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Seccia TM, Rossitto G, Rossi GP. A Worrying and Puzzling Case of Hypertension Presenting to the Emergency Department. Hypertension 2024; 81:1179-1185. [PMID: 38748766 DOI: 10.1161/hypertensionaha.123.22108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Teresa M Seccia
- Internal Emergency Medicine Unit, Department of Medicine-DIMED, University of Padua, Specialized Center for Blood Pressure Disorders-Regione Veneto, Italy
| | - Giacomo Rossitto
- Internal Emergency Medicine Unit, Department of Medicine-DIMED, University of Padua, Specialized Center for Blood Pressure Disorders-Regione Veneto, Italy
| | - Gian Paolo Rossi
- Internal Emergency Medicine Unit, Department of Medicine-DIMED, University of Padua, Specialized Center for Blood Pressure Disorders-Regione Veneto, Italy
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2
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van Doorn DPC, Abdul-Hamid MA, Frenken LAM, van Paassen P, Timmermans SAMEG. The spectrum of thrombotic microangiopathy related to monoclonal gammopathy. Clin Kidney J 2024; 17:sfad306. [PMID: 38250251 PMCID: PMC10797488 DOI: 10.1093/ckj/sfad306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 01/23/2024] Open
Abstract
Background Recent studies showed a high prevalence of monoclonal gammopathy (MG) in patients with thrombotic microangiopathy (TMA) aged over 50 years and suggested that complement dysregulation is pivotal for the disease to develop. Here, we studied this premise in seven patients with TMA and coexisting MG. Methods Patients with TMA on kidney biopsy and/or peripheral blood were recruited from the prospective COMPETE cohort (NCT04745195) and Limburg Renal Registry. Patients were screened for complement dysregulation, including genetics/factor H autoantibodies (FHAA) and functional ex vivo testing on microvascular endothelial cells. Results Seven (8%) out of 84 patients with TMA presented with a coexisting MG. MG clustered in patients aged over 50 years (n/N = 6/32, 19%). C4 and/or C3 levels were low in three patients, while four patients presented with normal complement levels. None of the patients carried rare variants in complement genes. Massive ex vivo C5b9 formation on the endothelium was noted in one patient; purified IgG from this patient caused massive ex vivo C5b9 formation via the alternative pathway of complement activation, pointing to complement dysregulation in the fluid phase. Kidney biopsies from other nephropathies linked to MG rarely exhibited concurrent TMA (n/N = 1/27, 4%). Conclusions MG clustered in patients with TMA aged over 50 years. TMA and coexisting MG represents a heterogeneous disease spectrum, including a small subset of patients who may present with complement dysregulation.
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Affiliation(s)
- Daan P C van Doorn
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Myrurgia A Abdul-Hamid
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leon A M Frenken
- Department of Internal Medicine, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Sjoerd A M E G Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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3
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Wehrmann F, von Bergwelt-Baildon A, Schönermarck U. Severe hypertension and (renal) thrombotic microangiopathy: solving the puzzle. J Nephrol 2023; 36:2175-2177. [PMID: 37256539 PMCID: PMC10638162 DOI: 10.1007/s40620-023-01659-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/28/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Florian Wehrmann
- Department of Medicine IV, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Anke von Bergwelt-Baildon
- Department of Medicine IV, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ulf Schönermarck
- Department of Medicine IV, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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4
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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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5
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Timmermans SA, van Doorn DP, van Paassen P. Rare Variants in Complement Genes May Not Be That Rare After All. Kidney Int Rep 2023; 8:1911-1913. [PMID: 37850005 PMCID: PMC10577486 DOI: 10.1016/j.ekir.2023.08.020] [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: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Sjoerd A.M.E.G. Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Daan P.C. van Doorn
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
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6
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Vuong KT, Joseph C, Angelo JR. Review of acute kidney injury and progression to chronic kidney disease in pediatric patients undergoing hematopoietic cell transplant. Front Oncol 2023; 13:1161709. [PMID: 37287918 PMCID: PMC10242001 DOI: 10.3389/fonc.2023.1161709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023] Open
Abstract
While acute kidney injury (AKI) after hematopoietic cell transplant (HCT) has been well-described in pediatric patients, literature regarding the long term renal consequences of HCT-related AKI, the development of chronic kidney disease (CKD), and CKD care in pediatric patients post-HCT is limited. CKD affects almost 50% of patients after HCT with multifactorial etiology including infection, nephrotoxic medications, transplant-associated thrombotic microangiopathy, graft-versus-host disease, and sinusoidal obstruction syndrome. As renal function declines in CKD, eventually progressing to end stage kidney disease (ESKD), mortality increases and is more than 80% among patients requiring dialysis. Using society guidelines and current literature, this review summarizes definitions and etiologies of and management strategies among patients with AKI and CKD post-HCT with an emphasis on albuminuria, hypertension, nutrition, metabolic acidosis, anemia, and mineral bone disease. The goal of this review is to aid early identification and intervention in patients with renal dysfunction prior to development of ESKD, and to discuss ESKD and renal transplant in these patients post-HCT.
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7
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Timmermans SA, van Doorn DP, van Paassen P. C3 Glomerulopathy and Thrombotic Microangiopathy: A "Hybrid" Phenotype. Kidney Int Rep 2023; 8:690-691. [PMID: 36938068 PMCID: PMC10014384 DOI: 10.1016/j.ekir.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/12/2023] Open
Affiliation(s)
- Sjoerd A.M.E.G. Timmermans
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
- Correspondence: Sjoerd A.M.E.G. Timmermans, Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Daan P.C. van Doorn
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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A Life-Threating Postpartum Atypical Hemolytic-Uremic Syndrome with Multiorgan Involvement. J Clin Med 2022; 11:jcm11236957. [PMID: 36498532 PMCID: PMC9738905 DOI: 10.3390/jcm11236957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Atypical Hemolytic Uremic Syndrome is a very rare condition that can be triggered in predisposed patients. It can remain undiagnosed and can result in a life-threatening event or permanent renal failure. We report a case of a 36-year-old pregnant woman who developed atypical hemolytic uremic syndrome postpartum. She underwent an emergency caesarean section due to abruptio placenta, and she developed biochemical alterations suggestive of a thrombotic microangiopathy. Due to worsening of renal function after plasma exchange therapy, we decided to start therapy with eculizumab. Therapy was carried out with a weekly dose of 900 mg IV for five weeks. An improvement of clinical and biochemical parameters was rapidly observed, and her renal function completely recovered. The therapy was continued for six months, with a dose of 1200 mg of eculizumab every two weeks. One year after discontinuation of the therapy, her blood pressure and renal function were still normal. Our case confirms that it is important to promptly identify a pregnancy-related thrombotic microangiopathy and that early therapy can be life-saving for the patient and can preserve renal function, avoiding dialysis.
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Topical Reappraisal of Molecular Pharmacological Approaches to Endothelial Dysfunction in Diabetes Mellitus Angiopathy. Curr Issues Mol Biol 2022; 44:3378-3397. [PMID: 36005129 PMCID: PMC9406839 DOI: 10.3390/cimb44080233] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/14/2022] Open
Abstract
Diabetes mellitus (DM) is a frequent medical problem, affecting more than 4% of the population in most countries. In the context of diabetes, the vascular endothelium can play a crucial pathophysiological role. If a healthy endothelium—which is a dynamic endocrine organ with autocrine and paracrine activity—regulates vascular tone and permeability and assures a proper balance between coagulation and fibrinolysis, and vasodilation and vasoconstriction, then, in contrast, a dysfunctional endothelium has received increasing attention as a potential contributor to the pathogenesis of vascular disease in diabetes. Hyperglycemia is indicated to be the major causative factor in the development of endothelial dysfunction. Furthermore, many shreds of evidence suggest that the progression of insulin resistance in type 2 diabetes is parallel to the advancement of endothelial dysfunction in atherosclerosis. To present the state-of-the-art data regarding endothelial dysfunction in diabetic micro- and macroangiopathy, we constructed this literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We interrogated five medical databases: Elsevier, PubMed, PMC, PEDro, and ISI Web of Science.
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10
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The Role of Complement in HSCT-TMA: Basic Science to Clinical Practice. Adv Ther 2022; 39:3896-3915. [PMID: 35781192 PMCID: PMC9402756 DOI: 10.1007/s12325-022-02184-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/06/2022] [Indexed: 12/05/2022]
Abstract
Hematopoietic stem cell transplantation-associated thrombotic microangiopathy (HSCT-TMA) is a common complication occurring post-HSCT and is associated with substantial morbidity and mortality if not promptly identified and treated. Emerging evidence suggests a central role for the complement system in the pathogenesis of HSCT-TMA. The complement system has also been shown to interact with other pathways and processes including coagulation and inflammation, all of which are activated following HSCT. Three endothelial cell-damaging “hits” are required for HSCT-TMA genesis: a genetic predisposition or existing damage, an endothelial cell-damaging conditioning regimen, and additional damaging insults. Numerous risk factors for the development of HSCT-TMA have been identified (including primary diagnosis, graft type, and conditioning regimen) and validated lists of relatively simple diagnostic signs and symptoms exist, many utilizing routine clinical and laboratory assessments. Despite the relative ease with which HSCT-TMA can be screened for, it is often overlooked or masked by other common post-transplant conditions. Recent evidence that patients with HSCT-TMA may also concurrently present with these differential diagnoses only serve to further confound its identification and treatment. HSCT-TMA may be treated, or even prevented, by removing or ameliorating triggering “hits”, and recent studies have also shown substantial utility of complement-targeted therapies in this patient population. Further investigation into optimal management and treatment strategies is needed. Greater awareness of TMA post-HSCT is urgently needed to improve patient outcomes; the objective of this article is to clarify current understanding, explain underlying complement biology and provide simple tools to aid the early recognition, management, and monitoring of HSCT-TMA.
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11
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Postsurgical Thrombotic Microangiopathy and Deregulated Complement. J Clin Med 2022; 11:jcm11092501. [PMID: 35566627 PMCID: PMC9100095 DOI: 10.3390/jcm11092501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/17/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023] Open
Abstract
Postsurgical thrombotic microangiopathy (TMA) is a complication associated with significant morbidity and mortality. Still, the pathophysiological underlying mechanism of postsurgical TMA, a diagnosis often overlooked in postoperative patients with acute kidney injury and thrombocytopenia, is largely unknown. Here, we report the case of a 56-year-old male that developed anuric acute kidney injury, Coombs-negative hemolysis, and thrombocytopenia after surgical aortic arch replacement. Massive ex vivo complement activation on the endothelium, a rare complement gene variant in C2, at-risk haplotype MCPggaac, and excellent response to therapeutic complement inhibition, points to the pivotal role of complement in the pathophysiology of disease. Moreover, the importance of a multidisciplinary team approach in (postsurgical) thrombocytopenia is emphasized.
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12
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Al-Tamimi M, Qiao J, Gardiner EE. The utility of platelet activation biomarkers in thrombotic microangiopathies. Platelets 2022; 33:503-511. [PMID: 35287530 DOI: 10.1080/09537104.2022.2026912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Primary thrombotic microangiopathies (TMAs) are observed in thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), while secondary TMAs have a wide range of etiologies. Early diagnosis and treatment of TMA are critical for patient well-being; however, distinguishing TTP from HUS on presentation is particularly challenging. Thrombocytopenia and platelet activation are central to different types of TMAs, thus limiting the utility of standard diagnostic approaches to evaluate the platelet function and hemostatic capacity. Alternative means of quantifying and monitoring changes to platelet activation and function are urgently needed. Activated platelets have been shown to interact with proteins of the complement and coagulation cascades and form part of inflammation processes engaged in TMA. Increased levels of platelet surface receptors as well as increased plasma levels of platelet-derived soluble proteins have been reported in TMAs. Elevated levels of platelet-leukocyte aggregates and platelet microparticles are also reported in different types of TMAs. Larger prospective evaluations of platelet activation markers in TMA using standardized assays, with comparison to cohorts of patients with thrombosis, coagulopathy, and thrombocytopenia, to evaluate the clinical usefulness of platelet markers in TMA are now needed. This review will summarize the current knowledge around platelet activation markers and critically evaluate their utility in diagnosis and prognosis of TMA patients.
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Affiliation(s)
- Mohammad Al-Tamimi
- Department of Basic Medical Sciences, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Jianlin Qiao
- Blood Diseases Institute, Xuzhou Medical University, Xuzhou, China
| | - Elizabeth E Gardiner
- ACRF Department of Cancer Biology and Therapeutics, John Curtin School of Medical Research, Australian National University, Canberra, Australia
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13
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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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14
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Urine Protein/Creatinine Ratio in Thrombotic Microangiopathies: A Simple Test to Facilitate Thrombotic Thrombocytopenic Purpura and Hemolytic and Uremic Syndrome Diagnosis. J Clin Med 2022; 11:jcm11030648. [PMID: 35160098 PMCID: PMC8836555 DOI: 10.3390/jcm11030648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Early diagnosis of thrombotic thrombocytopenic purpura (TTP) versus hemolytic and uremic syndrome (HUS) is critical for the prompt initiation of specific therapies. Objective: To evaluate the diagnostic performance of the proteinuria/creatininuria ratio (PU/CU) for TTP versus HUS. Patients/Methods: In a retrospective study, in association with the “French Score” (FS) (platelets < 30 G/L and serum creatinine level < 200 µmol/L), we assessed PU/CU for the diagnosis of TTP in patients above the age of 15 with thrombotic microangiopathy (TMA). Patients with a history of kidney disease or with on-going cancer, allograft or pregnancy were excluded from the analysis. Results: Between February 2011 and April 2019, we identified 124 TMA. Fifty-six TMA patients for whom PU/CU were available, including 35 TTP and 21 HUS cases, were considered. Using receiver–operating characteristic curves (ROC), those with a threshold of 1.5 g/g for the PU/CU had a 77% sensitivity (95% CI (63, 94)) and a 90% specificity (95% CI (71, 100)) for TTP diagnosis compared with those having an 80% sensitivity (95% CI (66, 92)) and a 90% specificity (95% CI (76, 100) with a FS of 2. In comparison, a composite score, defined as a FS of 2 or a PU/CU ≤ 1.5 g/g, improved sensitivity to 99.6% (95% CI (93, 100)) for TTP diagnosis and enabled us to reclassify seven false-negative TTP patients. Conclusions: The addition of urinary PU/CU upon admission of patients with TMA is a fast and readily available test that can aid in the differential diagnosis of TTP versus HUS alongside traditional scoring.
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Palma LMP, Vaisbich-Guimarães MH, Sridharan M, Tran CL, Sethi S. Thrombotic microangiopathy in children. Pediatr Nephrol 2022; 37:1967-1980. [PMID: 35041041 PMCID: PMC8764494 DOI: 10.1007/s00467-021-05370-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
The syndrome of thrombotic microangiopathy (TMA) is a clinical-pathological entity characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end organ involvement. It comprises a spectrum of underlying etiologies that may differ in children and adults. In children, apart from ruling out shigatoxin-associated hemolytic uremic syndrome (HUS) and other infection-associated TMA like Streptococcus pneumoniae-HUS, rare inherited causes including complement-associated HUS, cobalamin defects, and mutations in diacylglycerol kinase epsilon gene must be investigated. TMA should also be considered in the setting of solid organ or hematopoietic stem cell transplantation. In this review, acquired and inherited causes of TMA are described with a focus on particularities of the main causes of TMA in children. A pragmatic approach that may help the clinician tailor evaluation and management is provided. The described approach will allow for early initiation of treatment while waiting for the definitive diagnosis of the underlying TMA.
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Affiliation(s)
- Lilian Monteiro P. Palma
- grid.411087.b0000 0001 0723 2494Department of Pediatrics, Pediatric Nephrology, State University of Campinas (UNICAMP), Rua Tessalia Vieira de Camargo, 126, Cidade Universitaria, Campinas, SP 13,083–887 Brazil
| | | | - Meera Sridharan
- grid.66875.3a0000 0004 0459 167XHematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Cheryl L. Tran
- grid.66875.3a0000 0004 0459 167XPediatric Nephrology, Department of Pediatrics, Mayo Clinic, Rochester, MN USA
| | - Sanjeev Sethi
- grid.66875.3a0000 0004 0459 167XDepartment of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
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