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Seliga-Gąsior D, Sokól-Leszczyñska B, Krzysztoñ-Russjan J, Wierzbicka D, Stępieñ-Hołubczat K, Lewandowska P, Frankiewicz E, Cacko A, Leszczyñska B, Demkow U, Podsiadły E. Epidemiological Characteristics of Shiga Toxin-Producing Escherichia coli Responsible for Infections in the Polish Pediatric Population. Pol J Microbiol 2024; 73:177-187. [PMID: 38727736 PMCID: PMC11192175 DOI: 10.33073/pjm-2024-016] [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: 06/22/2024] Open
Abstract
Shiga toxin-producing Escherichia coli (STEC) are zoonotic pathogens causing hemorrhagic colitis and hemolytic uremic syndrome (HUS) in children and the elderly. Stool samples were collected from 180 children hospitalized in five pediatric centers in Poland in 2018-2022. Direct stx1/stx2 gene detection by PCR in feces and E. coli isolates was performed. Antibiotic susceptibility was tested according to EUCAST v.12. Randomly selected isolates were serotyped with O157 antiserum and genotyped by pulsed-field gel electrophoresis (PFGE). A total of 44 E. coli isolates were confirmed as STEC by PCR. Among them, 84.4% were positive for stx2, and equally 6,8% for only stx1 and both stx1 and stx2 genes. The stx1 gene was also found in one Citrobacter freundii isolate. E. coli serotype O157 was present in 97.6% of the isolates. STEC infections most often occurred between June-October with a peak in July and August (51%). The highest, 77.8% of STEC isolates were found in the 1-5 years old group. No extended-spectrum β-lactamases (ESBL) were found. Resistance only to amoxicillin/clavulanic acid (24.4%), piperacillin/tazobactam (3%), cefotaxime (6%), gentamicin (6%), ciprofloxacin (3%), azithromycin (3%), trimethoprim/sulfamethoxazole (24,2%) was detected. PFGE analysis showed 18 PFGE types with no clonal distribution. Eight isolates with A, B, and C PFGE types showed genetic relatedness in the type with no detection of transmission way of distribution. STEC strains pose a serious threat to human health, therefore demographic and epidemiological characteristics are crucial for their surveillance.
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Affiliation(s)
- Dominika Seliga-Gąsior
- Microbiological Laboratory, University Center for Laboratory Medicine, University Medical Center, Medical University of Warsaw, Warsaw, Poland
| | - Beata Sokól-Leszczyñska
- Microbiological Laboratory, University Center for Laboratory Medicine, University Medical Center, Medical University of Warsaw, Warsaw, Poland
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Krzysztoñ-Russjan
- Microbiological Laboratory, University Center for Laboratory Medicine, University Medical Center, Medical University of Warsaw, Warsaw, Poland
| | - Diana Wierzbicka
- Microbiological Laboratory, University Center for Laboratory Medicine, University Medical Center, Medical University of Warsaw, Warsaw, Poland
| | | | - Paulina Lewandowska
- Microbiological Laboratory, University Center for Laboratory Medicine, University Medical Center, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Frankiewicz
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Cacko
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
| | - Beata Leszczyñska
- Department of Pediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Urszula Demkow
- Department of Laboratory Medicine and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Edyta Podsiadły
- Microbiological Laboratory, University Center for Laboratory Medicine, University Medical Center, Medical University of Warsaw, Warsaw, Poland
- Department of Dental Microbiology, Medical University of Warsaw, Warsaw, Poland
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Acharya R, Clapp WL, Upadhyay K. Efficacy and Safety of Eculizumab in Enteroaggregative E. coli Associated Hemolytic Uremic Syndrome. Pediatr Rep 2024; 16:26-34. [PMID: 38251312 PMCID: PMC10801546 DOI: 10.3390/pediatric16010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) may present atypically without the full triad of classical HUS. Eculizumab has been shown to be efficacious in complement-mediated atypical HUS and some cases of Shiga-toxin (ST) associated HUS. We report the utility of eculizumab in enteroaggregative E. coli (EAEC) associated HUS. CASE SUMMARY A female toddler presented with hemolytic anemia, oliguric acute kidney injury (AKI) without thrombocytopenia, and peripheral schistocytes. The stool examination for ST was negative but positive for EAEC. She required several hemodialysis sessions and received one dosage of eculizumab with rapid reversal of AKI and hemolytic markers. A kidney biopsy revealed acute tubular injury and segmental glomerular basement membrane splitting. Genetic testing was negative for complement mutations or deficiencies. A follow-up six months later showed persistently normal renal function and hematological markers. CONCLUSION The clinical and histological manifestations of non-ST-associated diarrheal HUS and the role of eculizumab in this condition warrant future larger studies.
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Affiliation(s)
- Ratna Acharya
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Nemours Children’s Hospital, Orlando, FL 32827, USA;
| | - William L. Clapp
- Division of Anatomic Pathology, Department of Pathology, University of Florida, Gainesville, FL 32610, USA;
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
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Chen X, Zhang X, Wang Y, Wang S, Zhao M. Genetic, clinical, and pathological study of patients with severe hypertension-associated renal microangiopathy. J Nephrol 2023; 36:2477-2490. [PMID: 37103770 DOI: 10.1007/s40620-023-01644-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Severe hypertension may be a prominent manifestation of complement-mediated thrombotic microangiopathy. Furthermore, patients with severe hypertension-associated thrombotic microangiopathy may present with concurrent hematologic abnormalities that mimic complement-mediated thrombotic microangiopathy. Whether or not severe hypertension-associated thrombotic microangiopathy is associated with genetic susceptibility in complement- and/or coagulation-pathway genes remains unclear, and there is thus a need to identify clinicopathological clues to distinguish between these entities. METHODS Forty-five patients with concomitant severe hypertension and thrombotic microangiopathy on kidney biopsy were identified retrospectively. Whole-exome sequencing was performed to identify rare variants in 29 complement- and coagulation-cascade genes. Clinicopathological features were compared between patients with severe hypertension-associated thrombotic microangiopathy and complement-mediated thrombotic microangiopathy with severe hypertension. RESULTS Three patients with pathogenic variants diagnostic of complement-mediated thrombotic microangiopathy and two with anti-factor H antibody positivity were diagnosed with complement-mediated thrombotic microangiopathy with severe hypertension. Among the 40 patients with severe hypertension-associated thrombotic microangiopathy, 53 rare variants of uncertain significance were found in the analyzed genes in 34 (34/40, 85%) patients, of whom 12 patients harbored two or more variants. Compared with complement-mediated thrombotic microangiopathy patients with severe hypertension, patients with severe hypertension-associated thrombotic microangiopathy were more likely to have left ventricular wall thickening (p < 0.001), less-severe acute glomerular thrombotic microangiopathy lesions including mesangiolysis and subendothelial space widening (both p < 0.001), and less arteriolar thrombosis formation (p < 0.001). CONCLUSIONS Rare genetic variants involving complement and coagulation pathways can be found in patients with severe hypertension-associated thrombotic microangiopathy; their role needs further investigation. Cardiac remodeling and acute glomerular TMA lesions may help to differentiate between severe hypertension-associated thrombotic microangiopathy and complement-mediated thrombotic microangiopathy with severe hypertension.
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Affiliation(s)
- Xuejing Chen
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China
| | - Xu Zhang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China.
- Institute of Nephrology, Peking University, Beijing, China.
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China.
| | - Suxia Wang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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Byrne L, Douglas A, Launders N, Godbole G, Lynn R, Inward C, Jenkins C. Haemolytic uraemic syndrome in children England, Wales, Northern Ireland, and Ireland: A prospective cohort study. Epidemiol Infect 2023; 151:e160. [PMID: 37655611 PMCID: PMC10600734 DOI: 10.1017/s0950268823001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023] Open
Abstract
Haemolytic uraemic syndrome (HUS) caused by infection with Shiga toxin-producing Escherichia coli (STEC) is a relatively rare but potentially fatal multisystem syndrome clinically characterised by acute kidney injury. This study aimed to provide robust estimates of paediatric HUS incidence in England, Wales, Northern Ireland, and the Republic of Ireland by using data linkage and case reconciliation with existing surveillance systems, and to describe the characteristics of the condition. Between 2011 and 2014, 288 HUS patients were included in the study, of which 256 (89.5%) were diagnosed as typical HUS. The crude incidence of paediatric typical HUS was 0.78 per 100,000 person-years, although this varied by country, age, gender, and ethnicity. The majority of typical HUS cases were 1 to 4 years old (53.7%) and female (54.0%). Clinical symptoms included diarrhoea (96.5%) and/or bloody diarrhoea (71.9%), abdominal pain (68.4%), and fever (41.4%). Where STEC was isolated (59.3%), 92.8% of strains were STEC O157 and 7.2% were STEC O26. Comparison of the HUS case ascertainment to existing STEC surveillance data indicated an additional 166 HUS cases were captured during this study, highlighting the limitations of the current surveillance system for STEC for monitoring the clinical burden of STEC and capturing HUS cases.
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Affiliation(s)
- Lisa Byrne
- Gastro and Food Safety (One Health) Division, United Kingdom Health Security Agency, London, UK
| | - Amy Douglas
- Gastro and Food Safety (One Health) Division, United Kingdom Health Security Agency, London, UK
| | - Naomi Launders
- Gastro and Food Safety (One Health) Division, United Kingdom Health Security Agency, London, UK
| | - Gauri Godbole
- Gastro and Food Safety (One Health) Division, United Kingdom Health Security Agency, London, UK
| | - Richard Lynn
- British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Carol Inward
- British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
- University Hospitals Bristol and Weston, NHS Foundation Trust, Bristol, UK
| | - Claire Jenkins
- Gastro and Food Safety (One Health) Division, United Kingdom Health Security Agency, London, UK
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Malgaj Vrečko M, Aleš Rigler A, Večerić-Haler Ž. Coronavirus Disease 2019-Associated Thrombotic Microangiopathy: Literature Review. Int J Mol Sci 2022; 23:ijms231911307. [PMID: 36232608 PMCID: PMC9569470 DOI: 10.3390/ijms231911307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) can lead to clinically significant multisystem disorders that also affect the kidney. According to recent data, renal injury in the form of thrombotic microangiopathy (TMA) in native kidneys ranks third in frequency. Our review of global literature revealed 46 cases of TMA in association with COVID-19. Among identified cases, 18 patients presented as thrombotic thrombocytopenic purpura (TTP) and 28 cases presented as atypical hemolytic uremic syndrome (aHUS). Altogether, seven patients with aHUS had previously proven pathogenic or likely pathogenic genetic complement abnormalities. TMA occurred at the time of viremia or even after viral clearance. Infection with COVID-19 resulted in almost no or only mild respiratory symptoms in the majority of patients, while digestive symptoms occurred in almost one-third of patients. Regarding the clinical presentation of COVID-19-associated TMA, the cases showed no major deviations from the known presentation. Patients with TTP were treated with plasma exchange (88.9%) or fresh frozen plasma (11.1%), corticosteroids (88.9%), rituximab (38.9%), and caplacizumab (11.1%). Furthermore, 53.6% of patients with aHUS underwent plasma exchange with or without steroid as initial therapy, and 57.1% of patients received a C5 complement inhibitor. Mortality in the studied cohort was 16.7% for patients with TTP and 10.7% for patients with aHUS. The exact role of COVID-19 in the setting of COVID-19-associated TMA remains unclear. COVID-19 likely represents a second hit of aHUS or TTP that manifests in genetically predisposed individuals. Early identification of the TMA subtype and appropriate prompt and specific treatment could lead to good outcomes comparable to survival and recovery statistics for TMA of all causes.
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Affiliation(s)
- Marija Malgaj Vrečko
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Andreja Aleš Rigler
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Željka Večerić-Haler
- Department of Nephrology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
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Waggie KS, Snyder JM, Treuting PM. Acute renal injury from thrombotic microangiopathy associated with enteritis in New Zealand white rabbits. J Vet Diagn Invest 2022; 34:879-883. [PMID: 35949153 PMCID: PMC9446289 DOI: 10.1177/10406387221115139] [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: 11/15/2022] Open
Abstract
Over a 3-y period, 12 adult New Zealand white (NZW) rabbits were presented for postmortem examination following variably long periods of inappetence and soft-to-liquid stool production. Postmortem findings included serosanguineous fluid in abdominal and thoracic cavities, dark-red-to-white renal foci, reddened intestinal serosa, and pulmonary edema. Microscopically, mesangial changes and thrombi were observed in renal glomeruli, and mild-to-severe enteritis was observed. These findings resemble hemolytic uremic syndrome, which typically follows enterocolitis associated with Shiga toxin (Stx)-producing Escherichia coli infection. In our case series, various gram-negative bacteria, most commonly E. coli, were isolated from the intestinal tracts; however, Stx production was not demonstrated. Evidence of Encephalitozoon cuniculi infection, a common cause of renal disease in rabbits, was also not found. Our cases suggest that gram-negative enteric bacteria should be included in the differential diagnosis of renal disease in NZW rabbits, especially in cases with an accompanying clinical history of gastrointestinal disorder.
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Affiliation(s)
- Kimberly S. Waggie
- Department of Comparative Medicine, School of Medicine,
University of Washington, Seattle, WA, USA
| | - Jessica M. Snyder
- Department of Comparative Medicine, School of Medicine,
University of Washington, Seattle, WA, USA
| | - Piper M. Treuting
- Department of Comparative Medicine, School of Medicine,
University of Washington, Seattle, WA, USA
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Kim YJ. A new pathological perspective on thrombotic microangiopathy. Kidney Res Clin Pract 2022; 41:524-532. [PMID: 35791743 PMCID: PMC9576460 DOI: 10.23876/j.krcp.22.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Thrombotic microangiopathy (TMA) refers to a condition caused by microvascular injury that includes thrombosis, hemolytic anemia, and thrombocytopenia. There are two classic TMAs, hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura, as well as an atypical HUS (aHUS). aHUS includes a broad spectrum of disorders with diverse etiologies and shares clinical manifestations with classic TMA; however, it frequently lacks typical clinical and laboratory findings. These traits can confuse clinicians and pathologists in terms of renal pathologic diagnosis, especially in cases where TMA is associated with other glomerulopathies or hypertensive renal disease. In this review, new paradigms for classifying TMA and the diversity of histopathologic changes including associated renal diseases are discussed. Renal biopsy is an important and useful diagnostic tool for diagnosing TMA and identifying TMA changes in other renal diseases, including hypertension. Adopting the term “TMA features” for TMA-like changes in glomerulus or artery/arteriole in addition to the pathological diagnosis of glomerulopathy would be informative to clinicians for a prompt diagnosis and treatment of aHUS.
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Affiliation(s)
- Yong-Jin Kim
- Department of Pathology, Kyungpook National University Hospital, Daegu, Republic of Korea
- Correspondence: Yong-Jin Kim Department of Pathology, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea. E-mail:
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Witharana RA, Dissanayake A, Karunaratne I, Wijesinghe S. A Rare Case of Micro-Angiopathic Hemolytic Anemia Due to Envenoming by Giant Asian Honey Bee (Apis dorsata). Wilderness Environ Med 2021; 32:340-343. [PMID: 34030938 DOI: 10.1016/j.wem.2021.01.008] [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: 08/28/2020] [Revised: 01/10/2021] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Abstract
Giant Asian honey bee sting envenoming is a recognized cause of morbidity and mortality in rural Sri Lanka. Mass envenoming causes clinical effects, either as allergic and anaphylactic reactions or bee sting toxin-induced multiorgan damage. We report a patient who had mass envenoming from more than 1000 stingers who subsequently developed hematologic features suggestive of thrombotic microangiopathy-related hemolytic anemia. The transient acute kidney injury and acute hepatic failure seen in the patient were also considered to be secondary to thrombotic microangiopathy. A normal clotting profile and a high proportion of schistocytes in blood film ruled out disseminated intravascular coagulation as the underlying cause of the microangiopathic hemolytic anemia. The normal platelet count raised the possibility of a "partial" thrombotic microangiopathy, as has previously been reported in association with Shiga toxin-related hemolytic uremic syndrome and hump-nosed pit viper envenoming. Venom-induced direct toxicity on red cells was another possible explanation for the hemolysis, but the high proportion of schistocytes made it less likely. The place of therapeutic plasma exchange for venom-associated thrombotic microangiopathy is controversial. The patient recovered with symptomatic treatment and meticulous fluid management, without needing therapeutic plasma exchange as an adjunct treatment.
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Affiliation(s)
| | | | - Inoka Karunaratne
- Department of Zoology, University of Peradeniya, Peradeniya, Sri Lanka
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Noutsos T, Currie BJ, Brown SG, Isbister GK. Schistocyte quantitation, thrombotic microangiopathy and acute kidney injury in Australian snakebite coagulopathy [ASP28]. Int J Lab Hematol 2021; 43:959-965. [PMID: 33615713 PMCID: PMC8519151 DOI: 10.1111/ijlh.13497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/26/2021] [Accepted: 02/06/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The major systemic manifestation of hemotoxicity in human snakebite envenoming is venom-induced consumption coagulopathy (VICC). A subset of patients with VICC develop thrombotic microangiopathy (TMA), in which acute kidney injury (AKI) occurs. We aimed to investigate the association between schistocytosis in snakebite patients with VICC and AKI, compared to non-envenomed patients. METHODS Serial blood films collected from a prospective cohort of snakebite patients (Australian Snakebite Project) were examined. Cases were classified a priori as non-envenomed snakebites (normal controls), envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI based on defined clinical and laboratory criteria. The percentage of schistocytes between groups was compared and correlated by Kendall's tau b test. RESULTS Seven hundred and eighty blood films from 234 snakebite cases were analyzed. There was a statistically significant correlation (τ = .69, SE .03, P < .001) for schistocytosis between the ordered groups of non-envenomed snakebites, envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI groups. Patients with VICC and AKI had a platelet nadir median of 42 × 109 /L (interquartile range [IQR] :25-130 × 109 /L), hemoglobin nadir of median 107 g/L (IQR 66-122 g/L), and maximum LDH median of 1128 U/L (IQR 474-3255 U/L). A 1.0% threshold for schistocytosis yielded 90% sensitivity (95% CI: 67%-98%) and 71% specificity (95% CI: 62%-79%) for predicting AKI in patients with VICC. CONCLUSION Schistocyte quantitation has good diagnostic utility in snakebite patients with VICC. A definition of snakebite TMA as MAHA with ≥1.0% schistocytes and thrombocytopenia, would appear to be appropriate.
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Affiliation(s)
- Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Bart J Currie
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Simon G Brown
- Centre for Clinical Research in Emergency Medicine, University of Western Australia, Perth, WA, Australia.,Aeromedical and Medical Retrieval Division, Ambulance Tasmania, Hobart, TAS, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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Avila Bernabeu AI, Cavero Escribano T, Cao Vilarino M. Atypical Hemolytic Uremic Syndrome: New Challenges in the Complement Blockage Era. Nephron Clin Pract 2020; 144:537-549. [PMID: 32950988 DOI: 10.1159/000508920] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare cause of thrombotic microangiopathy (TMA), characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and multisystem end organ involvement, most commonly affecting the kidney. Diagnosis is clinical, after exclusion of other TMA causes. Primary aHUS arises from genetic abnormalities, resulting in uncontrolled complement activity, while a variety of clinical scenarios cause secondary aHUS, including infection, pregnancy, malignancy, autoimmune disease, and medications. They can also induce a temporary complement deregulation with an overlap between both scenarios, which can make differential diagnosis difficult. Primary aHUS can be sporadic or familial and is associated with a high rate of progression to ESRD. Many aHUS patients relapse in the native or transplanted kidneys, leading to kidney failure. The introduction of eculizumab has changed the prognosis of aHUS, by inducing hematologic remission, improving or stabilizing kidney functions, and preventing graft failure. The early institution of appropriate therapy can prevent multiorgan damage, so is essential to recognize and differentiate the TMA syndromes. Eculizumab is considered now the first-line treatment, and it is recommended lifelong therapy. However, the high cost of therapy has led to make efforts to develop precise complement functional and genetic studies that help physicians to determine the appropriate duration of eculizumab therapy. Nowadays, more studies are needed to select candidates to adjustment of therapy.
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Darshan R, Krishnamurthy S, Sivamurukan P, Kumar CGD, Dhayalini R, Gunasekaran D, Narayanan P, Ganesh RN. Anti-Complement Factor H Autoantibody-Associated Atypical Hemolytic Uremic Syndrome. Indian J Pediatr 2020; 87:462-463. [PMID: 31713210 DOI: 10.1007/s12098-019-03115-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rangaswamy Darshan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sriram Krishnamurthy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Palanisamy Sivamurukan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - C G Delhi Kumar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raj Dhayalini
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Dhandapany Gunasekaran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Parameswaran Narayanan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Rajesh Nachiappa Ganesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Daviet F, Rouby F, Poullin P, Moussi‐Francès J, Sallée M, Burtey S, Mancini J, Duffaud F, Sabatier R, Pourroy B, Grandvuillemin A, Grange S, Frémeaux‐Bacchi V, Coppo P, Micallef J, Jourde‐Chiche N. Thrombotic microangiopathy associated with gemcitabine use: Presentation and outcome in a national French retrospective cohort. Br J Clin Pharmacol 2019; 85:403-412. [PMID: 30394581 PMCID: PMC6339967 DOI: 10.1111/bcp.13808] [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: 07/09/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS Gemcitabine has been associated with thrombotic microangiopathy (TMA). We conducted a national retrospective study of gemcitabine-associated TMA (G-TMA). METHODS From 1998 to 2015, all cases of G-TMA reported to the French Pharmacovigilance Network and the French TMA Reference Center, and cases explored for complement alternative pathway abnormalities, were analysed. RESULTS G-TMA was diagnosed in 120 patients (median age 61.5 years), after a median of 210 days of treatment, and a cumulative dose of 12 941 mg m-2 . Gemcitabine indications were: pancreatic (52.9%), pulmonary (12.6%) and breast (7.6%) cancers, metastatic in 34.2% of cases. Main symptoms were oedema (56.7%) and new-onset or exacerbated hypertension (62.2%). Most patients presented with haemolytic anaemia (95.6%) and thrombocytopenia (74.6%). Acute kidney injury was reported in 97.4% and dialysis was required in 27.8% of patients. Treatment consisted of: plasma exchange (PE; 39.8%), fresh frozen plasma (21.4%), corticosteroids (15.3%) and eculizumab (5.1%). A complete remission of TMA was obtained in 42.1% of patients and haematological remission in 23.1%, while 34.7% did not improve. The survival status was known for 52 patients, with 29 deaths (54.7%). Patients treated with PE, despite a more severe acute kidney injury, requiring dialysis more frequently, displayed comparable rates of remission, but with more adverse events. No abnormality in complement alternative pathway was documented in patients explored. CONCLUSION This large cohort confirms the severity of G-TMA, associated with severe renal failure and death. Oedema and hypertension could be monitored in patients treated with gemcitabine to detect early TMA. The benefit of PE or eculizumab deserves further investigation.
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Affiliation(s)
- Florence Daviet
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Franck Rouby
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Pascale Poullin
- Department of Apheresis, Regional Reference Center for Thrombotic MicroangiopathyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Julie Moussi‐Francès
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Marion Sallée
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Stéphane Burtey
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Julien Mancini
- Department of Public HealthAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Florence Duffaud
- Department of Clinical OncologyAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Renaud Sabatier
- Department of Clinical Oncology, Institut Paoli Calmettes, Laboratory of Molecular OncologyAix‐Marseille UniversityCRCM INSERM UMR 1068MarseilleFrance
| | - Bertrand Pourroy
- Department of Parmacy, OncoPharma UnitAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | | | - Steven Grange
- Medical intensive care unit, Regional Center for Thrombotic Microangiopathy, Hôpital Charles NicolleRouen University HospitalRouenFrance
| | | | - Paul Coppo
- Department of Hematology, French Reference Center for Thrombotic Microangiopathy (www.cnr‐mat.fr)Paris 6 UniversityParisFrance
| | - Joëlle Micallef
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Noémie Jourde‐Chiche
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
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13
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Kara MA, Demircioğlu Kılıç B. Çocukluk Çağında Atipik Hemolitik Üremik Sendrom. DICLE MEDICAL JOURNAL 2018. [DOI: 10.5798/dicletip.497936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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Baghli S, Abendroth C, Farooq U, Schaub JA. Atypical Presentation of Pregnancy-Related Hemolytic Uremic Syndrome. Am J Kidney Dis 2018; 72:451-456. [DOI: 10.1053/j.ajkd.2017.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/08/2017] [Indexed: 01/27/2023]
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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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16
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Claes KJ, Massart A, Collard L, Weekers L, Goffin E, Pochet JM, Dahan K, Morelle J, Adams B, Broeders N, Stordeur P, Abramowicz D, Bosmans JL, Van Hoeck K, Janssens P, Pipeleers L, Peeters P, Van Laecke S, Levtchenko E, Sprangers B, van den Heuvel L, Godefroid N, Van de Walle J. Belgian consensus statement on the diagnosis and management of patients with atypical hemolytic uremic syndrome. Acta Clin Belg 2018; 73:80-89. [PMID: 29058539 DOI: 10.1080/17843286.2017.1345185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Kathleen J Claes
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Annick Massart
- Department of Nephrology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Laurent Weekers
- Department of Internal Medicine, Division of Nephrology, ULg, CHU Liège, Liège, Belgium
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Michel Pochet
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Karin Dahan
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institut de Génétique et de Pathologie, IPG, Gosselies, Belgium
| | - Johann Morelle
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Brigitte Adams
- Queen Fabiola Children’s University Hospital, Brussels, Belgium
| | - Nilufer Broeders
- Department of Nephrology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Stordeur
- Immunobiology Clinic, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, University Hospital Antwerp, Antwerp, Belgium
| | | | - Koen Van Hoeck
- Department of Pediatrics, University Hospital Antwerp, Antwerp, Belgium
| | - Peter Janssens
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussels, Brussels, Belgium
| | - Lissa Pipeleers
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussels, Brussels, Belgium
| | - Patrick Peeters
- Department of Nephrology, University Hospital Ghent, Ghent, Belgium
| | | | - Elena Levtchenko
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Nephrology, Department of Microbiology and Immunology, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Nathalie Godefroid
- Pediatric Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Johan Van de Walle
- Department of Pediatric Nephrology, University Hospital Ghent, Ghent, Belgium
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17
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Rafat C, Coppo P, Fakhouri F, Frémeaux-Bacchi V, Loirat C, Zuber J, Rondeau E. [Hemolytic and uremic syndrome and related thrombotic microangiopathies: Epidemiology, pathophysiology and clinics]. Rev Med Interne 2017; 38:817-824. [PMID: 28711159 DOI: 10.1016/j.revmed.2017.06.004] [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: 04/11/2017] [Accepted: 06/01/2017] [Indexed: 01/25/2023]
Abstract
Thrombotic microangiopathies (TMA) represent an eclectic group of conditions, which share hemolytic anemia and thrombocytopenia as a common defining basis. Remarkable breakthroughs in the physiopathological setting have allowed for a thorough recomposition of the disparate syndromes, which form the constellation of TMA. In this view, clinicians now discriminate thrombocytopenic thrombotic purpura (TTP) defined by a severe deficiency in ADAMTS13, which is rarely associated with a severe renal involvement and the hemolytic and uremic syndrome (HUS) in which renal impairment is the most prominent clinical feature. HUS can result from toxins stemming from bacterial infections of the digestive tract, alternate complement pathway abnormalities, metabolic or coagulation disorders or, lastly, drug and various toxic compounds. The diverse forms of HUS reflect the insights gained in the understanding of the pathophysiological mechanisms underpinning TMA. In this first part, a broad overview of the epidemiological, physiopathological and clinical aspects of HUS and related TMA syndromes is presented.
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Affiliation(s)
- C Rafat
- Urgences néphrologiques et transplantation rénale, hôpital Tenon, Assistance publique des Hôpitaux de Paris, Paris, France; Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France.
| | - P Coppo
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service d'hématologie, hôpital Saint-Antoine, Assistance publique des Hôpitaux de Paris, Paris, France; Unité Inserm UMR 1170, Villejuif, France
| | - F Fakhouri
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service de néphrologie et d'immunologie, unité Inserm UMR 643, centre hospitalo-universitaire de Nantes, Nantes, France
| | - V Frémeaux-Bacchi
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Laboratoire d'immunologie, hôpital européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, Paris, France
| | - C Loirat
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service de néphrologie pédiatrique, hôpital Robert-Debré, Assistance publique des Hôpitaux de Paris, Paris, France
| | - J Zuber
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service de transplantation rénale, unité Inserm UMR_S1163, institut imagine, hôpital Necker, Assistance publique des Hôpitaux de Paris, Paris, France
| | - E Rondeau
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Urgences néphrologiques et transplantation rénale, unité Inserm UMR 1155, hôpital Tenon, Assistance publique des Hôpitaux de Paris, Paris, France
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18
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Wöchtl B, Gunzer F, Gerner W, Gasse H, Koch M, Bagó Z, Ganter M, Weissenböck H, Dinhopl N, Coldewey SM, von Altrock A, Waldmann KH, Saalmüller A, Zimmermann K, Steinmann J, Kehrmann J, Klein-Hitpass L, Blom J, Ehricht R, Engelmann I, Hennig-Pauka I. Comparison of clinical and immunological findings in gnotobiotic piglets infected with Escherichia coli O104:H4 outbreak strain and EHEC O157:H7. Gut Pathog 2017; 9:30. [PMID: 28559930 PMCID: PMC5445466 DOI: 10.1186/s13099-017-0179-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/17/2017] [Indexed: 11/26/2022] Open
Abstract
Background Shiga toxin (Stx) producing Escherichia coli (E. coli) (STEC) is the most frequent cause of diarrhoea-positive haemolytic uraemic syndrome (D + HUS) in humans. In 2011, a huge outbreak with an STEC O104:H4 strain in Germany highlighted the limited possibilities for causative treatment of this syndrome. The responsible STEC strain was found to combine Stx production with adherence mechanisms normally found in enteroaggregative E. coli (EAEC). Pathotypes of E. coli evolve and can exhibit different adhesion mechanisms. It has been shown previously that neonatal gnotobiotic piglets are susceptible for infection with STEC, such as STEC O157:H7 as well as for EAEC, which are considered to be the phylogenetic origin of E. coli O104:H4. This study was designed to characterise the host response to infection with the STEC O104:H4 outbreak strain in comparison to an STEC O157:H7 isolate by evaluating clinical parameters (scoring) and markers of organ dysfunction (biochemistry), as well as immunological (flow cytometry, assessment of cytokines/chemokines and acute phase proteins) and histological alterations (light- and electron microscopy) in a gnotobiotic piglet model of haemolytic uraemic syndrome. Results We observed severe clinical symptoms, such as diarrhoea, dehydration and neurological disorders as well as attaching-and-effacing lesions (A/E) in the colon in STEC O157:H7 infected piglets. In contrast, STEC O104:H4 challenged animals exhibited only mild clinical symptoms including diarrhoea and dehydration and HUS-specific/severe histopathological, haematological and biochemical alterations were only inconsistently presented by individual piglets. A specific adherence phenotype of STEC O104:H4 could not be observed. Flow cytometric analyses of lymphocytes derived from infected animals revealed an increase of natural killer cells (NK cells) during the course of infection revealing a potential role of this subset in the anti-bacterial activity in STEC disease. Conclusions Unexpectedly, E. coli O104:H4 infection caused only mild symptoms and minor changes in histology and blood parameters in piglets. Outcome of the infection trial does not reflect E. coli O104:H4 associated human disease as observed during the outbreak in 2011. The potential role of cells of the innate immune system for STEC related disease pathogenesis should be further elucidated.
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Affiliation(s)
- Bettina Wöchtl
- University Clinic for Swine, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Florian Gunzer
- Institute of Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Wilhelm Gerner
- Institute of Immunology, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Hagen Gasse
- Institute of Anatomy, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Michaela Koch
- University Clinic for Swine, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Zoltán Bagó
- Institute for Veterinary Disease Control Mödling, Austrian Agency for Health and Food Safety, Robert-Koch-Gasse 17, 2340 Mödling, Austria
| | - Martin Ganter
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Herbert Weissenböck
- Institute for Pathology and Forensic Veterinary Medicine, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Nora Dinhopl
- Institute for Pathology and Forensic Veterinary Medicine, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany.,Centre for Innovation Competence (ZIK) Septomics, University Hospital Jena, Albert-Einstein-Strasse 10, 07745 Jena, Germany
| | - Alexandra von Altrock
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Karl-Heinz Waldmann
- Clinic for Swine, Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine Hannover, Foundation, Bischofsholer Damm 15, 30173 Hannover, Germany
| | - Armin Saalmüller
- Institute of Immunology, Department of Pathobiology, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
| | | | - Jörg Steinmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Jan Kehrmann
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Ludger Klein-Hitpass
- Institute of Cell Biology, Medical Faculty, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Jochen Blom
- Bioinformatics and Systems Biology, Justus-Liebig-University Giessen, Heinrich-Buff-Ring 58, 35392 Gießen, Germany
| | - Ralf Ehricht
- Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany
| | - Ines Engelmann
- Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany
| | - Isabel Hennig-Pauka
- University Clinic for Swine, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, Veterinärplatz 1, 1220 Vienna, Austria
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19
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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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20
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Timmermans SAMEG, Abdul-Hamid MA, Vanderlocht J, Damoiseaux JGMC, Reutelingsperger CP, van Paassen P. Patients with hypertension-associated thrombotic microangiopathy may present with complement abnormalities. Kidney Int 2017; 91:1420-1425. [PMID: 28187980 DOI: 10.1016/j.kint.2016.12.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/24/2016] [Accepted: 12/08/2016] [Indexed: 12/11/2022]
Abstract
Thrombotic microangiopathy (TMA) is a pattern of endothelial damage that can be found in association with diverse clinical conditions such as malignant hypertension. Although the pathophysiological mechanisms differ, accumulating evidence links complement dysregulation to various TMA syndromes and in particular the atypical hemolytic uremic syndrome. Here, we evaluated the role of complement in nine consecutive patients with biopsy-proven renal TMA attributed to severe hypertension. Profound hematologic symptoms of TMA were uncommon. In six out of nine patients, we found mutations C3 in three, CFI in one, CD46 in one, and/or CFH in two patients either with or without the risk CFH-H3 haplotype in four patients. Elevated levels of the soluble C5b-9 and renal deposits of C3c and C5b-9 along the vasculature and/or glomerular capillary wall, confirmed complement activation in vivo. In contrast to patients without genetic defects, patients with complement defects invariably progressed to end-stage renal disease, and disease recurrence after kidney transplantation seems common. Thus, a subset of patients with hypertension-associated TMA falls within the spectrum of complement-mediated TMA, the prognosis of which is poor. Hence, testing for genetic complement abnormalities is warranted in patients with severe hypertension and TMA on renal biopsy to adopt suitable treatment options and prophylactic measures.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Myrurgia A Abdul-Hamid
- Department of Pathology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Joris Vanderlocht
- Department of Transplantation Immunology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Chris P Reutelingsperger
- Deptartment of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Centre, Maastricht, the Netherlands.
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21
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Isnard P, Labaye J, Bourgault M, Sarret D, Hérody M. [TTP or HUS? About a case revealing an IgA nephropathy]. Nephrol Ther 2016; 10:532-6. [PMID: 25458228 DOI: 10.1016/j.nephro.2014.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 09/09/2014] [Accepted: 10/07/2014] [Indexed: 02/02/2023]
Abstract
Thrombotic microangiopathy includes a set of conditions characterized by the association of mechanical hemolytic anemia, thrombocytopenia and organ failure which accurate diagnosis is sometimes difficult. We report the case of a patient who presented a thrombotic microangiopathy (TMA) due to an atypical hemolytic and uremic syndrome (HUS) associated with an immunoglobulin A (IgA) nephropathy with a favorable outcome under corticosteroid.
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Affiliation(s)
- Pierre Isnard
- Service de néphrologie, hôpital d’instruction des armées du Val-De-Grâce, 74, boulevard de Port-Royal, 75230 Paris cedex 05, France.
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22
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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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Kozlovskaya NL, Chebotareva NV, Nikogosova AD, Demyanova KA, Varshavsky VA, Roshchupkina SV. [Incomplete thrombotic microangiopathy as a variant of hemolytic-uremic syndrome]. TERAPEVT ARKH 2016; 88:77-79. [PMID: 27296266 DOI: 10.17116/terarkh201688677-79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The described case illustrates difficulties in diagnosing atypical hemolytic-uremic syndrome (aHUS) in incomplete thrombotic microangiopathy (TMA) in the absence of thrombocytopenia, one of the signs of the classic triad of aHUS, which has resulted in the delayed verification of its diagnosis and in progressive kidney injury. The paper discusses the need to carry out kidney biopsy and to include sHUS in both the presence of a complete set of symptoms of this disease and in the absence of one of them into a range of diagnostic search.
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Affiliation(s)
- N L Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - N V Chebotareva
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - A D Nikogosova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - K A Demyanova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - V A Varshavsky
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - S V Roshchupkina
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
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Improved renal recovery in patients with atypical hemolytic uremic syndrome following rapid initiation of eculizumab treatment. J Nephrol 2016; 30:127-134. [PMID: 26995002 PMCID: PMC5316393 DOI: 10.1007/s40620-016-0288-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/13/2016] [Indexed: 11/30/2022]
Abstract
Background Eculizumab is approved for atypical hemolytic uremic syndrome (aHUS). Guidelines discuss the importance of prompt treatment. We report a post hoc analysis investigating the effect of baseline factors, including patient characteristics and time from the latest aHUS manifestation to eculizumab initiation, on change from baseline in estimated glomerular filtration rate (eGFR) and other outcomes. Methods Data were pooled from four phase 2, open-label, single-arm, prospective clinical studies of eculizumab for patients with aHUS. Multivariate regressions identified predictors of eGFR change from baseline. The proportion of patients achieving sustained eGFR increase (defined: ≥15 ml/min/1.73 m2 for ≥28 days) and platelet count normalization were evaluated 1 year post-treatment. Baseline characteristics and eGFR outcomes were summarized by time to treatment from last aHUS manifestation [≤7 days (n = 21) versus >7 days (n = 76)]. Results Baseline eGFR were similar between groups. Multivariate regression analysis demonstrated time from aHUS manifestation to eculizumab treatment, age, baseline lactate dehydrogenase (LDH) and baseline hemoglobin were independently predictive of eGFR change from baseline. Mean eGFR change from baseline at 1 year was significantly higher in patients treated in ≤7 days than >7 days (57 vs. 23 ml/min/1.73 m2, p = 0.0098). After 1 year, 17/21 and 36/76 patients in the ≤7 and >7 day groups, respectively, achieved a sustained increase in eGFR. Mean time to platelet count normalization was similar between groups. Conclusions Younger age, higher baseline LDH and lower baseline hemoglobin were associated with greater eGFR improvements. Early eculizumab initiation led to improved renal recovery, demonstrating the importance of rapid diagnosis and treatment of patients with aHUS. Electronic supplementary material The online version of this article (doi:10.1007/s40620-016-0288-3) contains supplementary material, which is available to authorized users.
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Fakhouri F, Delmas Y, Provot F, Barbet C, Karras A, Makdassi R, Courivaud C, Rifard K, Servais A, Allard C, Besson V, Cousin M, Châtelet V, Goujon JM, Coindre JP, Laurent G, Loirat C, Frémeaux-Bacchi V. Insights From the Use in Clinical Practice of Eculizumab in Adult Patients With Atypical Hemolytic Uremic Syndrome Affecting the Native Kidneys: An Analysis of 19 Cases. Am J Kidney Dis 2014; 63:40-8. [DOI: 10.1053/j.ajkd.2013.07.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 07/16/2013] [Indexed: 01/06/2023]
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Fakhouri F, Frémeaux-Bacchi V, Loirat C. Atypical hemolytic uremic syndrome: from the rediscovery of complement to targeted therapy. Eur J Intern Med 2013; 24:492-5. [PMID: 23756030 DOI: 10.1016/j.ejim.2013.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a devastating form of renal thrombotic microangiopathy. In the last five years, we have finally witnessed a dramatic improvement in the management of aHUS patients, and three breakthroughs in our understanding of aHUS have led to such an improvement. The first breakthrough was the emergence of a new clinical picture of aHUS (frequency of adult cases, and overall poor renal prognosis despite plasma therapy). The second breakthrough was the identification of complement alternative pathway dysregulation as a major risk factor for aHUS. The third breakthrough was the availability in clinical practice of the first complement inhibitor, the anti-C5 monoclonal antibody, eculizumab. Available data from case series and prospective studies indicate that eculizumab use has dramatically improved the renal prognosis of aHUS. These breakthroughs have prompted the French working group on aHUS to propose a new algorithm for the management of aHUS in children and in adults. This algorithm will evolve as we gain new insights in the pathogenesis and evolution of aHUS in the eculizumab era.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology and Immunology, CHU de Nantes, ITUN and INSERM UMR S-1064, Nantes, France.
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