1
|
Mocanu A, Bogos RA, Lazaruc TI, Cianga AL, Lupu VV, Ioniuc I, Alecsa M, Lupu A, Ivanov AV, Miron IC, Starcea IM. Pitfalls of Thrombotic Microangiopathies in Children: Two Case Reports and Literature Review. Diagnostics (Basel) 2023; 13:diagnostics13071228. [PMID: 37046448 PMCID: PMC10093431 DOI: 10.3390/diagnostics13071228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
Thrombotic microangiopathy can present itself in the form of several clinical entities, representing a real challenge for diagnosis and treatment in pediatric practice. Our article aims to explore the evolution of two rare cases of pediatric thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) with extremely similar clinical pictures, which, coincidentally, presented at approximately the same time in our hospital. These cases and our literature review demonstrate the multiple facets of thrombotic microangiopathy, which can produce various determinations and salient manifestations even among the pediatric population. TTP and aHUS may represent genuine diagnostic pitfalls through the overlap of their clinical and biological findings, although they develop through fundamentally different mechanisms that require different therapeutic approaches. As a novelty, we underline that COVID-19 infection cannot be excluded as potential trigger for TTP and aHUS in our patients and we predict that other reports of such an association will follow, raising a complex question of COVID-19's implication in the occurrence and evolution of thrombotic microangiopathies. On this matter, we conducted literature research that resulted in 15 cases of COVID-19 pediatric infections associated with either TTP or aHUS. Taking into consideration the morbidity associated with TTP and aHUS, an elaborate differential diagnosis and prompt intervention are of the essence.
Collapse
Affiliation(s)
- Adriana Mocanu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Roxana Alexandra Bogos
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| | - Tudor Ilie Lazaruc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Lavinia Cianga
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ileana Ioniuc
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Mirabela Alecsa
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ancuta Lupu
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Anca Viorica Ivanov
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ingrith Crenguta Miron
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Mother and Child Medicine Department, Discipline of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary's Emergency Children Hospital, 700309 Iasi, Romania
| |
Collapse
|
2
|
Smirnova TV, Kazaryan EE, Sheludchenko VM. [Retinal tomography features of thrombotic microangiopathy associated with atypical hemolytic-uremic syndrome]. Vestn Oftalmol 2022; 138:20-28. [PMID: 36004587 DOI: 10.17116/oftalma202213804120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate structural and morphological changes in the retina using optical coherence tomography (OCT) in patients with thrombotic microangiopathy (TMA) associated with atypical hemolytic-uremic syndrome (aHUS). MATERIAL AND METHODS The study analyzed OCT data of 14 patients (28 eyes) with an established diagnosis of aHUS including such indicators as central retinal thickness (CRT), thickness of the retinal nerve fiver layer (RNFL), ganglion cell layer (GCL), retinal pigment epithelium (RPE), etc. RESULTS Patients with aHUS were noted to have an increase in CRT, paracentral acute middle maculopathy in the form of a hyperreflective defect primarily of the inner nuclear layer of paracentral localization, as well as disorganization of the RPE, which was observed statistically significantly more often compared to healthy persons (p=0.0001, p=0.001 and p=0.009 respectively). In the subgroup with thrombotic retinopathy (6 people) a statistically significant increase in CRT and peripapillary RNFL was found (p=0.004 and p=0.001) compared to patients without thrombotic retinopathy, as well as the presence of paracentral acute middle maculopathy and transudative macular retinoschisis (p=0.0001 and p=0.004). A statistically significant thinning of the peripapillary RNFL was revealed (p=0.0001) in the subgroup with symptoms of Purtscher-like retinopathy (PLR) found retrospectively (4 people) compared to patients without retrospective PLR symptoms. A statistically significant decrease in CRT was revealed (p=0.018) in the subgroup of patients receiving systemic therapy with eculizumab (5 people) compared with patients not receiving this therapy. Statistically significant correlations were recorded between the studied OCT indicators, laboratory indicators, and the level of systolic blood pressure (p<0.05). CONCLUSION According to OCT, paracentral acute middle maculopathy is a biomarker of thrombotic retinopathy and the activity of systemic TMA associated with aHUS. Arterial hypertension is an additional aggravating factor in the development of paracentral acute middle maculopathy and transudative macular retinoschisis. Targeted therapy with eculizumab leads to an effective decrease in CRT, which is potentially associated with regression of ischemic edema. The outcome of PLR involves thinning of peripapillary RNFL.
Collapse
Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
| | - E E Kazaryan
- Research Institute of Eye Diseases, Moscow, Russia
| | | |
Collapse
|
3
|
Lavrishcheva YV, Yakovenko AA, Kudlai DA. [The experience of using the Russian biosimilar of the original drug eculizumab for the treatment of patients with atypical hemolytic-uremic syndrome]. TERAPEVT ARKH 2020; 92:76-80. [PMID: 33346497 DOI: 10.26442/00403660.2020.06.000649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 02/08/2023]
Abstract
Atypical hemolytic-uremic syndrome (aHUS) is a chronic systemic disease of a genetic nature, which is based on uncontrolled activation of the alternative complement pathway, leading to generalized thrombosis in the vessels of the microvasculature (complement-mediated thrombotic microangiopathy). To date, therapy with eculizumab is the most effective and pathogenetically substantiated method of treating patients with ASH. Using the example of three clinical cases of patients with a verified diagnosis of aHUS, the high efficiency and safety of the worlds first bioanalogue of eculizumab in the treatment of adult patients with aHUS (complement-mediated thrombotic microangiopathy) was demonstrated.
Collapse
Affiliation(s)
| | - A A Yakovenko
- Pavlov First Saint Petersburg State Medical University
| | | |
Collapse
|
4
|
Pouw RB, Gómez Delgado I, López Lera A, Rodríguez de Córdoba S, Wouters D, Kuijpers TW, Sánchez-Corral P. Corrigendum: High Complement Factor H-Related (FHR)-3 Levels Are Associated With the Atypical Hemolytic-Uremic Syndrome-Risk Allele CFHR3 * B. Front Immunol 2020; 10:3073. [PMID: 32038624 PMCID: PMC6993581 DOI: 10.3389/fimmu.2019.03073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Richard B Pouw
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Irene Gómez Delgado
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Alberto López Lera
- Immunology Unit, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Biological Research Center (CIB)-CSIC, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands.,Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Pilar Sánchez-Corral
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| |
Collapse
|
5
|
Smirnova TV, Kozlovskaya NL, Sheludchenko VM, Budzinskaya MV. [Optical coherence tomography angiography in the diagnosis of retinal microangiopathy in atypical hemolytic-uremic syndrome (a case report)]. Vestn Oftalmol 2020; 136:226-234. [PMID: 32880144 DOI: 10.17116/oftalma2020136042226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The article describes a clinical case of acute macular neuroretinopathy and «chronic» paracentral acute middle maculopathy in a patient with atypical hemolytic-uremic syndrome - an orphan disease characterized by systemic thrombosis in the vessels of the microcirculatory bed due to chronic uncontrolled activation of the alternative complement pathway. Optical coherence tomography angiography data confirm the ischemic nature of the disease with localization in the deep vascular plexus of the retina in acute macular neuroretinopathy and in the superficial vascular plexus of the retina in «chronic» paracentral acute middle maculopathy. The use of modern diagnostic methods, including optical coherence tomography angiography, can help improve detection of the pathology and expand its understanding in severe microangiopathic syndromes, which include atypical hemolytic-uremic syndrome.
Collapse
Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, Moscow, Russia
| | | | | | | |
Collapse
|
6
|
Smirnova TV, Sheludchenko VM, Kozlovskaya NL, Kazaryan EE, Andzhelova DV, Sherstneva LV, Velieva IA, Kuchieva AM, Akaeva MI. [Ocular thrombotic microangiopathy in atypical hemolytic-uremic syndrome (a clinical case study)]. Vestn Oftalmol 2018; 134:215-226. [PMID: 30499520 DOI: 10.17116/oftalma2018134051215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The article presents a clinical observation of ocular thrombotic microangiopathy in atypical hemolytic-uremic syndrome - a rare genetic disease characterized by systemic thrombosis caused by uncontrolled activation of alternative complement pathway. A typical manifestation of this ocular lesion in this disease is bilateral Purtscher-like retinopathy. Timely diagnostics of atypical hemolytic-uremic syndrome, including ophthalmologic examination, determines the early start of a highly effective pathogenetic therapy with complement inhibitor eculizumab.
Collapse
Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - V M Sheludchenko
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - N L Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - E E Kazaryan
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - D V Andzhelova
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - L V Sherstneva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - I A Velieva
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - A M Kuchieva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - M I Akaeva
- I.M. Sechenov First Moscow State Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| |
Collapse
|
7
|
Pouw RB, Gómez Delgado I, López Lera A, Rodríguez de Córdoba S, Wouters D, Kuijpers TW, Sánchez-Corral P. High Complement Factor H-Related (FHR)-3 Levels Are Associated With the Atypical Hemolytic-Uremic Syndrome-Risk Allele CFHR3*B. Front Immunol 2018; 9:848. [PMID: 29740447 PMCID: PMC5928496 DOI: 10.3389/fimmu.2018.00848] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/05/2018] [Indexed: 02/05/2023] Open
Abstract
Dysregulation of the complement alternative pathway (AP) is a major pathogenic mechanism in atypical hemolytic-uremic syndrome (aHUS). Genetic or acquired defects in factor H (FH), the main AP regulator, are major aHUS drivers that associate with a poor prognosis. FH activity has been suggested to be downregulated by homologous FH-related (FHR) proteins, including FHR-3 and FHR-1. Hence, their relative levels in plasma could be disease-relevant. The genes coding for FH, FHR-3, and FHR-1 (CFH, CFHR3, and CFHR1, respectively) are polymorphic and located adjacent to each other on human chromosome 1q31.3. We have previously shown that haplotype CFH(H3)–CFHR3*B–CFHR1*B associates with aHUS and reduced FH levels. In this study, we used a specific enzyme-linked immunosorbent assay to quantify FHR-3 in plasma samples from controls and patients with aHUS genotyped for the three known CFHR3 alleles (CFHR3*A, CFHR3*B, and CFHR3*Del). In the 218 patients carrying at least one copy of CFHR3, significant differences between CFHR3 genotype groups were found, with CFHR3*A/Del patients having the lowest FHR-3 concentration (0.684–1.032 µg/mL), CFHR3*B/Del and CFHR3*A/A patients presenting intermediate levels (1.437–2.201 µg/mL), and CFHR3*A/B and CFHR3*B/B patients showing the highest concentration (2.330–4.056 µg/mL) (p < 0.001). These data indicate that CFHR3*A is a low-expression allele, whereas CFHR3*B, associated with increased risk of aHUS, is a high-expression allele. Our study reveals that the aHUS-risk haplotype CFH(H3)–CFHR3*B–CFHR1*B generates twofold more FHR-3 than the non-risk CFH(H1)–CFHR3*A–CFHR1*A haplotype. In addition, FHR-3 levels were higher in patients with aHUS than in control individuals with the same CFHR3 genotype. These data suggest that increased plasma levels of FHR-3, altering the balance between FH and FHR-3, likely impact the FH regulatory functions and contribute to the development of aHUS.
Collapse
Affiliation(s)
- Richard B Pouw
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Irene Gómez Delgado
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Alberto López Lera
- Immunology Unit, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Santiago Rodríguez de Córdoba
- Biological Research Center (CIB)-CSIC, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| | - Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands.,Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Pilar Sánchez-Corral
- Complement Research Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Center for Biomedical Network Research on Rare Diseases (CIBERER), Madrid, Spain
| |
Collapse
|
8
|
Epand RM, So V, Jennings W, Khadka B, Gupta RS, Lemaire M. Diacylglycerol Kinase-ε: Properties and Biological Roles. Front Cell Dev Biol 2016; 4:112. [PMID: 27803897 PMCID: PMC5067486 DOI: 10.3389/fcell.2016.00112] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/27/2016] [Indexed: 12/20/2022] Open
Abstract
In mammals there are at least 10 isoforms of diacylglycerol kinases (DGK). All catalyze the phosphorylation of diacylglycerol (DAG) to phosphatidic acid (PA). Among DGK isoforms, DGKε has several unique features. It is the only DGK isoform with specificity for a particular species of DAG, i.e., 1-stearoyl-2-arachidonoyl glycerol. The smallest of all known DGK isoforms, DGKε, is also the only DGK devoid of a regulatory domain. DGKε is the only DGK isoform that has a hydrophobic segment that is predicted to form a transmembrane helix. As the only membrane-bound, constitutively active DGK isoform with exquisite specificity for particular molecular species of DAG, the functional overlap between DGKε and other DGKs is predicted to be minimal. DGKε exhibits specificity for DAG containing the same acyl chains as those found in the lipid intermediates of the phosphatidylinositol-cycle. It has also been shown that DGKε affects the acyl chain composition of phosphatidylinositol in whole cells. It is thus likely that DGKε is responsible for catalyzing one step in the phosphatidylinositol-cycle. Steps of this cycle take place in both the plasma membrane and the endoplasmic reticulum membrane. DGKε is likely present in both of these membranes. DGKε is the only DGK isoform that is associated with a human disease. Indeed, recessive loss-of-function mutations in DGKε cause atypical hemolytic-uremic syndrome (aHUS). This condition is characterized by thrombosis in the small vessels of the kidney. It causes acute renal insufficiency in infancy and most patients develop end-stage renal failure before adulthood. Disease pathophysiology is poorly understood and there is no therapy. There are also data suggesting that DGKε may play a role in epilepsy and Huntington disease. Thus, DGKε has many unique molecular and biochemical properties when compared to all other DGK isoforms. DGKε homologs also contain a number of conserved sequence features that are distinctive characteristics of either the rodents or specific groups of primate homologs. How cells, tissues and organisms harness DGKε's catalytic prowess remains unclear. The discovery of DGKε's role in causing aHUS will hopefully boost efforts to unravel the mechanisms by which DGKε dysfunction causes disease.
Collapse
Affiliation(s)
- Richard M Epand
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Vincent So
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences CentreHamilton, ON, Canada; Nephrology Division and Cell Biology Program, Hospital for Sick ChildrenToronto, ON, Canada
| | - William Jennings
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Bijendra Khadka
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Radhey S Gupta
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Mathieu Lemaire
- Nephrology Division and Cell Biology Program, Hospital for Sick ChildrenToronto, ON, Canada; Department of Biochemistry, University of TorontoToronto, ON, Canada; Institute of Medicine, University of TorontoToronto, ON, Canada
| |
Collapse
|
9
|
Abstract
In mammals there are at least 10 isoforms of diacylglycerol kinases (DGK). All catalyze the phosphorylation of diacylglycerol (DAG) to phosphatidic acid (PA). Among DGK isoforms, DGKε has several unique features. It is the only DGK isoform with specificity for a particular species of DAG, i.e., 1-stearoyl-2-arachidonoyl glycerol. The smallest of all known DGK isoforms, DGKε, is also the only DGK devoid of a regulatory domain. DGKε is the only DGK isoform that has a hydrophobic segment that is predicted to form a transmembrane helix. As the only membrane-bound, constitutively active DGK isoform with exquisite specificity for particular molecular species of DAG, the functional overlap between DGKε and other DGKs is predicted to be minimal. DGKε exhibits specificity for DAG containing the same acyl chains as those found in the lipid intermediates of the phosphatidylinositol-cycle. It has also been shown that DGKε affects the acyl chain composition of phosphatidylinositol in whole cells. It is thus likely that DGKε is responsible for catalyzing one step in the phosphatidylinositol-cycle. Steps of this cycle take place in both the plasma membrane and the endoplasmic reticulum membrane. DGKε is likely present in both of these membranes. DGKε is the only DGK isoform that is associated with a human disease. Indeed, recessive loss-of-function mutations in DGKε cause atypical hemolytic-uremic syndrome (aHUS). This condition is characterized by thrombosis in the small vessels of the kidney. It causes acute renal insufficiency in infancy and most patients develop end-stage renal failure before adulthood. Disease pathophysiology is poorly understood and there is no therapy. There are also data suggesting that DGKε may play a role in epilepsy and Huntington disease. Thus, DGKε has many unique molecular and biochemical properties when compared to all other DGK isoforms. DGKε homologs also contain a number of conserved sequence features that are distinctive characteristics of either the rodents or specific groups of primate homologs. How cells, tissues and organisms harness DGKε's catalytic prowess remains unclear. The discovery of DGKε's role in causing aHUS will hopefully boost efforts to unravel the mechanisms by which DGKε dysfunction causes disease.
Collapse
Affiliation(s)
- Richard M Epand
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Vincent So
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences CentreHamilton, ON, Canada; Nephrology Division and Cell Biology Program, Hospital for Sick ChildrenToronto, ON, Canada
| | - William Jennings
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Bijendra Khadka
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Radhey S Gupta
- Department of Biochemistry and Biomedical Sciences, McMaster University Health Sciences Centre Hamilton, ON, Canada
| | - Mathieu Lemaire
- Nephrology Division and Cell Biology Program, Hospital for Sick ChildrenToronto, ON, Canada; Department of Biochemistry, University of TorontoToronto, ON, Canada; Institute of Medicine, University of TorontoToronto, ON, Canada
| |
Collapse
|
10
|
Abstract
Introduction Early diagnosis of atypical uremic-hemolytic syndrome may be challenging during the puerperium period. Correct diagnosis and timely management are crucial to improve outcomes. Background Pregnancy-associated atypical hemolytic-uremic syndrome (p-aHUS) is a rare condition characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Triggered by pregnancy, genetically predisposed women develop the syndrome, leading to a disastrous hemolytic disease characterized by diffuse endothelial damage and platelet consumption. This disease is a life-threatening condition that requires prompt diagnosis and therapy. Case A 19-year-old G1P1 Caucasian female with suspicion of HELLP syndrome was treated at our facility for severe thrombocytopenia and acute kidney injury. A diagnosis of atypical uremic-hemolytic syndrome was later confirmed. The patient's condition improved with normalization of platelets and improvement in kidney function after 14 days of plasmapheresis. She was subsequently treated with eculizumab, a monoclonal antibody against C5. The patient tolerated well the therapy and is currently in remission. Conclusion Diagnosis of p-aHUS is challenging, as it can mimic various diseases found during pregnancy and the postpartum. Plasma exchange should be promptly initiated within 24 hours of diagnosis. Eculizumab has risen to become an important tool to improve long-term comorbidities and mortality in this group population.
Collapse
Affiliation(s)
- Antonio F Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Jorge Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Aaron Wyble
- Division of Transfusion Medicine, Department of Pathology, The University of Texas Medical Branch, Galveston, Texas
| | - Luis D Pacheco
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas; Division of Surgical Critical Care, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
| |
Collapse
|