DOI: 10.1097/md.0000000000025069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Atypical hemolytic uremic syndrome (aHUS) is an uncommon and serious disease that manifests hemolytic anemia, thrombocytopenia, and acute kidney injury. Genetic complement abnormalities have been shown to be responsible. Compared with the aHUS caused by other mutated genes, aHUS secondary to CFB mutation in adults is extremely rare. We report an adult with CFB mutation developing aHUS. PATIENT CONCERNS A 56-year-old man was admitted for 4-day history of nausea and fatigue, anuria for 2 days, and unconsciousness for 10 hours. DIAGNOSES The patient presented with life-threatening anemia, thrombocytopenia, acute kidney injury, and nervous system abnormalities. The patient had schistocytes on the peripheral blood smear, increased lactate dehydrogenase (LDH), and plasma-free hemoglobin levels. The patient was later found to harbor a pathogenic variant in the CFB gene (C.1598A>G), and was diagnosed with aHUS and acute kidney injury. INTERVENTION The patient was treated by plasmapheresis, continuous renal replacement therapy, blood transfusion, and anti-infective and antihypertensive treatment. OUTCOMES After the treatment, the patient's consciousness returned to normal, and the hemoglobin, platelet, and serum creatinine recovered. The disease activity remained quiescent during the follow-up. LESSONS A rare heterozygous variant c.1598A>G p.Lys 533Arg in the CFB gene, which was associated with adult-onset aHUS, was described and successfully treated. This case can help in understanding the early diagnosis and effective therapies of this rare disease.
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5
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Wijnsma KL, Duineveld C, Volokhina EB, van den Heuvel LP, van de Kar NCAJ, Wetzels JFM. Safety and effectiveness of restrictive eculizumab treatment in atypical haemolytic uremic syndrome. Nephrol Dial Transplant 2019; 33:635-645. [PMID: 29106598 DOI: 10.1093/ndt/gfx196] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/10/2017] [Indexed: 11/12/2022] Open
Abstract
Background Atypical haemolytic uremic syndrome (aHUS) is a rare but severe form of thrombotic microangiopathy as a consequence of complement dysregulation. aHUS has a poor outcome with high mortality and >50% of patients developing end-stage renal disease. Since the end of 2012, these outcomes have greatly improved with the introduction of eculizumab. Currently the duration of treatment is debated. Most guidelines advise lifelong treatment. However, there is no hard evidence to support this advice. Historically, a substantial number of aHUS patients were weaned of plasma therapy, often without disease recurrence. Moreover, the long-term consequences of eculizumab treatment are unknown. In this retrospective study we describe 20 patients who received a restrictive treatment regimen. Methods All aHUS patients who presented in the Radboud University Medical Center, Nijmegen, The Netherlands, between 2012 and 2016 and who received eculizumab are described. Clinical, diagnostic and follow-up data were gathered and reviewed. Results Twenty patients (14 adults, 6 children) with aHUS have received eculizumab. Eculizumab was tapered in all and stopped in 17 patients. aHUS recurrence occurred in five patients. Due to close monitoring, recurrence was detected early and eculizumab was restarted. No clinical sequela such as proteinuria or progressive kidney dysfunction was detected subsequently. In total, eculizumab has been discontinued in 13 patients without aHUS recurrence, of which 5 are event free for >1 year. With this strategy ∼€11.4 million have been saved. Conclusions A restrictive eculizumab regimen in aHUS appears safe and effective. Prospective studies should further evaluate the most optimal treatment strategy.
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Affiliation(s)
- Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lambertus P van den Heuvel
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pediatrics, University Hospital Leuven, Leuven, Belgium
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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6
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Mezger M, Nording H, Sauter R, Graf T, Heim C, von Bubnoff N, Ensminger SM, Langer HF. Platelets and Immune Responses During Thromboinflammation. Front Immunol 2019; 10:1731. [PMID: 31402914 PMCID: PMC6676797 DOI: 10.3389/fimmu.2019.01731] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/09/2019] [Indexed: 12/17/2022] Open
Abstract
Besides mediating hemostatic functions, platelets are increasingly recognized as important players of inflammation. Data from experiments in mice and men revealed various intersection points between thrombosis, hemostasis, and inflammation, which are addressed and discussed in this review in detail. One such example is the intrinsic coagulation cascade that is initiated after platelet activation thereby further propagating and re-enforcing wound healing or thrombus formation but also contributing to the pathophysiology of severe diseases. FXII of the intrinsic pathway connects platelet activation with the coagulation cascade during immune reactions. It can activate the contact system thereby either creating an inflammatory state or accelerating inflammation. Recent insights into platelet biology could show that platelets are equipped with complement receptors. Platelets are important for tissue remodeling after injury has been inflicted to the endothelial barrier and to the subendothelial tissue. Thus, platelets are increasingly recognized as more than just cells relevant for bleeding arrest. Future insights into platelet biology are to be expected. This research will potentially offer novel opportunities for therapeutic intervention in diseases featuring platelet abundance.
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Affiliation(s)
- Matthias Mezger
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Henry Nording
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, Lübeck, Germany
| | - Reinhard Sauter
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Tobias Graf
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Christian Heim
- Department of Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Nikolas von Bubnoff
- Department of Hematology and Oncology, Medical Center, University of Schleswig-Holstein, Lübeck, Germany
| | - Stephan M Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, Lübeck, Germany
| | - Harald F Langer
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, Lübeck, Germany
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Frémeaux-Bacchi V, Sellier-Leclerc AL, Vieira-Martins P, Limou S, Kwon T, Lahoche A, Novo R, Llanas B, Nobili F, Roussey G, Cailliez M, Ulinski T, Deschênes G, Alberti C, Weill FX, Mariani P, Loirat C. Complement Gene Variants and Shiga Toxin-Producing Escherichia coli-Associated Hemolytic Uremic Syndrome: Retrospective Genetic and Clinical Study. Clin J Am Soc Nephrol 2019; 14:364-377. [PMID: 30674459 PMCID: PMC6419292 DOI: 10.2215/cjn.05830518] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 12/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Inherited complement hyperactivation is critical for the pathogenesis of atypical hemolytic uremic syndrome (HUS) but undetermined in postdiarrheal HUS. Our aim was to investigate complement activation and variants of complement genes, and their association with disease severity in children with Shiga toxin-associated HUS. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Determination of complement biomarkers levels and next-generation sequencing for the six susceptibility genes for atypical HUS were performed in 108 children with a clinical diagnosis of post-diarrheal HUS (75 Shiga toxin-positive, and 33 Shiga toxin-negative) and 80 French controls. As an independent control cohort, we analyzed the genotypes in 503 European individuals from the 1000 Genomes Project. RESULTS During the acute phase of HUS, plasma levels of C3 and sC5b-9 were increased, and half of patients had decreased membrane cofactor protein expression, which normalized after 2 weeks. Variants with minor allele frequency <1% were identified in 12 Shiga toxin-positive patients with HUS (12 out of 75, 16%), including pathogenic variants in four (four out of 75, 5%), with no significant differences compared with Shiga toxin-negative patients with HUS and controls. Pathogenic variants with minor allele frequency <0.1% were found in three Shiga toxin-positive patients with HUS (three out of 75, 4%) versus only four European controls (four out of 503, 0.8%) (odds ratio, 5.2; 95% confidence interval, 1.1 to 24; P=0.03). The genetic background did not significantly affect dialysis requirement, neurologic manifestations, and sC5b-9 level during the acute phase, and incident CKD during follow-up. However, the only patient who progressed to ESKD within 3 years carried a factor H pathogenic variant. CONCLUSIONS Rare variants and complement activation biomarkers were not associated with severity of Shiga toxin-associated HUS. Only pathogenic variants with minor allele frequency <0.1% are more frequent in Shiga toxin-positive patients with HUS than in controls.
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Affiliation(s)
- Véronique Frémeaux-Bacchi
- Service d’Immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
- Team “Complement and Disease,” Centre de recherche des Cordeliers, Sorbonne Université, INSERM, Paris, France
| | | | - Paula Vieira-Martins
- Service d’Immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Limou
- Institute for Transplantation in Urology and Nephrology, Centre Hospitalo-Universitaire de Nantes, Centre de Recherche en Transplantation et Immunologie, Institut National de la Santé et de la Recherche Médicale U1064, Université de Nantes, Ecole Centrale de Nantes, Nantes, France
| | | | - Annie Lahoche
- Pediatric Nephrology Department, Hôpital Jeanne de Flandre, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Robert Novo
- Pediatric Nephrology Department, Hôpital Jeanne de Flandre, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Brigitte Llanas
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France
| | - François Nobili
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Besançon, Besançon, France
| | - Gwenaëlle Roussey
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Nantes, Nantes, France
| | - Mathilde Cailliez
- Pediatric Nephrology Department, Centre Hospitalo-Universitaire de Marseille, Marseille, France
| | - Tim Ulinski
- Pediatric Nephrology Department, Hôpital Trousseau, University Pierre and Marie Curie, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | | | - Corinne Alberti
- Unit of Clinical Epidemiology, Institut National de la Santé et de la Recherche Médicale U1123 and Centre d'Investigation Clinique-Epidémiologie Clinique 1426, and
| | - François-Xavier Weill
- Institut Pasteur, Unité des Bactéries Pathogènes Entériques, Centre National de Référence des Escherichia coli, Shigella et Salmonella, Paris, France
| | - Patricia Mariani
- Laboratory of Microbiology, Escherichia coli Associated National Reference Center, Hôpital Robert Debré, University Paris Diderot, Assistance Publique-Hôpitaux de Paris, Paris, France
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8
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Cidon EU, Martinez PA, Hickish T. Gemcitabine-induced haemolytic uremic syndrome, although infrequent, can it be prevented: A case report and review of literature. World J Clin Cases 2018; 6:531-537. [PMID: 30397609 PMCID: PMC6212612 DOI: 10.12998/wjcc.v6.i12.531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/08/2018] [Accepted: 10/09/2018] [Indexed: 02/05/2023] Open
Abstract
Gemcitabine is an antineoplastic used to treat several malignancies including pancreatic cancer. Its toxicity profile is well known with myelotoxicity, increased vascular permeability and peripheral oedema as most frequent adverse events. However, several cases of acute renal failure have been reported and haemolytic uremic syndrome (HUS) seems to be the underlying process. The cause of HUS remains unknown but its consequences can be lethal. Therefore, a high grade of suspicion is crucial to diagnose it and promptly treat it. This hopefully will reduce its morbidity. HUS is characterized by progressive renal failure associated with microangiopathic haemolytic anaemia and thrombocytopenia. The primary event is damage to endothelial cells and thrombotic microangiopathy (TMA) is the histopathological lesion. TMA affects mainly renal microvasculature. However, some cases evolve with central nervous or cardiovascular systems involvement. We present here a case of gemcitabine-induced HUS, with renal and cardiovascular system affected at the time of diagnosis which to our knowledge this is the first time of such case to be reported.
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Affiliation(s)
- Esther U Cidon
- Department of Medical Oncology, Royal Bournemouth and Christchurch Hospital NHS Foundation Trust, Bournemouth BH7 7DW, United Kingdom
| | - Pilar A Martinez
- Department of Oncology, Clinical University Hospital, Valladolid 47003, Spain
| | - Tamas Hickish
- Department of Medical Oncology, Royal Bournemouth and Christchurch Hospital NHS Foundation Trust and Bournemouth University, Bournemouth BH7 7DW, United Kingdom
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9
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Bury S, Soundararajan M, Bharti R, von Bünau R, Förstner KU, Oelschlaeger TA. The Probiotic Escherichia coli Strain Nissle 1917 Combats Lambdoid Bacteriophages stx and λ. Front Microbiol 2018; 9:929. [PMID: 29896160 PMCID: PMC5987069 DOI: 10.3389/fmicb.2018.00929] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/20/2018] [Indexed: 01/21/2023] Open
Abstract
Shiga toxin (Stx) producing E. coli (STEC) such as Enterohemorrhagic E. coli (EHEC) are the major cause of foodborne illness in humans. In vitro studies showed the probiotic Escherichia coli strain Nissle 1917 (EcN) to efficiently inhibit the production of Stx. Life threatening EHEC strains as for example the serotype O104:H4, responsible for the great outbreak in 2011 in Germany, evolutionary developed from certain E. coli strains which got infected by stx2-encoding lambdoid phages turning the E. coli into lysogenic and subsequently Stx producing strains. Since antibiotics induce stx genes and Stx production, EHEC infected persons are not recommended to be treated with antibiotics. Therefore, EcN might be an alternative medication. However, because even commensal E. coli strains might be converted into Stx-producers after becoming host to a stx encoding prophage, we tested EcN for stx-phage genome integration. Our experiments revealed the resistance of EcN toward not only stx-phages but also against lambda-phages. This resistance was not based on the lack of or by mutated phage receptors. Rather it involved the expression of a phage repressor (pr) gene of a defective prophage in EcN which was able to partially protect E. coli K-12 strain MG1655 against stx and lambda phage infection. Furthermore, we observed EcN to inactivate phages and thereby to protect E. coli K-12 strains against infection by stx- as well as lambda-phages. Inactivation of lambda-phages was due to binding of lambda-phages to LamB of EcN whereas inactivation of stx-phages was caused by a thermostable protein of EcN. These properties together with its ability to inhibit Stx production make EcN a good candidate for the prevention of illness caused by EHEC and probably for the treatment of already infected people.
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Affiliation(s)
- Susanne Bury
- Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany
| | | | - Richa Bharti
- Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany
| | | | - Konrad U Förstner
- Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany
| | - Tobias A Oelschlaeger
- Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany
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10
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Affiliation(s)
- J H Foley
- Freeline Therapeutics, Stevenage, UK
| | - E M Conway
- Centre for Blood Research, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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11
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Kallianpur AR, Bradford Y, Mody RK, Garman KN, Comstock N, Lathrop SL, Lyons C, Saupe A, Wymore K, Canter JA, Olson LM, Palmer A, Jones TF. Genetic Susceptibility to Postdiarrheal Hemolytic-Uremic Syndrome After Shiga Toxin-Producing Escherichia coli Infection: A Centers for Disease Control and Prevention FoodNet Study. J Infect Dis 2018; 217:1000-1010. [PMID: 29216383 PMCID: PMC11318523 DOI: 10.1093/infdis/jix633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/01/2017] [Indexed: 12/15/2022] Open
Abstract
Background Postdiarrheal hemolytic-uremic syndrome (D+HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is a serious condition lacking specific treatment. Host immune dysregulation and genetic susceptibility to complement hyperactivation are implicated in non-STEC-related HUS. However, genetic susceptibility to D+HUS remains largely uncharacterized. Methods Patients with culture-confirmed STEC diarrhea, identified through the Centers for Disease Control and Prevention FoodNet surveillance system (2007-2012), were serotyped and classified by laboratory and/or clinical criteria as having suspected, probable, or confirmed D+HUS or as controls and underwent genotyping at 200 loci linked to nondiarrheal HUS or similar pathologies. Genetic associations with D+HUS were explored by multivariable regression, with adjustment for known risk factors. Results Of 641 enrollees with STEC O157:H7, 80 had suspected D+HUS (41 with probable and 32 with confirmed D+HUS). Twelve genes related to cytokine signaling, complement pathways, platelet function, pathogen recognition, iron transport, and endothelial function were associated with D+HUS in multivariable-adjusted analyses (P ≤ .05). Of 12 significant single-nucleotide polymorphisms (SNPs), 5 were associated with all levels of D+HUS (intergenic SNP rs10874639, TFRC rs3804141, EDN1 rs5370, GP1BA rs121908064, and B2M rs16966334), and 7 SNPs (6 non-complement related) were associated with confirmed D+HUS (all P < .05). Conclusions Polymorphisms in many non-complement-related genes may contribute to D+HUS susceptibility. These results require replication, but they suggest novel therapeutic targets in patients with D+HUS.
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Affiliation(s)
- Asha R Kallianpur
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Yuki Bradford
- Department of Biomedical and Translational Informatics, Geisinger Health System, Danville, Pennsylvania
| | - Rajal K Mody
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Nicole Comstock
- Colorado Department of Public Health and Environment, Denver
| | - Sarah L Lathrop
- Department of Pathology, University of New Mexico, Albuquerque
| | - Carol Lyons
- Connecticut Emerging Infections Program, Yale University School of Public Health, New Haven, Connecticut
| | - Amy Saupe
- Minnesota Department of Health, St. Paul, Oakl
| | | | - Jeffrey A Canter
- Department of Molecular Physiology and Biophysics, Nashville, Tennessee
| | - Lana M Olson
- Center for Quantitative Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amanda Palmer
- Maryland Department of Health and Mental Hygiene, Baltimore
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12
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Keenswijk W, Raes A, Vande Walle J. Is eculizumab efficacious in Shigatoxin-associated hemolytic uremic syndrome? A narrative review of current evidence. Eur J Pediatr 2018; 177:311-318. [PMID: 29288280 DOI: 10.1007/s00431-017-3077-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 12/16/2017] [Accepted: 12/20/2017] [Indexed: 01/09/2023]
Abstract
UNLABELLED Severe complications due to Shigatoxin-associated hemolytic uremic syndrome (STEC-HUS) currently present a serious challenge since no specific treatment for this condition is available. Eculizumab, a terminal complement inhibitor, has been used especially in STEC-HUS patients with severe neurological involvement, but the efficacy remains undetermined. In order to determine its efficacy, we searched the databases Pubmed, Web of Science, Embase, and LiLACS for reports describing outcomes of eculizumab administration in STEC-HUS. We retrieved 11 reports ranging from case reports to cohort studies with the largest study population emanating from the 2011 German outbreak. Outcomes were variable and difficult to interpret in light of the absence of high-quality studies but seemed to point towards potential efficacy of eculizumab if administered early in the course. CONCLUSION The efficacy of eculizumab in STEC-HUS could not be established nor disproven based on current data, and there is a desperate need for randomized controlled trials. What is known? • Eculizumab has been used in complicated cases of Shigatoxin-associated hemolytic uremic syndrome but the efficacy remains unknown? What is new? • Eculizumab might be efficacious if given early in selected cases of Shigatoxin-associated hemolytic uremic syndrome; however, randomized trials are needed to assess this.
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Affiliation(s)
- Werner Keenswijk
- Department of Pediatrics, Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium. .,Department of Pediatrics, Diakonessenhuis , Paramaribo, Suriname.
| | - Ann Raes
- Department of Pediatrics, Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
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13
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Loos S, Aulbert W, Hoppe B, Ahlenstiel-Grunow T, Kranz B, Wahl C, Staude H, Humberg A, Benz K, Krause M, Pohl M, Liebau MC, Schild R, Lemke J, Beringer O, Müller D, Härtel C, Wigger M, Vester U, Konrad M, Haffner D, Pape L, Oh J, Kemper MJ. Intermediate Follow-up of Pediatric Patients With Hemolytic Uremic Syndrome During the 2011 Outbreak Caused by E. coli O104:H4. Clin Infect Dis 2018; 64:1637-1643. [PMID: 28329394 DOI: 10.1093/cid/cix218] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 03/07/2017] [Indexed: 11/15/2022] Open
Abstract
Background. In 2011 Escherichia coli O104:H4 caused an outbreak with >800 cases of hemolytic uremic syndrome (HUS) in Germany, including 90 children. Data on the intermediate outcome in children after HUS due to E. coli O104:H4 have been lacking. Methods. Follow-up data were gathered retrospectively from the medical records of patients who had been included in the German Pediatric HUS Registry during the 2011 outbreak. Results. Seventy-two of the 89 (81%) patients were included after a median follow-up of 3.0 (0.9-4.7) years. Hypertension and proteinuria were present in 19% and 28% of these patients, respectively. Of 4 patients with chronic kidney disease (CKD) > stage 2 at short-term follow-up, 1 had a normalized estimated glomerular filtration rate, and 3 (4%) had persistent CKD > stage 2. In 1 of these patients, CKD improved from stage 4 to 3; 1 who had CKD stage 5 at presentation received kidney transplantation; and 1 patient required further hemodialysis during follow-up. One patient (1.4%) still had major neurological symptoms at the latest follow-up. Dialysis during the acute phase (P = .01), dialysis duration (P = .01), and the duration of oligo-/anuria (P = .005) were associated with the development of renal sequelae. Patients treated with eculizumab (n = 11) and/or plasmapheresis (n = 13) during the acute phase of HUS had comparable outcomes. Conclusions. The overall outcome of pediatric patients after HUS due to E. coli O104:H4 was equivalent to previous reports on HUS due to other types of Shiga toxin-producing E. coli (STEC). Regular follow-up visits in patients are recommended after STEC-HUS.
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Affiliation(s)
- Sebastian Loos
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Wiebke Aulbert
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Bernd Hoppe
- Department of Pediatric Nephrology, University Children's Hospital Bonn
| | | | - Birgitta Kranz
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Muenster
| | | | - Hagen Staude
- Department of Pediatrics, University Hospital Rostock
| | - Alexander Humberg
- Department of Pediatrics, University Hospital Schleswig-Holstein, Lu¨beck
| | - Kerstin Benz
- Department of Pediatrics, University Hospital Erlangen
| | - Martin Krause
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Martin Pohl
- Department of Pediatrics, University Hospital Freiburg
| | - Max C Liebau
- Department of Pediatrics, Department II of Internal Medicine, Center for Molecular Medicine, Cologne Excellence Cluster on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), and Systems Biology of Ageing Cologne (Sybacol), University of Cologne
| | - Raphael Schild
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Johanna Lemke
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | | | | | - Christoph Härtel
- Department of Pediatrics, University Hospital Schleswig-Holstein, Lu¨beck
| | | | - Udo Vester
- Department of Pediatrics, University Hospital Essen
| | - Martin Konrad
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Muenster
| | - Dieter Haffner
- Departement of Pediatric Nephrology, Medical School Hannover
| | - Lars Pape
- Departement of Pediatric Nephrology, Medical School Hannover
| | - Jun Oh
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Markus J Kemper
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
- Department of Pediatrics, AK Hamburg Nord, Asklepios Medical School, Germany
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14
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Birlutiu V, Birlutiu RM. Haemolytic-uremic syndrome due to infection with adenovirus: A case report and literature review. Medicine (Baltimore) 2018; 97:e9895. [PMID: 29443761 PMCID: PMC5839859 DOI: 10.1097/md.0000000000009895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RATIONALE Haemolytic-uremic syndrome is a rare but serious complication of bacterial and viral infections, which is characterized by the triad of: acute renal failure, microangiopathic haemolytic anemia and thrombocytopenia, sometimes severe, requiring peritoneal dialysis. In Europe, hemolytic-uremic syndrome (HUS) in paediatric pathology is primarily caused by Shiga toxin-producing Escherichia coli (STEC) O157, followed by O26. Beside these etiologies, there are other bacterial and viral infections, and also noninfectious ones that have been associated to lead to HUS as well: in the progression of neoplasia, medication-related, post-transplantation, during pregnancy or associated with the antiphospholipid syndrome, systemic lupus erythematosus or family causes with autosomal dominant or recessive inheritance. In terms of pathogenesis, HUS is the result of endothelial injury, most commonly being a result of the action of Shiga toxin. The unfavorable prognosis factors being represented by the age of more than 5 years old, different etiologies from STEC, persistent oligoanuria, central nervous system and glomerular impairment, the association of fever with leukocytosis. HUS is responsible for 7% of cases of hypertension in infants, and an important cause of significant kidney damage in adults. PATIENT CONCERNS We present one case of HUS caused by adenovirus in a boy of 1 year and 7 months old with severe evolution, which required peritoneal dialysis. DIAGNOSE Stool sample repeated examination for adenovirus antigen was positive in 2 samples. INTERVENTION During hospitalization, the patient required 8 peritoneal dialysis sessions. OUTCOME The renal function was corrected on discharge, the patient required cardiovascular monitoring 1 month after discharge. LESSON Although the most common cause that leads to HUS remains STEC, other etiologies like viral ones that may be responsible for severe enteric infection with progression into HUS should not be neglected.
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Affiliation(s)
- Victoria Birlutiu
- Lucian Blaga University of Sibiu, Faculty of Medicine Sibiu; Academic Emergency Hospital Sibiu—Infectious Diseases Clinic
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15
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Mathur P, Hollowoa B, Lala N, Thanendrarajan S, Matin A, Kothari A, Schinke C. Enterococcus raffinosus infection with atypical hemolytic uremic syndrome in a multiple myeloma patient after autologous stem cell transplant. Hematol Rep 2017; 9:7094. [PMID: 29071054 PMCID: PMC5641830 DOI: 10.4081/hr.2017.7094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/18/2017] [Accepted: 08/18/2017] [Indexed: 01/29/2023] Open
Affiliation(s)
- Pankaj Mathur
- Myeloma Institute, University of Arkansas Medical Sciences, Medical Center, Little Rock, AR
| | - Blake Hollowoa
- MS4 University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Nupur Lala
- MS4 University of Arkansas Medical Sciences, Little Rock, AR, USA
| | | | - Aasiya Matin
- Myeloma Institute, University of Arkansas Medical Sciences, Medical Center, Little Rock, AR
| | - Atul Kothari
- Myeloma Institute, University of Arkansas Medical Sciences, Medical Center, Little Rock, AR
| | - Carolina Schinke
- Myeloma Institute, University of Arkansas Medical Sciences, Medical Center, Little Rock, AR
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16
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Geramita MA, Hofer J, Cooper J, Moritz ML. Decreased severity of Shiga toxin-producing Escherichia coli haemolytic uraemic syndrome (STEC-HUS) in a child with type 1 von Willebrand disease. BMJ Case Rep 2017; 2017:bcr-2017-221043. [PMID: 28855217 DOI: 10.1136/bcr-2017-221043] [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: 11/03/2022] Open
Abstract
Shiga toxin-producing Escherichia coli-associated haemolytic uraemic syndrome (STEC-HUS) is characterised by haemolytic anaemia, thrombocytopenia and acute kidney injury. Von Willebrand Factor (vWF) is an important mediator of normal thrombi formation and indirect evidence suggests that vWF may play an important role in Shiga toxin-induced thrombi formation. Clinical evidence supporting the role of vWF in STEC-HUS is lacking. A 10-year-old girl with type 1 von Willebrand Disease (vWD) had a mild case of STEC-HUS, with nadir haemoglobin 7.3 g/dL and platelet count 105×109 cells/L and peak serum creatinine 0.56 mg/L and lactate dehydrogenase 741 U/L. This is the first report of STEC-HUS in a patient with vWD. We speculate that the quantitative deficiency of vWF associated with type 1 vWD may have attenuated the course of disease by reducing platelet aggregation, complement activation and thrombi formation. This case adds to a growing literature supporting a link between vWF and STEC-HUS.
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Affiliation(s)
- Matthew A Geramita
- Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Johannes Hofer
- Department Zahn Mund und Kieferheilkunde und Mund Kiefer und Gesichtschirurgie, Medizinische Universitat Innsbruck, Innsbruck, Tirol, Austria
| | - James Cooper
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Michael L Moritz
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
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17
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is a disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury. The histopathologic lesions of aHUS include thrombotic microangiopathy involving the glomerular capillaries and thrombosis involving arterioles or interlobar arteries. Extra-renal manifestations occur in up to 20% of patients. The majority of aHUS is caused by complement system defects impairing ordinary regulatory mechanisms. Activating events therefore lead to unbridled, ongoing complement activity producing widespread endothelial injury. Pathologic mutations include those resulting in loss-of-function in a complement regulatory gene (CFH, CFI, CD46 or THBD) or gain-of-function in an effector gene (CFB or C3). Treatment with the late complement inhibitor, eculizumab – a monoclonal antibody directed against C5 – is effective.
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Affiliation(s)
- Kuixing Zhang
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Yuxin Lu
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Kevin T Harley
- Department of Internal Medicine, Division of Nephrology and Hypertension, Irvine School of Medicine, University of California, Orange, CA, USA
| | - Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
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18
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Singh K, Nadeem AJ, Doratotaj B. A rare case of thrombotic microangiopathy triggered by acute pancreatitis. BMJ Case Rep 2017; 2017:bcr-2016-218581. [PMID: 28512098 DOI: 10.1136/bcr-2016-218581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Thrombotic microangiopathy (TMA) occurring after acute pancreatitis is rarely described. Without prompt intervention, TMA can be, and often is, lethal, so prompt recognition is important. Here, we present a case of a 61-year-old woman with a history of alcohol misuse who presented with epigastric pain, nausea and vomiting after binge drinking. Elevated serum lipase and imaging were suggestive of acute-on-chronic pancreatitis. Although the patient's symptoms of acute pancreatitis subsided, her anaemia, thrombocytopenia and acute kidney injury worsened. A peripheral blood smear revealed schistocytes, prompting suspicion for TMA. Therapeutic plasma exchange (TPE) was promptly initiated and she completed 10 TPE sessions that improved her anaemia and serum creatinine and resolved the thrombocytopenia. Since TPE was effective and the ADAMTS13 assay revealed 55% activity in the absence of anti-ADAMTS13 IgG prior to initiation of therapy, a confident diagnosis of TMA caused by acute pancreatitis was made. There was no evidence of relapse 2 years later.
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Affiliation(s)
- Kevin Singh
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Ahmed Jamal Nadeem
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Behzad Doratotaj
- Department of Haematology and Oncology, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
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19
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Raufi AG, Scott S, Darwish O, Harley K, Kahlon K, Desai S, Lu Y, Tran MH. Atypical Hemolytic Uremic Syndrome Secondary to Lupus Nephritis, Responsive to Eculizumab. Hematol Rep 2016; 8:6625. [PMID: 27781079 PMCID: PMC5062623 DOI: 10.4081/hr.2016.6625] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/11/2016] [Accepted: 09/23/2016] [Indexed: 12/17/2022] Open
Abstract
Among the spectrum of disease manifestations associated with systemic lupus
erythematosus, lupus nephritis is particularly concerning due to the potential for
renal failure. This autoimmune attack may not, however, be limited to the kidney and
is increasingly being recognized as a trigger for atypical Hemolytic Uremic Syndrome
(aHUS). Atypical HUS falls under the spectrum of the thrombotic microangiopathies
(TMAs) – a group of disorders characterized by microangiopathic hemolytic
anemia, thrombocytopenia, and end organ damage. Although plasma exchange is
considered first-line therapy for thrombotic thrombocytopenic purpura – a TMA
classically associated with autoimmune depletion of ADAMTS-13 – aHUS
demonstrates less reliable responsiveness to this modality. Instead, use of the late
complement inhibitor Eculizumab has emerged as an effective modality for the
management of such patients. Diagnosis of aHUS, however, is largely clinically based,
relying heavily upon a multidisciplinary approach. Herein we present the case of a
patient with atypical HUS successfully treated with Eculizumab in the setting of
Class IV-G (A) lupus nephritis and hypocomplementemia.
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Affiliation(s)
- Alexander G Raufi
- Department of Internal Medicine, University of California , Irvine, CA, USA
| | - Shruti Scott
- Department of Internal Medicine, University of California , Irvine, CA, USA
| | - Omar Darwish
- Department of Internal Medicine, University of California , Irvine, CA, USA
| | - Kevin Harley
- Department of Internal Medicine, University of California , Irvine, CA, USA
| | - Kanwarpal Kahlon
- Department of Internal Medicine, University of California , Irvine, CA, USA
| | - Sheetal Desai
- Department of Internal Medicine, University of California , Irvine, CA, USA
| | - Yuxin Lu
- Department of Pathology and Laboratory Medicine, University of California , Irvine, CA, USA
| | - Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, University of California , Irvine, CA, USA
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20
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Schlagenhauf A, Pohl S, Haidl H, Leschnik B, Gallistl S, Muntean W. Non-enzymatic quantification of polyphosphate levels in platelet lysates and releasates. J Pharm Biomed Anal 2016; 131:1-5. [PMID: 27521983 DOI: 10.1016/j.jpba.2016.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/01/2016] [Accepted: 08/03/2016] [Indexed: 12/28/2022]
Abstract
Inorganic polyphosphate has been shown to be shed upon platelet activation inducing prothrombotic stimuli on the coagulation system. Several methods have been published to detect and quantify polyphosphate in various cells and tissues, but evaluation of platelet content has only been achieved by indirect detection of orthophosphate after enzymatic digestion, thus, relying heavily on specificity of an exopolyphosphatase that is not commercially available. We present a non-enzymatic method for quantification of platelet-derived polyphosphate featuring optimized extraction on silica spin-columns, followed by specific fluorescence detection using DAPI. This allowed us to quantify polyphosphate in platelet lysates, but also in releasates of TRAP-activated platelets for the first time. Extraction of exogenous polyphosphate from buffer and sample matrices resulted in quantitative yields while removing matrix effects observed with direct fluorescence detection. Treatment of eluted fractions with phosphatase completely abrogated polyphosphate-specific fluorescence arguing for no additional compounds influencing the fluorescence detection. This was confirmed by no change in fluorescence intensity in samples previously treated with DNase and RNase. Taken together, we developed a robust and easily standardizable method to quantify polyphosphate in platelet lysates and releasates that will facilitate polyphosphate related investigations of platelet physiology and coagulation.
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Affiliation(s)
- Axel Schlagenhauf
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Austria.
| | - Sina Pohl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Harald Haidl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Bettina Leschnik
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Siegfried Gallistl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
| | - Wolfgang Muntean
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
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21
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Guthoff M, Heyne N. [Clinical course and differential diagnosis of thrombotic microangiopathy]. Med Klin Intensivmed Notfmed 2016; 113:293-298. [PMID: 27405938 DOI: 10.1007/s00063-016-0193-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/24/2016] [Accepted: 05/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thrombotic microangiopathies are complex diseases, requiring early differential diagnosis and targeted intervention. OBJECTIVES Presentation of clinical phenotype and diagnostic algorithm, discussion of underlying pathophysiology, clinical management and therapy. METHODS Summary of current knowledge from literature and expert opinion. RESULTS Our understanding of pathophysiology and therapeutic options have changed substantially in recent years. Early differential diagnosis and targeted therapy are of prognostic relevance. CONCLUSIONS A better understanding of underlying pathophysiology, increased clinical awareness and novel therapeutic options allow for a better prognosis of patients with thrombotic microangiopathy.
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Affiliation(s)
- M Guthoff
- Medizinische Klinik IV, Abteilung für Endokrinologie und Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
| | - N Heyne
- Medizinische Klinik IV, Abteilung für Endokrinologie und Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
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22
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Gaggl M, Aigner C, Sunder-Plassmann G, Schmidt A. [Thrombotic microangiopathy : Relevant new aspects for intensive care physicians]. Med Klin Intensivmed Notfmed 2016; 111:434-9. [PMID: 27255224 PMCID: PMC7095971 DOI: 10.1007/s00063-016-0176-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/08/2016] [Indexed: 01/29/2023]
Abstract
Die thrombotische Mikroangiopathie (TMA) ist klinisch durch eine mechanische Hämolyse, eine geringradig bis stark ausgeprägte Thrombopenie und ein akutes Nierenversagen charakterisiert. Differenzialdiagnostisch kommen das atypische hämolytisch-urämische Syndrom (aHUS), die thrombotisch-thrombozytopenische Purpura (TTP), das Shiga-Toxin-assoziierte HUS (STEC-HUS, früher typisches HUS), und andere seltene Formen der TMA infrage. Ferner kann im Rahmen von diversen Autoimmunerkrankungen, maligner Hypertonie, Malignomen und Infektionen eine TMA als sekundäres Phänomen entstehen. Pathophysiologisch kommt es beim aHUS zu einer überschießenden Aktivierung des alternativen Wegs des Komplementsystems. Essenziell ist daher eine rasche Klärung der zugrunde liegenden Ursache der TMA und eine entsprechende Therapie der Grundkrankheit bei den wesentlich häufigeren sekundären TMA. Bei der TTP ist eine rasche Initiierung von Plasmainfusionen bzw. Plasmaaustausch unumgänglich. Für komplement-mediierte Formen bestehen als etablierte Therapie der Plasmaaustausch und als moderne sehr erfolgreiche Therapieoption Antikomplementtherapien.
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Affiliation(s)
- M Gaggl
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - C Aigner
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - G Sunder-Plassmann
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - A Schmidt
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Währinger Gürtel 18-20, 1090, Wien, Österreich
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