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Nagaoka K, Katagiri D, Matsunami M, Chinen M, Seki K, Fukuda J, Ohara M, Suzuki T. Kidney Biopsy Proven Thrombotic Microangiopathy Induced by Methamphetamine. Intern Med 2024; 63:1603-1608. [PMID: 37866922 PMCID: PMC11189718 DOI: 10.2169/internalmedicine.2143-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/31/2023] [Indexed: 10/24/2023] Open
Abstract
A 47-year-old man was admitted to our hospital with acute kidney injury, severe hypertension, heart failure, thrombocytopenia, and elevated lactate dehydrogenase. Renal biopsy revealed fibrin thrombi within the glomerular capillaries and moderate fibrotic intimal thickening in the interlobular arteries. The histological diagnosis was thrombotic microangiopathy (TMA). Regarding cardiac involvement, we found marked stenosis in the left anterior descending artery on coronary angiography and cardiomyopathy on myocardial biopsy. Blood concentrations of amphetamine and methamphetamine were high (14.1 ng/mL and 333 ng/mL, respectively). It is important to consider methamphetamine as a cause of renal TMA and multi-organ dysfunction.
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Affiliation(s)
| | - Daisuke Katagiri
- Department of Nephrology, National Center for Global Health and Medicine, Japan
| | | | - Miria Chinen
- Department of Nephrology, National Center for Global Health and Medicine, Japan
| | - Kurumi Seki
- Department of Pathology, Kameda Medical Center, Japan
| | - Junko Fukuda
- Department of Nephrology, Kameda Medical Center, Japan
| | - Mamiko Ohara
- Department of Nephrology, Kameda Medical Center, Japan
| | - Tomo Suzuki
- Department of Nephrology, Kameda Medical Center, Japan
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Koubar SH, Garcia-Rivera A, Mohamed MMB, Hall JE, Hall ME, Hassanein M. Underlying Mechanisms and Treatment of Hypertension in Glomerular Diseases. Curr Hypertens Rep 2024; 26:119-130. [PMID: 37982994 DOI: 10.1007/s11906-023-01287-9] [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] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the underlying mechanisms that lead to hypertension in glomerular diseases and the advancements in treatment strategies and to provide clinicians with valuable insights into the pathophysiological mechanisms and evidence-based therapeutic approaches for managing hypertension in patients with glomerular diseases. RECENT FINDINGS In recent years, there have been remarkable advancements in our understanding of the immune and non-immune mechanisms that are involved in the pathogenesis of hypertension in glomerular diseases. Furthermore, this review will encompass the latest data on management strategies, including RAAS inhibition, endothelin receptor blockers, SGLT2 inhibitors, and immune-based therapies. Hypertension (HTN) and cardiovascular diseases are leading causes of mortality in glomerular diseases. The latter are intricately related with hypertension and share common pathophysiological mechanisms. Hypertension in glomerular disease represents a complex and multifaceted interplay between kidney dysfunction, immune-mediated, and non-immune-mediated pathology. Understanding the complex mechanisms involved in this relationship has evolved significantly over the years, shedding light on the pathophysiological processes underlying the development and progression of glomerular disease-associated HTN, and is crucial for developing effective therapeutic strategies and improving patients' outcomes.
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Affiliation(s)
- Sahar H Koubar
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alejandro Garcia-Rivera
- Department of Nephrology. Hospital General Regional 46, Instituto Mexicano del Seguro Social, Guadalajara, Mexico
| | - Muner M B Mohamed
- Department of Nephrology, Ochsner Health System, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - John E Hall
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
- Mississippi Center for Obesity Research, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael E Hall
- Division of Cardiovascular Disease, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohamed Hassanein
- Division of Nephrology and Hypertension, Department of Medicine, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, USA.
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Leisring J, Brodsky SV, Parikh SV. Clinical Evaluation and Management of Thrombotic Microangiopathy. Arthritis Rheumatol 2024; 76:153-165. [PMID: 37610060 DOI: 10.1002/art.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
Thrombotic microangiopathy (TMA) refers to a diverse group of diseases that share clinical and histopathologic features. TMA is clinically characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and organ injury that stems from endothelial damage and vascular occlusion. There are several disease states with distinct pathophysiological mechanisms that manifest as TMA. These conditions are associated with significant morbidity and mortality and require urgent recognition and treatment. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are traditionally considered to be primary forms of TMA, but TMA more commonly occurs in association with a coexisting condition such as infection, pregnancy, autoimmune disease, or malignant hypertension, among others. Determining the cause of TMA is a diagnostic challenge because of limited availability of disease-specific testing. However, identifying the underlying etiology is imperative as treatment strategies differ. Our understanding of the conditions that cause TMA is evolving. Recent advances have led to improved comprehension of the varying pathogenic mechanisms that drive TMA. Development of targeted therapeutics has resulted in significant improvements in patient outcomes. In this article, we review the pathogenesis and clinical features of the different TMA-causing conditions. We outline a practical approach to diagnosis and management and discuss empiric and disease-specific treatment strategies.
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Affiliation(s)
- Joshua Leisring
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Samir V Parikh
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Addad VV, Palma LMP, Vaisbich MH, Pacheco Barbosa AM, da Rocha NC, de Almeida Cardoso MM, de Almeida JTC, de Paula de Sordi MA, Machado-Rugolo J, Arantes LF, de Andrade LGM. A comprehensive model for assessing and classifying patients with thrombotic microangiopathy: the TMA-INSIGHT score. Thromb J 2023; 21:119. [PMID: 37993892 PMCID: PMC10664252 DOI: 10.1186/s12959-023-00564-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Thrombotic Microangiopathy (TMA) is a syndrome characterized by the presence of anemia, thrombocytopenia and organ damage and has multiple etiologies. The primary aim is to develop an algorithm to classify TMA (TMA-INSIGHT score). METHODS This was a single-center retrospective cohort study including hospitalized patients with TMA at a single center. We included all consecutive patients diagnosed with TMA between 2012 and 2021. TMA was defined based on the presence of anemia (hemoglobin level < 10 g/dL) and thrombocytopenia (platelet count < 150,000/µL), signs of hemolysis, and organ damage. We classified patients in eight categories: infections; Malignant Hypertension; Transplant; Malignancy; Pregnancy; Thrombotic Thrombocytopenic Purpura (TTP); Shiga toxin-mediated hemolytic uremic syndrome (STEC-SHU) and Complement Mediated TMA (aHUS). We fitted a model to classify patients using clinical characteristics, biochemical exams, and mean arterial pressure at presentation. RESULTS We retrospectively retrieved TMA phenotypes using automatic strategies in electronic health records in almost 10 years (n = 2407). Secondary TMA was found in 97.5% of the patients. Primary TMA was found in 2.47% of the patients (TTP and aHUS). The best model was LightGBM with accuracy of 0.979, and multiclass ROC-AUC of 0.966. The predictions had higher accuracy in most TMA classes, although the confidence was lower in aHUS and STEC-HUS cases. CONCLUSION Secondary conditions were the most common etiologies of TMA. We retrieved comorbidities, associated conditions, and mean arterial pressure to fit a model to predict TMA and define TMA phenotypic characteristics. This is the first multiclass model to predict TMA including primary and secondary conditions.
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Affiliation(s)
- Vanessa Vilani Addad
- Department of Internal Medicine - UNESP, Univ Estadual Paulista, Rubião Jr, s/n, Botucatu/SP, 18618-687, Brazil
| | - Lilian Monteiro Pereira Palma
- Department of Pediatrics, Universidade Estadual de Campinas, R. Tessália Vieira de Camargo, 126 - Cidade Universitária, Campinas/SP, 13083-887, Brazil
| | - Maria Helena Vaisbich
- Pediatric Nephrology Service, Child Institute, University of São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, São Paulo, SP, 05403-000, Brazil
| | | | - Naila Camila da Rocha
- Department of Internal Medicine - UNESP, Univ Estadual Paulista, Rubião Jr, s/n, Botucatu/SP, 18618-687, Brazil
| | | | | | | | - Juliana Machado-Rugolo
- Health Technology Assessment Center of Hospital das Clínicas - HCFMB, Botucatu, SP, Brazil
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Largeau B, Thoreau B, Grangé S, Jonville-Béra AP, Halimi JM. Thrombotic microangiopathy associated with anticancer and immune system targeting drugs: New insights from real-world data using the WHO pharmacovigilance database. J Intern Med 2023; 294:665-678. [PMID: 37538031 DOI: 10.1111/joim.13703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND The worldwide development of immune system targeting/anticancer drugs has revolutionized immuno-oncology, but their implication in thrombotic microangiopathy syndromes (TMA) is increasingly suspected. Using real-world data, the aim of this study was to identify drugs associated with TMA reporting and to describe the evolution of TMA reporting over time with a focus on these drugs. METHODS A global disproportionality study was performed using the individual case safety reports (ICSRs) extracted from the World Health Organization (WHO) pharmacovigilance database (VigiBase) from its inception (1968) to April 30, 2022. RESULTS Of the 31,251,040 ICSRs, 6946 cases of suspected drug-induced TMA were included from 55 countries. The outcome was fatal in 18.2% of cases. A total of 72 immune system targeting/anticancer drugs were associated with significant overreporting, including 17 drugs with a potential new safety concern for TMA. Although the rate of TMA reporting per million of ICSRs has remained fairly stable, an absolute increase in reported cases of suspected drug-induced TMA has been observed over the last decade. The pattern of drugs reported in TMA has evolved with a substantial increase in the proportion of cases involving immune system-targeting drugs/anticancer drugs from 47.3% (205/433) in the period 1992-2001 to 80.7% (3819/4730) in the period 2012-2021. CONCLUSION Several recently marketed immune system targeting/anticancer drugs have been identified as potential new drugs associated with TMA, which will require confirmatory studies. The number of drugs associated with TMA reporting markedly increased within the past 10 years, primarily due to innovative anticancer drugs.
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Affiliation(s)
- Bérenger Largeau
- Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Benjamin Thoreau
- Service de Médecine Interne-Immunologie Clinique, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Steven Grangé
- Centre National de Référence pour les microangiopathies thrombotiques, Hôpital Saint-Antoine, Université de la Sorbonne, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Bois-Guillaume, CHU Rouen, Rouen, France
| | - Annie-Pierre Jonville-Béra
- Service de Pharmacosurveillance, Centre Régional de Pharmacovigilance, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Jean-Michel Halimi
- Centre National de Référence pour les microangiopathies thrombotiques, Hôpital Saint-Antoine, Université de la Sorbonne, AP-HP, Paris, France
- Service de Néphrologie, Hôpital Bretonneau, CHU Tours, Tours, France
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Werion A, Storms P, Zizi Y, Beguin C, Bernards J, Cambier JF, Dahan K, Dierickx D, Godefroid N, Hilbert P, Lambert C, Levtchenko E, Meyskens T, Poiré X, van den Heuvel L, Claes KJ, Morelle J. Epidemiology, Outcomes, and Complement Gene Variants in Secondary Thrombotic Microangiopathies. Clin J Am Soc Nephrol 2023; 18:881-891. [PMID: 37094330 PMCID: PMC10356144 DOI: 10.2215/cjn.0000000000000182] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The identification of complement defects as major drivers of primary atypical hemolytic uremic syndrome (HUS) has transformed the landscape of thrombotic microangiopathies (TMAs), leading to the development of targeted therapies and better patient outcomes. By contrast, little is known about the presentation, genetics, and outcomes of TMA associated with specific diseases or conditions, also referred to as secondary TMA. METHODS In this study, we assessed the relative incidence, clinical and genetic spectra, and long-term outcomes of secondary TMA versus other TMAs in consecutive patients hospitalized with a first episode of TMA from 2009 to 2019 at two European reference centers. RESULTS During the study period, 336 patients were hospitalized with a first episode of TMA. Etiologies included atypical HUS in 49 patients (15%), thrombotic thrombocytopenic purpura (TTP) in 29 (9%), shigatoxin-associated HUS in 70 (21%), and secondary TMA in 188 (56%). The main causes of secondary TMA were hematopoietic stem-cell transplantation ( n =56, 30%), solid-organ transplantation ( n =44, 23%), and malignant hypertension ( n =25, 13%). Rare variants in complement genes were identified in 32 of 49 patients (65%) with atypical HUS and eight of 64 patients (13%) with secondary TMA; pathogenic or likely pathogenic variants were found in 24 of 49 (49%) and two of 64 (3%) of them, respectively ( P < 0.001). After a median follow-up of 1157 days, death or kidney failure occurred in 14 (29%), eight (28%), five (7%), and 121 (64%) patients with atypical HUS, TTP, shigatoxin-associated HUS, and secondary TMA, respectively. Unadjusted and adjusted Cox regressions showed that patients with secondary TMA had the highest risk of death or kidney failure (unadjusted hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.85 to 6.07; P < 0.001; adjusted HR, 4.11; 95% CI, 2.00 to 8.46; P < 0.001; considering atypical HUS as reference). CONCLUSIONS Secondary TMAs represent the main cause of TMA and are independently associated with a high risk of death and progression to kidney failure.
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Affiliation(s)
- Alexis Werion
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Pauline Storms
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Ysaline Zizi
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Claire Beguin
- Department of Medical Informatics and Statistics, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Jelle Bernards
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Nephrology, ZNA Middelheim, Antwerpen, Belgium
| | | | - Karin Dahan
- Institut de Pathologie et de Génétique, Gosselies, Belgium
| | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Nathalie Godefroid
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Pediatric Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | - Catherine Lambert
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Elena Levtchenko
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | - Xavier Poiré
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
- Division of Hematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Lambert van den Heuvel
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kathleen J. Claes
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
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Comparison of clinical characteristics of first-episode thrombotic thrombocytopenic purpura and TTP-like syndrome: a retrospective cohort study in a level I hematology center in China. Ann Hematol 2023; 102:55-62. [PMID: 36385651 DOI: 10.1007/s00277-022-05030-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/04/2022] [Indexed: 11/18/2022]
Abstract
Comparing the characteristics of thrombotic thrombocytopenic purpura (TTP) and TTP-like syndrome patients at admission will allow early differentiation of TTP from TTP-like syndrome and help tailor initial treatment. The medical records of 78 patients with suspected TTP in the Emergency Department of Peking University People's Hospital in the past 5 years were retrospectively analyzed and divided into TTP and TTP-like syndrome groups based on ADAMTS13 activity and ADAMTS13 antibody titer. There were 25 and 53 patients in the TTP group and the TTP-like syndrome group, respectively. The neutrophil-to-lymphocyte ratio (P = 0.025) was tremendously higher, and albumin (P = 0.002) was lower in the TTP-like syndrome group, indicating a more severe inflammation. Compared with the TTP-like syndrome group, the TTP group had an approximately two-fold to three-fold higher prevalence of central nervous system dysfunction (P < 0.001). Also, hemolysis was more substantial in the TTP group as evidenced by higher schistocytes (P < 0.001), reticulocyte (P < 0.001), total bilirubin (P = 0.002), indirect bilirubin (P < 0.001), lactate dehydrogenase (P = 0.007) and cell-free hemoglobin (P < 0.001), simultaneously lower platelet (P < 0.001), haptoglobin (P = 0.044), and ADAMTS13 activity (P < 0.001). The Kaplan-Meier survival analysis showed that the TTP group significantly predicted poor prognosis (log-rank test: X2 = 5.368, P = 0.021). TTP and TTP-like syndrome are two kinds of distinct phenotypes with different hemolysis statuses and illustrated differentiated inflammatory reactions, target organ damage (TOD), and the clinical outcome.
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Fage N, Orvain C, Henry N, Mellaza C, Beloncle F, Tuffigo M, Geneviève F, Coppo P, Augusto JF, Brilland B. Proteinuria Increases the PLASMIC and French Scores Performance to Predict Thrombotic Thrombocytopenic Purpura in Patients With Thrombotic Microangiopathy Syndrome. Kidney Int Rep 2021; 7:221-231. [PMID: 35155861 PMCID: PMC8820983 DOI: 10.1016/j.ekir.2021.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/31/2021] [Accepted: 11/08/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction PLASMIC and French scores have been developed to help clinicians in the early identification of patients with thrombotic thrombocytopenic purpura (TTP). Nevertheless, the validity of these scores in thrombotic microangiopathy (TMA) cohorts with low TTP prevalence remains uncertain. We aimed to evaluate their diagnostic value in routine clinical practice using an unselected cohort of patients with TMA. We also analyzed the value of adding proteinuria level to the scores. Methods We retrospectively included all patients presenting with a biological TMA syndrome between January 1, 2008, and December 31, 2019, in a tertiary hospital. TMA etiology was ascertained, and scores were evaluated. Modified scores, built by adding 1 point for low proteinuria (<1.2 g/g), were compared with original scores for TTP prediction. Results Among 273 patients presenting with a full biological TMA syndrome, 238 were classified with a TMA diagnosis. Complete scores and proteinuria level were available in 134 patients with a TTP prevalence of 7.5%. Area under the receiver operating characteristic curve (AUC) of PLASMIC and French scores for TTP diagnosis was 0.65 (0.46–0.84) and 0.72 (0.51–0.93), respectively. AUC of modified PLASMIC and French scores was 0.76 (0.59–0.92) (P = 0.003 vs. standard score) and 0.81 (0.67–0.95) (P = 0.069 vs. standard score), respectively. Specificity, positive predictive value (PPV), and positive likelihood ratio of high-risk scores were significantly improved by adding proteinuria level. Conclusion PLASMIC and French scores have low predictive values when applied to an unselected TMA cohort. Including proteinuria level in the original scores improves their performance for TTP prediction.
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