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Gork I, Xiong F, Kitchlu A. Cancer drugs and acute kidney injury: new therapies and new challenges. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00164. [PMID: 38712677 DOI: 10.1097/mnh.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW Cancer therapies continue to evolve at a rapid pace and although novel treatments, including immunotherapies and targeted therapies have allowed for substantial improvements in cancer survival, they carry associated risks of acute kidney injury (AKI). We aim to summarize the existing literature on AKI associated with the spectrum of systemic cancer treatments, including conventional chemotherapies, newer immunotherapies, and the growing number of targeted cancer therapies, which may be associated with both AKI and 'pseudo-AKI'. RECENT FINDINGS Conventional cytotoxic chemotherapies (e.g. cisplatin and other platinum-based agents, methotrexate, pemetrexed, ifosfamide, etc.) with well recognized nephrotoxicities (predominantly tubulointerstitial injury) remain in widespread use. Immunotherapies (e.g., immune checkpoint inhibitors and CAR-T therapies) may be associated with kidney immune-related adverse events, most often acute interstitial nephritis, and rarely, glomerular disease. Recently, multiple targeted cancer therapies have been associated with reduced renal tubular secretion of creatinine, causing elevations in serum creatinine and apparent 'pseudo-AKI'. To complicate matters further, these agents have had biopsy-proven, 'true' kidney injury attributed to them in numerous case reports. SUMMARY Clinicians in nephrology and oncology must be aware of the various potential kidney risks with these agents and recognize those with clinically meaningful impact on both cancer and kidney outcomes.
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Affiliation(s)
- Ittamar Gork
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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2
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Jha VK, Akal RS, Mahapatra D, Sharma A, Singh BP, Arora R. Nephrotic Syndrome and Posterior Reversible Encephalopathy Syndrome as Clinical Presentations of Gemcitabine-Induced Thrombotic Micro-Angiopathy. Indian J Nephrol 2024; 34:74-78. [PMID: 38645915 PMCID: PMC11003583 DOI: 10.4103/ijn.ijn_277_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/18/2022] [Indexed: 04/23/2024] Open
Abstract
Gemcitabine-induced thrombotic micro-angiopathy (GiTMA) is a very rare pathology of micro-vascular occlusion with a poor prognosis. In this case report, we present a young male with pancreatic carcinoma who received gemcitabine as adjuvant chemotherapy and developed thrombotic micro-angiopathy (TMA) manifesting as nephrotic syndrome with renal dysfunction and posterior reversible encephalopathy syndrome (PRES). The case was successfully managed with discontinuation of the drug and conservative management. The pathogenesis of GiTMA might be direct endothelial dysfunction with consequent activation of the clotting system. The role of plasma exchanges and monoclonal antibodies is unclear in drug-induced TMA.
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Affiliation(s)
- Vijoy Kumar Jha
- Department of Nephrology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Ramanjit Singh Akal
- Department of Nephrology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Debasish Mahapatra
- Department of Nephrology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Alok Sharma
- Department of Renal Pathology and Electron Microscopy, Lal PathLabs Limited, New Delhi, India
| | - Bhanu Pratap Singh
- Department of Radiology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Rahil Arora
- Department of Medicine, Command Hospital Air Force, Bengaluru, Karnataka, India
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3
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Chaudhary A, Sethi J, Garg S, Sekar A, Kohli HS. Gemcitabine-Induced Renal Thrombotic Microangiopathy. Indian J Nephrol 2023; 33:319-320. [PMID: 37781548 PMCID: PMC10503579 DOI: 10.4103/ijn.ijn_321_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/19/2022] [Indexed: 10/03/2023] Open
Affiliation(s)
- Ankur Chaudhary
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmine Sethi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahil Garg
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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4
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Aklilu AM, Shirali AC. Chemotherapy-Associated Thrombotic Microangiopathy. KIDNEY360 2023; 4:409-422. [PMID: 36706238 PMCID: PMC10103319 DOI: 10.34067/kid.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023]
Abstract
Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as antiangiogenesis agents and proteasome inhibitors have been implicated in oncotherapy-associated TMA. Among TMA subtypes, drug-induced TMA is less well-understood. Treatment generally involves withdrawal of the offending agent and supportive care targeting blood pressure and proteinuria reduction. Immunosuppression and therapeutic plasma exchange have not shown clear benefit. The terminal complement inhibitor, eculizumab, has shown promising results in some cases of chemotherapy-associated TMA including in re-exposure. However, the data are limited, and unlike in primary atypical hemolytic uremic syndrome, the role of complement in the pathogenesis of drug-induced TMA is unclear. Larger multicenter studies and unified definitions are needed to elucidate the extent of the problem and potential treatment strategies.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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5
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Sabulski A, Jodele S. Peering into the darkness of drug-induced thrombotic microangiopathy: complement, are you in there? J Gastrointest Oncol 2023; 14:468-471. [PMID: 36915433 PMCID: PMC10007918 DOI: 10.21037/jgo-2022-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/20/2022] [Indexed: 03/03/2023] Open
Affiliation(s)
- Anthony Sabulski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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6
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Van den Eeckhaut L, Hannon H, Schurgers M, Monsaert E, Claes K. Gemcitabine-induced thrombotic microangiopathy treated with eculizumab: a case report. J Gastrointest Oncol 2022; 13:3314-3320. [PMID: 36636054 PMCID: PMC9830318 DOI: 10.21037/jgo-22-509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022] Open
Abstract
Background Gemcitabine is a broadly used chemotherapeutic agent that can cause a rare but life-threatening complication called thrombotic microangiopathy (TMA). Early recognition is crucial as therapy options are limited. Case Description We report the case of a 46-year-old patient with pancreatic adenocarcinoma who presented with severe anemia and thrombocytopenia as well as acute kidney injury. A diagnosis of gemcitabine-induced TMA was made. He became rapidly transfusion and dialysis dependent. Despite discontinuation of gemcitabine and treatment with high-dose corticotherapy as well as plasmapheresis, no improvement in both renal and hematological parameters was seen. Treatment with eculizumab was initiated. One week after the first administration, the patient no longer required packed cells nor platelet transfusions and one month later, dialysis could be discontinued. After five doses, treatment with eculizumab was stopped. Four months later, his serum creatinine was 1 mg/dL. Conclusions This case report illustrates the promising beneficial effects of eculizumab in gemcitabine-induced TMA, both regarding transfusion dependence as well as improvement in renal function, thereby allowing further therapy options in patients with an active malignancy.
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Affiliation(s)
| | - Heidi Hannon
- Department of Nephrology, AZ Maria Middelares, Ghent, Belgium
| | - Marie Schurgers
- Department of Nephrology, AZ Maria Middelares, Ghent, Belgium
| | - Els Monsaert
- Department of Gastroenterology, AZ Maria Middelares, Ghent, Belgium
| | - Kathleen Claes
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium.,Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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7
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Ghumman GM, Fatima H, Johnston TL, Leis R, Khatri V. Gemcitabine-Induced Thrombotic Microangiopathy Managed Conservatively in a Patient of Breast Cancer. Cureus 2022; 14:e28433. [PMID: 36176826 PMCID: PMC9509686 DOI: 10.7759/cureus.28433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
Thrombotic microangiopathy (TMA) consists of a group of occlusive microvascular disorders, which include thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TMA can be classified as primary or secondary based on the etiology. Gemcitabine-induced TMA is a rare side effect of the drug with varying clinical presentations. We present a case involving the classic triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and renal failure associated with gemcitabine. Gemcitabine was immediately stopped, and our patient's condition improved with conservative management.
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8
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Raina R, Abu-Arja R, Sethi S, Dua R, Chakraborty R, Dibb JT, Basu RK, Bissler J, Felix MB, Brophy P, Bunchman T, Alhasan K, Haffner D, Kim YH, Licht C, McCulloch M, Menon S, Onder AM, Khooblall P, Khooblall A, Polishchuk V, Rangarajan H, Sultana A, Kashtan C. Acute kidney injury in pediatric hematopoietic cell transplantation: critical appraisal and consensus. Pediatr Nephrol 2022; 37:1179-1203. [PMID: 35224659 DOI: 10.1007/s00467-022-05448-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a common therapy for the treatment of neoplastic and metabolic disorders, hematological diseases, and fatal immunological deficiencies. HCT can be subcategorized as autologous or allogeneic, with each modality being associated with their own benefits, risks, and post-transplant complications. One of the most common complications includes acute kidney injury (AKI). However, diagnosing HCT patients with AKI early on remains quite difficult. Therefore, this evidence-based guideline, compiled by the Pediatric Continuous Renal Replacement Therapy (PCRRT) working group, presents the various factors that contribute to AKI and recommendations regarding optimization of therapy with minimal complications in HCT patients.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Richa Dua
- Monmouth Medical Center, Long Branch, NJ, USA
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - James T Dibb
- Department of Internal Medicine, Summa Health System - Akron Campus, Akron, OH, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - John Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Melvin Bonilla Felix
- Department of Pediatrics, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Patrick Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Khalid Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Christopher Licht
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Shina Menon
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Ali Mirza Onder
- Division of Pediatric Nephrology, Le Bonheur Children's Hospital, University of Tennessee, School of Medicine, Memphis, TN, USA
- Division of Pediatric Nephrology, Batson Children's Hospital of Mississippi, University of Mississippi Medical Center, Jackson, MS, USA
| | - Prajit Khooblall
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Veronika Polishchuk
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Hemalatha Rangarajan
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Azmeri Sultana
- Department of Pediatric Nephrology, MR Khan Hospital & Institute of Child Health, Mirpur-2, Dhaka, Bangladesh
| | - Clifford Kashtan
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
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9
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Hanna RM, Henriksen K, Kalantar-Zadeh K, Ferrey A, Burwick R, Jhaveri KD. Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers. Adv Chronic Kidney Dis 2022; 29:149-160.e1. [PMID: 35817522 DOI: 10.1053/j.ackd.2021.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/11/2022]
Abstract
Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.
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Affiliation(s)
- Ramy M Hanna
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA.
| | - Kammi Henriksen
- Department of Pathology, University of Chicago Medical Center, Chicago, IL
| | - Kamyar Kalantar-Zadeh
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Antoney Ferrey
- UCI Medical Center Department of Medicine, Division of Nephrology, University of California Irvine, Orange, CA
| | - Richard Burwick
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Kenar D Jhaveri
- Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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10
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Braet P, Sartò GVR, Pirovano M, Sprangers B, Cosmai L. Treatment of Acute Kidney Injury in Cancer Patients. Clin Kidney J 2021; 15:873-884. [PMID: 35498895 PMCID: PMC9050558 DOI: 10.1093/ckj/sfab292] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Indexed: 11/22/2022] Open
Abstract
Acute kidney injury (AKI), either of pre-renal, renal or post-renal origin, is an important complication in cancer patients, resulting in worse prognosis, withdrawal from effective oncological treatments, longer hospitalizations and increased costs. The aim of this article is to provide a literature review of general and cause-specific treatment strategies for AKI, providing a helpful guide for clinical practice. We propose to classify AKI as patient-related, cancer-related and treatment-related in order to optimize therapeutic interventions. In the setting of patient-related causes, proper assessment of hydration status and avoidance of concomitant nephrotoxic medications is key. Cancer-related causes mainly encompass urinary compression/obstruction, direct tumoural kidney involvement and cancer-induced hypercalcaemia. Rapid recognition and specific treatment can potentially restore renal function. Finally, a pre-treatment comprehensive evaluation of risks and benefits of each treatment should always be performed to identify patients at high risk of treatment-related renal damage and allow the implementation of preventive measures without losing the potentialities of the oncological treatment. Considering the complexity of this field, a multidisciplinary approach is necessary with the goal of reducing the incidence of AKI in cancer patients and improving patient outcomes. The overriding research goal in this area is to gather higher quality data from international collaborative studies.
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Affiliation(s)
- Pauline Braet
- Division of Nephrology, Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Giulia Vanessa Re Sartò
- Onconephrology Outpatients Clinic, Nephrology and Dialysis, ASST Santi Carlo e Paolo, Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Marta Pirovano
- Onconephrology Outpatients Clinic, Nephrology and Dialysis, ASST Santi Carlo e Paolo, Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Ben Sprangers
- Division of Nephrology, Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Laura Cosmai
- Onconephrology Outpatients Clinic, Nephrology and Dialysis, ASST Santi Carlo e Paolo, Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
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11
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Gupta S, Portales-Castillo I, Daher A, Kitchlu A. Conventional Chemotherapy Nephrotoxicity. Adv Chronic Kidney Dis 2021; 28:402-414.e1. [PMID: 35190107 DOI: 10.1053/j.ackd.2021.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 12/27/2022]
Abstract
Conventional chemotherapies remain the mainstay of treatment for many malignancies. Kidney complications of these therapies are not infrequent and may have serious implications for future kidney function, cancer treatment options, eligibility for clinical trials, and overall survival. Kidney adverse effects may include acute kidney injury (via tubular injury, tubulointerstitial nephritis, glomerular disease and thrombotic microangiopathy), long-term kidney function loss and CKD, and electrolyte disturbances. In this review, we summarize the kidney complications of conventional forms of chemotherapy and, where possible, provide estimates of incidence, and identify risk factors and strategies for kidney risk mitigation. In addition, we provide recommendations regarding kidney dose modifications, recognizing that these adjustments may be limited by available supporting pharmacokinetic and clinical outcomes data. We discuss management strategies for kidney adverse effects associated with these therapies with drug-specific recommendations. We focus on frequently used anticancer agents with established kidney complications, including platinum-based chemotherapies (cisplatin, carboplatin, oxaliplatin), cyclophosphamide, gemcitabine, ifosfamide, methotrexate and pemetrexed, among others.
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12
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Gabr JB, Bilal H, Mirchia K, Perl A. The Use of Eculizumab in Tacrolimus-Induced Thrombotic Microangiopathy. J Investig Med High Impact Case Rep 2021; 8:2324709620947266. [PMID: 32757799 PMCID: PMC7412890 DOI: 10.1177/2324709620947266] [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] [Indexed: 11/23/2022] Open
Abstract
Drug-induced thrombotic microangiopathy (DITMA) is a secondary cause of thrombotic microangiopathy and a potentially fatal inflammatory disease. DITMA has been attributed to a variety of drugs, particularly chemotherapeutic and immunosuppressive agents. Prompt diagnosis is critical for survival and treatment necessitates withdrawal of the offending drug; however, many cases require further treatment including plasmapheresis, immunosuppression, and anticoagulation. In this article, we report a cutaneous biopsy-proven case of tacrolimus-induced DITMA, which was successfully treated with eculizumab after failing the conventional standard of care.
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Affiliation(s)
| | - Hiba Bilal
- SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Andras Perl
- SUNY Upstate Medical University, Syracuse, NY, USA
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How I treat microangiopathic hemolytic anemia in patients with cancer. Blood 2021; 137:1310-1317. [PMID: 33512445 PMCID: PMC8555418 DOI: 10.1182/blood.2019003810] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022] Open
Abstract
Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.
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14
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Grall M, Daviet F, Chiche NJ, Provot F, Presne C, Coindre JP, Pouteil-Noble C, Karras A, Guerrot D, François A, Benhamou Y, Veyradier A, Frémeaux-Bacchi V, Coppo P, Grangé S. Eculizumab in gemcitabine-induced thrombotic microangiopathy: experience of the French thrombotic microangiopathies reference centre. BMC Nephrol 2021; 22:267. [PMID: 34284729 PMCID: PMC8293501 DOI: 10.1186/s12882-021-02470-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gemcitabine is a broadly prescribed chemotherapy, the use of which can be limited by renal adverse events, including thrombotic microangiopathy (TMA). METHODS This study evaluated the efficacy of eculizumab, a monoclonal antibody targeting the terminal complement pathway, in patients with gemcitabine-induced TMA (G-TMA). We conducted an observational, retrospective, multicenter study in 5 French centres, between 2011 and 2016. RESULTS Twelve patients with a G-TMA treated by eculizumab were included. The main characteristics were acute renal failure (100%), including stage 3 acute kidney injury (AKI, 58%) and renal replacement therapy (17%), hypertension (92%) and diffuse oedema (83%). Eculizumab was started after a median of 15 days (range 4-44) following TMA diagnosis. A median of 4 injections of eculizumab was performed (range 2-22). Complete hematological remission was achieved in 10 patients (83%) and blood transfusion significantly decreased after only one injection of eculizumab (median of 3 packed red blood cells (range 0-10) before treatment vs 0 (range 0-1) after one injection, P < 0.001). Two patients recovered completely renal function (17%), and 8 achieved a partial remission (67%). Compared to a control group of G-TMA without use of eculizumab, renal outcome was more favourable. At the end of the follow up, median eGFR was 45 vs 33 ml/min/1.73m2 respectively in the eculizumab group and in the control group. CONCLUSIONS These results suggest that eculizumab is efficient on haemolysis and reduces transfusion requirement in G-TMA. Moreover, eculizumab may improve renal function recovery.
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Affiliation(s)
- Maximilien Grall
- Medical Intensive Care Unit, Rouen University Hospital, 37 boulevard Gambetta, 76031, Rouen Cedex, France
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
| | - Florence Daviet
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Conception University Hospital, APHM, Marseille, France
| | - Noémie Jourde Chiche
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Conception University Hospital, APHM, Marseille, France
| | - François Provot
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Lille University Hospital, Lille, France
| | - Claire Presne
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Amiens University Hospital, Amiens, France
| | - Jean-Philippe Coindre
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, Le Mans General Hospital, Le Mans, France
| | - Claire Pouteil-Noble
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Nephrology, E. Herriot Hospital, Lyon I university, Lyon, France
| | - Alexandre Karras
- Department of Nephrology, Georges Pompidou Hospital, APHP, Paris, France
| | | | - Arnaud François
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Ygal Benhamou
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Internal Medicine, Rouen University Hospital, Rouen, France
| | - Agnès Veyradier
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Biological Hematology, Lariboisière University Hospital, APHP, Paris, France
| | - Véronique Frémeaux-Bacchi
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of immunology, Georges Pompidou Hospital, APHP, Paris, France
| | - Paul Coppo
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
- Department of Hematology, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France
| | - Steven Grangé
- Medical Intensive Care Unit, Rouen University Hospital, 37 boulevard Gambetta, 76031, Rouen Cedex, France.
- French TMA Reference Centre, Hopital Saint-Antoine, Sorbonne Université, AP-HP, Paris, France.
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15
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Cervantes CE, Kant S, Atta MG. The Link Between Conventional and Novel Anti-Cancer Therapeutics with Thrombotic Microangiopathy. Drug Metab Lett 2021; 14:97-105. [PMID: 34279209 DOI: 10.2174/1872312814666210716141633] [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: 01/06/2021] [Revised: 04/28/2021] [Accepted: 05/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Kidney disease associated with cancer and anti-cancer therapies has been increasingly recognized in the field of onco-nephrology. In particular, drug-induced nephrotoxicity has important implications since most chemotherapeutic agents have a nephrotoxic potential. Also, standard creatinine clearance methods used for the measurement of kidney function have been questioned in cancer patients due to factors like low muscle mass and poor nutritional status. Overestimations of the glomerular filtration rate, not only can increase the nephrotoxic potential of different agents, but also further limit the use of first-line therapies. OBJECTIVE This review covers specifically the drug-induced thrombotic microangiopathy and its two pathophysiologic mechanisms which include immune or idiosyncratic reactions, and non-immune or dose-dependent ones. CONCLUSION As novel cancer therapies are developed, it is paramount to pursue a better understanding of conventional and novel chemotherapeutic agents and their role in kidney disease.
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Affiliation(s)
- Carmen E Cervantes
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
| | - Sam Kant
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
| | - Mohamed G Atta
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
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16
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Valério P, Barreto JP, Ferreira H, Chuva T, Paiva A, Costa JM. Thrombotic microangiopathy in oncology - a review. Transl Oncol 2021; 14:101081. [PMID: 33862523 PMCID: PMC8065296 DOI: 10.1016/j.tranon.2021.101081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Thrombotic microangiopathy is a syndrome triggered by a wide spectrum of situations, some of which are specific to the Oncology setting. It is characterized by a Coombs-negative microangiopathic haemolytic anemia, thrombocytopenia and organ injury, with characteristic pathological features, resulting from platelet microvascular occlusion. TMA is rare and its cancer-related subset even more so. TMA triggered by drugs is the most common within this group, including classic chemotherapy and the latest targeted therapies. The neoplastic disease itself and hematopoietic stem-cell transplantation could also be potential triggers. Evidence-based medical guidance in the management of cancer-related TMA is scarce and the previous knowledge about primary TMA is valuable to understand the disease mechanisms and the potential treatments. Given the wide spectrum of potential causes for TMA in cancer patients, the aim of this review is to gather the vast information available. For each entity, pathophysiology, clinical features, therapeutic approaches and prognosis will be covered.
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Affiliation(s)
- Patrícia Valério
- Nephrology Department, Setúbal Hospital Center, Portugal Rua Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal.
| | - João Pedro Barreto
- Laboratory Diagnosis Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Hugo Ferreira
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Teresa Chuva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - Ana Paiva
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
| | - José Maximino Costa
- Nephrology Department, Portuguese Oncology Institute of Porto, Portugal Rua Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
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17
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MacDougall KN, Schwartz B, Harewood J, Bukhari Z, Neculiseanu E. A Case of Gemcitabine-Induced Thrombotic Microangiopathy Treated With Ravulizumab in a Patient With Stage IV Pancreatic Cancer. Cureus 2021; 13:e13031. [PMID: 33680585 PMCID: PMC7931775 DOI: 10.7759/cureus.13031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 47-year-old male with stage IV pancreatic cancer developed gemcitabine-induced thrombotic microangiopathy (GiTMA) after treatment with gemcitabine and nab-paclitaxel. GiTMA is a rare and life-threatening complication with an incidence ranging from 0.015% to 1.4% and reported mortality rate ranging from 50% to 90%. Clinically, GiTMA manifests as microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Early identification of GiTMA is essential to initiate early treatment and improve survival. Treatment of GiTMA includes discontinuation of gemcitabine, along with initiation of steroids, therapeutic plasma exchange (TPE), rituximab, and eculizumab. To our knowledge, this is the first case of GiTMA treated with ravulizumab, a long-acting complement inhibitor. Given the increasing number of patients treated with gemcitabine and seriousness of this complication, it is important for physicians to be aware of this disease entity and maintain a high index of suspicion when evaluating patients with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure.
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Affiliation(s)
| | - Benjamin Schwartz
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Janine Harewood
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Zaheer Bukhari
- Pathology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Elvira Neculiseanu
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
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18
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Palma LMP, Sridharan M, Sethi S. Complement in Secondary Thrombotic Microangiopathy. Kidney Int Rep 2020; 6:11-23. [PMID: 33102952 PMCID: PMC7575444 DOI: 10.1016/j.ekir.2020.10.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a condition characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA) with varying degrees of organ damage in the setting of normal international normalized ratio and activated partial thromboplastin time. Complement has been implicated in the etiology of TMA, which are classified as primary TMA when genetic and acquired defects in complement proteins are the primary drivers of TMA (complement-mediated TMA or atypical hemolytic uremic syndrome, aHUS) or secondary TMA, when complement activation occurs in the context of other disease processes, such as infection, malignant hypertension, autoimmune disease, malignancy, transplantation, pregnancy, and drugs. It is important to recognize that this classification is not absolute because genetic variants in complement genes have been identified in patients with secondary TMA, and distinguishing complement/genetic-mediated TMA from secondary causes of TMA can be challenging and lead to potentially harmful delays in treatment. In this review, we focus on data supporting the involvement of complement in aHUS and in secondary forms of TMA associated with malignant hypertension, drugs, autoimmune diseases, pregnancy, and infections. In aHUS, genetic variants in complement genes are found in up to 60% of patients, whereas in the secondary forms, the finding of genetic defects is variable, ranging from almost 60% in TMA associated with malignant hypertension to less than 10% in drug-induced TMA. On the basis of these findings, a new approach to management of TMA is proposed.
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Affiliation(s)
| | - Meera Sridharan
- Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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19
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Malyszko J, Tesarova P, Capasso G, Capasso A. The link between kidney disease and cancer: complications and treatment. Lancet 2020; 396:277-287. [PMID: 32711803 DOI: 10.1016/s0140-6736(20)30540-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 02/19/2020] [Accepted: 02/28/2020] [Indexed: 12/12/2022]
Abstract
Acute and chronic kidney disease encompasses a complex set of diseases that can both lead to, and result from, cancer. In particular, kidney disease can arise from the use of chemotherapeutic agents. Many of the current and newly developed cancer chemotherapeutic agents are nephrotoxic and can promote kidney dysfunction, which frequently manifests during the terminal stages of cancer. Given the link between kidney disease and cancer development and treatment, the aim of this Review is to highlight the importance of multidisciplinary collaboration between oncologists and nephrologists to predict and prevent chemotherapeutic-induced nephrotoxicity. As new therapies are introduced to treat cancer, new renal toxicities require proper diagnosis and management. We anticipate that multidisciplinary collaborations will lead to the development and implementation of guidelines for clinicians to improve the therapeutic management of patients with both cancer and renal impairment.
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Affiliation(s)
- Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Poland.
| | - Petra Tesarova
- Department of Oncology, Charles University, Prague, Czech Republic
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University Campania Luigi Vanvitelli, Naples, Italy; Biogem Institute, Ariano Irpino, Italy
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, TX, USA
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20
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Schulte-Kemna L, Reister B, Bettac L, Ludwig U, Fürst D, Mytilineos J, Bergmann C, van Erp R, Schröppel B. Eculizumab in chemotherapy-induced thrombotic microangiopathy. Clin Nephrol Case Stud 2020; 8:25-32. [PMID: 32318323 PMCID: PMC7171698 DOI: 10.5414/cncs109836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 02/28/2020] [Indexed: 01/08/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but severe complication of tumors and their chemotherapeutic treatment. We report on two patients with chemotherapy-induced TMA who were successfully treated with a short course of the terminal complement inhibitor eculizumab. Both patients quickly achieved remission of microangiopathic hemolytic anemia and recovery of renal function. After withdrawal of eculizumab, remission was stable over an observation period of 47 months and 15 months, respectively. Our data show that eculizumab is effective in treating chemotherapy-induced TMA. Discontinuation of eculizumab is feasible once the complement-activating condition is controlled and the trigger is eliminated. Additional studies need to determine the optimal duration of complement-directed therapies and validate effective monitoring strategies after discontinuation of such therapy.
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Affiliation(s)
| | | | | | - Ulla Ludwig
- Section of Nephrology, University Hospital, Ulm
| | - Daniel Fürst
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg-Hessen, and University Hospital Ulm
- Institute of Transfusion Medicine, University of Ulm, and
| | - Joannis Mytilineos
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg-Hessen, and University Hospital Ulm
- Institute of Transfusion Medicine, University of Ulm, and
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21
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Pliquett RU, Lübbert C, Schäfer C, Girndt M. Thrombotic microangiopathy and liver toxicity due to a combination therapy of leflunomide and methotrexate: a case report. J Med Case Rep 2020; 14:26. [PMID: 32019572 PMCID: PMC7001335 DOI: 10.1186/s13256-020-2349-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/13/2020] [Indexed: 01/22/2023] Open
Abstract
Background Treatment of active rheumatoid arthritis may necessitate a methotrexate mono- or combination therapy. As in the present case, novel side effects may occur, when escalating therapy. Case presentation A 63-year-old Caucasian female patient with rheumatoid arthritis on methotrexate for 8 years and on leflunomide for 6 years was admitted for weakness, edema, ascites, and petechiae of the lower legs. Comorbidities included a urinary tract infection, metabolic syndrome with obesity, type-2 diabetes without necessity for insulin or oral antidiabetics, and non-alcoholic fatty liver disease. Laboratory results showed acute liver failure, oliguric acute kidney injury, thrombocytopenia, and schistocyte-positive, Coombs-negative hemolytic anemia. On admission, her ADAMTS13 activity was decreased, and her leflunomide plasma level was elevated (120 μg/l). Due to severe hypoalbuminemia, an intravascular hypovolemia, and severe metabolic alcalosis with hypokalemia were found. For the newly diagnosed thrombotic microangiopathy, leflunomide and methotrexate were discontinued, and 4 units of fresh-frozen plasma were given. Steroid therapy was administered for 5 days, until thrombotic thrombocytopenic purpura was excluded. Intravenous human albumin, oral vitamin K, and cholestyramine were administered for liver failure and leflunomide overdosage, respectively. Liver biopsy revealed a non-alcoholic fatty liver disease transforming into liver cirrhosis. After 2 weeks, our patient was discharged. However, within 3 weeks after discharge, our patient was rehospitalized for a relapse of acute liver failure, urinary tract infection, and influenza. Leflunomide and methotrexate were not reintroduced before or thereafter. Over a period of 11 months after discharge, her thrombotic microangiopathy subsided, and her renal and liver function fully recovered. Conclusions Under a combination of leflunomide and methotrexate, liver toxicity and, for the first time, thrombotic microangiopathy occurred as side effects. Non-alcoholic fatty liver disease may have predisposed for the drug-induced liver toxicity.
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Affiliation(s)
- Rainer Ullrich Pliquett
- Department of Internal Medicine 2, Halle University Hospital, Martin-Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany. .,Department of Nephrology and Diabetology, Carl-Thiem Hospital, Thiemstrasse 111, 03048, Cottbus, Germany.
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Christoph Schäfer
- Department of Internal Medicine 2, Halle University Hospital, Martin-Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Matthias Girndt
- Department of Internal Medicine 2, Halle University Hospital, Martin-Luther University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
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22
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A review of thrombotic microangiopathies in multiple myeloma. Leuk Res 2019; 85:106195. [DOI: 10.1016/j.leukres.2019.106195] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
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23
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Higuero Saavedra V, González-Calle V, Sobejano E, Sebastiá J, Cabrero M, Bastida JM, Puig N, Ocio EM, Mateos MV. Drug-induced Thrombotic Microangiopathy During Maintenance Treatment in a Patient With Multiple Myeloma. Hemasphere 2019; 3:e192. [PMID: 31723829 PMCID: PMC6746023 DOI: 10.1097/hs9.0000000000000192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 01/14/2023] Open
Affiliation(s)
- Víctor Higuero Saavedra
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Verónica González-Calle
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Eduardo Sobejano
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Josefa Sebastiá
- Nephrology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Mónica Cabrero
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Jose María Bastida
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Noemi Puig
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Enrique M. Ocio
- Hematology Department, Hospital Universitario Marqués de Valdecilla
| | - María-Victoria Mateos
- Hematology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
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25
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Raina R, Krishnappa V, Blaha T, Kann T, Hein W, Burke L, Bagga A. Atypical Hemolytic-Uremic Syndrome: An Update on Pathophysiology, Diagnosis, and Treatment. Ther Apher Dial 2018; 23:4-21. [PMID: 30294946 DOI: 10.1111/1744-9987.12763] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/25/2018] [Indexed: 12/25/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS), a rare variant of thrombotic microangiopathy, is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. The condition is associated with poor clinical outcomes with high morbidity and mortality. Atypical HUS predominantly affects the kidneys but has the potential to cause multi-organ system dysfunction. This uncommon disorder is caused by a genetic abnormality in the complement alternative pathway resulting in over-activation of the complement system and formation of microvascular thrombi. Abnormalities of the complement pathway may be in the form of mutations in key complement genes or autoantibodies against specific complement factors. We discuss the pathophysiology, clinical manifestations, diagnosis, complications, and management of aHUS. We also review the efficacy and safety of the novel therapeutic agent, eculizumab, in aHUS, pregnancy-associated aHUS, and aHUS in renal transplant patients.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General and Akron Children's Hospital, Akron, OH, USA.,Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA
| | - Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates, Akron, OH, USA.,Northeast Ohio Medical University, Rootstown, OH, USA
| | - Taryn Blaha
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Taylor Kann
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - William Hein
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Linda Burke
- Atypical Hemolytic Uremic Syndrome Alliance, Cape Elizabeth, ME, USA
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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26
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Raina R, Chauvin A, Fox K, Kesav N, Ascha M, Vachharajani TJ, Krishnappa V. Effect of Immunosuppressive Therapy on the Occurrence of Atypical Hemolytic Uremic Syndrome in Renal Transplant Recipients. Ann Transplant 2018; 23:631-638. [PMID: 30190449 PMCID: PMC6248048 DOI: 10.12659/aot.909781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS), a rare thrombotic microangiopathy, is characterized by hemolytic anemia, thrombocytopenia, and acute renal failure. Caused by genetic mutations in the alternative complement cascade, aHUS often will culminate in end-stage renal disease and occasionally death. Renal transplantation in aHUS patients has been contraindicated in the past due to the recurrence risk, with certain immunosuppressive regimens being commonly attributed. In this study, we analyzed the association between aHUS and immunosuppressive agents so as to offer evidence for the use of certain immunosuppressive regimens in renal transplant recipients. Material/Methods Our study is a retrospective analysis using data from the United States Renal Data System from 2004 to 2012. A cohort of renal transplantation patients diagnosed with aHUS were identified to include in the study. The primary endpoint was the determination of aHUS incidence in renal transplant recipients due to various immunosuppressive agents. The secondary endpoints were to check the relationship between the drug type as well as the demographic variables that increase the risk for aHUS. Results It was found that there was a higher usage of sirolimus (P=0.015) and corticosteroids (P=0.030) in the aHUS patients compared to patients in other diagnoses group. Conclusions There was a higher usage of sirolimus and corticosteroids in renal transplantation patients diagnosed with aHUS. Unfortunately, due to the rarity of this disease, the sample size was small (n=14). Despite the small sample size, this data analysis throws light on the relationship between aHUS and immunosuppressive agents in renal transplant recipients, although we still have much to learn.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General and Akron Children Hospital, Akron, OH, USA.,Akron Nephrology Associates/Cleveland Clinic Akron General, Akron, OH, USA
| | | | - Kelli Fox
- Lake Erie College of Osteopathic Medicine, Brandenton, FL, USA
| | - Natasha Kesav
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Mustafa Ascha
- Center for Clinical Investigation, Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Tushar J Vachharajani
- Division of Nephrology and Hypertension, Salisbury VA Health Care System, Salisbury, NC, USA
| | - Vinod Krishnappa
- Akron Nephrology Associates/Cleveland Clinic Akron General, Akron, OH, USA
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27
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Fakhouri F, Loirat C. Anticomplement Treatment in Atypical and Typical Hemolytic Uremic Syndrome. Semin Hematol 2018; 55:150-158. [DOI: 10.1053/j.seminhematol.2018.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/13/2018] [Indexed: 01/06/2023]
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