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Sethi SK, S S, Nair A, Soni K, Bihari Bansal S, Rana AS, Raina R. What came first, atypical hemolytic uremic syndrome or malignant hypertension: a clinical dilemma. Ren Fail 2024; 46:2327484. [PMID: 38466192 DOI: 10.1080/0886022x.2024.2327484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/01/2024] [Indexed: 03/12/2024] Open
Affiliation(s)
- Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Savita S
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Aishwarya Nair
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Kritika Soni
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | | | - Abhyuday S Rana
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Akron, Ohio, USA
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Schwotzer N, Fakhouri F, Martins PV, Delmas Y, Caillard S, Zuber J, Moranne O, Mesnard L, Frémeaux-Bacchi V, El-Sissy C. Hot Spot of Complement Factor I Rare Variant p.Ile357Met in Patients With Hemolytic Uremic Syndrome. Am J Kidney Dis 2024; 84:244-249. [PMID: 38423159 DOI: 10.1053/j.ajkd.2023.12.021] [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: 06/28/2023] [Revised: 11/21/2023] [Accepted: 12/23/2023] [Indexed: 03/02/2024]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare kidney disease due to a dysregulation of the complement alternative pathway. Complement factor I (CFI) negatively regulates the alternative pathway and CFI gene rare variants have been associated to aHUS with a low disease penetrance. We report 10 unrelated cases of HUS associated to a rare CFI variant, p.Ile357Met (c.1071T>G). All patients with isolated p.Ile357Met CFI missense variant were retrospectively identified among patients included between January 2007 and January 2022 in the French HUS Registry. We identified 10 unrelated patients (70% women; median age at HUS diagnosis, 36.5 years) who carry the same rare variant p.Ile357Met in the CFI gene. Seven patients (cases 1-7) presented with aHUS in the native kidney associated with malignant hypertension in 5 patients. None received a C5 inhibitor. Two of these cases occurred in the peripartum period with complete recovery of kidney function, while 5 of these patients reached kidney failure requiring replacement therapy (KFRT). Four patients with KFRT subsequently underwent kidney transplantation. Three later developed C3 glomerulopathy in their kidney graft, but none had aHUS recurrence. Three other patients (cases 8-10) experienced de novo thrombotic microangiopathy after kidney transplantation, precipitated by various triggers. The rare CFI variant p.Ile357Met appears to be a facilitating genetic factor for HUS and for some forms of secondary HUS.
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Affiliation(s)
- Nora Schwotzer
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Paula Vieira Martins
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France
| | - Yahsou Delmas
- Nephrology Department, CHU de Bordeaux Bordeaux, France
| | - Sophie Caillard
- Nephrology Department, Strasbourg University Hospital, Strasbourg, France
| | - Julien Zuber
- Department of Renal and Metabolic Diseases, Transplantation, and Clinical Immunology Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Olivier Moranne
- Department of Nephrology, Dialysis and Apheresis, Nîmes Hôpital Universitaire, Nîmes, France
| | - Laurent Mesnard
- Sorbonne Université, Paris, France; Nephrology Intensive Care Unit, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Véronique Frémeaux-Bacchi
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France; Inflammation, Complement and Cancer Team, Cordeliers Research Center, INSERM Unité Mixte de Recherche (UMR) S1138, Paris, France
| | - Carine El-Sissy
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France
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Akaeva MI, Kozlovskaya NL, Bobrova LA, Vorobyeva OA, Stoliarevich ES, Shatalov PA, Smirnova TV, Anan'eva AO. [Clinical characteristics and genetic profile of complement system in renal thrombotic microangiopathy in patients with severe forms of arterial hypertension]. TERAPEVT ARKH 2024; 96:571-579. [PMID: 39106497 DOI: 10.26442/00403660.2024.06.202724] [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: 07/06/2024] [Accepted: 07/06/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND The spectrum of diseases characterized by the development of renal thrombotic microangiopathy (TMA) encompasses the malignant hypertension (MHT). TMA in MHT has conventionally been regarded as a variation of secondary TMA, the treatment of which is restricted to the stabilization of blood pressure levels, a measure that frequently fails to prevent the rapid progression to end-stage renal disease in patients. Nevertheless, there exists a rationale to suggest that, in certain instances, endothelial damage in MHT might be rooted in the dysregulation of the complement system (CS), thereby presenting potential opportunities for the implementation of complement-blocking therapy. AIM To study clinical manifestations and genetic profile of CS in patients with morphologically confirmed renal TMA combined with severe AH. MATERIALS AND METHODS 28 patients with morphologically verified renal TMA and severe AH were enrolled to the study. Patients with signs of microangiopathic hemolysis and thrombocytopenia were not included in the study due to possible compliance with the criteria for atypical hemolytic uremic syndrome (aHUS). The prevalence of rare genetic defects (GD) of the CS was assessed by molecular genetic analysis (search for mutations in the clinically significant part of the human genome - exome) by next-generation sequencing technology (NGS). RESULTS GD of CS were detected in a quarter of patients. Rare genetic variants classified as "likely pathogenic" including defects in CFI, C3, CD46, CFHR4, CFHR5 genes were detected in five cases. Two patients were found to have chromosomal deletions containing CFH-related proteins genes (CFHR1, CFHR3). CONCLUSION Rare variants of CS genes linked to aHUS were found in 25% of patients with renal TMA, the genesis of which was originally thought to be secondary and attributed to MHT, with partial or complete absence of hematological manifestations of microangiopathic pathology. The key to confirming TMA associated with MHT, particularly in the absence of microangiopathic hemolysis and thrombocytopenia, elucidating its nature, and potentially effective complement-blocking therapy in patients with GD of CS, appears to be a genetic study of CS combined with a morphological study of a renal biopsy.
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Affiliation(s)
- M I Akaeva
- Sechenov First Moscow State Medical University (Sechenov University)
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - N L Kozlovskaya
- Patrice Lumumba People's Friendship University of Russia
- Yeramishantsev City Clinical Hospital
| | - L A Bobrova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O A Vorobyeva
- National Center for Clinical Morphological Diagnostics
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Obata S, Hullekes F, Riella LV, Cravedi P. Recurrent complement-mediated Hemolytic uremic syndrome after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100857. [PMID: 38749097 DOI: 10.1016/j.trre.2024.100857] [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: 03/13/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 06/16/2024]
Abstract
Hereditary forms of hemolytic uremic syndrome (HUS), formerly known as atypical HUS, typically involve mutations in genes encoding for components of the alternative pathway of complement, therefore they are often referred to as complement-mediated HUS (cHUS). This condition has a high risk of recurrence in the transplanted kidney, leading to accelerated graft loss. The availability of anti-complement component C5 antibody eculizumab has enabled successful transplantation with a notably reduced recurrence rate and improved prognosis. Open questions are related to the potential for complement inhibitor discontinuation, ideal timing of treatment withdrawal, and patient selection based on genetic abnormalities. Our review delves into the pathophysiology, classification, genetic predispositions, and management strategies for cHUS in the native and transplant kidneys.
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Affiliation(s)
- Shota Obata
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Frank Hullekes
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Paolo Cravedi
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Story CM, Gerber GF, Chaturvedi S. Medical consult: aHUS, TTP? How to distinguish and what to do. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:745-753. [PMID: 38066937 PMCID: PMC10727109 DOI: 10.1182/hematology.2023000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) caused by an autoantibody-mediated deficiency of ADAMTS13 and atypical hemolytic syndrome (aHUS) caused by alternative complement dysregulation are the most common primary thrombotic microangiopathies (TMAs). The evaluation of a patient with TMA is a medical emergency since it is critical to quickly distinguish iTTP and aHUS from other causes of TMA. Untreated iTTP is rapidly fatal, and delays in initiating complement inhibition in aHUS increase the risk of irreversible renal failure. An ADAMTS13 activity level of less than 10% is diagnostic of iTTP in the appropriate clinical setting. In settings where rapid-turnaround ADAMTS13 testing is not available, clinical features and clinical prediction tools are useful to identify patients who should receive emergent plasma exchange. We present an evidence-based approach to the initial (first 24 hours) diagnosis and management of iTTP and review the clinical and laboratory features that can be used to identify patients with aHUS who will benefit from early C5 blockade. We also discuss the potential use of complement blockade to improve outcomes in selected patients with secondary TMA.
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Affiliation(s)
- Charlotte M Story
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gloria F Gerber
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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6
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Chen X, Zhang X, Wang Y, Wang S, Zhao M. Genetic, clinical, and pathological study of patients with severe hypertension-associated renal microangiopathy. J Nephrol 2023; 36:2477-2490. [PMID: 37103770 DOI: 10.1007/s40620-023-01644-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Severe hypertension may be a prominent manifestation of complement-mediated thrombotic microangiopathy. Furthermore, patients with severe hypertension-associated thrombotic microangiopathy may present with concurrent hematologic abnormalities that mimic complement-mediated thrombotic microangiopathy. Whether or not severe hypertension-associated thrombotic microangiopathy is associated with genetic susceptibility in complement- and/or coagulation-pathway genes remains unclear, and there is thus a need to identify clinicopathological clues to distinguish between these entities. METHODS Forty-five patients with concomitant severe hypertension and thrombotic microangiopathy on kidney biopsy were identified retrospectively. Whole-exome sequencing was performed to identify rare variants in 29 complement- and coagulation-cascade genes. Clinicopathological features were compared between patients with severe hypertension-associated thrombotic microangiopathy and complement-mediated thrombotic microangiopathy with severe hypertension. RESULTS Three patients with pathogenic variants diagnostic of complement-mediated thrombotic microangiopathy and two with anti-factor H antibody positivity were diagnosed with complement-mediated thrombotic microangiopathy with severe hypertension. Among the 40 patients with severe hypertension-associated thrombotic microangiopathy, 53 rare variants of uncertain significance were found in the analyzed genes in 34 (34/40, 85%) patients, of whom 12 patients harbored two or more variants. Compared with complement-mediated thrombotic microangiopathy patients with severe hypertension, patients with severe hypertension-associated thrombotic microangiopathy were more likely to have left ventricular wall thickening (p < 0.001), less-severe acute glomerular thrombotic microangiopathy lesions including mesangiolysis and subendothelial space widening (both p < 0.001), and less arteriolar thrombosis formation (p < 0.001). CONCLUSIONS Rare genetic variants involving complement and coagulation pathways can be found in patients with severe hypertension-associated thrombotic microangiopathy; their role needs further investigation. Cardiac remodeling and acute glomerular TMA lesions may help to differentiate between severe hypertension-associated thrombotic microangiopathy and complement-mediated thrombotic microangiopathy with severe hypertension.
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Affiliation(s)
- Xuejing Chen
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China
| | - Xu Zhang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China.
- Institute of Nephrology, Peking University, Beijing, China.
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China.
| | - Suxia Wang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8 Xishiku St., Xicheng District, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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Caravaca-Fontán F, Gutiérrez E, Sevillano ÁM, Praga M. Targeting complement in IgA nephropathy. Clin Kidney J 2023; 16:ii28-ii39. [PMID: 38053977 PMCID: PMC10695513 DOI: 10.1093/ckj/sfad198] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Indexed: 12/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. Recent years have witnessed significant improvements in the understanding of the pathogenesis of IgAN and particularly, the pathogenic role of complement activation. The alternative complement pathway is the major complement cascade activator in IgAN, and glomerular C3 deposition has been shown to correlate with disease progression. In addition, several studies have provided insight into the pathogenic role of factor H-related proteins -1 and -5 in IgAN, as independent players in complement dysregulation. The lectin pathway has also been shown to be associated with the severity of IgAN. Glomerular deposition of C4d has been associated with increased histologic disease activity, faster decline in estimated glomerular filtration rate and higher risk of kidney failure. On the other hand, although overlooked in the Oxford classification, numerous studies have shown that the coexistence of thrombotic microangiopathy in IgAN is a significant indicator of a poorer prognosis. All the breakthroughs in the understanding of the contributing role of complement in IgAN have paved the way for the development of new complement-targeted therapies in this disease. Several ongoing trials are evaluating the efficacy of new agents against factor B (iptacopan, Ionis-FB-LRX), C3 (pegcetacoplan), factor D (vemircopan, pelecopan), C5 (ravulizumab, cemdisiran) and C5a receptor 1 (avacopan). In this study, we provide a comprehensive review of the role of complement in IgAN, including the emerging mechanisms of complement activation and the promising potential of complement inhibitors as a viable treatment option for IgAN.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Ángel M Sevillano
- Department of Nephrology, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
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8
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Jelicic I, Kovacic V, Luketin M, Mikacic M, Skaro DB. Atypical HUS with multiple complement system mutations triggered by synthetic psychoactive drug abuse: a case report. J Nephrol 2023; 36:2371-2373. [PMID: 37145269 PMCID: PMC10161151 DOI: 10.1007/s40620-023-01646-4] [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: 02/27/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Abstract
Atypical hemolytic uremic syndrome is a rare disorder with an estimated annual incidence of about two cases per million in the adult population. It is caused by the overactivation of the alternative pathway of the complement system. The disease can be triggered by many factors, including pregnancy, viral diseases, and sepsis; approximately 30% of atypical hemolytic uremic syndrome cases are caused by unknown processes. We present a case of a patient with C3-complement system mutations and aHUS triggered by the use of a new synthetic psychoactive drug.
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Affiliation(s)
- Ivo Jelicic
- Internal Medicine Department, Nephrology and Haemodialysis Division, School of Medicine, University Hospital of Split, University of Split, 21000, Split, Croatia
| | - Vedran Kovacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, School of Medicine, University Hospital of Split, University of Split, Spinciceva 1, 21000, Split, Croatia.
| | - Mirko Luketin
- Internal Medicine Department, Nephrology and Haemodialysis Division, School of Medicine, University Hospital of Split, University of Split, 21000, Split, Croatia
| | - Marijana Mikacic
- Internal Medicine Department, Division of Emergency and Intensive Medicine with Clinical Pharmacology and Toxicology, School of Medicine, University Hospital of Split, University of Split, Spinciceva 1, 21000, Split, Croatia
| | - Dijana Boric Skaro
- Internal Medicine Department, Nephrology and Haemodialysis Division, School of Medicine, University Hospital of Split, University of Split, 21000, Split, Croatia
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Nobile G, Doreille A, Raymond L, Robert T, Dancer M, Mesnard L, Rafat C. Role of the I416L Variant of Complement Factor I in Thrombotic Microangiopathy Among Patients of African Ancestry. Kidney Int Rep 2023; 8:2136-2140. [PMID: 37849999 PMCID: PMC10577482 DOI: 10.1016/j.ekir.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Giulio Nobile
- Service de Soins Intensifs Néphrologique et Rein Aigu, hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Alice Doreille
- Service de Soins Intensifs Néphrologique et Rein Aigu, hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
- Faculté de médecine, Sorbonne Université, Paris, France
- France Intensive Renal Network, Paris, France
| | - Laure Raymond
- Département de génétique, Eurofins Biomnis, Lyonm France
| | - Thomas Robert
- Faculté de médecine, Sorbonne Université, Paris, France
- Service de Néphrologie, Assistance Publique – Hôpitaux de Marseille, Marseille, France
| | - Marine Dancer
- Département de génétique, Eurofins Biomnis, Lyonm France
| | - Laurent Mesnard
- Service de Soins Intensifs Néphrologique et Rein Aigu, hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
- Faculté de médecine, Sorbonne Université, Paris, France
- France Intensive Renal Network, Paris, France
- Centre National de Référence de la Microangiopathie Thrombotique
| | - Cédric Rafat
- Service de Soins Intensifs Néphrologique et Rein Aigu, hôpital Tenon, Assistance Publique – Hôpitaux de Paris, Paris, France
- France Intensive Renal Network, Paris, France
- Centre National de Référence de la Microangiopathie Thrombotique
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10
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Von Tokarski F, Fillon A, Maisons V, Thoreau B, Bayer G, Gatault P, Longuet H, Sautenet B, Buchler M, Vigneau C, Fakhouri F, Halimi JM. Thrombotic microangiopathies after kidney transplantation in modern era: nosology based on chronology. BMC Nephrol 2023; 24:278. [PMID: 37730583 PMCID: PMC10512637 DOI: 10.1186/s12882-023-03326-8] [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: 03/15/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Thrombotic microangiopathies (TMAs) are rare but can be severe in kidney transplant. recipients (KTR). METHODS We analysed the epidemiology of adjudicated TMA in consecutive KTR during the. 2009-2021 period. RESULTS TMA was found in 77/1644 (4.7%) KTR. Early TMA (n = 24/77 (31.2%); 1.5% of all KTR) occurred during the first two weeks ((median, IQR) 3 [1-8] days). Triggers included acute antibody-mediated rejection (ABMR, n = 4) and bacterial infections (n = 6). Graft survival (GS) was 100% and recurrence rate (RR) was 8%. Unexpected TMA (n = 31/77 (40.2%); 1.5/1000 patient-years) occurred anytime during follow-up (3.0 (0.5-6.2) years). Triggers included infections (EBV/CMV: n = 10; bacterial: n = 6) and chronic active ABMR (n = 5). GS was 81% and RR was 16%. Graft-failure associated TMA (n = 22/77 (28.6%); 2.2% of graft losses) occurred after 8.8 (4.9-15.5) years). Triggers included acute (n = 4) or chronic active (n = 14) ABMR, infections (viral: n = 6; bacterial: n = 5) and cancer (n = 6). 15 patients underwent transplantectomy. RR was 27%. Atypical (n = 6) and typical (n = 2) haemolytic and uremic syndrome, and isolated CNI toxicity (n = 4) were rare. Two-third of biopsies presented TMA features. CONCLUSIONS TMA are mostly due to ABMR and infections; causes of TMA are frequently combined. Management often is heterogenous. Our nosology based on TMA timing identifies situations with distinct incidence, causes and prognosis.
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Affiliation(s)
- Florent Von Tokarski
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
| | - Alexandre Fillon
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
| | - Valentin Maisons
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
| | - Benjamin Thoreau
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
| | - Guillaume Bayer
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
| | - Philippe Gatault
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
- EA4245, François-Rabelais University, Tours, France
| | - Hélène Longuet
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
| | - Bénédicte Sautenet
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
- Inserm U1246, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Matthias Buchler
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France
- EA4245, François-Rabelais University, Tours, France
| | - Cécile Vigneau
- Service de Néphrologie, CHU Pontchaillou, 35033, Rennes, France
- Université Rennes 1, Inserm IRSET, UMR 1085, 35033, Rennes, France
| | - Fadi Fakhouri
- Department of medicine, Service of Nephrology, CHUV and Université de Lausanne, Lausanne, Switzerland
| | - Jean-Michel Halimi
- Service de Néphrologie-HTA, Dialyses, Transplantation Rénale, Hôpital Bretonneau Et Hôpital Clôcheville, CHU Tours, 2 Bd Tonnellé, 37044, Tours, Tours Cedex, France.
- EA4245, François-Rabelais University, Tours, France.
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Chabannes M, Rabant M, El Sissy C, Dragon-Durey MA, Vieira Martins P, Meuleman MS, Karras A, Buob D, Bridoux F, Daugas E, Audard V, Caillard S, Olagne J, Kandel C, Ferlicot S, Philipponnet C, Crepin T, Thervet E, Ducloux D, Frémeaux-Bacchi V, Chauvet S. C3 Glomerulopathy With Concurrent Thrombotic Microangiopathy: Clinical and Immunological Features. Am J Kidney Dis 2023; 82:279-289. [PMID: 37061020 DOI: 10.1053/j.ajkd.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/31/2022] [Indexed: 04/17/2023]
Abstract
RATIONALE & OBJECTIVE C3 glomerulopathy (C3GN) and atypical hemolytic uremic syndrome (aHUS) are 2 distinct rare kidney diseases caused by dysregulation of the alternative complement pathway. Patients with C3GN and concurrent kidney lesions of thrombotic microangiopathy (TMA) have been rarely reported. We characterized the clinical features and underlying immunological abnormalities in these patients. STUDY DESIGN Case series. SETTING & PARTICIPANTS Patients with C3GN and concomitant TMA lesions on biopsy registered from 2009 to 2019 in the French National Registry of C3GN. FINDINGS Among 278 registered patients with C3GN, 16 (6%) had biopsy-proven glomerular and/or vascular TMA lesions. Their median age at diagnosis was 39 years (range, 7-76), and 59% were female. Fourteen of the 16 patients (88%) had an estimated glomerular filtration rate of<30mL/min/1.73m2 and 3 of 16 (19%) required dialysis. Twelve of the 14 evaluated patients (86%) showed evidence of mechanical hemolysis. Fifty percent of the patients had low C3 levels. Six of the 14 evaluated patients had a rare variant in complement genes, and 4 of the 16 patients (25%) had monoclonal gammopathy. Among the 16 patients, 10 (63%) received eculizumab, 5 (31%) received immunosuppressive therapy, and 4 (25%) received clone-targeted chemotherapy. Median kidney survival was 49 months. LIMITATIONS Small retrospective case series with a limited number of biopsies including electron microscopy. CONCLUSIONS Concomitant C3GN and TMA is extremely rare and is associated with poor kidney outcomes. Genetic or acquired abnormalities of the alternative complement pathway are common as is the presence of monoclonal gammopathy, which may inform the selection of treatment approaches.
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Affiliation(s)
- Melchior Chabannes
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Besançon
| | - Marion Rabant
- Department of Pathology, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris; Université de Paris Cité, Paris, France
| | - Carine El Sissy
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - Marie-Agnès Dragon-Durey
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris; INSERM UMRS 1138, Cordelier Research Center, Paris; Université de Paris Cité, Paris, France
| | - Paula Vieira Martins
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - Marie Sophie Meuleman
- INSERM UMRS 1138, Cordelier Research Center, Paris; Université de Paris Cité, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - David Buob
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris
| | - Frank Bridoux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Poitiers
| | - Eric Daugas
- Department of Nephrology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris
| | - Vincent Audard
- Department of Nephrology and Transplantation, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Créteil; Univ Paris Est Creteil, INSERM, IMRB, Créteil, France
| | - Sophie Caillard
- Department of Nephrology and Transplantation, University Hospital, Strasbourg
| | - Jérôme Olagne
- Department of Pathology, University Hospital, Strasbourg
| | | | - Sophie Ferlicot
- Department of Pathology, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre
| | | | - Thomas Crepin
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Besançon
| | - Eric Thervet
- INSERM UMRS 1138, Cordelier Research Center, Paris
| | - Didier Ducloux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Besançon
| | - Véronique Frémeaux-Bacchi
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - Sophie Chauvet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris; INSERM UMRS 1138, Cordelier Research Center, Paris; Université de Paris Cité, Paris, France.
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12
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Schwotzer N, Frémeaux-Bacchi V, Fakhouri F. Hemolytic Uremic Syndrome: A Question of Terminology. Clin J Am Soc Nephrol 2023; 18:831-833. [PMID: 37249504 PMCID: PMC10356109 DOI: 10.2215/cjn.0000000000000198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Nora Schwotzer
- Service of Nephrology and Hypertension, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, Paris, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
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13
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Donadelli R, Sinha A, Bagga A, Noris M, Remuzzi G. HUS and TTP: traversing the disease and the age spectrum. Semin Nephrol 2023; 43:151436. [PMID: 37949684 DOI: 10.1016/j.semnephrol.2023.151436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenia purpura (TTP) are rare diseases sharing a common pathological feature, thrombotic microangiopathy (TMA). TMA is characterized by microvascular thrombosis with consequent thrombocytopenia, microangiopathic hemolytic anemia and/or multiorgan dysfunction. In the past, the distinction between HUS and TTP was predominantly based on clinical grounds. However, clinical presentation of the two syndromes often overlaps and, the differential diagnosis is broad. Identification of underlying pathogenic mechanisms has enabled the classification of these syndromes on a molecular basis: typical HUS caused by Shiga toxin-producing Escherichia coli (STEC-HUS); atypical HUS or complement-mediated TMA (aHUS/CM-TMA) associated with genetic or acquired defects leading to dysregulation of the alternative pathway (AP) of complement; and TTP that results from a severe deficiency of the von Willebrand Factor (VWF)-cleaving protease, ADAMTS13. The etiology of TMA differs between pediatric and adult patients. Childhood TMA is chiefly caused by STEC-HUS, followed by CM-TMA and pneumococcal HUS (Sp-HUS). Rare conditions such as congenital TTP (cTTP), vitamin B12 metabolism defects, and coagulation disorders (diacylglycerol epsilon mutation) present as TMA chiefly in children under 2 years of age. In contrast secondary causes and acquired ADAMT13 deficiency are more common in adults. In adults, compared to children, diagnostic delays are more frequent due to the wide range of differential diagnoses. In this review we focus on the three major forms of TMA, STEC-HUS, aHUS and TTP, outlining the clinical presentation, diagnosis and management of the affected patients, to help highlight the salient features and the differences between adult and pediatric patients which are relevant for management.
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Affiliation(s)
- Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Aditi Sinha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Ranica, Italy.
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14
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Halimi JM, Al-Dakkak I, Anokhina K, Ardissino G, Licht C, Lim WH, Massart A, Schaefer F, Walle JV, Rondeau E. Clinical characteristics and outcomes of a patient population with atypical hemolytic uremic syndrome and malignant hypertension: analysis from the Global aHUS registry. J Nephrol 2023; 36:817-828. [PMID: 36152218 PMCID: PMC10090001 DOI: 10.1007/s40620-022-01465-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Atypical hemolytic uremic syndrome (aHUS) is a rare form of thrombotic microangiopathy (TMA) often caused by alternative complement dysregulation. Patients with aHUS can present with malignant hypertension (MHT), which may also cause TMA. METHODS This analysis of the Global aHUS Registry (NCT01522183) assessed demographics and clinical characteristics in eculizumab-treated and not-treated patients with aHUS, with (n = 71) and without (n = 1026) malignant hypertension, to further elucidate the potential relationship between aHUS and malignant hypertension. RESULTS While demographics were similar, patients with aHUS + malignant hypertension had an increased need for renal replacement therapy, including kidney transplantation (47% vs 32%), and more pathogenic variants/anti-complement factor H antibodies (56% vs 37%) than those without malignant hypertension. Not-treated patients with malignant hypertension had the highest incidence of variants/antibodies (65%) and a greater need for kidney transplantation than treated patients with malignant hypertension (65% vs none). In a multivariate analysis, the risk of end-stage kidney disease or death was similar between not-treated patients irrespective of malignant hypertension and was significantly reduced in treated vs not-treated patients with aHUS + malignant hypertension (adjusted HR (95% CI), 0.11 [0.01-0.87], P = 0.036). CONCLUSIONS These results confirm the high severity and poor prognosis of untreated aHUS and suggest that eculizumab is effective in patients with aHUS ± malignant hypertension. Furthermore, these data highlight the importance of accurate, timely diagnosis and treatment in these populations and support consideration of aHUS in patients with malignant hypertension and TMA. TRIAL REGISTRATION DETAILS Atypical Hemolytic-Uremic Syndrome (aHUS) Registry. Registry number: NCT01522183 (first listed 31st January, 2012; start date 30th April, 2012).
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Affiliation(s)
- Jean-Michel Halimi
- Service de Néphrologie-Hypertension Artérielle, Dialyses, Transplantation Rénale, CHRU Tours, Tours, France.
- University of Tours, Equipe d'Accueil 4245 (EA4245), Tours, France.
| | | | | | - Gianluigi Ardissino
- Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Annick Massart
- Department of Nephrology and Hypertension, Antwerp University Hospital, Edegem, Belgium
| | - Franz Schaefer
- Division of Pediatric Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Eric Rondeau
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Paris, France
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15
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Fakhouri F, Schwotzer N, Frémeaux-Bacchi V. How I diagnose and treat atypical hemolytic uremic syndrome. Blood 2023; 141:984-995. [PMID: 36322940 DOI: 10.1182/blood.2022017860] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Our understanding and management of atypical hemolytic uremic syndrome (aHUS) have dramatically improved in the last decade. aHUS has been established as a prototypic disease resulting from a dysregulation of the complement alternative C3 convertase. Subsequently, prospective nonrandomized studies and retrospective series have shown the efficacy of C5 blockade in the treatment of this devastating disease. C5 blockade has become the cornerstone of the treatment of aHUS. This therapeutic breakthrough has been dulled by persistent difficulties in the positive diagnosis of aHUS, and the latter remains, to date, a diagnosis by exclusion. Furthermore, the precise spectrum of complement-mediated renal thrombotic microangiopathy is still a matter of debate. Nevertheless, long-term management of aHUS is increasingly individualized and lifelong C5 blockade is no longer a paradigm that applies to all patients with this disease. The potential benefit of complement blockade in other forms of HUS, notably secondary HUS, remains uncertain.
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Affiliation(s)
- Fadi Fakhouri
- Department of Medicine, Service of Nephrology and Hypertension, Lausanne University Hospital and Université de Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Department of Medicine, Service of Nephrology and Hypertension, Lausanne University Hospital and Université de Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Laboratory of Immunology, Paris University, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges-Pompidou, Paris, France
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16
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How I treat thrombotic microangiopathy in the era of rapid genomics. Blood 2023; 141:147-155. [PMID: 36347020 DOI: 10.1182/blood.2022015583] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/08/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022] Open
Abstract
Thrombotic microangiopathy (TMA) encompasses various genetically-driven diseases. The emergence of ultrafast genomic sequencing has recently opened up new avenues of research for genetic investigations in the setting of intensive care units. TMA is likely to be a suitable focus for fast-track genomic sequencing. By establishing an expeditious molecular diagnosis of patients with the complement-dependent hemolytic uremic syndrome, fast-track genomic sequencing allows for the timely implementation or withdrawal of anti-C5 treatment while averting unnecessary, costly, and potentially harmful therapy in patients testing negative for the syndrome. Furthermore, genomics has the potential to reshape the taxonomic classification of TMA owing to comprehensive genomic analysis. The most significant results from such analysis can be categorized as (1) new descriptions of genetic diseases previously not recognized as associated with TMA and (2) an enrichment of the phenotypic spectrum of diseases traditionally related to TMA. The latter draws on the concept of retrophenotyping, wherein genomic investigation precedes full clinical description. By taking precedence over a phenotypic approach, an unbiased genomic-focused analysis maximizes the chances of discovering new descriptions of a given variant. Presented here are 4 cases of TMA which highlight these issues and substantiate the promise of fast-track genomic sequencing.
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17
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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18
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Cavero T, Auñón P, Caravaca-Fontán F, Trujillo H, Arjona E, Morales E, Guillén E, Blasco M, Rabasco C, Espinosa M, Blanco M, Rodríguez-Magariños C, Cao M, Ávila A, Huerta A, Rubio E, Cabello V, Barros X, Goicoechea de Jorge E, Rodríguez de Córdoba S, Praga M. Thrombotic microangiopathy in patients with malignant hypertension. Nephrol Dial Transplant 2022; 38:1217-1226. [PMID: 36002030 DOI: 10.1093/ndt/gfac248] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a complication of malignant hypertension (mHTN) attributed to the high levels of blood pressure (BP). However, no studies have investigated in patients with mHTN of different etiologies whether the presence of TMA is associated with specific causes of mHTN. METHODS We investigate the presence of TMA (microangiopathic hemolytic anemia and thrombocytopenia) in a large and well characterized cohort of 199 patients with mHTN of different etiologies (primary HTN 44%, glomerular diseases 16.6%, primary atypical hemolytic uremic syndrome (aHUS) 13.1%, renovascular HTN 9.5%, drug-related HTN 7%, systemic diseases 5.5%, endocrine diseases 4.5%). Outcomes of the study were kidney recovery and kidney failure. RESULTS Patients with TMA (40 cases, 20.1%) were younger, had a lower proportion of males, lower BP levels and worse kidney function at presentation. Their underlying diseases were primary aHUS (60%), drug-related mHTN (15%), glomerular diseases (all of them IgA nephropathy) (10%), systemic diseases (10%) and primary HTN (5%). The presence of TMA was 92.3% in primary aHUS, 42.9% in drug-related HTN, 36.4% in systemic diseases, 12.1% in glomerular diseases and 2.3% in primary HTN. No patient with renovascular HTN or mHTN caused by endocrine diseases developed TMA, despite BP levels as severe as patients with TMA. A higher proportion of TMA patients developed kidney failure as compared to patients without TMA (56.4% versus 38.9%, respectively). CONCLUSIONS The presence of TMA in patients with mHTN should guide the diagnosis towards primary aHUS, drug-related mHTN, some systemic diseases and IgA nephropathy, while it is exceptional in other causes of mHTN.
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Affiliation(s)
- Teresa Cavero
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Auñón
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Caravaca-Fontán
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Emi Arjona
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Elena Guillén
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Miquel Blasco
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Marta Blanco
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | - Mercedes Cao
- Department of Nephrology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Ana Ávila
- Department of Nephrology, Hospital Universitario Dr Peset, Valencia, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Esther Rubio
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitario Dr Josep Trueta, Gerona, Spain
| | - Elena Goicoechea de Jorge
- Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Complutense University, Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Manuel Praga
- Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
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19
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Joseph A, Eloit M, Azoulay E, Kaplanski G, Provot F, Presne C, Wynckel A, Grangé S, Rondeau É, Pène F, Delmas Y, Lautrette A, Barbet C, Mousson C, Coindre J, Perez P, Jamme M, Augusto J, Poullin P, Jacobs F, El Karoui K, Vigneau C, Ulrich M, Kanouni T, Le Quintrec M, Hamidou M, Ville S, Charvet‐Rumpler A, Ojeda‐Uribe M, Godmer P, Fremeaux‐Bacchi V, Veyradier A, Halimi J, Coppo P. Immune‐mediated thrombotic thrombocytopenic purpura prognosis is affected by blood pressure. Res Pract Thromb Haemost 2022; 6:e12702. [PMID: 35599703 PMCID: PMC9115975 DOI: 10.1002/rth2.12702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 12/28/2022] Open
Abstract
Background The prevalence, prognostic role, and diagnostic value of blood pressure in immune-mediated thrombotic thrombocytopenic purpura (iTTP) and other thrombotic microangiopathies (TMAs) remain unclear. Methods Using a national cohort of iTTP (n = 368), Shigatoxin-induced hemolytic uremic syndrome (n = 86), atypical hemolytic uremic syndrome (n = 84), and hypertension-related thrombotic microangiopathy (n = 25), we sought to compare the cohort's blood pressure profile to assess its impact on prognosis and diagnostic performances. Results Patients with iTTP had lower blood pressure than patients with other TMAs, systolic (130 [interquartile range (IQR) 118-143] vs 161 [IQR 142-180] mmHg) and diastolic (76 [IQR 69-83] vs 92 [IQR 79-105] mmHg, both p < 0.001). The best threshold for iTTP diagnosis corresponded to a systolic blood pressure <150 mmHg. iTTP patients presenting with hypertension had a significantly poorer survival (hazard ratio 1.80, 95% confidence interval 1.07-3.04), and this effect remained significant after multivariable adjustment (hazard ratio = 1.14, 95% confidence interval 1.00-1.30). Addition of a blood pressure criterion modestly improved the French clinical score to predict a severe A disintegrin and metalloprotease with thrombospondin type 1 deficiency in patients with an intermediate score (i.e., either platelet count <30 × 109/L or serum creatinine <200 µM). Conclusions Elevated blood pressure at admission affects the prognosis of iTTP patients and may help discriminate them from other TMA patients. Particular attention should be paid to blood pressure and its management in these patients.
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Affiliation(s)
- Adrien Joseph
- INSERM, U1138, INSERM, Équipe 11 labellisée Ligue Nationale Contre le Cancer, Centre de Recherche des Cordeliers Paris France
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Martin Eloit
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et Thérapie Cellulaire CHRU de Tours Tours France
| | - Elie Azoulay
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Médecine intensive réanimation Hôpital Saint Louis AP‐HP Paris France
| | - Gilles Kaplanski
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Hôpital la Conception Marseille France
| | - François Provot
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Albert‐Calmette Lille France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Nord Amiens France
| | - Alain Wynckel
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Maison Blanche Reims France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale CHU Charles Nicolle Rouen France
| | - Éric Rondeau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Urgences Néphrologiques et Transplantation Rénale Hôpital Tenon Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Intensive–Réanimation Hôpital Cochin APHP Centre & Université de Paris Paris France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Bordeaux Bordeaux France
| | - Alexandre Lautrette
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Gabriel Montpied Clermont‐Ferrand France
| | - Christelle Barbet
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Christiane Mousson
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Dijon Dijon France
| | - Jean‐Philippe Coindre
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CH Le Mans Le Mans France
| | - Pierre Perez
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Polyvalente CHU de Nancy Nancy France
| | - Matthieu Jamme
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Centre Hospitalier Intercommunal Poissy Saint‐Germain Poissy France
| | - Jean‐François Augusto
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Dialyse et Transplantation CHU Larrey Angers France
| | - Pascale Poullin
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’hémaphérèse et d’autotransfusion Hôpital la Conception Marseille France
| | - Frédéric Jacobs
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Réanimation Médicale Hôpital Antoine Béclère Clamart France
| | - Khalil El Karoui
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie et Transplantation rénale Groupe Hospitalier Henri‐Mondor Créteil France
| | - Cécile Vigneau
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Université de Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)–UMR_S 1085 Rennes France
| | - Marc Ulrich
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie Hôpital Jean Bernard Valenciennes France
| | - Tarik Kanouni
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Unité d’Hémaphérèse Service d’Hématologie CHU de Montpellier Montpellier France
| | - Moglie Le Quintrec
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Montpellier Montpellier France
| | - Mohamed Hamidou
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne CHU de Nantes Nantes France
| | - Simon Ville
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie CHU de Nantes Nantes France
| | - Anne Charvet‐Rumpler
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Centre Hospitalier Régional Universitaire Hôpital Jean Minjoz Besançon France
| | - Mario Ojeda‐Uribe
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie et de Thérapie Cellulaire Groupe Hospitalier Region Mulhouse‐Sud‐Alsace (GHRMSA) Mulhouse France
| | - Pascal Godmer
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Médecine Interne Centre Hospitalier Bretagne Atlantique de Vannes Vannes France
| | - Véronique Fremeaux‐Bacchi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Immunologie Biologique Hôpital Européen Georges Pompidou, AP‐HP Paris France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Biologique Hôpital Lariboisière, AP‐HP Paris France
| | - Jean‐Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service de Néphrologie‐hypertension, Dialyses, Transplantation Rénale Hôpitaux Bretonneau et Clocheville Tours France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR‐MAT) AP‐HP Paris France
- Service d’Hématologie Hôpital Saint‐Antoine AP‐HP Paris France
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20
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Pry JM, Vinikoor MJ, Bolton Moore C, Roy M, Mody A, Sikazwe I, Sharma A, Chihota B, Duran-Frigola M, Daultrey H, Mutale J, Kerkhoff AD, Geng EH, Pollock BH, Vera JH. Evaluation of kidney function among people living with HIV initiating antiretroviral therapy in Zambia. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000124. [PMID: 36962175 PMCID: PMC10021838 DOI: 10.1371/journal.pgph.0000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022]
Abstract
As the response to the HIV epidemic in sub-Saharan Africa continues to mature, a growing number of people living with HIV (PLHIV) are aging and risk for non-communicable diseases increases. Routine laboratory tests of serum creatinine have been conducted to assess HIV treatment (ART) suitability. Here we utilize those measures to assess kidney function impairment among those initiating ART. Identification of non-communicable disease (NCD) risks among those in HIV care creates opportunity to improve public health through care referral and/or NCD/HIV care integration. We estimated glomerular filtration rates (eGFR) using routinely collected serum creatinine measures among a cohort of PLHIV with an HIV care visit at one of 113 Centre for Infectious Disease Research Zambia (CIDRZ) supported sites between January 1, 2011 and December 31, 2017, across seven of the ten provinces in Zambia. We used mixed-effect Poisson regression to assess predictors of eGFR <60ml/min/1.73m2 allowing random effects at the individual and facility level. Additionally, we assessed agreement between four eGFR formulae with unadjusted CKD-EPI as a standard using Scott/Fleiss method across five categories of kidney function. A total of 72,933 observations among 68,534 individuals met the inclusion criteria for analysis. Of the 68,534, the majority were female 41,042 (59.8%), the median age was 34 (interquartile range [IQR]: 28-40), and median CD4 cell count was 292 (IQR: 162-435). The proportion of individuals with an eGFR <60ml/min/1.73m2 was 6.9% (95% CI: 6.7-7.1%) according to the unadjusted CKD-EPI equation. There was variation in agreement across eGFR formulas considered compared to unadjusted CKD-EPI (χ2 p-value <0.001). Estimated GFR less than 60ml/min/1.73m2, per the unadjusted CKD-EPI equation, was significantly associated with age, sex, body mass index, and blood pressure. Using routine serum creatinine measures, we identified a significant proportion of individuals with eGFR indicating moderate or great kidney function impairment among PLHIV initiating ART in Zambia. It is possible that differentiated service delivery models could be developed to address this subset of those in HIV care with increased risk of chronic kidney disease.
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Affiliation(s)
- Jake M. Pry
- Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
| | - Michael J. Vinikoor
- School of Medicine University of Alabama, Birmingham, Alabama, United States of America
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
- School of Medicine University of Alabama, Birmingham, Alabama, United States of America
| | - Monika Roy
- School of Medicine, University of California, San Francisco, California, United States of America
| | - Aaloke Mody
- School of Medicine, Washington University, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
| | - Belinda Chihota
- Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
| | | | - Harriet Daultrey
- School of Medicine, University of California, Davis, California, United States of America
| | - Jacob Mutale
- Centre for Infectious Disease Research Zambia (CIDRZ), Lusaka, Zambia
| | - Andrew D. Kerkhoff
- School of Medicine, University of California, San Francisco, California, United States of America
| | - Elvin H. Geng
- School of Medicine, Washington University, St. Louis, Missouri, United States of America
| | - Brad H. Pollock
- School of Medicine, University of California, Davis, California, United States of America
| | - Jaime H. Vera
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
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21
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Werion A, Rondeau E. Application of C5 inhibitors in glomerular diseases in 2021. Kidney Res Clin Pract 2022; 41:412-421. [PMID: 35354244 PMCID: PMC9346396 DOI: 10.23876/j.krcp.21.248] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 11/04/2022] Open
Abstract
The complement pathway is an essential mechanism in innate immunity, but it is also involved in multiple pathologies. For kidney diseases, strong evidence of a dysregulation in the alternative pathway in atypical hemolytic uremic syndrome (aHUS) led to the use of eculizumab, the first anti-C5 inhibitor available in clinical practice. Intensive fundamental research resulted in the development of subsequent new drugs, such as long-acting C5 inhibitors, oral medications, or antagonists of C5aR, the receptor for C5a. New data in the domain of C5-inhibition in glomerular diseases are still limited and mainly focus on 1) the efficacy of ravulizumab, a long-acting C5 inhibitor in aHUS, and 2) the use of avacopan, a C5aR antagonist, in antineutrophil cytoplasmic antibody vasculitis. Several new studies ongoing or planned for the next few years will evaluate the efficacy of C5 inhibition in secondary thrombotic microangiopathy, C3 glomerulopathy, membranous nephropathy, or immunoglobulin A nephropathy.
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Affiliation(s)
- Alexis Werion
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
- Correspondence: Eric Rondeau Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Rue de la Chine 4, 75020 Paris, France. E-mail:
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22
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Prével R, Delmas Y, Guillotin V, Gruson D, Rivière E. Complement Blockade Is a Promising Therapeutic Approach in a Subset of Critically Ill Adult Patients with Complement-Mediated Hemolytic Uremic Syndromes. J Clin Med 2022; 11:jcm11030790. [PMID: 35160242 PMCID: PMC8837052 DOI: 10.3390/jcm11030790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) gathers consumptive thrombocytopenia, mechanical haemolytic anemia, and organ damage. Hemolytic uremic syndromes (HUS) are historically classified as primary or secondary to another disease once thrombotic thrombocytopenic purpura (TTP), Shiga-toxin HUS, and cobalamin C-related HUS have been ruled out. Complement genetics studies reinforced the link between complement dysregulation and primary HUS, contributing to reclassifying some pregnancy- and/or post-partum-associated HUS and to revealing complement involvement in severe and/or refractory hypertensive emergencies. By contrast, no firm evidence allows a plausible association to be drawn between complement dysregulation and Shiga-toxin HUS or other secondary HUS. Nevertheless, rare complement gene variants are prevalent in healthy individuals, thus providing an indication that an investigation into complement dysregulation should be carefully balanced and that the results should be cautiously interpreted with the help of a trained geneticist. Several authors have suggested reclassifying HUS in two entities, regardless of they are complement-mediated or not, since the use of eculizumab, an anti-C5 antibody, dramatically lowers the proportion of patients who die or suffer from end-stage renal disease within the year following diagnosis. Safety and the ideal timing of eculizumab discontinuation is currently under investigation, and the long-term consequences of HUS should be closely monitored over time once patients exit emergency departments.
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Affiliation(s)
- Renaud Prével
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-(0)5-56-79-55-17; Fax: +33-(0)5-56-79-54-18
| | - Yahsou Delmas
- CHU Bordeaux, Nephrology Transplantation Dialysis Apheresis Unit, F-33076 Bordeaux, France;
| | - Vivien Guillotin
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, F-33000 Bordeaux, France; (V.G.); (D.G.)
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, F-33000 Bordeaux, France
| | - Etienne Rivière
- CHU Bordeaux, Internal Medicine Department, F-33000 Bordeaux, France;
- University Bordeaux, Biology of Cardiovascular Diseases, InsermU1034, F-33604 Pessac, France
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23
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Halimi JM, Thoreau B, von Tokarski F, Bauvois A, Gueguen J, Goin N, Barbet C, Cloarec S, Mérieau E, Lachot S, Garot D, Lemaignen A, Gyan E, Perrotin F, Pouplard C, Maillot F, Gatault P, Sautenet B, Rusch E, Frémeaux-Bacchi V, Vigneau C, Bayer G, Fakhouri F. What is the impact of blood pressure on neurological symptoms and the risk of ESKD in primary and secondary thrombotic microangiopathies based on clinical presentation: a retrospective study. BMC Nephrol 2022; 23:39. [PMID: 35057750 PMCID: PMC8781095 DOI: 10.1186/s12882-022-02672-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/05/2022] [Indexed: 12/26/2022] Open
Abstract
Abstract
Background
The impact of blood pressure on neurological symptoms and risk of end-stage kidney disease (ESKD) is unknown in primary and secondary thrombotic microangiopathies (TMAs).
Methods
We measured baseline systolic (SBP) and diastolic (DBP) BP in consecutive 563 patients with adjudicated primary and secondary TMAs, and assessed its association with the risk of ESKD.
Results
Normal BP, grade 1, 2 and 3 hypertension were present in 243 (43.1%), 132 (23.4%), 101 (17.9%) and 88 (15.6%), respectively.
Significant BP differences were noted in relation to the cause of TMA: highest BP values were found in patients with atypical hemolytic-uremic syndrome (aHUS), pregnancy, transplantation and auto-immune-related TMAs. Normal BP or grade 1 hypertension was found in 17/18 (94.4%) patients with thrombotic thrombocytopenic patients (only 1/18 (5.6%) had a SBP value>150 mmHg). In contrast, BP values could not differentiate isolated “essential” malignant hypertension (MH) from MH associated with aHUS (isolated MH (n=15): BP (median (IQR)): 220 (182-249)/132 (101-150) mmHg; MH with aHUS (n=5): BP: 223 (196-245)/131 (111-144) mmHg).
The risk of vigilance disturbances (6.9%, 15.0%, 25.0%, respectively), epileptic seizures (1.5%, 4.0%, 12.5%, respectively) and posterior reversible encephalopathy syndrome (0.76%, 2.97%, 6.82%, respectively) increased with increasing baseline BP values from grade 1 to grade 3 hypertension.
ESKD occurred in 35/563 (6.2%) patients (1.23%, 2.27%, 11.9% and 19.3% of patients with normal BP, grade 1, 2 and 3 hypertension, respectively). As compared to patients with normal BP (<120/139 mmHg), grade 1, grade 2 and grade 3 hypertension were associated with a greater risk of ESKD in univariate (OR: 1.91 [0.83-4.40], 13.2 [3.56-48.9] and 34.8 [9.31-130], respectively) and multivariate (OR: 0.89 [0.30-2.69], 7.00 [1.57-31.3] and 19.7 [4.53-85.2], respectively) analyses. The association between BP and the risk of ESRD was unchanged after adjustment on eculizumab use (OR: 3.46 [1.41-8.49], 17.7 [4.44-70.0] and 70.6 [8.61-579], respectively). Patients with MH, regardless of its cause, had a greater risk of ESKD (OR: 26.4 [10.0-69.8] vs other patients).
Conclusions
Baseline BP differs in primary and secondary TMAs. High BP reduces the neurological tolerance of TMAs and is a powerful independent risk factor of ESKD, even after adjustment on TMA’s cause.
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24
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Rodrigues EM, Ardissino G, Pintarelli G, Capone V, Mariotti J, Verna M, Bernardo ME, Faraci M, Tozzi M, Bucalossi A, Schiavello E, Biassoni V, Guidetti A, Carotti A, Facchini L, Terruzzi E, Giglio F, Zecca M, Onida F, Caroti L, Cesaro S, Consonni D, Cugno M, Porcaro L. Gene Abnormalities in Transplant Associated-Thrombotic Microangiopathy: Comparison between Recipient and Donor's DNA. Thromb Haemost 2021; 122:1247-1250. [PMID: 34965590 DOI: 10.1055/s-0041-1740498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Evangeline Millicent Rodrigues
- Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Ardissino
- Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Pintarelli
- Laboratory of Medical Genetics, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Capone
- Center for HUS Control, Prevention and Management, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Mariotti
- Bone Marrow Transplant Unit, Hematology-Oncology Department, Humanitas Cancer Center, Rozzano, Italy
| | - Marta Verna
- Paediatric Foundation MBBM, San Gerardo Hospital, Monza, Italy
| | - Maria Ester Bernardo
- Paediatric Immunohaematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Maura Faraci
- Hematopoietic Stem Cell Unit, Department of Hematology-Oncology, IRCCS Istituto G. Gaslini, Genova, Italy
| | - Monica Tozzi
- Cellular Therapy Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | - Elisabetta Schiavello
- Paediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Veronica Biassoni
- Paediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Anna Guidetti
- Hematology Division, Hemato-Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandra Carotti
- HST Program, Hematology Immunology Department, University Hospital, Perugia, Italy
| | - Luca Facchini
- Haematology Department, Azienda USL IRCCS, Reggio Emilia, Italy
| | | | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Zecca
- Paediatric Hematoloy/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Onida
- Hematology-BMT Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Leonardo Caroti
- Nephrology and Dialysis Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Dario Consonni
- Unit of Epidemiology in Public Health, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Internal Medicine and Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Porcaro
- Laboratory of Medical Genetics, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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25
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Fakhouri F, Frémeaux-Bacchi V. Thrombotic microangiopathy in aHUS and beyond: clinical clues from complement genetics. Nat Rev Nephrol 2021; 17:543-553. [PMID: 33953366 DOI: 10.1038/s41581-021-00424-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/02/2023]
Abstract
Studies of complement genetics have changed the landscape of thrombotic microangiopathies (TMAs), particularly atypical haemolytic uraemic syndrome (aHUS). Knowledge of complement genetics paved the way for the design of the first specific treatment for aHUS, eculizumab, and is increasingly being used to aid decisions regarding discontinuation of anti-complement treatment in this setting. Complement genetic studies have also been used to investigate the pathogenic mechanisms that underlie other forms of HUS and provided evidence that contributed to the reclassification of pregnancy- and postpartum-associated HUS within the spectrum of complement-mediated aHUS. By contrast, complement genetics has not provided definite evidence of a link between constitutional complement dysregulation and secondary forms of HUS. Therefore, the available data do not support systematic testing of complement genes in patients with typical HUS or secondary HUS. The potential relevance of complement genetics for distinguishing the underlying mechanisms of malignant hypertension-associated TMA should be assessed with caution owing to the overlap between aHUS and other causes of malignant hypertension. In all cases, the interpretation of complement genetics results remains complex, as even complement-mediated aHUS is not a classical monogenic disease. Such interpretation requires the input of trained geneticists and experts who have a comprehensive view of complement biology.
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Affiliation(s)
- Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Immunologie, Paris, France
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26
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The Syndromes of Thrombotic Microangiopathy: A Critical Appraisal on Complement Dysregulation. J Clin Med 2021; 10:jcm10143034. [PMID: 34300201 PMCID: PMC8307963 DOI: 10.3390/jcm10143034] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 01/12/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare and potentially life-threatening condition that can be caused by a heterogeneous group of diseases, often affecting the brain and kidneys. TMAs should be classified according to etiology to indicate targets for treatment. Complement dysregulation is an important cause of TMA that defines cases not related to coexisting conditions, that is, primary atypical hemolytic uremic syndrome (HUS). Ever since the approval of therapeutic complement inhibition, the approach of TMA has focused on the recognition of primary atypical HUS. Recent advances, however, demonstrated the pivotal role of complement dysregulation in specific subtypes of patients considered to have secondary atypical HUS. This is particularly the case in patients presenting with coexisting hypertensive emergency, pregnancy, and kidney transplantation, shifting the paradigm of disease. In contrast, complement dysregulation is uncommon in patients with other coexisting conditions, such as bacterial infection, drug use, cancer, and autoimmunity, among other disorders. In this review, we performed a critical appraisal on complement dysregulation and the use of therapeutic complement inhibition in TMAs associated with coexisting conditions and outline a pragmatic approach to diagnosis and treatment. For future studies, we advocate the term complement-mediated TMA as opposed to the traditional atypical HUS-type classification.
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Hemolytic uremic syndrome and kidney transplantation in uncontrolled donation after circulatory death (DCD): A two-case report. Clin Nephrol Case Stud 2021; 9:59-66. [PMID: 34084691 PMCID: PMC8170123 DOI: 10.5414/cncs110434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/11/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Hemolytic uremic syndrome (HUS) is a rare disease characterized by microangiopathic hemolysis, thrombocytopenia, and renal involvement. Complement-mediated atypical HUS (aHUS) is a result of genetic defects in the alternative complement pathway components or regulators. The introduction of eculizumab has improved renal and overall survival of aHUS patients. Nowadays, given organ shortage, it is necessary to consider kidney transplantation (KT) even in protocols with a high risk of HUS recurrence, such as from donation after circulatory death (DCD) donors. Here, we describe two patients with HUS who underwent a KT from an uncontrolled DCD (uDCD). Case summary: The first patient, affected by aHUS due to a heterozygous deletion in CFHR3-CFHR1 and a novel heterozygous variant in CFHR5 gene, underwent a KT with eculizumab prophylaxis. The patient did not experience a post-transplant aHUS recurrence. The second patient, who experienced an HUS episode characterized by a hypertensive crisis and with no underlying mutations in complement system genes, underwent a KT without eculizumab prophylaxis. At day 5, anti-complement treatment commenced due to hematological signs of thrombotic microangiopathy (TMA). After the introduction of eculizumab, we observed a stabilization of kidney function and hematological remission. Conclusion: We present herein two different patients with HUS who both underwent successful KT from uDCD donation under the umbrella of eculizumab therapy. Taking into account the importance of increasing the number of organs available for transplantation, uDCD could represent an additional resource in this subset of HUS patients.
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28
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Timmermans SAMEG, Damoiseaux JGMC, Werion A, Reutelingsperger CP, Morelle J, van Paassen P. Functional and Genetic Landscape of Complement Dysregulation Along the Spectrum of Thrombotic Microangiopathy and its Potential Implications on Clinical Outcomes. Kidney Int Rep 2021; 6:1099-1109. [PMID: 33912760 PMCID: PMC8071658 DOI: 10.1016/j.ekir.2021.01.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 01/30/2023] Open
Abstract
Introduction The syndromes of thrombotic microangiopathy (TMA) are diverse and represent severe endothelial damage caused by various mechanisms. The complement system plays a major role in a subset of patients with TMA, and its recognition is of clinical importance because it guides choice and duration of treatment. Methods We studied a well-defined cohort of patients with TMA and hypothesized that assessment of serum-induced ex vivo C5b9 formation on the endothelium and screening for rare variants in complement genes can better categorize TMA. Results Massive ex vivo C5b9 formation was found in all patients with primary atypical hemolytic uremic syndrome (n/N = 11/11) and in 59% of patients with TMA and coexisting conditions (n/N = 30/51). Massive ex vivo C5b9 formation was associated with rare genetic variants (45% [n/N = 20/44] vs. 0% [n/N = 0/21] patients with normal ex vivo C5b9 formation; P < 0.001). Massive ex vivo C5b9 formation was associated with favorable renal response to therapeutic complement inhibition in patients with TMA and coexisting conditions (86% [n/N = 12/14] vs. 31% [n/N = 5/16] of untreated patients; P < 0.001), indicating complement-mediated TMA rather than secondary disease. Among treated patients, the odds ratio for 1-year kidney survival was 12.0 (95% confidence interval 1.2-115.4). TMA recurrence was linked to rare genetic variants in all cases. Patients with normal ex vivo C5b9 formation had an acute, nonrelapsing form of TMA. Conclusions Ex vivo C5b9 formation and genetic testing appears to categorize TMAs into different groups because it identifies complement as a driving factor of disease, with potential therapeutic and prognostic implications.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology.,Department of Biochemistry, Cardiovascular Research Institute, Maastricht, The Netherlands
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alexis Werion
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Johann Morelle
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Institut de Recherche Experimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology.,Department of Biochemistry, Cardiovascular Research Institute, Maastricht, The Netherlands
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Fakhouri F, Sadallah S, Frémeaux-Bacchi V. Malignant hypertension and thrombotic microangiopathy: complement as a usual suspect. Nephrol Dial Transplant 2020; 36:gfaa362. [PMID: 33301026 DOI: 10.1093/ndt/gfaa362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 02/24/2024] Open
Affiliation(s)
- Fadi Fakhouri
- Service of nephrology and hypertension, Department of Medicine, Lausanne University Hospital
| | - Salima Sadallah
- Service of Immunology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Immunologie and Paris University, Paris, France
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Neves PDMDM, Souza RA, Torres FM, Reis FA, Pinheiro RB, Dias CB, Yu L, Woronik V, Furukawa LS, Cavalcante LB, de Almeida Araújo S, Wanderley DC, Malheiros DM, Jorge LB. Evidences of histologic thrombotic microangiopathy and the impact in renal outcomes of patients with IgA nephropathy. PLoS One 2020; 15:e0233199. [PMID: 33147224 PMCID: PMC7641451 DOI: 10.1371/journal.pone.0233199] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/30/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION IgA nephropathy (IgAN) is the most common primary glomerulopathy worldwide. According to the Oxford Classification, changes in the kidney vascular compartment are not related with worse outcomes. This paper aims to assess the impact of thrombotic microangiopathy (TMA) in the outcomes of Brazilian patients with IgAN. MATERIALS AND METHODS Analysis of clinical data and kidney biopsy findings from patients with IgAN to assess the impact of TMA on renal outcomes. RESULTS The majority of the 118 patients included were females (54.3%); mean age of 33 years (25;43); hypertension and hematuria were observed in 67.8% and 89.8%, respectively. Median creatinine: 1.45mg/dL; eGFR: 48.8ml/min/1.73m2; 24-hour proteinuria: 2.01g; low serum C3: 12.5%. Regarding to Oxford Classification: M1: 76.3%; E1: 35.6%; S1: 70.3%; T1/T2: 38.3%; C1/C2: 28.8%. Average follow-up: 65 months. Histologic evidence of TMA were detected in 21 (17.8%) patients and those ones presented more frequently hypertension (100% vs. 61%, p <0.0001), hematuria (100% vs 87.6%, p = 0.0001), worse creatinine levels (3.8 vs. 1.38 mg/dL, p = 0.0001), eGFR (18 vs. 60 ml/min/1.73m2), p = 0.0001), low serum C3 (28.5% vs. 10.4%, p = 0.003), lower hemoglobin levels (10.6 vs. 12.7g/dL, p<0.001) and platelet counts (207,000 vs. 267,000, p = 0.001). Biopsy findings of individuals with TMA revealed only greater proportions of E1 (68% vs. 32%, p = 0.002). Individuals with TMA were followed for less time (7 vs. 65 months, p<0.0001) since they progressed more frequently to chronic kidney disease (CKD) requiring kidney replacement therapy (KRT) (71.4% vs. 21,6%, p<0.0001). Male sex, T1/T2, and TMA were independently associated with progression to CKD-KRT. CONCLUSIONS In this study patients with TMA had worse clinical manifestations and outcomes. In terms of histologic evidence, E1 distinguished patients with TMA from other patients. Further studies are necessary to analyze the impact of vascular lesions on IgAN prognosis.
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Affiliation(s)
| | - Rafael A. Souza
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Fábio M. Torres
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Fábio A. Reis
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Rafaela B. Pinheiro
- Pathology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Cristiane B. Dias
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Luis Yu
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Viktoria Woronik
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Luzia S. Furukawa
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Lívia B. Cavalcante
- Pathology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Stanley de Almeida Araújo
- Nephropathology Institute, Belo Horizonte, MG, Brazil
- Pathology Division, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - David Campos Wanderley
- Nephropathology Institute, Belo Horizonte, MG, Brazil
- Pathology Division, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Denise M. Malheiros
- Pathology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Lectícia B. Jorge
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
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Timmermans SAMEG, Wérion A, Damoiseaux JGMC, Morelle J, Reutelingsperger CP, van Paassen P. Diagnostic and Risk Factors for Complement Defects in Hypertensive Emergency and Thrombotic Microangiopathy. Hypertension 2019; 75:422-430. [PMID: 31865800 DOI: 10.1161/hypertensionaha.119.13714] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hypertensive emergency can cause thrombotic microangiopathy (TMA) in the kidneys with high rates of end-stage renal disease (ESRD) and vice versa. The conundrum of hypertension as the cause of TMA or consequence of TMA on the background of defects in complement regulation remains difficult. Patients with hypertensive emergency and TMA on kidney biopsy were tested for ex vivo C5b9 formation on the endothelium and rare variants in complement genes to identify complement-mediated TMA. We identified factors associated with defects in complement regulation and poor renal outcomes. Massive ex vivo C5b9 formation was found on resting endothelial cells in 18 (69%) out of 26 cases at the presentation, including the 9 patients who carried at least one rare genetic variant. Thirteen (72%, N=18) and 3 (38%, N=8) patients with massive and normal ex vivo complement activation, respectively, progressed to ESRD (P=0.03). In contrast to BP control, inhibition of C5 activation prevented ESRD to occur in 5 (83%, N=6) patients with massive ex vivo complement activation. TMA-related graft failure occurred in 7 (47%, N=15) donor kidneys and was linked to genetic variants. The assessment of both ex vivo C5b9 formation and screening for rare variants in complement genes may categorize patients with hypertensive emergency and TMA into different groups with potential therapeutic and prognostic implications. We propose an algorithm to recognize patients at the highest risk for defects in complement regulation.
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Affiliation(s)
- Sjoerd A M E G Timmermans
- From the Department of Nephrology and Clinical Immunology (S.A.M.E.G.T., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
- Department of Biochemistry (S.A.M.E.G.T., C.P.R., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
| | - Alexis Wérion
- Division of Nephrology, Cliniques universitaires Saint-Luc (A.W., J.M.)
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center (J.G.M.C.D.), Cardiovascular Research Institute Maastricht, the Netherlands
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc (A.W., J.M.)
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium (J.M.)
| | - Chris P Reutelingsperger
- Department of Biochemistry (S.A.M.E.G.T., C.P.R., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
| | - Pieter van Paassen
- From the Department of Nephrology and Clinical Immunology (S.A.M.E.G.T., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
- Department of Biochemistry (S.A.M.E.G.T., C.P.R., P.v.P.), Cardiovascular Research Institute Maastricht, the Netherlands
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Cavero T, Rodríguez de Córdoba S, Praga M. The authors reply. Kidney Int 2019; 96:1239-1240. [DOI: 10.1016/j.kint.2019.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022]
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Atypical hemolytic uremic syndrome and hypertensive crisis. Kidney Int 2019; 96:1239. [DOI: 10.1016/j.kint.2019.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/24/2019] [Indexed: 11/23/2022]
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Abstract
The thrombotic microangiopathies (TMAs) are a group of diseases characterised by microangiopathic haemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. Traditionally, TMAs have been classified as either thrombotic thrombocytopenic purpura (TTP) or haemolytic uremic syndrome (HUS) based on the clinical presentation, with neurological involvement predominating in the former and acute kidney injury in the latter. However, as our understanding of the pathogenesis of these conditions has increased, it has become clear that this is an over-simplification; there is significant overlap in the clinical presentation of TTP and HUS, there are different forms of HUS, and TMAs can occur in other, diverse clinical scenarios. This review will discuss recent developments in the diagnosis of HUS, focusing on the different forms of HUS and how to diagnose and manage these potentially life-threatening diseases.
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Affiliation(s)
- Neil S Sheerin
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Emily Glover
- National Renal Complement Therapeutics Centre, Institute of Cellular Medicine, Newcastle University and Biomedical Research Centre, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
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Boudhabhay I, Frémeaux-Bacchi V, Roumenina LT, Moktefi A, Goujon JM, Matignon M, Caudwell V, Audard V, El Karoui K. Glomerulonephritis With Isolated C3 Deposits as a Manifestation of Subtotal Factor I Deficiency. Kidney Int Rep 2019; 4:1354-1358. [PMID: 31517156 PMCID: PMC6732777 DOI: 10.1016/j.ekir.2019.05.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 11/03/2022] Open
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Le Clech A, Frémeaux-Bacchi V, Fakhouri F. The authors reply. Kidney Int 2019; 96:517-518. [DOI: 10.1016/j.kint.2019.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/23/2019] [Indexed: 11/29/2022]
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