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Toker Dincer Z, Dincer MT, Sen G, Ugurlu S, Seyahi N, Seyahi E. Targeting complement dysregulation: eculizumab in scleroderma renal crisis management-a case-based review. Rheumatol Int 2024:10.1007/s00296-024-05689-z. [PMID: 39147912 DOI: 10.1007/s00296-024-05689-z] [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: 05/11/2024] [Accepted: 08/08/2024] [Indexed: 08/17/2024]
Abstract
Systemic sclerosis (SSc) poses significant challenges in clinical management, especially when complicated by scleroderma renal crisis (SRC), a rare but life-threatening manifestation. Here, we report a 41-year-old female patient with SSc who presented with SRC and concurrent thrombotic microangiopathy. Her condition persisted despite conventional treatments such as plasma exchange and renin-angiotensin-aldosterone system blockade. In particular, treatment with eculizumab, a C5 complement inhibitor, led to a rapid improvement in platelet count, reduction in lactate dehydrogenase levels, and complete recovery of renal function. Genetic testing revealed a variant of unknown significance in the thrombomodulin (THBD) gene, which is associated with the complement system. This case highlights the complex interplay between complement dysregulation and SRC, and highlights the promising role of eculizumab in refractory cases. Further investigation of complement involvement and the efficacy of eculizumab in SRC warrants attention to improving therapeutic outcomes in this challenging condition.
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Affiliation(s)
- Zeynep Toker Dincer
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey.
| | - Mevlut Tamer Dincer
- Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gozde Sen
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serdal Ugurlu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey
| | - Nurhan Seyahi
- Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey
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Farrukh L, Steen VD, Shapiro L, Mehta S. Studying the Role of C5-Inhibition Therapy in Scleroderma Renal Crisis-Induced Thrombotic Microangiopathy - A Review of Literature. Semin Arthritis Rheum 2023; 63:152256. [PMID: 37689027 DOI: 10.1016/j.semarthrit.2023.152256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND The pathogenesis of scleroderma renal crisis (SRC) remains poorly understood but a growing body of evidence suggests that activation of the complement system may be involved in the disease. Recent studies have shown that Eculizumab (monoclonal antibody directed against the complement component C5) is effective in treating patients with SRC who present with symptoms of thrombotic microangiopathy (SRC-TMA). OBJECTIVES In this study, we conducted a systematic review to characterize the published experience of the presentation and outcome of patients with SRC who were treated with C5 inhibitor, Eculizumab. METHODS A literature search was conducted from inception to December 2022 using Medical Subject Headings (MeSH) terms for 'scleroderma', 'scleroderma renal crisis, and 'Eculizumab'. We included case reports, case series, and observational studies which reported the use of Eculizumab with or without Angiotensin-converting enzyme inhibitors (ACE-I) for the treatment of scleroderma renal crisis (SRC) in patients with systemic sclerosis. RESULTS The study included 17 patients, all of whom were treated with Eculizumab. Additionally, the use of ACE-I was reported in 11/17 (64.7%) patients. Further, plasmapheresis was used in 9/17 (52.9%), steroids in 5/17 (29.4%), cyclophosphamide in 3/17 (17.6%), calcium channel blockers in 3/17 (17.6%), and Rituximab in 3/17 (17.6%) patients. Renal replacement therapy was required in 11/17 (64.7%) patients. 14/17 patients (82.3%) were reported to have clinical (renal or hematologic) improvement with Eculizumab therapy (Table 1). CONCLUSION These findings should prompt testing on a larger cohort of SRC-TMA patients. This would help us determine whether aggressive treatment combining ACE-I and Eculizumab can target the various underlying endothelial, inflammatory, and immunologic mechanisms involved in SRC-TMA, and improve patient outcomes.
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Affiliation(s)
- Larabe Farrukh
- Department of Medicine, Albany Medical Center, Albany, NY, USA.
| | - Virginia D Steen
- Department of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Lee Shapiro
- Department of Rheumatology, Albany Medical Center, Albany, NY, USA
| | - Swati Mehta
- Department of Nephrology, Albany Medical Center, Albany, NY, USA
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Cabarcas-Barbosa O, Aroca-Martínez G, Musso CG, Ramos-Bolaños E, González-Tórres H, Espitaleta-Vergara Z, Domínguez-Vargas A, Ararat-Rodriguez E, Orozco J, Castillo-Parodi L, Conde-Manotas J, Daza-Arnedo R, Rodríguez-SanJuan V, Gómez-Navarro L, Acosta-Madiedo R, Barros-Camargo L, Aduen-Carrillo A, Ayola-Anaya F, Pulgar-Emiliani M, Cadena-Bonfanti A. Atypical hemolytic uremic syndrome in the Colombian Caribbean: its particular characteristics. Int Urol Nephrol 2021; 54:1323-1330. [PMID: 34643860 PMCID: PMC8513378 DOI: 10.1007/s11255-021-03011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/04/2021] [Indexed: 11/26/2022]
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a rare and genetically mediated systemic disease most often caused by uncontrolled and chronic complement activation that leads to systemic thrombotic microangiopathy, renal and extra-renal damage. Materials and methods This is descriptive, retrospective and multicenter study, which reports demographic, clinical, laboratory, and genetic characteristics, as well as their treatment response and outcome of 20 aHUS patients diagnosed between 2014 and 2018. Results Most patients were female adults (75%) and 30% were associated to pregnancy/postpartum, 15% to autoimmune disease, and 65% to infections. Gastrointestinal involvement (75%) was the most frequent extra-renal organ damage. Antenatal mortality and mortality rate were 5% and 10%, respectively. 25% of the patients progressed to end-stage renal disease. In 4/8 of patients treated within 1 week of presentation, eculizumab treatment restored multi-organ function after 4 weeks of treatment. CFH (37%) and CFI (25%) mutations were the most frequent. Conclusion This is the first series of aHUS cases of Colombian Caribbean region which reports the clinical and epidemiological characteristics of this condition in this region.
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Affiliation(s)
- Omar Cabarcas-Barbosa
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Gustavo Aroca-Martínez
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Carlos G Musso
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia.
- Unidad de Biología Del Envejecimiento, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - Henry González-Tórres
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Zilac Espitaleta-Vergara
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Alex Domínguez-Vargas
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | | | - José Orozco
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Luis Castillo-Parodi
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Juan Conde-Manotas
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica San Rafael, Sabanalarga, Colombia
| | - Rodrigo Daza-Arnedo
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Servicio de Cuidados Intensivos Obstétricos, Hospital Niño Jesús, Barranquilla, Colombia
| | | | | | | | | | | | | | - María Pulgar-Emiliani
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Andrés Cadena-Bonfanti
- Facultad de Ciencias de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
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Hanna RM, Abdelnour L, Zuckerman JE, Ferrey AJ, Pai A, Vahabzadeh K, Wilson J, Torres EA, Kalantar-Zadeh K, Kurtz IB. Refractory scleroderma renal crisis precipitated after high-dose oral corticosteroids and concurrent intravitreal injection of bevacizumab. SAGE Open Med Case Rep 2020; 8:2050313X20952650. [PMID: 32913652 PMCID: PMC7443985 DOI: 10.1177/2050313x20952650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022] Open
Abstract
Scleroderma renal crisis is a serious complication that can develop in certain patients with systemic sclerosis. Some risks have been identified as potential triggers of scleroderma renal crisis, including the high-dose oral corticosteroids. Here, we present a patient who developed clinically severe systemic sclerosis and scleroderma renal crisis after exposure to oral corticosteroids and intravitreal vascular endothelial growth factor blockade with bevacizumab for cotton wool spots. The patient's scleroderma renal crisis was severe, progressive, and refractory to the standard of care therapy: oral captopril. Biopsy showed a diffuse thrombotic microangiopathy and findings consistent with scleroderma renal crisis. We hypothesize that depletion of systemic vascular endothelial growth factor with intravitreal anti-vascular endothelial growth factor injections likely contributed to the particularly severe presentation seen in this case. Though the finding of a monoclonal gammopathy of undetermined significance is another complicating factor, this case suggests that vascular endothelial growth factor inhibition may be a newly recognized trigger of scleroderma renal crisis.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
- UC Irvine School of Medicine, Orange,
CA, USA
| | - Lama Abdelnour
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Antoney J Ferrey
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Alex Pai
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | | | - James Wilson
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Everado A Torres
- Department of Medicine, University of
California Irvine, Irvine, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Ira B Kurtz
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Brain Research Institute, Westwood, CA,
USA
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