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Kurihara S, Yamaguchi A, Sonoda K, Yamada Y, Harada M, Hashimoto K, Shimojo H, Ikeda Y, Kamijo Y. Anti-C5 monoclonal antibody treatment showing pathological resolution of complement-mediated atypical hemolytic uremic syndrome: a case report. BMC Nephrol 2024; 25:224. [PMID: 39009967 PMCID: PMC11247795 DOI: 10.1186/s12882-024-03662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND No reports have shown histological changes before and after anti-C5 monoclonal antibody treatment in patients with atypical hemolytic uremic syndrome (aHUS). Here, we report a rare case of complement-mediated aHUS with a complement factor H (CFH) mutation and anti-CFH antibodies who underwent multiple kidney biopsies. CASE PRESENTATION A 53-year-old woman developed aHUS with CFH gene mutation [c.3572C > T (p. Ser1191 Leu)] and anti-CFH antibodies. Her father had succumbed to acute kidney injury (AKI) in his 30 s. She exhibited AKI, thrombocytopenia, and hemolytic anemia with schistocytes. After improving the platelet count with one session of plasma exchange, a kidney biopsy was performed one month after the onset of symptoms. Blood vessel thrombosis, obvious endothelial swelling, endocapillary hypercellularity, and subendothelial exudative lesions in the glomeruli and arterioles were detected. Anti-C5 monoclonal antibody treatment with eculizumab immediately improved disease activity. A second biopsy 3 months later revealed marked improvement of endothelial injuries with residual membrane double contours and exudative lesions. A third biopsy at 17 months after gradual improvement of kidney function showed a further decrease of double contours along with alterations of the exudative lesions to fibrous intimal thickening. CONCLUSIONS This is the first report showing the pathophysiology of aHUS in the kidneys and the efficacy of anti-C5 monoclonal antibody treatment by presenting serial kidney pathological features before and after anti-C5 monoclonal antibody treatment. Since her CFH mutation was considered the most important pathological condition, treatment centered on eculizumab was administered, resulting in a good long-term prognosis. In addition, kidney pathological resolution in aHUS occurred over 1 year after anti-C5 monoclonal antibody treatment.
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Affiliation(s)
- Shigekazu Kurihara
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Akinori Yamaguchi
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kosuke Sonoda
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hisashi Shimojo
- Department of Pathology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
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2
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Khandelwal P, Nambiar S, Saini R, Saini S, Coshic P, Sinha A, Hari P, Palanichamy JK, Bagga A. Anti-factor B antibodies in atypical hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:1909-1916. [PMID: 38252289 DOI: 10.1007/s00467-024-06284-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The etiology of atypical hemolytic uremic syndrome (aHUS) is unknown in 30-40% of patients. Anti-factor B (FB) antibodies are reported in C3 glomerulopathy (C3G) and immune-complex membranoproliferative glomerulonephritis (IC-MPGN), though not in aHUS. METHODS We screened patients < 18-year-old from cohorts of aHUS and C3G/idiopathic IC-MPGN. Anti-FB IgG antibodies were measured by ELISA and confirmed by Western blot. Normative levels were based on antibody levels in 103 healthy blood donors. RESULTS Prevalence of anti-FB antibodies was 9.7% (95% CI 6.1-14.5%; n = 21) in 216 patients with aHUS, including 11.5% (95% CI 6.4-18.5%; n = 14) in anti-FH associated aHUS and 11.8% (95% CI 4.4-23.9%; n = 6) in patients without a definitive genetic or autoimmune etiology. Patients with significant genetic variants did not show anti-FB antibodies. In patients with concomitant anti-FB and anti-FH antibodies, median anti-FH titers were higher (11,312 AU/mL vs. 4920 AU/mL; P = 0.04). Anti-FB antibody titer correlated with disease severity (hemoglobin and platelets; P < 0.05), declined following plasma exchange and increased during relapse. While 4/64 patients with C3G (6.3%) and 1/17 with IC-MPGN showed anti-FB antibodies, titers were higher in aHUS (544.8 AU/mL vs. 1028.8 AU/mL; P = 0.003). CONCLUSION Anti-FB antibodies are present in 6-10% of patients with aHUS and C3G/IC-MPGN, with higher titers in the former. The diagnostic and therapeutic implication of anti-FB antibodies in aHUS needs confirmation and further studies. The study shows propensity for autoantibody generation and co-existence of multiple risk factors for aHUS in Indian children.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Shreesha Nambiar
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Saini
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Saini
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Coshic
- Department of Transfusion Medicine and Blood Bank, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India.
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3
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Fung WWS, Chao ACW, Pang WF, Wong RSM, Chow KM, Szeto CC. An unusual case of adult-onset still's disease complicated with anti-complement factor H antibodies associated atypical haemolytic uraemic syndrome. BMC Nephrol 2024; 25:164. [PMID: 38745129 PMCID: PMC11094913 DOI: 10.1186/s12882-024-03548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/15/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Atypical haemolytic uremic syndrome (aHUS) is an uncommon form of thrombotic microangiopathy (TMA). However, it remains difficult to diagnose the disease early, given its non-specific and overlapping presentation to other conditions such as thrombotic thrombocytopenic purpura and typical HUS. It is also important to identify the underlying causes and to distinguish between primary (due to a genetic abnormality leading to a dysregulated alternative complement pathway) and secondary (often attributed by severe infection or inflammation) forms of the disease, as there is now effective treatment such as monoclonal antibodies against C5 for primary aHUS. However, primary aHUS with severe inflammation are often mistaken as a secondary HUS. We presented an unusual case of adult-onset Still's disease (AOSD) with macrophage activation syndrome (MAS), which is in fact associated with anti-complement factor H (anti-CFH) antibodies related aHUS. Although the aHUS may be triggered by the severe inflammation from the AOSD, the presence of anti-CFH antibodies suggests an underlying genetic defect in the alternative complement pathway, predisposing to primary aHUS. One should note that anti-CFH antibodies associated aHUS may not always associate with genetic predisposition to complement dysregulation and can be an autoimmune form of aHUS, highlighting the importance of genetic testing. CASE PRESENTATION A 42 years old man was admitted with suspected adult-onset Still's disease. Intravenous methylprednisolone was started but patient was complicated with acute encephalopathy and low platelet. ADAMTS13 test returned to be normal and concurrent aHUS was eventually suspected, 26 days after the initial thrombocytopenia was presented. Plasma exchange was started and patient eventually had 2 doses of eculizumab after funding was approved. Concurrent tocilizumab was also used to treat the adult-onset Still's disease with MAS. The patient was eventually stabilised and long-term tocilizumab maintenance treatment was planned instead of eculizumab following haematology review. Although the aHUS may be a secondary event to MAS according to haematology opinion and the genetic test came back negative for the five major aHUS gene, high titre of anti-CFH antibodies was detected (1242 AU/ml). CONCLUSION Our case highlighted the importance of prompt anti-CFH antibodies test and genetic testing for aHUS in patients with severe AOSD and features of TMA. Our case also emphasized testing for structural variants within the CFH and CFH-related proteins gene region, as part of the routine genetic analysis in patients with anti-CFH antibodies associated aHUS to improve diagnostic approaches.
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Affiliation(s)
- Winston Wing-Shing Fung
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China.
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China.
| | - Amelia Chien-Wei Chao
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Wing-Fai Pang
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Raymond Siu-Ming Wong
- Division of Haematology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Kai-Ming Chow
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Cheuk-Chun Szeto
- Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Li Ka Shing Institute of Health Sciences (LiHS), The Chinese University of Hong Kong, Shatin, Hong Kong, China
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
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4
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Khandelwal P, Bagga A. Managing anti-factor H antibody-associated hemolytic uremic syndrome: time for consensus. Pediatr Nephrol 2024:10.1007/s00467-024-06374-w. [PMID: 38634874 DOI: 10.1007/s00467-024-06374-w] [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: 03/06/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Priyanka Khandelwal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Department of Pediatrics, Indraprastha Apollo Hospitals, New Delhi, India.
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5
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Bortolotti M, Barcellini W, Fattizzo B. Molecular pharmacology in complement-mediated hemolytic disorders. Eur J Haematol 2023. [PMID: 37308291 DOI: 10.1111/ejh.14026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
In the last decade, a deeper understanding of the pathogenesis of complement mediated hemolytic disorders, such as paroxysmal nocturnal hemoglobinuria (PNH), cold agglutinin disease (CAD), warm type autoimmune hemolytic anemia (AIHA) with complement activation (wAIHA), and atypical hemolytic uremic syndrome (aHUS), paved the way to the therapeutic shift from purely supportive approaches to complement-targeted therapies. This resulted in a significant improvement in disease management, survival, and quality of life. In this review, we will provide a snapshot of novel therapies for complement-mediated hemolytic anemias with a focus on those ready to use in clinical practice. C5 inhibitors eculizumab and the long-acting ravulizumab, are the established gold standard for untreated PNH patients, whilst the C3 inhibitor pegcetacoplan should be considered for suboptimal responders to anti-C5 drugs. Several additional compounds targeting the complement cascade at different levels (other C5 inhibitors, factor B and D inhibitors) are under active investigation with promising results. In CAD, immunosuppression with rituximab remains the first-line. However, recently FDA and EMA approved the anti-C1s monoclonal antibody, sutimlimab, that showed dramatic responses and whose regulatory approval is soon awaited in many countries. Other drugs under investigation in AIHA include the C3 inhibitor pegcetacoplan, and the anti-C1q ANX005 for warm AIHA with complement activation. Finally, aHUS is an indication for complement inhibitors. Eculizumab and ravulizumab have been approved, whilst other C5 inhibitors, and novel lectin pathway inhibitors are under active investigation in this disease.
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Affiliation(s)
- Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
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6
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Favi E, Molinari P, Alfieri C, Castellano G, Ferraresso M, Cresseri D. Case report: Eculizumab plus obinutuzumab induction in a deceased donor kidney transplant recipient with DEAP-HUS. Front Immunol 2022; 13:1073808. [PMID: 36591301 PMCID: PMC9795842 DOI: 10.3389/fimmu.2022.1073808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022] Open
Abstract
The wide-spread use of the anti-complement component 5 monoclonal antibody (moAb) eculizumab has greatly reduced the incidence of relapsing atypical hemolytic uremic syndrome (aHUS) after kidney transplantation (KT). However, the optimal management of aHUS transplant candidates with anti-Complement Factor H (CFH) antibodies remains debated. In these patients, the benefits of chronic eculizumab administration should be weighed against the risk of fatal infections, repeated hospital admissions, and excessive costs. We report the case of a 45-year-old female patient with CFHR1/CFHR3 homozygous deletion-associated aHUS who underwent deceased-donor KT despite persistently elevated anti-CFH antibody titers. As induction and aHUS prophylaxis, she received a combination of eculizumab and obinutuzumab, a humanized type 2 anti-CD20 moAb. The post-operative course was uneventful. After 1-year of follow-up, she is doing well with excellent allograft function, undetectable anti-CFH antibodies, sustained B-cell depletion, and no signs of aHUS activity. A brief review summarizing current literature on the topic is also included. Although anecdotal, our experience suggests that peri-operative obinutuzumab administration can block anti-CFH antibodies production safely and effectively, thus ensuring long-lasting protection from post-transplant aHUS relapse, at a reasonable cost. For the first time, we have demonstrated in vivo that obinutuzumab B-cell depleting properties are not significantly affected by eculizumab-induced complement inhibition.
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Affiliation(s)
- Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy,*Correspondence: Evaldo Favi,
| | - Paolo Molinari
- Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Alfieri
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy,Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Castellano
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy,Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mariano Ferraresso
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Donata Cresseri
- Nephrology, Dialysis, and Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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7
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Boyer O, Niaudet P. Hemolytic-Uremic Syndrome in Children. Pediatr Clin North Am 2022; 69:1181-1197. [PMID: 36880929 DOI: 10.1016/j.pcl.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hemolytic uremic syndrome is characterized by a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Most cases are caused by Shiga-toxin-producing bacteria, especially Escherichia coli. Transmission occurs through ground beef and unpasteurized milk. STEC-HUS is the main cause of acute renal failure in children. Management remains supportive. Immediate outcome is most often. Atypical HUS represents about 5% of cases, has a relapsing course with more than half of the patients progressing to end-stage kidney failure. Most cases are due to variants in complement regulators of the alternative pathway. Complement inhibitors, such as eculizumab, have considerably improved the prognosis.
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Affiliation(s)
- Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France; Néphrologie Pédiatrique, Hôpital Necker, 149 Rue de Sèvres, Paris 75015, France
| | - Patrick Niaudet
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, France.
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8
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Li Q, Kong X, Tian M, Wang J, Yang Z, Yu L, Liu S, Wang C, Wang X, Sun S. Clinical features of children with anti-CFH autoantibody-associated hemolytic uremic syndrome: a report of 8 cases. Ren Fail 2022; 44:1061-1069. [PMID: 35730179 PMCID: PMC9225730 DOI: 10.1080/0886022x.2022.2089167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective To explore the clinical characteristics, treatment protocol and prognosis of children with anti-complement factor H (CFH) autoantibody (Ab)-associated hemolytic uremic syndrome (HUS). Methods Clinical data of 8 patients with anti-CFH Ab-associated HUS who were admitted to Shandong Provincial Hospital from January 2011 to December 2020 were collected retrospectively. Results The age at disease onset ranged between 5.83 and 13.5 years, with a male: female ratio of 1.67:1. The time of onset was distributed from May to June and November to December. Digestive and upper respiratory tract infections were common prodromal infections. Positivity for anti-CFH Ab and reduced C3 levels were observed among all patients. Heterozygous mutation of the CHFR5 gene (c.669del A) and homozygous loss of the CFHR1 gene [loss2(EXON:2-6)] were found in two patients. All patients received early treatment with plasma exchange and corticosteroid therapy. Six patients were given immunosuppressive agents (cyclophosphamide and/or mycophenolate mofetil) for persistent proteinuria. The follow-up period was 12–114 months. Four of 8 patients achieved complete remission, 3 achieved partial remission, and 1 died. Relapse occurred in two patients. Conclusion Children with anti-CFH Ab-associated HUS were mainly school-aged and predominantly male, with onset times of summer and winter. Digestive and upper respiratory tract infections were common prodromal infections. Plasma exchange combined with methylprednisolone pulse therapy in the acute phase and cyclophosphamide or mycophenolate mofetil treatment for maintenance can be utilized in children with anti-CFH Ab-associated HUS if eculizumab is not available.
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Affiliation(s)
- Qian Li
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Xinxin Kong
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Minle Tian
- School of Basic Medical Sciences, Shandong First Medical University, Taian, Shandong, China
| | - Jing Wang
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Zhenle Yang
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Lichun Yu
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Suwen Liu
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Cong Wang
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Xiaoyuan Wang
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
| | - Shuzhen Sun
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, P. R. China.,Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, P. R. China
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9
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Raina R, Mangat G, Hong G, Shah R, Nair N, Abboud B, Bagga S, Sethi SK. Anti-factor H antibody and its role in atypical hemolytic uremic syndrome. Front Immunol 2022; 13:931210. [PMID: 36091034 PMCID: PMC9448717 DOI: 10.3389/fimmu.2022.931210] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/08/2022] [Indexed: 11/19/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) an important form of a thrombotic microangiopathy (TMA) that can frequently lead to acute kidney injury (AKI). An important subset of aHUS is the anti-factor H associated aHUS. This variant of aHUS can occur due to deletion of the complement factor H genes, CFHR1 and CFHR3, along with the presence of anti-factor H antibodies. However, it is a point of interest to note that not all patients with anti-factor H associated aHUS have a CFHR1/R3 deletion. Factor-H has a vital role in the regulation of the complement system, specifically the alternate pathway. Therefore, dysregulation of the complement system can lead to inflammatory or autoimmune diseases. Patients with this disease respond well to treatment with plasma exchange therapy along with Eculizumab and immunosuppressant therapy. Anti-factor H antibody associated aHUS has a certain genetic predilection therefore there is focus on further advancements in the diagnosis and management of this disease. In this article we discuss the baseline characteristics of patients with anti-factor H associated aHUS, their triggers, various treatment modalities and future perspectives.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, United States
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States
- *Correspondence: Rupesh Raina, ;
| | - Guneive Mangat
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States
| | - Gordon Hong
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Raghav Shah
- Department of Medicine, Ohio States University, Columbus, OH, United States
| | - Nikhil Nair
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Brian Abboud
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Sumedha Bagga
- Questrom School of Business, Boston University, Boston, MA, United States
| | - Sidharth Kumar Sethi
- Paediatric Nephrology & Paediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
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10
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Raina R, Sethi SK, Dragon-Durey MA, Khooblall A, Sharma D, Khandelwal P, Shapiro R, Boyer O, Yap HK, Bagga A, Licht C. Systematic review of atypical hemolytic uremic syndrome biomarkers. Pediatr Nephrol 2022; 37:1479-1493. [PMID: 35118546 DOI: 10.1007/s00467-022-05451-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Observing biomarkers that affect alternative pathway dysregulation components may be effective in obtaining a new and more rapid diagnostic portrayal of atypical hemolytic uremic syndrome. We have conducted a systematic review on the aHUS biomarkers: C3, C5a, C5b-9, factor B, complement factor B, H, and I, CH50, AH50, D-dimer, as well as anti-CFH antibodies. METHODS An exhaustive literature search was conducted for aHUS patient population plasma/serum, collected/reported at the onset of diagnosis. A total of 60 studies were included with the data on 837 aHUS subjects, with at least one biomarker reported. RESULTS The biomarkers C3 [mean (SD): 72.1 (35.0), median: 70.5 vs. reference range: 75-175 mg/dl, n = 752]; CH50 [28.3 (32.1), 24.3 vs. 30-75 U/ml, n = 63]; AH50 [27.6% (30.2%), 10% vs. ≥ 46%, n = 23]; and CFB [13.1 (6.6), 12.4, vs. 15.2-42.3 mg/dl, n = 19] were lower among aHUS subjects as compared with the reference range. The biomarkers including C4 [mean (SD): 20.4 (9.5), median: 20.5 vs. reference range: 14-40 mg/dl, n = 343]; C4d [7.2 (6.5), 4.8 vs. ≤ 9.8 μg/ml, n = 108]; CFH [40.2 (132.3), 24.5 vs. 23.6-43.1 mg/dl, n = 123 subjects]; and CFI [8.05 (5.01), 6.55 mg/dl vs. 4.4-18.1 mg/dl, n = 38] were all observed to be within the reference range among aHUS subjects. The biomarkers C5a [mean (SD): 54.9 (32.9), median: 48.8 vs. reference range: 10.6-26.3 mg/dl, n = 117]; C5b-9 [466.0 (401.4), 317 (186-569.7) vs. ≤ 250 ng/ml, n = 174]; Bb [2.6 (2.1), 1.9 vs. ≤ 1.6 μg/ml, n = 77] and D-dimer [246 (65.05), 246 vs. < 2.2 ng/ml, 2, n = 2 subjects] were higher among patients with aHUS compared with the reference range. CONCLUSION If a comprehensive complement profile were built using our data, aHUS would be identified by low levels of C3, CH50, AH50, and CFB along with increased levels of C5a, C5b-9, Bb, anti-CFH autoantibodies, and D-dimer. A higher resolution version of the Graphical abstract is available as Supplementary information.
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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.
| | - Sidharth K Sethi
- Kidney and Renal Transplant Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | | | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Divya Sharma
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Olivia Boyer
- Service de Néphrologie Pédiatrique, AP-HP, Centre de Référence de maladies rénales rares de l'enfant et de l'adulte (MARHEA), Hôpital Necker - Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France.,Institut Imagine, Laboratoire des maladies rénales héréditaires, INSERM UMR 1163, Université de Paris, Paris, France
| | - Hui Kim Yap
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Kent Ridge, Singapore.,Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Christoph Licht
- Cell Biology Program, SickKids Research Institute, Toronto, ON, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
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11
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Unraveling Structural Rearrangements of the CFH Gene Cluster in Atypical Hemolytic Uremic Syndrome Patients Using Molecular Combing and Long-Fragment Targeted Sequencing. J Mol Diagn 2022; 24:619-631. [PMID: 35398599 DOI: 10.1016/j.jmoldx.2022.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/01/2022] [Accepted: 02/25/2022] [Indexed: 11/22/2022] Open
Abstract
Complement factor H (CFH) and its related proteins have an essential role in regulating the alternative pathway of the complement system. Mutations and structural variants (SVs) of the CFH gene cluster, consisting of CFH and its five related genes (CFHR1-5), have been reported in renal pathologies as well as in complex immune diseases like age-related macular degeneration and systemic lupus erythematosus. SV analysis of this cluster is challenging because of its high degree of sequence homology. Following first-line next-generation sequencing gene panel sequencing, we applied Genomic Vision's Molecular Combing Technology to detect and visualize SVs within the CFH gene cluster and resolve its structural haplotypes completely. This approach was tested in three patients with atypical hemolytic uremic syndrome and known SVs and 18 patients with atypical hemolytic uremic syndrome or complement factor 3 glomerulopathy with unknown CFH gene cluster haplotypes. Three SVs, a CFH/CFHR1 hybrid gene in two patients and a rare heterozygous CFHR4/CFHR1 deletion in trans with the common CFHR3/CFHR1 deletion in a third patient, were newly identified. For the latter, the breakpoints were determined using a targeted enrichment approach for long DNA fragments (Samplix Xdrop) in combination with Oxford Nanopore sequencing. Molecular combing in addition to next-generation sequencing was able to improve the molecular genetic yield in this pilot study. This (cost-)effective approach warrants validation in larger cohorts with CFH/CFHR-associated disease.
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12
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Patriquin CJ, Pavenski K, Garland J, Girard LP, Isenring P. Complement-Amplifying Conditions in Atypical Hemolytic Uremic Syndrome: A Canadian Case Series. Can J Kidney Health Dis 2022; 9:20543581221100288. [PMID: 35615072 PMCID: PMC9125052 DOI: 10.1177/20543581221100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022] Open
Abstract
Rationale Thrombotic microangiopathies (TMAs) are systemic disorders that often affect the kidneys and encompass a heterogeneous group of conditions, including atypical hemolytic uremic syndrome (aHUS). The complement pathway is thought to play a crucial role in the pathogenesis of aHUS, and a favorable response can be obtained through complement C5 inhibition. There is emerging evidence to suggest that the same is also true for several other forms of TMA. Objective The purpose of this series is to report cases of aHUS in which both an innate defect of the alternative complement pathway and a complement-amplifying condition were suspected. Methods This case series describes 8 patients who were managed in Canadian tertiary centers for aHUS and who presented initially with complement-amplifying conditions. Results In all cases, aHUS was associated with organ dysfunction and in some, with an innate defect of the alternative complement pathway. The complement-amplifying conditions identified were diverse including immune disorders, pregnancy, and a Shiga toxin infection. Patients improved rapidly when treated with eculizumab or plasma exchange. Conclusions These observations illustrate the seriousness of secondary aHUS. They also add to existing lines of evidence that the complement pathway is potentially involved in this condition and that it should be considered as a therapeutic target of interest under such circumstances.
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Affiliation(s)
| | - Katerina Pavenski
- St. Michael’s Hospital, Unity Health Toronto, University of Toronto, ON, Canada
| | - Jocelyn Garland
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | | | - Paul Isenring
- Nephrology Research Group, Department of Medicine, L’Hôtel-Dieu de Québec Institution, Laval University, Québec, QC, Canada
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13
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Riedl Khursigara M, Matsuda-Abedini M, Radhakrishnan S, Hladunewich MA, Lemaire M, Teoh CW, Noone D, Licht C. A Guide for Adult Nephrologists and Hematologists to Managing Atypical Hemolytic Uremic Syndrome and C3 Glomerulopathy in Teens Transitioning to Young Adults. Adv Chronic Kidney Dis 2022; 29:231-242. [PMID: 36084970 DOI: 10.1053/j.ackd.2022.04.003] [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: 03/12/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022]
Abstract
Atypical hemolytic uremic syndrome and C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis are ultra-rare chronic, complement-mediated diseases with childhood manifestation in a majority of cases. Transition of clinical care of patients from pediatric to adult nephrologists-typically with controlled disease in native or transplant kidneys in case of atypical hemolytic uremic syndrome and often with chronic progressive disease despite treatment efforts in case of C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis-identifies a challenging juncture in the journey of these patients. Raising awareness for the vulnerability of this patient cohort; providing education on disease pathophysiology and management including the use of new, high-precision complement antagonists; and establishing an ongoing dialog of patients, families, and all members of the health care team involved on either side of the age divide will be inevitable to ensure optimal patient outcomes and a safe transition of these patients to adulthood.
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Affiliation(s)
| | - Mina Matsuda-Abedini
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Seetha Radhakrishnan
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle A Hladunewich
- Division of Nephrology and Obstetric Medicine, Department of Medicine, Sunnybrook Health Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mathieu Lemaire
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
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14
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Cortes C, Desler C, Mazzoli A, Chen JY, Ferreira VP. The role of properdin and Factor H in disease. Adv Immunol 2022; 153:1-90. [PMID: 35469595 DOI: 10.1016/bs.ai.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The complement system consists of three pathways (alternative, classical, and lectin) that play a fundamental role in immunity and homeostasis. The multifunctional role of the complement system includes direct lysis of pathogens, tagging pathogens for phagocytosis, promotion of inflammatory responses to control infection, regulation of adaptive cellular immune responses, and removal of apoptotic/dead cells and immune complexes from circulation. A tight regulation of the complement system is essential to avoid unwanted complement-mediated damage to the host. This regulation is ensured by a set of proteins called complement regulatory proteins. Deficiencies or malfunction of these regulatory proteins may lead to pro-thrombotic hematological diseases, renal and ocular diseases, and autoimmune diseases, among others. This review focuses on the importance of two complement regulatory proteins of the alternative pathway, Factor H and properdin, and their role in human diseases with an emphasis on: (a) characterizing the main mechanism of action of Factor H and properdin in regulating the complement system and protecting the host from complement-mediated attack, (b) describing the dysregulation of the alternative pathway as a result of deficiencies, or mutations, in Factor H and properdin, (c) outlining the clinical findings, management and treatment of diseases associated with mutations and deficiencies in Factor H, and (d) defining the unwanted and inadequate functioning of properdin in disease, through a discussion of various experimental research findings utilizing in vitro, mouse and human models.
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Affiliation(s)
- Claudio Cortes
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, United States.
| | - Caroline Desler
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Amanda Mazzoli
- Oakland University William Beaumont School of Medicine, Rochester, MI, United States
| | - Jin Y Chen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Viviana P Ferreira
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States.
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15
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Freiwald T, Afzali B. Renal diseases and the role of complement: Linking complement to immune effector pathways and therapeutics. Adv Immunol 2021; 152:1-81. [PMID: 34844708 PMCID: PMC8905641 DOI: 10.1016/bs.ai.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complement system is an ancient and phylogenetically conserved key danger sensing system that is critical for host defense against pathogens. Activation of the complement system is a vital component of innate immunity required for the detection and removal of pathogens. It is also a central orchestrator of adaptive immune responses and a constituent of normal tissue homeostasis. Once complement activation occurs, this system deposits indiscriminately on any cell surface in the vicinity and has the potential to cause unwanted and excessive tissue injury. Deposition of complement components is recognized as a hallmark of a variety of kidney diseases, where it is indeed associated with damage to the self. The provenance and the pathophysiological role(s) played by complement in each kidney disease is not fully understood. However, in recent years there has been a renaissance in the study of complement, with greater appreciation of its intracellular roles as a cell-intrinsic system and its interplay with immune effector pathways. This has been paired with a profusion of novel therapeutic agents antagonizing complement components, including approved inhibitors against complement components (C)1, C3, C5 and C5aR1. A number of clinical trials have investigated the use of these more targeted approaches for the management of kidney diseases. In this review we present and summarize the evidence for the roles of complement in kidney diseases and discuss the available clinical evidence for complement inhibition.
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Affiliation(s)
- Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States; Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Behdad Afzali
- Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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16
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Anti-Factor H Antibody-Associated Atypical Hemolytic Uremic Syndrome: A Case Report. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2021; 42:109-115. [PMID: 34699711 DOI: 10.2478/prilozi-2021-0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Atypical hemolytic uremic syndrome (aHUS) is a rare form of thrombotic microangiopathy, caused by dysregulation of the complement alternative pathway. Deletion of the complement factor H-related genes, CFHR1 and CFHR3, together with the presence of CFH autoantibodies are reported in aHUS patients, representing 10% of cases of patients with aHUS. Case presentation: We report here on a case of 4-year-old girl with anti-CFH antibody-associated aHUS. The measurement of complement factors and anti-factor H antibodies, was the main guideline for making an accurate diagnosis and providing the appropriate therapy, with the patient responding positively to plasma exchanges (PEs) and cyclophosphamide pulses. We then, one year after disease onset, continued with glucocorticoids and mycophenolate mofetil (MMF), as maintenance therapy. There were no complications during the therapy other than neutropenia. Now, one year after the cessation of the immune suppression therapy, she is in remission with normal kidney function, no signs of hemolysis, normal C3 levels, and normal range proteinuria. The anti-factor H autoantibody titer decreased but still remained positive, the factor H antigen values remained low all throughout. Close follow-up is applied with frequent urine testing and complete blood count with an intention for early detection of relapse of the disease. Conclusion: The purpose of this case report is to emphasize the value of complement factor measurements and also to separate anti-CFH antibody-associated aHUS as an entity, because immunosuppressive therapy provides an excellent response..
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17
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Zununi Vahed S, Rahbar Saadat Y, Ardalan M. Thrombotic microangiopathy during pregnancy. Microvasc Res 2021; 138:104226. [PMID: 34252400 DOI: 10.1016/j.mvr.2021.104226] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
Pregnancy is a high-risk time for the development of different kinds of thrombotic microangiopathy (TMA). Three major syndromes including TTP (thrombotic thrombocytopenic purpura), PE/HELLP (preeclampsia/hemolysis, elevated liver function tests, low platelets), and aHUS (atypical hemolytic- uremic syndrome) should be sought in pregnancy-TMA. These severe disorders share multiple clinical features and overlaps and even the coexistence of more than one pathologic mechanism. Each of these disorders finally ends in endothelial damage and fibrin thrombi formation within the microcirculation that fragments RBCs (schystocytes), aggregates platelets, and creates ischemic injury in the targeted organs i.e.; kidney and brain. Although the mechanisms of these severe disorders have been revealed, pregnancy-related TMA still interfaces with diagnostic and therapeutic challenges. Here, we highlight the current knowledge of diagnosis and management of these complications during pregnancy.
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18
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Wu D, Chen J, Ling C, Chen Z, Fan J, Sun Q, Meng Q, Liu X. Clinical and Genetic Characteristics of Atypical Hemolytic Uremic Syndrome in Children: A Chinese Cohort Study. Nephron Clin Pract 2021; 145:415-427. [PMID: 33873197 DOI: 10.1159/000513009] [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: 06/04/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atypical hemolytic uremic syndrome (aHUS) is a rare but critical illness. To this date, few studies have reported on the disease in Chinese children. METHODS We studied a Chinese pediatric cohort to delineate the clinical characteristics, genotypes, and prognosis. Ninety-one patients with aHUS were enrolled in this study. RESULTS Fifty-nine children (64.8%) had anti-complement-factor-H autoantibody-associated aHUS (anti-CFH aHUS). Of these children, 21 (46.7%) had complement factor-H-related protein 1 (CFHR1) homozygous deletion, and most patients with CFHR1 homozygous deletion also had complement factor-H-related protein 3 (CFHR3) homozygous deletions (76.2%). Using gene sequencing of 15 candidate genes, we identified 14 genetic variants in 46 aHUS patients, including 5 pathogenic or like pathogenic variants and 9 variants of uncertain significance. The average follow-up time was 46.1 ± 28 months. Among patients with anti-CFH aHUS, there was a correlation between CFHR1 homozygous deletion and patients with persistent proteinuria (odds ratio [OR] 6.954, 95% confidence interval [CI] 1.033-46.821, p = 0.046). As of the last follow-up, ESRD or deaths occurred in 3.6% of the children with anti-CFH aHUS and 26.7% of children with aHUS who were negative for anti-CFH. CONCLUSIONS Anti-complement-factor-H antibody positivity is the main cause of morbidity in Chinese children with aHUS. There may be a correlation between CFHR1 homozygous deletion and persistent proteinuria. Comprehensive assessment of anti-CFH antibodies and genetic variants is essential for the management of aHUS children.
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Affiliation(s)
- Dan Wu
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiahui Chen
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chen Ling
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhi Chen
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Fan
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qiang Sun
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qun Meng
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaorong Liu
- Department of Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
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19
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Minato S, Iijima H, Nakao H, Nishi K, Hidaka Y, Inoue N, Kubota M, Ishiguro A. Anti-complement factor H (CFH) antibodies and a novel CFH gene mutation in an atypical hemolytic uremic syndrome patient with complement activation of the classical pathway. Immunol Med 2021; 44:274-277. [PMID: 33784485 DOI: 10.1080/25785826.2021.1905303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease caused by overactivation of the complement alternative pathway. aHUS involves the presence of antibodies against complement factor H and its mutations in the complement genes. A 2-month-old boy presented with discoid rash, hemolytic anemia, thrombocytopenia, multiple antibodies, and hypocomplementemia with a very low level of C4 (< 3 mg/dL), indicating activation of the complement pathway, together fulfilling the systemic lupus erythematosus (SLE) criteria of the American College of Rheumatology at 5 months of age. However, most of these findings normalized spontaneously without any intervention. Further investigations revealed a high level of anti-complement factor H antibodies and a novel heterozygous missense mutation (p.Glu1172Ala, located in exon 22) in a complement gene, CFH. At 2 years of age, his SLE-like symptoms have not recurred, but hematuria and schistocytes were persistent. Eventually, aHUS was diagnosed rather than SLE. Our findings suggest that multiple antibody complex, including anti-complement factor H antibody, may temporarily activate the classical pathway, resulting in SLE-like findings.
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Affiliation(s)
- Sonoko Minato
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan.,Center for Postgraduate Education and Training, NCCHD, Tokyo, Japan
| | - Hiroyuki Iijima
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Hiro Nakao
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Kentaro Nishi
- Division of Nephrology and Rheumatology, NCCHD, Tokyo, Japan
| | - Yoshihiko Hidaka
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Norimitsu Inoue
- Department of Molecular Genetics, Wakayama Medical University, Wakayama, Japan
| | - Mitsuru Kubota
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, NCCHD, Tokyo, Japan.,Division of Hematology, NCCHD, Tokyo, Japan
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20
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Mohtashami M, Razavi A, Abolhassani H, Aghamohammadi A, Yazdani R. Primary Immunodeficiency and Thrombocytopenia. Int Rev Immunol 2021; 41:135-159. [PMID: 33464134 DOI: 10.1080/08830185.2020.1868454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Primary immunodeficiency (PID) or Inborn errors of immunity (IEI) refers to a heterogeneous group of disorders characterized by immune system impairment. Although patients with IEI manifest highly variable symptoms, the most common clinical manifestations are recurrent infections, autoimmunity and malignancies. Some patients present hematological abnormality including thrombocytopenia due to different pathogenic mechanisms. This review focuses on primary and secondary thrombocytopenia as a complication, which can occur in IEI. Based on the International Union of Immunological Societies phenotypic classification for IEI, the several innate and adaptive immunodeficiency disorders can lead to thrombocytopenia. This review, for the first time, describes manifestation, mechanism and therapeutic modalities for thrombocytopenia in different classes of IEI.
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Affiliation(s)
- Maryam Mohtashami
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran.,Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadehsadat Razavi
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran.,Department of Animal Biology, Faculty of Biology Sciences, University of Kharazmi, Tehran, Iran.,Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran.,Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
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21
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Hofer J, Riedl Khursigara M, Perl M, Giner T, Rosales A, Cortina G, Waldegger S, Jungraithmayr T, Würzner R. Early relapse rate determines further relapse risk: results of a 5-year follow-up study on pediatric CFH-Ab HUS. Pediatr Nephrol 2021; 36:917-925. [PMID: 33025207 PMCID: PMC7910231 DOI: 10.1007/s00467-020-04751-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/19/2020] [Accepted: 08/31/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND The complement factor H antibody (CFH-Ab)-associated hemolytic uremic syndrome (HUS) forms a distinct subgroup within the complement-mediated HUS disease spectrum. The autoimmune nature of this HUS subgroup implies the potential benefit of a targeted immunosuppressive therapy. Data on long-term outcome are scarce. METHODS This observational study evaluates the clinical outcome of 19 pediatric CFH-Ab HUS patients from disease onset until their 5-year follow-up. RESULTS All but one relapse occurred during the first 2 years, and patients who had no relapse within the first 6 months were relapse-free until the end of the observation period. Kidney function at disease onset determines long-term kidney function: all individuals with normal kidney function at disease onset had normal kidney function after 5 years, and all patients with reduced kidney function at onset had impaired kidney function at the last follow-up. Level of CFH-Ab titer at disease onset was not correlated with a higher risk of recurrences or worse long-term outcome after 5 years. Resolution of CFH-Ab titers after 5 years was common. CONCLUSIONS CFH-Ab HUS patients have a varied overall long-term course. Early relapses are common, making close surveillance during the first years essential, regardless of the initial CFH-Ab titer.
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Affiliation(s)
- Johannes Hofer
- Institute of Neurology of Senses and Language, Hospital of St John of God, Linz, Austria. .,Research Institute of Developmental Medicine, Johannes Kepler University Linz, Linz, Austria. .,Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria.
| | - Magdalena Riedl Khursigara
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria ,grid.17063.330000 0001 2157 2938Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Markus Perl
- grid.5361.10000 0000 8853 2677Department of Pediatrics III, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Giner
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Alejandra Rosales
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerard Cortina
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Siegfied Waldegger
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Therese Jungraithmayr
- grid.5361.10000 0000 8853 2677Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria ,Department of Pediatric Nephrology, Hospital Memmingen, Memmingen, Germany
| | - Reinhard Würzner
- Institute of Hygiene & Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria.
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22
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Yun JW, Oh J, Lee KO, Lee SJ, Kim JO, Kim NK, Kim JS, Koh Y, Yoon SS, Yhim HY, Jo SK, Park Y, Lee JE, Park J, Lee JW, Kim SH, Kim HJ, Oh D. Distinct genetic profile with recurrent population-specific missense variants in Korean adult atypical hemolytic uremic syndrome. Thromb Res 2020; 194:45-53. [PMID: 33213850 DOI: 10.1016/j.thromres.2020.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/27/2020] [Accepted: 06/08/2020] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Atypical hemolytic uremic syndrome (aHUS) is a rare thrombotic microangiopathy (TMA), characterized by micro-angiopathic hemolytic anemia, thrombocytopenia, and renal failure. In more than half of cases, genetic defects leading to overactivation of the alternative complement system have been identified. In this study, we investigated genetic defects in Korean adult patients with aHUS. MATERIALS AND METHODS Sixty-six Korean adult patients with aHUS were ascertained from the Korean TMA Registry. Genetic variants of 15 aHUS-related genes (eight core genes [CFH, CFB, CFI, CD46, C3, THBD, PLG, and DGKE] and seven candidate genes [CFP, C4BPA, and CHFR1-5]) were analyzed from exome sequencing data. Multiplex ligation-dependent probe amplification of CFH and related genes was performed to detect hybrid genes or large deletions. RESULTS Thirty patients (45%) had at least one aHUS-related variant (s) in eight core genes (total 40 variant alleles). The most frequently affected gene was CFH (13/40, 32%), followed by THBD (8/40, 20%) and CD46 (7/40, 18%). The two most common variants were Asp486Tyr of THBD (N = 7) and Tyr1058His-Val1060Leu of CFH (N = 5, linked on the same allele), accounting for 30% (12/40). In seven candidate genes, 19 variants were detected. When combined, 40 patients (61%) had at least one variant in 15 core or candidate genes. No patients had anti-CFH Ab or hybrid gene/CFHR1 homozygous deletions. CONCLUSIONS The genetic profile of Korean adult aHUS was unique with recurrent missense variants, demonstrating ethnicity- and age-dependent differences in the genetic background of aHUS.
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Affiliation(s)
- Jae Won Yun
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jisu Oh
- Department of Internal Medicine, School of Medicine, CHA University, Seongnam, Republic of Korea
| | - Ki-O Lee
- Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Seon Ju Lee
- Department of Biomedical Science, CHA University College of Life Science, Seongnam, Republic of Korea
| | - Jung Oh Kim
- Department of Biomedical Science, CHA University College of Life Science, Seongnam, Republic of Korea
| | - Nam Keun Kim
- Department of Biomedical Science, CHA University College of Life Science, Seongnam, Republic of Korea
| | - Jin Seok Kim
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Young Yhim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Sang-Kyung Jo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yong Park
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinny Park
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun-Hee Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Doyeun Oh
- Department of Internal Medicine, School of Medicine, CHA University, Seongnam, Republic of Korea.
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23
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The Immunopathology of Complement Proteins and Innate Immunity in Autoimmune Disease. Clin Rev Allergy Immunol 2020; 58:229-251. [PMID: 31834594 DOI: 10.1007/s12016-019-08774-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The complement is a powerful cascade of the innate immunity and also acts as a bridge between innate and acquired immune defence. Complement activation can occur via three distinct pathways, the classical, alternative and lectin pathways, each resulting in the common terminal pathway. Complement activation results in the release of a range of biologically active molecules that significantly contribute to immune surveillance and tissue homeostasis. Several soluble and membrane-bound regulatory proteins restrict complement activation in order to prevent complement-mediated autologous damage, consumption and exacerbated inflammation. The crucial role of complement in the host homeostasis is illustrated by association of both complement deficiency and overactivation with severe and life-threatening diseases. Autoantibodies targeting complement components have been described to alter expression and/or function of target protein resulting in a dysregulation of the delicate equilibrium between activation and inhibition of complement. The spectrum of diseases associated with complement autoantibodies depends on which complement protein and activation pathway are targeted, ranging from autoimmune disorders to kidney and vascular diseases. Nevertheless, these autoantibodies have been identified as differential biomarkers for diagnosis or follow-up of disease only in a small number of clinical conditions. For some autoantibodies, a clear relationship with clinical manifestations has been identified, such as anti-C1q, anti-Factor H, anti-C1 Inhibitor antibodies and C3 nephritic factor. For other autoantibodies, the origin and the functional consequences still remain to be elucidated, questioning about the pathophysiological significance of these autoantibodies, such as anti-mannose binding lectin, anti-Factor I, anti-Factor B and anti-C3b antibodies. The detection of autoantibodies targeting complement components is performed in specialized laboratories; however, there is no consensus on detection methods and standardization of the assays is a real challenge. This review summarizes the current panorama of autoantibodies targeting complement recognition proteins of the classical and lectin pathways, associated proteases, convertases, regulators and terminal components, with an emphasis on autoantibodies clearly involved in clinical conditions.
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24
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Soraru J, Isbel N, Wong G, Coates PT, Mantha M, Abraham A, Juneja R, Hsu D, Brown F, Bose B, Mudge D, Carroll R, Kausman J, Hughes P, Barbour T, Durkan A, Mount P, Lee D, Larkins N, Ranganathan D, Lim WH. Baseline characteristics of patients with atypical haemolytic uraemic syndrome (aHUS): The Australian cohort in a global aHUS registry. Nephrology (Carlton) 2020; 25:683-690. [PMID: 32378251 DOI: 10.1111/nep.13722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/27/2020] [Accepted: 04/14/2020] [Indexed: 11/27/2022]
Abstract
AIMS To describe the baseline characteristics and treatment of Australian patients diagnosed with atypical haemolytic uraemic syndrome (aHUS) reported to the Global aHUS Registry. METHODS Descriptive analysis of the Australian cohort with aHUS (n = 106) was undertaken for demographics, disease characteristics and prior treatment with eculizumab; comparing with the global cohort (n = 1688) for certain pre-specified disease characteristics. RESULTS In Australia, almost two-thirds of patients diagnosed with aHUS were female and over 80% of patients were Caucasians, with similar proportions reported in the global cohort. Less than 6% of patients in the Australia and global cohorts were reported to have a history of autoimmune disease (4% vs 2%, respectively; P = .21) or cancer (5% vs 5%, respectively; P = .93), conditions that have been associated with secondary HUS. In the Australian cohort, 26% had received a kidney transplant and 68% of patients had received eculizumab. Kidneys were the most common organ involvement, followed by gastrointestinal tract (26%) and cardiovascular system (19%), with 35% of patients reported to have had at least two organs involved within 6 months prior to baseline visit or entry into the registry. Complement factor H was the most common pathogenic complement gene variant in the Australian patients. CONCLUSION Data from the aHUS registry confirms and defines region-specific disease characteristics among a selected group of Australian children and adults with aHUS reported to the registry. Ongoing and more inclusive data will provide further information about temporal trends and treatment outcomes, representing a unique opportunity for clinicians and researchers to further develop knowledge surrounding this rare disease.
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Affiliation(s)
- Jacqueline Soraru
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Nicole Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patrick Toby Coates
- Central and Northern Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Murty Mantha
- Department of Nephrology, Cairns Base Hospital, Cairns, Queensland, Australia
| | - Abu Abraham
- Department of Nephrology and Renal Transplant, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Rajiv Juneja
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Danny Hsu
- Department of Haematology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Fiona Brown
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Bhadran Bose
- Department of Nephrology, Nepean Hospital, Blue Mountains, New South Wales, Australia
| | - David Mudge
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Robert Carroll
- Central and Northern Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Kausman
- Department of Nephrology and Renal Transplantation, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Peter Hughes
- Department of Nephrology and Transplantation, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Thomas Barbour
- Department of Nephrology and Transplantation, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anne Durkan
- Department of Nephrology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Peter Mount
- Department of Nephrology, Austin Health, Melbourne, Australia
| | - Darren Lee
- Department of Renal Medicine, Eastern Health Clinical School, Monash University Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Larkins
- Department of Nephrology and Hypertension, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Dwarakanathan Ranganathan
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, School of Medicine, Griffith University, Mount Gravatt, Queensland, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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25
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Philipponnet C, Desenclos J, Brailova M, Aniort J, Kemeny JL, Deville C, Fremeaux-Bacchi V, Souweine B, Heng AE. Cobalamin c deficiency associated with antifactor h antibody-associated hemolytic uremic syndrome in a young adult. BMC Nephrol 2020; 21:96. [PMID: 32164588 PMCID: PMC7066776 DOI: 10.1186/s12882-020-01748-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
Background Thrombotic microangiopathy (TMA) syndromes are characterized by the association of hemolytic anemia, thrombocytopenia and organ injury due to arteriolar and capillary thrombosis. Case presentation We report the first case of adult onset cobalamin C (Cbl C) disease associated with anti-factor H antibody-associated hemolytic uremic syndrome (HUS). A 19-year-old woman was admitted to the nephrology department owing to acute kidney failure, proteinuria, and hemolytic anemia with schizocytes. TMA was diagnosed and plasma exchanges were started in emergency. Exhaustive analyses showed 1) circulating anti factor H antibody and 2) hyperhomocysteinemia, hypomethioninemia and high levels of methylmalonic aciduria pointing towards Clb C disease. Cbl C disease has been confirmed by methylmalonic aciduria and homocystinuria type C protein gene sequencing revealing two heterozygous pathogenic variants. The kidney biopsy showed 1) intraglomerular and intravascular thrombi 2) noticeable thickening of the capillary wall with a duplication aspect of the glomerular basement membrane and a glomerular capillary wall IgM associated with Cbl C disease related TMA. We initiated treatment including hydroxycobalamin, folinic acid, betaine and levocarnitine and Eculizumab. Rituximab infusions were performed allowing a high decrease in anti-factor H antibody rate. Six month after the disease onset, Eculizumab was weaning and vitaminotherapy continued. Outcome was favorable with a dramatic improvement in kidney function. Conclusion TMA with renal involvement can have a complex combination of risk factors including anti-FH autoantibody in the presence of cblC deficiency.
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Affiliation(s)
- C Philipponnet
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France.
| | - J Desenclos
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - M Brailova
- Biochemistry Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - J Aniort
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - J L Kemeny
- Anatomy and Pathology Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - C Deville
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - V Fremeaux-Bacchi
- Assistance Publique-Hopitaux de Paris; Laboratory of Immunology, Georges Pompidou Hospital, Paris, France
| | - B Souweine
- Médecine intensive et réanimation, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
| | - A E Heng
- Nephrology, Dialysis and Transplantation Department, CHU Clermont Ferrand, University Clermont Auvergne, Clermont Ferrand, France
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26
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Kise T, Fukuyama S, Uehara M. Successful Treatment of Anti-Factor H Antibody-Associated Atypical Hemolytic Uremic Syndrome. Indian J Nephrol 2020; 30:35-38. [PMID: 32015599 PMCID: PMC6977382 DOI: 10.4103/ijn.ijn_336_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/17/2019] [Accepted: 05/07/2019] [Indexed: 12/01/2022] Open
Abstract
Anti-complement factor H (CFH) autoantibody (Ab)-associated atypical hemolytic uremic syndrome (aHUS) has a poor prognosis in terms of frequent relapses. Although eculizumab is an effective treatment for this type of aHUS, the method of eculizumab discontinuation is not yet established. Herein, we report a case of anti-CFH Ab-associated aHUS in a 6-year-old boy. Eculizumab induction therapy following plasma exchange improved his condition. After 14 months, eculizumab was discontinued because of meningococcal bacteremia. After 6 months of eculizumab cessation, prednisolone (20 mg/alternate days) and mycophenolate mofetil (500 mg/day) were initiated. There were no relapses or increases in anti-CFH Ab titers for 26 months after treatment initiation. We believe that eculizumab induction therapy, following plasma exchange and maintenance therapy with immunosuppressants after eculizumab discontinuation are effective treatments for anti-CFH Ab-related aHUS.
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Affiliation(s)
- Tomoo Kise
- Division of Pediatric Nephrology, Okinawa Prefectural Nanbu Medical Center, Children's Medical Center, Arakawa 118-1, Haebaru, Okinawa 901-1193, Japan
| | - Shigeru Fukuyama
- Division of Pediatric Nephrology, Okinawa Prefectural Nanbu Medical Center, Children's Medical Center, Arakawa 118-1, Haebaru, Okinawa 901-1193, Japan
| | - Masatsugu Uehara
- Division of Pediatric Nephrology, Okinawa Prefectural Nanbu Medical Center, Children's Medical Center, Arakawa 118-1, Haebaru, Okinawa 901-1193, Japan
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27
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Puraswani M, Khandelwal P, Saini H, Saini S, Gurjar BS, Sinha A, Shende RP, Maiti TK, Singh AK, Kanga U, Ali U, Agarwal I, Anand K, Prasad N, Rajendran P, Sinha R, Vasudevan A, Saxena A, Agarwal S, Hari P, Sahu A, Rath S, Bagga A. Clinical and Immunological Profile of Anti-factor H Antibody Associated Atypical Hemolytic Uremic Syndrome: A Nationwide Database. Front Immunol 2019; 10:1282. [PMID: 31231391 PMCID: PMC6567923 DOI: 10.3389/fimmu.2019.01282] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Atypical hemolytic uremic syndrome (aHUS), an important cause of acute kidney injury (AKI), is characterized by dysregulation of the alternative complement pathway. Autoantibodies to factor H (FH), a chief regulator of this pathway, account for a distinct subgroup. While high anti-FH titers predict relapse, they do not correlate well with disease activity and their functional characterization is required. Methods: Of 781 patients <18-year-old of aHUS in the nationwide database from 2007 to 2018, 436 (55.8%) had anti-FH antibodies. Clinical features and outcome of patients managed in the last 6-year (n = 317) were compared to before (n = 119). In plasma samples of 44 patients, levels of serial circulating FH immune complexes (CIC), free FH, soluble terminal complement complex (sC5b-9), sheep red blood cell (SRBC) lysis and epitope specificity (n = 8) were examined. Functional renal reserve, ambulatory hypertension, left ventricular hypertrophy (LVH), and proteinuria were evaluated in a subset. Results: Patients presented with markedly elevated anti-FH titers (10,633.2 ± 998.5 AU/ml). Management varied by center, comprising plasma exchange (PEX; 77.5%) and immunosuppression (73.9%). Patients managed in the last 6-year showed better renal survival at mean 28.5 ± 27.3 months (log rank P = 0.022). Mean anti-FH titers stayed 700–1,164 AU/ml during prolonged follow-up, correlating with CIC. Patients with relapse had lower free-FH during remission [Generalized estimating equations (GEE), P = 0.001]; anti-FH levels ≥1,330 AU/ml and free FH ≤440 mg/l predicted relapse (hazards ratio, HR 6.3; P = 0.018). Epitope specificity was similar during onset, remission and relapse. Antibody titer ≥8,000 AU/ml (HR 2.23; P = 0.024), time to PEX ≥14 days (HR 2.09; P = 0.071) and PEX for <14 days (HR 2.60; P = 0.017) predicted adverse renal outcomes. Combined PEX and immunosuppression improved long-term outcomes (HR 0.37; P = 0.026); maintenance therapy reduced risk of relapses (HR 0.11; P < 0.001). At 4.4±2.5 year, median renal reserve was 15.9%; severe ambulatory, masked and pre-hypertension were found in 38, 30, and 18%, respectively. Proteinuria and LVH occurred in 58 and 28% patients, respectively. Conclusion: Prompt recognition and therapy with PEX and immunosuppression, is associated with satisfactory outcomes. Free-FH predicts early relapses in patients with high anti-FH titers. A significant proportion of impaired functional reserve, ambulatory hypertension, proteinuria and LVH highlight the need for vigilant long-term follow-up.
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Affiliation(s)
- Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Bahadur Singh Gurjar
- Immuno Biology Laboratory II, National Institute of Immunology, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - Uma Kanga
- Department of Transplant Immunology and Immunogenetics, All India Institute of Medical Sciences, New Delhi, India
| | - Uma Ali
- Department of Pediatrics, BJ Wadia Hospital for Children, Mumbai, India
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Kanav Anand
- Division of Pediatric Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Padmaraj Rajendran
- Department of Pediatric Nephrology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, India
| | - Rajiv Sinha
- Department of Pediatrics, Institute of Child Health, Kolkata, India
| | - Anil Vasudevan
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Sahu
- National Centre for Cell Science, Pune, India
| | - Satyajit Rath
- National Centre for Cell Science, Pune, India.,Translational Health Science and Technology Institute, Faridabad, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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28
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Valoti E, Alberti M, Iatropoulos P, Piras R, Mele C, Breno M, Cremaschi A, Bresin E, Donadelli R, Alizzi S, Amoroso A, Benigni A, Remuzzi G, Noris M. Rare Functional Variants in Complement Genes and Anti-FH Autoantibodies-Associated aHUS. Front Immunol 2019; 10:853. [PMID: 31118930 PMCID: PMC6504697 DOI: 10.3389/fimmu.2019.00853] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/02/2019] [Indexed: 01/06/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by microangiopathic hemolytic anemia, thrombocytopenia and renal failure. It is caused by genetic or acquired defects of the complement alternative pathway. Factor H autoantibodies (anti-FHs) have been reported in 10% of aHUS patients and are associated with the deficiency of factor H-related 1 (FHR1). However, FHR1 deficiency is not enough to cause aHUS, since it is also present in about 5% of Caucasian healthy subjects. In this study we evaluated the prevalence of genetic variants in CFH, CD46, CFI, CFB, C3, and THBD in aHUS patients with anti-FHs, using healthy subjects with FHR1 deficiency, here defined “supercontrols,” as a reference group. “Supercontrols” are more informative than general population because they share at least one risk factor (FHR1 deficiency) with aHUS patients. We analyzed anti-FHs in 305 patients and 30 were positive. The large majority were children (median age: 7.7 [IQR, 6.6–9.9] years) and 83% lacked FHR1 (n = 25, cases) due to the homozygous CFHR3-CFHR1 deletion (n = 20), or the compound heterozygous CFHR3-CFHR1 and CFHR1-CFHR4 deletions (n = 4), or the heterozygous CFHR3-CFHR1 deletion combined with a frameshift mutation in CFHR1 that generates a premature stop codon (n = 1). Of the 960 healthy adult subjects 48 had the FHR1 deficiency (“supercontrols”). Rare likely pathogenetic variants in CFH, THBD, and C3 were found in 24% of cases (n = 6) compared to 2.1% of the “supercontrols” (P-value = 0.005). We also found that the CFH H3 and the CD46GGAAC haplotypes are not associated with anti-FHs aHUS, whereas these haplotypes are enriched in aHUS patients without anti-FHs, which highlights the differences in the genetic basis of the two forms of the disease. Finally, we confirm that common infections are environmental factors that contribute to the development of anti-FHs aHUS in genetically predisposed individuals, which fits with the sharp peak of incidence during scholar-age. Further studies are needed to fully elucidate the complex genetic and environmental factors underlying anti-FHs aHUS and to establish whether the combination of anti-FHs with likely pathogenetic variants or other risk factors influences disease outcome and response to therapies.
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Affiliation(s)
- Elisabetta Valoti
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Marta Alberti
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Paraskevas Iatropoulos
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Rossella Piras
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Caterina Mele
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Matteo Breno
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Alessandra Cremaschi
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Elena Bresin
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Roberta Donadelli
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Alizzi
- Azienda Ospedaliera-Universitaria, Città della Salute e della Scienza and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Azienda Ospedaliera-Universitaria, Città della Salute e della Scienza and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ariela Benigni
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.,'L. Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Immunological features and functional analysis of anti-CFH autoantibodies in patients with atypical hemolytic uremic syndrome. Pediatr Nephrol 2019; 34:269-281. [PMID: 30315407 DOI: 10.1007/s00467-018-4074-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 08/12/2018] [Accepted: 08/30/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Atypical hemolytic uremic syndrome (aHUS) is associated with defective complement regulation. Anti-complement factor H (CFH) antibodies were thought to participate in the pathogenesis of aHUS. The aim of this study was to address the functions and properties of CFH autoantibodies in a Chinese Han cohort of aHUS patients. METHODS Thirty-six anti-CFH antibody-positive aHUS patients at the acute phase of the disease were involved in this study. Clinical data of the patients were collected. Anti-CFH immunoglobulin G (IgG) subclasses and antibody isotypes were detected by ELISA. Epitope mapping was performed using recombinant CFH fragments (SCRs 1-4, SCR 7, SCRs 11-14, and SCRs 19-20). Purified IgG from plasma from seven patients were used for functional analyses. RESULTS All patients presented with the classic triad of HUS. The anti-CFH autoantibodies mostly bound to the SCRs 19-20 domains of CFH but not the SCRs 1-4 domains. CFI cofactor activity was not disturbed by the anti-CFH antibody in any of the seven patients. Purified IgG interfered with the binding of CFH to C3b and CFH-mediated sheep erythrocyte protection in all seven patients. IgG from 4/5 (80%) patients tested inhibited the binding of CFH to glomerular endothelial cells. CONCLUSIONS Our study suggests that the properties of CFH antibodies from patients with aHUS, including the recognition of SCRs and IgG subclasses, can influence and impair the biological role of CFH and therefore contribute to aHUS susceptibility.
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Michels MAHM, Volokhina EB, van de Kar NCAJ, van den Heuvel LPWJ. The role of properdin in complement-mediated renal diseases: a new player in complement-inhibiting therapy? Pediatr Nephrol 2019; 34:1349-1367. [PMID: 30141176 PMCID: PMC6579773 DOI: 10.1007/s00467-018-4042-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/31/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022]
Abstract
Properdin is known as the only positive regulator of the complement system. Properdin promotes the activity of this defense system by stabilizing its key enzymatic complexes: the complement alternative pathway (AP) convertases. Besides, some studies have indicated a role for properdin as an initiator of complement activity. Though the AP is a powerful activation route of the complement system, it is also involved in a wide variety of autoimmune and inflammatory diseases, many of which affect the kidneys. The role of properdin in regulating complement in health and disease has not received as much appraisal as the many negative AP regulators, such as factor H. Historically, properdin deficiency has been strongly associated with an increased risk for meningococcal disease. Yet only recently had studies begun to link properdin to other complement-related diseases, including renal diseases. In the light of the upcoming complement-inhibiting therapies, it is interesting whether properdin can be a therapeutic target to attenuate AP-mediated injury. A full understanding of the basic concepts of properdin biology is therefore needed. Here, we first provide an overview of the function of properdin in health and disease. Then, we explore its potential as a therapeutic target for the AP-associated renal diseases C3 glomerulopathy, atypical hemolytic uremic syndrome, and proteinuria-induced tubulointerstitial injury. Considering current knowledge, properdin-inhibiting therapy seems promising in certain cases. However, knowing the complexity of properdin's role in renal pathologies in vivo, further research is required to clarify the exact potential of properdin-targeted therapy in complement-mediated renal diseases.
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Affiliation(s)
- Marloes A. H. M. Michels
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO Box 9101, 6525 GA Nijmegen, The Netherlands
| | - Elena B. Volokhina
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO Box 9101, 6525 GA Nijmegen, The Netherlands ,Department of Laboratory Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO Box 9101, 6525 GA Nijmegen, The Netherlands
| | - Nicole C. A. J. van de Kar
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO Box 9101, 6525 GA Nijmegen, The Netherlands
| | - Lambertus P. W. J. van den Heuvel
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO Box 9101, 6525 GA Nijmegen, The Netherlands ,Department of Laboratory Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO Box 9101, 6525 GA Nijmegen, The Netherlands ,Department of Pediatrics/Pediatric Nephrology and Department of Development & Regeneration, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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Gastrointestinal pathogens in anti-FH antibody positive and negative Hemolytic Uremic Syndrome. Pediatr Res 2018; 84:118-124. [PMID: 29795200 DOI: 10.1038/s41390-018-0009-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 03/06/2018] [Accepted: 03/17/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prodromal symptoms are frequently reported in the atypical form of Hemolytic uremic syndrome (aHUS) suggesting implication of infectious triggers. Some pathogens may also play a role in the mechanisms of production of autoantibody directed against Factor H (FH), a complement regulator, leading to aHUS. METHODS The presence of 15 gastrointestinal (GI) pathogens was investigated by using xTAG-based multiplex PCR techniques on stools collected at the acute phase in a cohort of Indian HUS children classified according to the presence or absence of anti-FH autoantibodies. RESULTS Prevalence of pathogens in patients with anti-FH antibody (62.5%) was twice that in those without (31.5%). Different pathogens were detected, the most frequent being Clostridium difficile, Giardia intestinalis, Salmonella, Shigella, Rotavirus, Norovirus and Entamoeba histolytica. No stool was positive for Shigatoxin. CONCLUSION This study reveals a higher prevalence of GI pathogens in anti-FH positive than in negative patients. No single pathogen was implicated exclusively in one form of HUS. These pathogens may play a role in the disease initiation by inducing complement activation or an autoimmune response.
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Schaefer F, Ardissino G, Ariceta G, Fakhouri F, Scully M, Isbel N, Lommelé Å, Kupelian V, Gasteyger C, Greenbaum LA, Johnson S, Ogawa M, Licht C, Vande Walle J, Frémeaux-Bacchi V. Clinical and genetic predictors of atypical hemolytic uremic syndrome phenotype and outcome. Kidney Int 2018; 94:408-418. [PMID: 29907460 DOI: 10.1016/j.kint.2018.02.029] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 02/01/2018] [Accepted: 02/15/2018] [Indexed: 10/28/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare, genetic, life-threatening disease. The Global aHUS Registry collects real-world data on the natural history of the disease. Here we characterize end-stage renal disease (ESRD)-free survival, the rate of thrombotic microangiopathy, organ involvement and the genetic background of 851 patients in the registry, prior to eculizumab treatment. A sex-specific difference was apparent according to age at initial disease onset as the ratio of males to females was 1.3:1 for childhood presentation and 1:2 for adult presentation. Complement Factor I and Membrane Cofactor Protein mutations were more common in patients with initial presentation as adults and children, respectively. Initial presentation in childhood significantly predicted ESRD risk (adjusted hazard ratio 0.55 [95% confidence interval 0.41-0.73], whereas sex, race, family history of aHUS, and time from initial presentation to diagnosis, did not. Patients with a Complement Factor H mutation had reduced ESRD-free survival, whereas Membrane Cofactor Protein mutation was associated with longer ESRD-free survival. Additionally extrarenal organ manifestations occur in 19%-38% of patients within six months of initial disease presentation (dependent on organ). Thus, our real-world results provide novel insights regarding phenotypic variables and genotypes on the clinical manifestation and progression of aHUS.
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Affiliation(s)
- Franz Schaefer
- Division of Pediatric Nephrology, Heidelberg University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany.
| | - Gianluigi Ardissino
- Pediatric Nephrology, Dialysis and Transplantation Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gema Ariceta
- Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Fadi Fakhouri
- Department of Nephrology and Immunology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marie Scully
- Department of Haematology, University College London Hospital and Cardiometabolic Programme-National Institute for Health Research University College London Hospitals National Health Service Foundation Trust/University College London Biomedical Research Center, London, UK
| | - Nicole Isbel
- Department of Nephrology, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | | | | | | | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sally Johnson
- Paediatric Nephrology, Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, UK
| | - Masayo Ogawa
- Alexion Pharmaceuticals, Inc., New Haven, Connecticut, USA
| | - Christoph Licht
- Division of Nephrology and Program in Cell Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Johan Vande Walle
- Pediatric Nephrology, Safepedrug Consortium, Ghent University Hospital, Ghent, Belgium
| | - Véronique Frémeaux-Bacchi
- Department of Immunology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
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Rafat C, Coppo P, Fakhouri F, Frémeaux-Bacchi V, Loirat C, Zuber J, Rondeau E. Syndromes hémolytiques et urémiques (SHU) et syndromes de microangiopathie thrombotique apparentés : traitement et pronostic. Rev Med Interne 2017; 38:833-839. [DOI: 10.1016/j.revmed.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/26/2017] [Accepted: 07/24/2017] [Indexed: 10/18/2022]
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Khandelwal P, Birla S, Bhatia D, Puraswani M, Saini H, Sinha A, Hari P, Sharma A, Bagga A. Mutations in membrane cofactor protein ( CD46) gene in Indian children with hemolytic uremic syndrome. Clin Kidney J 2017; 11:198-203. [PMID: 29644059 PMCID: PMC5888602 DOI: 10.1093/ckj/sfx078] [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] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 06/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background Mutations in the CD46 gene account for an important proportion of patients with atypical hemolytic uremic syndrome (aHUS) who characteristically show multiple relapses, no response to plasma exchange and low recurrence risk in allograft. We screened for mutations in CD46 in patients with and without circulating anti-factor H (FH) antibodies-associated aHUS. Methods We estimated CD46 surface expression by flow cytometry and sequenced the CD46 gene in 23 and 56 patients with and without circulating anti-FH antibodies, respectively. Human Splicing Finder and PolyPhen2 were used for in silico prediction of pathogenicity. Results Two novel and three known (c.286 +2T > G, c.104G > A and c.565T > G) mutations in CD46 were found in nine (11.4%) patients; one patient had a variant of unknown significance and two patients presented during the first year of life. Novel intronic (c.1127 + 46C > G) and exonic (c.911C > T) mutations are proposed to activate cryptic splicing sites or alter protein conformation. Markedly reduced CD46 surface expression was found in homozygous states in five patients. Conclusion Patients with mutations in CD46 present at all ages, including the first year of life. Mutations in intron 2, (c.286 +2T > G) may be a potential hot spot in Indian children. Flow cytometry for CD46 expression is a satisfactory screening tool enabling early diagnosis.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Birla
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Divya Bhatia
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Puraswani
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Himanshi Saini
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arundhati Sharma
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Brocklebank V, Johnson S, Sheerin TP, Marks SD, Gilbert RD, Tyerman K, Kinoshita M, Awan A, Kaur A, Webb N, Hegde S, Finlay E, Fitzpatrick M, Walsh PR, Wong EKS, Booth C, Kerecuk L, Salama AD, Almond M, Inward C, Goodship TH, Sheerin NS, Marchbank KJ, Kavanagh D. Factor H autoantibody is associated with atypical hemolytic uremic syndrome in children in the United Kingdom and Ireland. Kidney Int 2017; 92:1261-1271. [PMID: 28750931 PMCID: PMC5652378 DOI: 10.1016/j.kint.2017.04.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/31/2017] [Accepted: 04/28/2017] [Indexed: 01/23/2023]
Abstract
Factor H autoantibodies can impair complement regulation, resulting in atypical hemolytic uremic syndrome, predominantly in childhood. There are no trials investigating treatment, and clinical practice is only informed by retrospective cohort analysis. Here we examined 175 children presenting with atypical hemolytic uremic syndrome in the United Kingdom and Ireland for factor H autoantibodies that included 17 children with titers above the international standard. Of the 17, seven had a concomitant rare genetic variant in a gene encoding a complement pathway component or regulator. Two children received supportive treatment; both developed established renal failure. Plasma exchange was associated with a poor rate of renal recovery in seven of 11 treated. Six patients treated with eculizumab recovered renal function. Contrary to global practice, immunosuppressive therapy to prevent relapse in plasma exchange-treated patients was not adopted due to concerns over treatment-associated complications. Without immunosuppression, the relapse rate was high (five of seven). However, reintroduction of treatment resulted in recovery of renal function. All patients treated with eculizumab achieved sustained remission. Five patients received renal transplants without specific factor H autoantibody-targeted treatment with recurrence in one who also had a functionally significant CFI mutation. Thus, our current practice is to initiate eculizumab therapy for treatment of factor H autoantibody-mediated atypical hemolytic uremic syndrome rather than plasma exchange with or without immunosuppression. Based on this retrospective analysis we see no suggestion of inferior treatment, albeit the strength of our conclusions is limited by the small sample size.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Sally Johnson
- Great North Children's Hospital, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, UK
| | - Thomas P Sheerin
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen D Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rodney D Gilbert
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Meredith Kinoshita
- The Department for Paediatric Nephrology & Transplantation, The Children's University Hospital, Dublin, Ireland
| | - Atif Awan
- The Department for Paediatric Nephrology & Transplantation, The Children's University Hospital, Dublin, Ireland
| | - Amrit Kaur
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Nicholas Webb
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Eric Finlay
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Patrick R Walsh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Edwin K S Wong
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | | | - Larissa Kerecuk
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Alan D Salama
- UCL Centre for Nephrology, Royal Free London NHS Foundation Trust, Rowland Hill Street, London, UK
| | - Mike Almond
- Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, UK
| | - Carol Inward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | - Timothy H Goodship
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Kevin J Marchbank
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle University, Newcastle upon Tyne, UK.
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Münch J, Bachmann A, Grohmann M, Mayer C, Kirschfink M, Lindner TH, Bergmann C, Halbritter J. Effective immunosuppressive management with belatacept and eculizumab in post-transplant aHUS due to a homozygous deletion of CFHR1/ CFHR3 and the presence of CFH antibodies. Clin Kidney J 2017; 10:742-746. [PMID: 29225802 PMCID: PMC5716210 DOI: 10.1093/ckj/sfx053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/08/2017] [Indexed: 01/29/2023] Open
Abstract
Atypical haemolytic uraemic syndrome (aHUS) may clinically present as acute renal graft failure resulting from excessive activation of the complement cascade. While mutations of complement-encoding genes predispose for aHUS, it is generally thought to require an additional insult (e.g. drugs) to trigger and manifest the full-blown clinical syndrome. Calcineurin inhibitors (CNIs) used for immunosuppression act as potential triggers, especially in the post-transplantation setting. Therefore, CNI-free immunosuppressive regimens may be beneficial. We report on a 58-year-old woman who developed aHUS with acute graft failure within 20 days after renal transplantation. Genetic investigation revealed a homozygous deletion of the CFH-related 1 (CFHR1) and CFHR3 genes in addition to the presence of autoantibodies against complement factor H (CFH). The patient was treated with plasmapheresis and administration of the complement component 5 (C5) antibody eculizumab, and her immunosuppressive regimen was switched from CNI (tacrolimus) to the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor belatacept. Renal graft function recovered and stabilized over an 18-month follow-up period. We describe the successful management of post-transplant aHUS using a CNI-free immunosuppressive regimen based on eculizumab and belatacept. Ideally, adequate molecular diagnostics, performed prior to transplantation, can identify relevant genetic risk factors for graft failure and help to select patients for individualized immunosuppressive regimens.
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Affiliation(s)
- Johannes Münch
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | - Anette Bachmann
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | - Maik Grohmann
- Center for Human Genetics, Bioscientia, Ingelheim, Germany
| | - Christof Mayer
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | | | - Tom H Lindner
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
| | | | - Jan Halbritter
- Division of Nephrology, Department of Internal Medicine, University Clinic Leipzig, Germany
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Hackl A, Ehren R, Kirschfink M, Zipfel PF, Beck BB, Weber LT, Habbig S. Successful discontinuation of eculizumab under immunosuppressive therapy in DEAP-HUS. Pediatr Nephrol 2017; 32:1081-1087. [PMID: 28220235 DOI: 10.1007/s00467-017-3612-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/09/2017] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Deficiency of complement factor H-related plasma proteins and complement factor H autoantibody-positive hemolytic uremic syndrome (DEAP-HUS), which is characterized by the deficiency of complement-factor H-related (CFHR) plasma proteins and the subsequent formation of autoantibodies against complement factor H (CFH), has been reported to have an adverse outcome in one third of patients. Therapy options include prompt removal of antibodies by plasma exchange and immunosuppressive therapy. Recently, restoration of complement control using the monoclonal antibody eculizumab has been shown to be effective as first- and as second-line therapy in cases of therapy resistance or severe side effects of the applied therapy. DIAGNOSIS/TREATMENT Here, we report a 6-year-old girl with DEAP-HUS and first-line therapy with eculizumab under immunosuppressive therapy with glucocorticoids and mycophenolate mofetil (MMF). This therapy led to a prompt and sustained clinical recovery, to a stable reduction of complement activation, and to a rapid decline in autoantibody titer. A second increase in the autoantibody titer was successfully treated with methylprednisolone and the child remained in remission. After 8.3 months of sustained complement control and 4.5 months of stable antibody suppression, eculizumab was successfully discontinued without any sign of relapse. CONCLUSIONS To our knowledge, this is the first reported case of a child with DEAP-HUS treated with the combination of eculizumab and immunosuppression as first-line therapy avoiding any HUS- or therapy-related complications and resulting in prompt clinical recovery. Importantly, clinical remission is maintained after discontinuation of eculizumab under stable immunosuppression.
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Affiliation(s)
- Agnes Hackl
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Rasmus Ehren
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | | | - Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.,Friedrich Schiller University, Jena, Germany
| | - Bodo B Beck
- Institute of Human Genetics, University Hospital of Cologne, Cologne, Germany.,Center for Molecular Medicine, University Hospital of Cologne, Cologne, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Sandra Habbig
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
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Song D, Liu XR, Chen Z, Xiao HJ, Ding J, Sun SZ, Liu HY, Guo WY, Wang SX, Yu F, Zhao MH. The clinical and laboratory features of Chinese Han anti-factor H autoantibody-associated hemolytic uremic syndrome. Pediatr Nephrol 2017; 32:811-822. [PMID: 28035470 DOI: 10.1007/s00467-016-3562-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-complement factor H (CFH) autoantibody-associated hemolytic uremic syndrome (HUS) is a severe sub-type of HUS. METHODS We assessed the clinical and renal pathological features, circulating complement levels, and genetic background of Chinese pediatric patients with this sub-type of HUS. Thirty-three consecutive patients with acute kidney injury who tested positive for serum anti-CFH autoantibodies were enrolled in this study. RESULTS All of the eight patients who underwent renal biopsies presented with changes typical of thrombotic microangiopathy, especially changes in chronic characteristics. Compared to patients in remission and normal control subjects, patients with acute disease had significantly lower plasma CFH levels and significantly higher plasma complement 3a (C3a), C5a, and terminal complement complex (SC5b-9) levels. The CFH-anti-CFH immunoglobin G (IgG) circulating immunocomplex (CFH-CIC) titers were more closely correlated with CFH plasma levels than anti-CFH IgG levels. Of the 22 patients, four (18%) were homozygous for CFHR3-1Δ and ten were heterozygous for CFHR1 or CFHR3 deletions. Most patients responded well to a combination of plasma and immunosuppressive therapies, with a remission rate of 87%. At the end of the follow-up, nine patients reached the combined end-points, including two with end-stage renal disease and seven with relapses. CONCLUSION Plasma C3a, C5a, and SC5b-9 levels predicted disease activity in anti-CFH autoantibody-associated HUS patients enrolled in this study. These patients responded well to plasma therapy combined with immunosuppression.
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Affiliation(s)
- Di Song
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Xiao-Rong Liu
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China.
| | - Zhi Chen
- Department of Nephrology, Beijing Children's Hospital affiliated to Capital Medical University, West District Nan Li Shi Lu 56th, Beijing, 100045, People's Republic of China
| | - Hui-Jie Xiao
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, People's Republic of China
| | - Shu-Zhen Sun
- Department of Pediatrics, Shandong Provincial Hospital affiliated with Shandong University, Jinan, People's Republic of China
| | - Hong-Yan Liu
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Wei-Yi Guo
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Feng Yu
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China.
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.
- Department of Nephrology, Peking University International Hospital, Beijing, 102206, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University Institute of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
- Key laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
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40
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Trojnár E, Józsi M, Uray K, Csuka D, Szilágyi Á, Milosevic D, Stojanović VD, Spasojević B, Rusai K, Müller T, Arbeiter K, Kelen K, Szabó AJ, Reusz GS, Hyvärinen S, Jokiranta TS, Prohászka Z. Analysis of Linear Antibody Epitopes on Factor H and CFHR1 Using Sera of Patients with Autoimmune Atypical Hemolytic Uremic Syndrome. Front Immunol 2017; 8:302. [PMID: 28424685 PMCID: PMC5371605 DOI: 10.3389/fimmu.2017.00302] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/03/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction In autoimmune atypical hemolytic uremic syndrome (aHUS), the complement regulator factor H (FH) is blocked by FH autoantibodies, while 90% of the patients carry a homozygous deletion of its homolog complement FH-related protein 1 (CFHR1). The functional consequence of FH-blockade is widely established; however, the molecular basis of autoantibody binding and the role of CFHR1 deficiency in disease pathogenesis are still unknown. We performed epitope mapping of FH to provide structural insight in the autoantibody recruitment on FH and potentially CFHR1. Methods Eight anti-FH positive aHUS patients were enrolled in this study. With overlapping synthetic FH and CFHR1 peptides, we located the amino acids (aa) involved in binding of acute and convalescence stage autoantibodies. We confirmed the location of the mapped epitopes using recombinant FH domains 19–20 that carried single-aa substitutions at the suspected antibody binding sites in three of our patients. Location of the linear epitopes and the introduced point mutations was visualized using crystal structures of the corresponding domains of FH and CFHR1. Results We identified three linear epitopes on FH (aa1157–1171; aa1177–1191; and aa1207–1226) and one on CFHR1 (aa276–290) that are recognized both in the acute and convalescence stages of aHUS. We observed a similar extent of autoantibody binding to the aHUS-specific epitope aa1177–1191 on FH and aa276–290 on CFHR1, despite seven of our patients being deficient for CFHR1. Epitope mapping with the domain constructs validated the location of the linear epitopes on FH with a distinct autoantibody binding motif within aa1183–1198 in line with published observations. Summary According to the results, the linear epitopes we identified are located close to each other on the crystal structure of FH domains 19–20. This tertiary configuration contains the amino acids reported to be involved in C3b and sialic acid binding on the regulator, which may explain the functional deficiency of FH in the presence of autoantibodies. The data we provide identify the exact structures involved in autoantibody recruitment on FH and confirm the presence of an autoantibody binding epitope on CFHR1.
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Affiliation(s)
- Eszter Trojnár
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Mihály Józsi
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, Eötvös Loránd University, Budapest, Hungary
| | - Katalin Uray
- MTA-ELTE Research Group of Peptide Chemistry, Hungarian Academy of Sciences, Eötvös Loránd University, Budapest, Hungary
| | - Dorottya Csuka
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Ágnes Szilágyi
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
| | - Danko Milosevic
- Department of Pediatric Nephrology, Dialysis and Transplantation, University of Zagreb, School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Vesna D Stojanović
- Medical Faculty, Institute for Child and Youth Health Care of Vojvodina, University of Novi Sad, Novi Sad, Serbia
| | - Brankica Spasojević
- University Children's Hospital, Nephrology, Dialysis and Transplantation Unit, Belgrade, Serbia
| | - Krisztina Rusai
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Thomas Müller
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Klaus Arbeiter
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Kata Kelen
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabó
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - György S Reusz
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Satu Hyvärinen
- Research Programs Unit, Immunobiology, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - T Sakari Jokiranta
- Research Programs Unit, Immunobiology, University of Helsinki, Helsinki University Central Hospital, Helsinki, Finland
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Research Laboratory, Semmelweis University, Budapest, Hungary
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41
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In 2013, we developed diagnostic criteria to enable early diagnosis and timely initiation of appropriate treatment for aHUS. Recent clinical and molecular findings have resulted in several proposed classifications and definitions of thrombotic microangiopathy and aHUS. Based on recent advances in this field and the emerging international consensus to exclude secondary TMAs from the definition of aHUS, we have redefined aHUS and proposed diagnostic algorithms, differential diagnosis, and therapeutic strategies for aHUS.
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42
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Liszewski MK, Java A, Schramm EC, Atkinson JP. Complement Dysregulation and Disease: Insights from Contemporary Genetics. ANNUAL REVIEW OF PATHOLOGY 2017; 12:25-52. [PMID: 27959629 PMCID: PMC6020056 DOI: 10.1146/annurev-pathol-012615-044145] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The vertebrate complement system consists of sequentially interacting proteins that provide for a rapid and powerful host defense. Nearly 60 proteins comprise three activation pathways (classical, alternative, and lectin) and a terminal cytolytic pathway common to all. Attesting to its potency, nearly half of the system's components are engaged in its regulation. An emerging theme over the past decade is that variations in these inhibitors predispose to two scourges of modern humans. One, occurring most often in childhood, is a rare but deadly thrombomicroangiopathy called atypical hemolytic uremic syndrome. The other, age-related macular degeneration, is the most common form of blindness in the elderly. Their seemingly unrelated clinical presentations and pathologies share the common theme of overactivity of the complement system's alternative pathway. This review summarizes insights gained from contemporary genetics for understanding how dysregulation of this powerful innate immune system leads to these human diseases.
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Affiliation(s)
- M Kathryn Liszewski
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110;
| | - Anuja Java
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110
| | | | - John P Atkinson
- Division of Rheumatology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110;
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Abstract
Recent advances in our understanding of the disease pathology of membranoproliferative glomerulonephritis has resulted in its re-classification as complement C3 glomerulopathy (C3G) and immune complex-mediated glomerulonephritis (IC-GN). The new consensus is based on its underlying pathomechanism, with a key pathogenetic role for the complement alternative pathway (AP), rather than on histomorphological characteristics. In C3G, loss of AP regulation leads to predominant glomerular C3 deposition, which distinguishes C3G from IC-GN with predominant immunoglobulin G staining. Electron microscopy further subdivides C3G into C3 glomerulonephritis and dense deposit disease depending on the presence and distribution pattern of electron-dense deposits within the glomerular filter. Mutations or autoantibodies affecting the function of AP activators or regulators, in particular the decay of the C3 convertase (C3 nephritic factor), have been detected in up to 80 % of C3G patients. The natural outcome of C3G is heterogeneous, but 50 % of patients progress slowly and reach end-stage renal disease within 10-15 years. The new classification not only marks significant advancement in the pathogenic understanding of this rare disease, but also opens doors towards more specific treatment with the potential for improved outcomes.
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Affiliation(s)
- Magdalena Riedl
- Cell Biology Program of the Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Paul Thorner
- Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Cell Biology Program of the Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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44
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Smirnov AV, Karunnaya AV, Dobronravov VA. Nephrological aspects of complement-mediated thrombotic microangiopathy. TERAPEVT ARKH 2017; 89:34-40. [DOI: 10.17116/terarkh201789634-40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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45
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Nagar VS, Chaterjee R, Sood A, Sajjan B, Kaushik A, Vyahalkar SV. Complements Spurned: Our Experience with Atypical Hemolytic Uremic Syndrome. Indian J Crit Care Med 2017; 21:102-104. [PMID: 28250608 PMCID: PMC5330049 DOI: 10.4103/ijccm.ijccm_341_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disorder resulting from a dysregulated activation of the alternative pathway of the complement system. It results in significant morbidity and mortality if not diagnosed and treated promptly. It lends itself to myriad renal and extrarenal manifestations, all potentially disabling. Eculizumab, a monoclonal antibody to complement C5 is now the widely accepted norm for treatment. However, in resource-limited settings, plasma exchange if instituted early may be as beneficial. We report a case of aHUS treated with extended plasma exchange with excellent results. Critical care monitoring is essential for the management of the disease in view of a tendency to develop multiple complications. Long-term immunosuppression may be successful in maintaining remission.
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Affiliation(s)
- Vidya S Nagar
- Department of General Medicine, Grant Medical College and Sir JJ Group of Hospital, Mumbai, Maharashtra, India
| | - Rudrarpan Chaterjee
- Department of General Medicine, Grant Medical College and Sir JJ Group of Hospital, Mumbai, Maharashtra, India
| | - Ankita Sood
- Department of General Medicine, Grant Medical College and Sir JJ Group of Hospital, Mumbai, Maharashtra, India
| | - Basavaraj Sajjan
- Department of General Medicine, Grant Medical College and Sir JJ Group of Hospital, Mumbai, Maharashtra, India
| | - Aniruddha Kaushik
- Department of General Medicine, Grant Medical College and Sir JJ Group of Hospital, Mumbai, Maharashtra, India
| | - Sameer V Vyahalkar
- Department of Nephrology, Grant Medical College and Sir JJ Group of Hospital, Mumbai, Maharashtra, India
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Association among Complement Factor H Autoantibodies, Deletions of CFHR, and the Risk of Atypical Hemolytic Uremic Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13121209. [PMID: 27929404 PMCID: PMC5201350 DOI: 10.3390/ijerph13121209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 12/02/2022]
Abstract
To evaluate the association among complement factor H-related (CFHRs) gene deficiency, complement factor H (CFH) autoantibodies, and atypical hemolytic uremic syndrome (aHUS) susceptibility. EMBASE, PubMed, and the ISI Web of Science databases were searched for all eligible studies on the relationship among CFHRs deficiency, anti-FH autoantibodies, and aHUS risk. Eight case-control studies with 927 cases and 1182 controls were included in this study. CFHR1 deficiency was significantly associated with an increased risk of aHUS (odds ratio (OR) = 3.61, 95% confidence interval (95% CI), 1.96, 6.63, p < 0.001), while no association was demonstrated in individuals with only CFHR1/R3 deficiency (OR = 1.32, 95% CI, 0.50, 3.50, p = 0.56). Moreover, a more significant correlation was observed in people with both FH-anti autoantibodies and CFHR1 deficiency (OR = 11.75, 95% CI, 4.53, 30.44, p < 0.001) in contrast to those with only CFHR1 deficiency. In addition, the results were essentially consistent among subgroups stratified by study quality, ethnicity, and gene detection methods. The present meta-analysis indicated that CFHR1 deletion was significantly associated with the risk of aHUS, particularly when combined with anti-FH autoantibodies, indicating that potential interactions among CFHR1 deficiency and anti-FH autoantibodies might impact the risk of aHUS.
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47
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Deville C, Garrouste C, Coppo P, Evrard B, Lautrette A, Heng AE. Efficacy of rituximab and plasmapharesis in an adult patient with antifactor H autoantibody-associated hemolytic uremic syndrome: A case report and literature review. Medicine (Baltimore) 2016; 95:e5007. [PMID: 27684863 PMCID: PMC5265956 DOI: 10.1097/md.0000000000005007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antifactor H antibody (anti-CFHAb) is found in 6% to 25% cases of atypical hemolytic uremic syndrome (aHUS) in children, but has been only exceptionally reported in adults. There is no consensus about the best treatment for this type of aHUS. We report the case of an adult patient treated successfully with plasma exchange (PE), steroids, and rituximab.A 27-year-old Caucasian male presented to hospital with anemia, thrombocytopenia, and acute renal failure. One week earlier, he had digestive problems with diarrhea. The diagnosis of anti-CFHAb-associated aHUS (82,000 AU/mL) without CFHR gene mutations was established.He received Rituximab 375 mg/m (4 pulses) with PE and steroids. This treatment achieved renal and hematological remission at day (D) 31 and negative anti-CFHAb at D45 (<100 AU/mL). At D76, a fifth rituximab pulse was performed while CD19 was higher than 10/mm. Steroids were stopped at month (M) 9. The patient has not relapsed during long-term follow-up (M39).Rituximab therapy can be considered for anti-CFHAb-associated aHUS. Monitoring of anti-CFHAb titer may help to guide maintenance therapeutic strategies including Rituximab infusion.
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Affiliation(s)
- Clemence Deville
- CHU Clermont-Ferrand, Service de Néphrologie, Pôle REUNNIRH, Clermont-Ferrand
| | - Cyril Garrouste
- CHU Clermont-Ferrand, Service de Néphrologie, Pôle REUNNIRH, Clermont-Ferrand
- Correspondence: Dr Cyril Garrouste, Department of Nephrology, Clermont-Ferrand University Hospital, CHU Gabriel Montpied, 58 Rue Montalembert, 63003 Clermont-Ferrand, France (e-mail: )
| | - Paul Coppo
- CHU Paris Est, Hôpital Saint-Antoine, Service d’Hématologie, AP-HP
- Centre de Référence des Microangiopathies Thrombotiques
- Université Pierre et Marie Curie UPMC Université Paris 6, Paris
| | | | - Alexandre Lautrette
- CHU Clermont-Ferrand, Service de Réanimation, Pôle REUNNIRH, Clermont-Ferrand, France
| | - Anne Elisabeth Heng
- CHU Clermont-Ferrand, Service de Néphrologie, Pôle REUNNIRH, Clermont-Ferrand
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48
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Durey MAD, Sinha A, Togarsimalemath SK, Bagga A. Anti-complement-factor H-associated glomerulopathies. Nat Rev Nephrol 2016; 12:563-78. [PMID: 27452363 DOI: 10.1038/nrneph.2016.99] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atypical haemolytic uraemic syndrome (aHUS), an important cause of acute kidney injury, is characterized by dysregulation of the complement pathway, frequent need for dialysis, and progression to end-stage renal disease. Autoantibodies against complement factor H (FH), the main plasma regulatory protein of the alternative pathway of the complement system, account for a considerable proportion of children with aHUS. The autoantibodies are usually associated with the occurrence of a homozygous deletion in the genes encoding the FH-related proteins FHR1 and FHR3. High levels of autoantibodies, noted at the onset of disease and during relapses, induce functional deficiency of FH, whereas their decline, in response to plasma exchanges and/or immunosuppressive therapy, is associated with disease remission. Management with plasma exchange and immunosuppression is remarkably effective in inducing and maintaining remission in aHUS associated with FH autoantibodies, whereas terminal complement blockade with eculizumab is considered the most effective therapy in other forms of aHUS. Anti-FH autoantibodies are also detected in a small proportion of patients with C3 glomerulopathies, which are characterized by chronic glomerular injury mediated by activation of the alternative complement pathway and predominant C3 deposits on renal histology.
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Affiliation(s)
- Marie-Agnes Dragon Durey
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 15 rue de l'ecole de medecine, 75006 Paris, France.,Université Paris Descartes, Paris, France.,Service d'Immunologie Biologique, Hôpital Européen Georges Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Shambhuprasad Kotresh Togarsimalemath
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Université Pierre et Marie Curie, 15 rue de l'ecole de medecine, 75006 Paris, France.,Université Paris Descartes, Paris, France
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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49
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Kato H, Nangaku M, Hataya H, Sawai T, Ashida A, Fujimaru R, Hidaka Y, Kaname S, Maruyama S, Yasuda T, Yoshida Y, Ito S, Hattori M, Miyakawa Y, Fujimura Y, Okada H, Kagami S. Clinical guides for atypical hemolytic uremic syndrome in Japan. Pediatr Int 2016; 58:549-55. [PMID: 27460397 DOI: 10.1111/ped.13044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/27/2016] [Indexed: 01/16/2023]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In 2013, we developed diagnostic criteria to enable early diagnosis and timely initiation of appropriate treatment for aHUS. Recent clinical and molecular findings have resulted in several proposed classifications and definitions of thrombotic microangiopathy and aHUS. Based on recent advances in this field and the emerging international consensus to exclude secondary TMAs from the definition of aHUS, we have redefined aHUS and proposed diagnostic algorithms, differential diagnosis, and therapeutic strategies for aHUS.
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Affiliation(s)
- Hideki Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akira Ashida
- Department of Pediatrics, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Rika Fujimaru
- Department of Pediatrics, Osaka City General Hospital, Miyakojima, Osaka, Japan
| | - Yoshihiko Hidaka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Shinya Kaname
- First Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | | | - Yoko Yoshida
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Kanazawa, Yokohama, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Yoshitaka Miyakawa
- Department of General Internal Medicine, Faculty of Medicine, Saitama Medical University, Iruma, Saitama, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Iruma, Saitama, Japan
| | - Shoji Kagami
- Department of Pediatrics, Graduate School of Medical Sciences, Tokushima University, Tokushima, Japan
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50
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Nozal P, López-Trascasa M. Autoantibodies against alternative complement pathway proteins in renal pathologies. Nefrologia 2016; 36:489-495. [PMID: 27267919 DOI: 10.1016/j.nefro.2016.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/04/2015] [Accepted: 01/14/2016] [Indexed: 11/19/2022] Open
Abstract
Complement system activation plays an important role in several renal pathologies, including antibody-mediated glomerulonephritis, ischaemia-reperfusion injury of trasplanted kidneys or renal allograft rejection. Besides these conditions, alternative pathway abnormalities are directly involved in the pathogenesis of C3 glomerulopathies and atypical haemolytic uraemic syndrome. These abnormalities may be inherited or acquired, the latter as autoantibodies directed against the various components and regulators of the alternative complement pathway. The functional consequences of some of these antibodies and their association with these conditions are well known, whereas for other antibodies only isolated cases have been reported. This article describes the autoantibodies that target the alternative complement pathway proteins, their characteristics and their clinical relevance in renal pathologies.
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Affiliation(s)
- Pilar Nozal
- Unidad de Inmunología, Hospital Universitario La Paz. IdiPAZ. CIBERER U-754, Madrid, España
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