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Le Tilly O, Gatault P, Semlali S, Sberro-Soussan R, Passot C, Bertrand D, Desvignes C, Caillard S, Paintaud G, Halimi JM, Ternant D. Eculizumab dose tapering should take into account the nonlinearity of its pharmacokinetics. Br J Clin Pharmacol 2024; 90:1312-1321. [PMID: 38373846 DOI: 10.1111/bcp.16019] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/21/2024] Open
Abstract
AIMS Eculizumab is a monoclonal antibody targeting complement protein C5 used in renal diseases. As recommended dosing regimen leads to unnecessarily high concentrations in some patients, tailored dosing therapeutic drug monitoring was proposed to reduce treatment cost. The objectives of the present work were (i) to investigate the target-mediated elimination of eculizumab and (ii) whether a pharmacokinetic model integrating a nonlinear elimination allows a better prediction of eculizumab concentrations than a linear model. METHODS We analysed 377 eculizumab serum concentrations from 44 patients treated for atypical haemolytic uraemic syndrome and C3 glomerulopathy with a population pharmacokinetic approach. Critical concentrations (below which a non-log-linear decline of concentration over time is evidenced) were computed to estimate the relevance of the target-mediated elimination. Simulations of dosing regimens were then performed to predict probabilities of target attainment (i.e. trough >100 mg/L). RESULTS Pharmacokinetics of eculizumab was nonlinear and followed a mixture of first-order (CL = 1.318 mL/day/kg) and Michaelis-Menten elimination (Vmax = 26.07 mg/day, Km = 24.06 mg/L). Volume of distribution (72.39 mL/kg) and clearance were weight-dependent. Critical concentrations (Vmax/CL) ranged from 144.7 to 759.7 mg/L and were inversely related to body weight (P = .013). Nonlinearity was thus noticeable at therapeutic concentrations. Simulations predicted that 1200 mg of eculizumab every 21 days would allow 85% and 76% of patients to maintain a therapeutic exposure, for 50 or 90 kg body weight, respectively. CONCLUSIONS Our study investigates the nonlinear elimination of eculizumab and discusses the importance of accounting for eculizumab target-mediated elimination in therapeutic drug monitoring.
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Affiliation(s)
- Olivier Le Tilly
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
| | - Philippe Gatault
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Nephrology, Arterial Hypertension, Dialysis and Transplant Department, CHRU Tours, Tours, France
| | | | - Rebecca Sberro-Soussan
- Necker-Enfants Malades Institute, French National Institute of Health and Medical Research, Paris, France
| | | | - Dominique Bertrand
- Nephrology Department and Transplantation Center, Rouen University Hospital, Rouen, France
| | - Céline Desvignes
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, Strasbourg University Hospital, Strasbourg, France
| | - Gilles Paintaud
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
| | - Jean-Michel Halimi
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Nephrology, Arterial Hypertension, Dialysis and Transplant Department, CHRU Tours, Tours, France
| | - David Ternant
- Inserm U1327 ISCHEMIA "Membrane signalling and inflammation in reperfusion injuries", Université de Tours, Tours, France
- Medical Pharmacology, CHRU Tours, Tours, France
- Pilot Centre for Therapeutic Antibodies Monitoring (PiTAM), CHRU Tours, Tours, France
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2
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Peterson CG, Jackson RL. Successful use of eculizumab in immediate ANCA vasculitis recurrence in a pediatric kidney transplant. Pediatr Transplant 2024; 28:e14760. [PMID: 38623882 DOI: 10.1111/petr.14760] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Kidney transplantation is an acceptable therapy end-stage kidney disease secondary to antineutrophil cytoplasmic antibody-associated vasculitis with risk of disease recurrence ranging from 3% to 17%. Standard posttransplant immunosuppression is the mainstay of therapy after recurrence. Recently, new medications focused on complement regulation and avoidance of steroids have been shown to be effective in treating antineutrophil cytoplasmic antibody (ANCA) vasculitis with no studies in the pediatric population. METHODS We report a 5-year-old patient with immediate recurrence of positive myeloperoxidase (MPO)-ANCA vasculitis after deceased donor kidney transplant and the novel use of eculizumab to salvage the graft. RESULTS Eculizumab and transition to ravulizumab has been successful in improving graft function and maintenance of disease remission after immediate MPO-ANCA vasculitis recurrence posttransplant. CONCLUSIONS Complement inhibitors may be used in addition to standard immunosuppression postkidney transplant in a pediatric patient with MPO-ANCA vasculitis recurrence without higher rates of infections.
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Affiliation(s)
| | - Rachel L Jackson
- Intermountain Healthcare, Primary Children's Hospital, Salt Lake City, Utah, USA
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3
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Joseph A, Harel S, Mesnard L, Rafat C, Knapp S, Rumpler A, Philipponnet C, Barba C, Rebibou JM, Buob D, Hertig A, Vargaftig J, Halimi JM, Arnulf B, Bretaud AS, Joly B, Grangé S, Coppo P. Carfilzomib-associated thrombotic microangiopathy: clinical features and outcomes. Nephrol Dial Transplant 2024:gfae096. [PMID: 38658194 DOI: 10.1093/ndt/gfae096] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND AND HYPOTHESIS Carfilzomib, a new proteasome inhibitor indicated for patients with relapsed/refractory myeloma, has been associated with cases of thrombotic microangiopathy (CFZ-TMA). The role of variants in the complement alternative pathway and therapeutic potential of complement blockade with eculizumab remain to be determined. METHODS We report 37 cases of CFZ-TMA recorded in the French reference center for TMA with their clinical characteristics, genetic analysis and outcome according to treatments. RESULTS A trigger was identified in more than half of cases, including 8 influenza and 5 SARS-CoV-2 cases. All patients presented with acute kidney injury (AKI) (KDIGO stage 3 in 31 (84%) patients) while neurological (n=13, 36%) and cardiac damage (n=7, 19%) were less frequent. ADAMTS13 and complement activity were normal (n= 28 and 18 patients tested) and no pathogenic variant in the alternative complement pathway was found in 7 patients tested.TMA resolved in most (n=34, 94%) patients but 12 (44%) still displayed stage 3 AKI at discharge. Nineteen (51%) patients were treated with therapeutic plasma exchange, 14 (38%) patients received corticosteroids and 18 (50%) were treated with eculizumab. However none of these treatments demonstrated a significant impact on outcomes. CONCLUSION This study is the largest case series of CFZ-TMA since its approval in 2012. Patients present with severe AKI and experience frequent sequelae. Complement variants and blockade therapy do not seem to play a role in the pathophysiology and prognosis of the disease.
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Affiliation(s)
- Adrien Joseph
- Service de Médecine intensive réanimation, Hôpital Saint Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Stéphanie Harel
- Service d'immuno-hématologie, Hôpital Saint Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Laurent Mesnard
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, Paris, France
- UMR_S1155, INSERM, Sorbonne Université, Paris, France
| | - Cédric Rafat
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Soins Intensifs Néphrologiques et Rein Aigu, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Silène Knapp
- Service d'immuno-hématologie, Hôpital Saint Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Anne Rumpler
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service d'hématologie, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Carole Philipponnet
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service de Néphrologie, dialyse et transplantation, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Christophe Barba
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service de Néphrologie et Nutrition, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Jean-Michel Rebibou
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service de Néphrologie, Centre Hospitalier Universitaire Dijon Bourgogne, Dijon, France
| | - David Buob
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service d'anatomo-pathologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Alexandre Hertig
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service de néphrologie, Hôpital Foch, Suresnes, France
| | - Jacques Vargaftig
- Service d'hématologie, Institut Curie - Hôpital René Huguenin, Saint-Cloud, France
| | - Jean-Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service de Néphrologie-hypertension, Dialyses, Transplantation Rénale, Hôpital Bretonneau ; Hôpital Clocheville, Centre Hospitalier Universitaire de Tours, Tours, France et EA4245 T2i, Hôpital Trousseau, CHRU de Tours, Université de Tours, Tours, France
| | - Bertrand Arnulf
- Service d'immuno-hématologie, Hôpital Saint Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Anne-Sophie Bretaud
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Bérangère Joly
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Steven Grangé
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service de Néphrologie, dialyse et transplantation, Centre Hospitalier Universitaire de Rouen, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique des Hôpitaux de Paris, Paris, France
- Service d'Hématologie, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France
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Bicskó RR, Illés Á, Hevessy Z, Ivády G, Kerekes G, Méhes G, Csépány T, Gergely L. Eculizumab Treatment of Massive Hemolysis Occurring in a Rare Co-Existence of Paroxysmal Nocturnal Hemoglobinuria and Myasthenia Gravis. Hematol Rep 2024; 16:255-259. [PMID: 38651454 PMCID: PMC11036238 DOI: 10.3390/hematolrep16020025] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/02/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
The co-occurrence of myasthenia gravis (MG) and paroxysmal nocturnal hemoglobinuria (PNH) is rare; only one case has been published so far. We report a 63-year-old Caucasian female patient who was diagnosed with MG at the age of 43. Thymoma was also detected, and so it was surgically resected, which resulted in reasonable disease control for nearly 20 years. Slight hemolysis began to emerge, and then myasthenia symptoms progressed, so immunosuppressive therapy was started. Due to progressive disease and respiratory failure, the patient underwent plasmapheresis, and ventilatory support was stopped. Marked hemolysis was present, and diagnostic tests confirmed PNH with type III PNH cells. Her myasthenia symptoms aggravated, mechanical ventilation had to be started again, and due to the respiratory acidosis, massive hemolysis occurred. After two plasmapheresis sessions, the patient received eculizumab at 600 mg, resulting in prompt hemolysis control. After the second dose of the treatment, the patient was extubated. Still, due to their inability to cough, she developed another respiratory failure and pneumonia-sepsis, resulting in the patient's death. This case highlights the rare association between these two serious diseases and similar immune-mediated pathophysiology mechanisms involving the complement system.
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Affiliation(s)
- Ráhel Réka Bicskó
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
| | - Árpád Illés
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
| | - Zsuzsanna Hevessy
- Department of Laboratory Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Z.H.); (G.I.)
| | - Gergely Ivády
- Department of Laboratory Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Z.H.); (G.I.)
| | - György Kerekes
- Intensive Care Unit, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Gábor Méhes
- Department of Pathology, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Tünde Csépány
- Department of Neurology, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary;
| | - Lajos Gergely
- Department of Hematology, Institute of Internal Medicine, Faculty of Medicine, Clinical Center, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (L.G.)
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5
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Zilucoplan (Zilbrysq) for myasthenia gravis. Med Lett Drugs Ther 2024; 66:60-62. [PMID: 38576149 DOI: 10.58347/tml.2024.1700c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The FDA has approved the complement C5 inhibitor zilucoplan (Zilbrysq – UCB) for once-daily subcutaneous treatment of generalized myasthenia gravis (gMG) in adults who are anti-acetylcholine receptor (AChR) antibody-positive. Zilucoplan is the first complement inhibitor to be approved for treatment of myasthenia gravis that can be self-administered.
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Okusa S, Takizawa T, Imai S, Oyama M, Ishizuchi K, Nakahara J, Hori S, Suzuki S. Serious Bacterial Infections Associated with Eculizumab: A Pharmacovigilance Study. Intern Med 2024; 63:1061-1066. [PMID: 37690847 DOI: 10.2169/internalmedicine.1893-23] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Objective Molecular-targeted agents, including eculizumab and rituximab, are considered treatment options for refractory myasthenia gravis (MG), but bacterial infections can occur as serious adverse events when using these agents. The present study elucidated the relative risks of bacterial infections associated with eculizumab and rituximab using a pharmacovigilance database. Methods We analyzed eculizumab- and rituximab-associated adverse events reported between 2007 and 2021 in the US Food and Drug Administration Adverse Event Reporting System (FAERS) and herein report a refractory MG patient who developed streptococcal toxic shock syndrome during eculizumab treatment. Patients We evaluated a 74-year-old Japanese woman with refractory MG who developed severe bacteremia after receiving eculizumab. Results A total of 44,215 and 108,485 adverse events were reported with eculizumab and rituximab, respectively, from among 13,742,321 individual case safety reports in the FAERS database after data cleaning. We found a strong association between eculizumab and Neisseria infections. In contrast, we found only one case of meningococcal meningitis treated with rituximab. Both eculizumab and rituximab were weakly associated with streptococcal infections. Two cases of streptococcal toxic shock syndrome were associated with rituximab. Conclusion Careful monitoring of serious bacterial infections associated with eculizumab treatment is warranted.
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Affiliation(s)
- Shohei Okusa
- Department of Neurology, Keio University School of Medicine, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Japan
| | - Shungo Imai
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Japan
| | - Munenori Oyama
- Department of Neurology, Keio University School of Medicine, Japan
| | - Kei Ishizuchi
- Department of Neurology, Keio University School of Medicine, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Japan
| | - Satoko Hori
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Japan
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Japan
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7
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Di Matteo S, Freilone R, Bruno GM, Notaro R, Moumene S, Martone N, Teruzzi C, Ciccarone A, Colombo GL. Cost-Utility Analysis Comparing Pegcetacoplan to Anti-C5 Monoclonal Antibodies in the Treatment of Paroxysmal Nocturnal Hemoglobinuria. Clinicoecon Outcomes Res 2024; 16:225-232. [PMID: 38623087 PMCID: PMC11018133 DOI: 10.2147/ceor.s442906] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria is a rare, acquired disease characterized by hemolytic episodes and associated with significant clinical burden. The introduction of C5 inhibitory monoclonal antibodies (C5i) represented a major breakthrough in PNH treatment, effectively reducing intravascular hemolysis (IVH) but showing limited impact on extravascular hemolysis (EVH). In 2021, the C3 inhibitor pegcetacoplan was approved by EMA and recently reimbursed in Italy, which also has the advantages in the reduction of both IVH and EVH, increasing hemoglobin values and simultaneously improving the quality of life and fatigue of patients. A cost-utility analysis was developed to compare pegcetacoplan to C5i (eculizumab and ravulizumab) in the PNH population who remain anemic after treatment with C5i for at least 3 months. Materials and Methods The analysis employed a Markov model with a 5-year time horizon whereby patients can transition among 3 PNH health states, adopting the perspective of the Italian NHS. Efficacy data were sourced from the PEGASUS study, with drug prices reflecting ex-factory costs. Additionally, costs associated with resource utilization, adverse events, and complications were estimated based on outpatient and hospital care rates, excluding indirect expenses. Utility and disutility values related to transfusions were also considered, with pegcetacoplan allowing for dose escalation. Results The cumulative cost of treatment per individual patient at 5 years was estimated to be €1,483,454 for pegcetacoplan, €1,585,763 for eculizumab, and €1,574,826 for ravulizumab. Pegcetacoplan demonstrated a superior increase in quality-adjusted life years (QALYs) compared to both eculizumab (0.51 increase) and ravulizumab (0.27 increase). Furthermore, pegcetacoplan showed a reduction in complication management costs (€22,891 less compared to eculizumab and €22,611 less compared to ravulizumab) and lower transfusion-related expenses (€14,147 less than both C5i treatments). Conclusion Pegcetacoplan emerged as the dominant strategy in this analysis, being more effective, less expensive and improves quality of life in the analyzed population affected by PNH.
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Affiliation(s)
- Sergio Di Matteo
- Center of Research, SAVE Studi - Health Economics and Outcomes Research, Milan, Italy
| | - Roberto Freilone
- Dipartimento di Oncologia - Direttore SC Ematologia, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Torino e componente Tumor Molecular Board (TMB) Regione Piemonte, Torino, Italy
| | - Giacomo Matteo Bruno
- Center of Research, SAVE Studi - Health Economics and Outcomes Research, Milan, Italy
- Department of Drug Sciences, University of Pavia, Pavia, Italy
| | - Rosario Notaro
- Direttore S.C. Core Research Laboratory in ISPRO, Firenze, Italy
| | - Sabrin Moumene
- Center of Research, SAVE Studi - Health Economics and Outcomes Research, Milan, Italy
| | | | | | - Antonio Ciccarone
- Center of Research, SAVE Studi - Health Economics and Outcomes Research, Milan, Italy
| | - Giorgio Lorenzo Colombo
- Center of Research, SAVE Studi - Health Economics and Outcomes Research, Milan, Italy
- Department of Drug Sciences, University of Pavia, Pavia, Italy
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8
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Sonnentag SJ, Dopler A, Kleiner K, Garg BK, Mannes M, Späth N, Akilah A, Höchsmann B, Schrezenmeier H, Anliker M, Boyanapalli R, Huber-Lang M, Schmidt CQ. Triple-fusion protein (TriFu): A potent, targeted, enzyme-like inhibitor of all three complement activation pathways. J Biol Chem 2024; 300:105784. [PMID: 38401844 DOI: 10.1016/j.jbc.2024.105784] [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] [Received: 07/26/2023] [Revised: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024] Open
Abstract
The introduction of a therapeutic anti-C5 antibody into clinical practice in 2007 inspired a surge into the development of complement-targeted therapies. This has led to the recent approval of a C3 inhibitory peptide, an antibody directed against C1s and a full pipeline of several complement inhibitors in preclinical and clinical development. However, no inhibitor is available that efficiently inhibits all three complement initiation pathways and targets host cell surface markers as well as complement opsonins. To overcome this, we engineered a novel fusion protein combining selected domains of the three natural complement regulatory proteins decay accelerating factor, factor H and complement receptor 1. Such a triple fusion complement inhibitor (TriFu) was recombinantly expressed and purified alongside multiple variants and its building blocks. We analyzed these proteins for ligand binding affinity and decay acceleration activity by surface plasmon resonance. Additionally, we tested complement inhibition in several in vitro/ex vivo assays using standard classical and alternative pathway restricted hemolysis assays next to hemolysis assays with paroxysmal nocturnal hemoglobinuria erythrocytes. A novel in vitro model of the alternative pathway disease C3 glomerulopathy was established to evaluate the potential of the inhibitors to stop C3 deposition on endothelial cells. Next to the novel engineered triple fusion variants which inactivate complement convertases in an enzyme-like fashion, stoichiometric complement inhibitors targeting C3, C5, factor B, and factor D were tested as comparators. The triple fusion approach yielded a potent complement inhibitor that efficiently inhibits all three complement initiation pathways while targeting to surface markers.
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Affiliation(s)
- Sophia J Sonnentag
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Arthur Dopler
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Katharina Kleiner
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | | | - Marco Mannes
- Institute of Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Nadja Späth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Amira Akilah
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany
| | - Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Markus Anliker
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | | | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christoph Q Schmidt
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Centre, Ulm, Germany; Institute of Pharmacy, Biochemical Pharmacy Group, Martin Luther University Halle-Wittenberg, Halle, Germany.
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9
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Obata S, Vaz de Castro PAS, Riella LV, Cravedi P. Recurrent C3 glomerulopathy after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100839. [PMID: 38412598 DOI: 10.1016/j.trre.2024.100839] [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] [Received: 01/25/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
The complement system is part of innate immunity and is pivotal in protecting the body against pathogens and maintaining host homeostasis. Activation of the complement system is triggered through multiple pathways, including antibody deposition, a mannan-binding lectin, or activated complement deposition. C3 glomerulopathy (C3G) is a rare glomerular disease driven by complement dysregulation with high post-transplantation recurrence rates. Its treatment is mainly based on immunosuppressive therapies, specifically mycophenolate mofetil and glucocorticoids. Recent years have seen significant progress in understanding complement biology and its role in C3G pathophysiology. New complement-tergeting treatments have been developed and initial trials have shown promising results. However, challenges persist in C3G, with recurrent post-transplantation cases leading to suboptimal outcomes. This review discusses the pathophysiology and management of C3G, with a focus on its recurrence after kidney transplantation.
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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
| | - Pedro A S Vaz de Castro
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Brazil
| | - Leonardo V Riella
- Division of Nephrology and Center for Transplantation Sciences, Department of Surgery, 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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10
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Yu L, Wang Y, Tang X, Zhao X, Song Z. Malignant atrophic papulosis treated with eculizumab and hirudin: a fatal case report and literature review. Front Cardiovasc Med 2024; 11:1347587. [PMID: 38606375 PMCID: PMC11007069 DOI: 10.3389/fcvm.2024.1347587] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/14/2024] [Indexed: 04/13/2024] Open
Abstract
Background Malignant atrophic papulosis (MAP) is a rare obliterative vasculopathy whose etiology and pathophysiological mechanisms remain unknown, and the treatment is still empirical. It can involve multiple systems, especially the gastrointestinal tract and central nervous system, and has a poor prognosis. Case presentation A 20-year-old Chinese male appeared to have Widespread atrophic papules and plaques, intermittent abdominal pain, recurrent bowel perforation, and psoas abscess. The clinical diagnosis of MAP was supported by skin biopsy. He was then treated with anticoagulants, antiplatelets, glucocorticoids, and immunosuppressants and started on eculizumab and hirudin after the first surgical interventions. Despite the aggressive immunosuppression, anticoagulant, antiplatelet, humanized monoclonal antibodies, and surgery therapy, he died five months after presentation. Conclusions MAP is an extremely rare obliterative vasculopathy manifesting as benign cutaneous involvement or potentially malignant systemic involvement. MAP patients who exhibit any abdominal symptoms should undergo laparoscopy and evaluation in time and start on eculizumab and treprostinil as soon as possible, as the combination of them is presently the most effective treatment option for gastrointestinal MAP and hopefully reduce mortality.
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Affiliation(s)
- Linna Yu
- Department of Gastroenterology, The First People’s Hospital of Yunnan Province, Kunming, China
- The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Yun Wang
- Department of Gastroenterology, The First People’s Hospital of Yunnan Province, Kunming, China
- The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Xiaodan Tang
- Department of Gastroenterology, The First People’s Hospital of Yunnan Province, Kunming, China
- The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Xueru Zhao
- Department of Gastroenterology, The First People’s Hospital of Yunnan Province, Kunming, China
- The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Zhengji Song
- Department of Gastroenterology, The First People’s Hospital of Yunnan Province, Kunming, China
- The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
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11
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Peixoto VP, Prudêncio C, Vieira M, Sousa SF. Evaluation of the impact of two C5 genetic variants on C5- eculizumab complex stability at the molecular level. J Biomol Struct Dyn 2024:1-10. [PMID: 38529903 DOI: 10.1080/07391102.2024.2331091] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/11/2024] [Indexed: 03/27/2024]
Abstract
Complement C5 is the target of the monoclonal antibody eculizumab, used in complement dysregulating disorders, like the rare disease Paroxysmal Nocturnal Hemoglobinuria (PNH). PNH is an acquired hematopoietic stem cell condition characterized by aberrant destruction of erythrocytes, chronic hemolytic anemia, and thromboembolism propensity. C5 is a protein component of the complement system which is part of the immune system of the body and plays a prominent role in the destruction of red blood cells, misidentifying them as a threat. This work describes the application of molecular dynamics simulations to the study of the underlying interactions between complement C5 and eculizumab. This study also reveals the importance of single nucleotide polymorphisms on C5 protein concerning the effective inhibition of the mAB, involving the mechanistic events taking place at the interface spots of the complex. The predicted conformational change in the C5 Arg885/His/Cys mutation has implications on the protein's interaction with eculizumab, compromising their compatibility. The acquired insights into the conformational changes, dynamics, flexibility, and interactions shed light on the knowledge of the function of this biomolecule providing answers about the poor response to the treatment in PNH patient carriers of the mutations. By investigating the intricate dynamics, significant connections between C5 and eculizumab can be uncovered. Such insights may aid in the creation of novel compounds or lead to the enhancement of eculizumab's efficacy.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Vanda P Peixoto
- Chemical and Biomolecular Sciences, School of Health, Polytechnic Institute of Porto, Porto, Portugal
- Center for Translational Health and Medical Biotechnology Research (TBIO), Polytechnic Institute of Porto, Porto, Portugal
- LAQV/REQUIMTE, BioSIM - Departamento de Biomedicina, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Cristina Prudêncio
- Chemical and Biomolecular Sciences, School of Health, Polytechnic Institute of Porto, Porto, Portugal
- Center for Translational Health and Medical Biotechnology Research (TBIO), Polytechnic Institute of Porto, Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Mónica Vieira
- Chemical and Biomolecular Sciences, School of Health, Polytechnic Institute of Porto, Porto, Portugal
- Center for Translational Health and Medical Biotechnology Research (TBIO), Polytechnic Institute of Porto, Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Sérgio F Sousa
- LAQV/REQUIMTE, BioSIM - Departamento de Biomedicina, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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12
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Kanbay M, Copur S, Yilmaz ZY, Baydar DE, Bilge I, Susal C, Kocak B, Ortiz A. The role of anticomplement therapy in the management of the kidney allograft. Clin Transplant 2024; 38:e15277. [PMID: 38485664 DOI: 10.1111/ctr.15277] [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] [Received: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Abstract
As the number of patients living with kidney failure grows, the need also grows for kidney transplantation, the gold standard kidney replacement therapy that provides a survival advantage. This may result in an increased rate of transplantation from HLA-mismatched donors that increases the rate of antibody-mediated rejection (AMR), which already is the leading cause of allograft failure. Plasmapheresis, intravenous immunoglobulin therapy, anti-CD20 therapies (i.e., rituximab), bortezomib and splenectomy have been used over the years to treat AMR as well as to prevent AMR in high-risk sensitized kidney transplant recipients. Eculizumab and ravulizumab are monoclonal antibodies targeting the C5 protein of the complement pathway and part of the expanding field of anticomplement therapies, which is not limited to kidney transplant recipients, and also includes complement-mediated microangiopathic hemolytic anemia, paroxysmal nocturnal hemoglobinuria, and ANCA-vasculitis. In this narrative review, we summarize the current knowledge concerning the pathophysiological background and use of anti-C5 strategies (eculizumab and ravulizumab) and C1-esterase inhibitor in AMR, either to prevent AMR in high-risk desensitized patients or to treat AMR as first-line or rescue therapy and also to treat de novo thrombotic microangiopathy in kidney transplant recipients.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Zeynep Y Yilmaz
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dilek Ertoy Baydar
- Department of Pathology, Koc University School of Medicine, Istanbul, Turkey
| | - Ilmay Bilge
- Department of Pediatrics, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Caner Susal
- Transplant Immunology Research Center of Excellence, Koc University Hospital, Istanbul, Turkey
| | - Burak Kocak
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Alberto Ortiz
- Department of Medicine, Universidad Autonoma de Madrid and IIS-Fundacion Jimenez Diaz, Madrid, Spain
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13
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Laber DA, Patel PC, Logothetis CN, Patel AK, Jaglal M, Haider M, Visweshwar N, Rajasekaran-Rathnakumar G, Eatrides J. Complement-mediated thrombotic microangiopathy treated with anticomplement protein 5 therapy, a retrospective study. Eur J Haematol 2024; 112:450-457. [PMID: 37984551 DOI: 10.1111/ejh.14136] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Complement-mediated thrombotic microangiopathy (CM-TMA), also called atypical hemolytic uremic syndrome (aHUS), is a difficult-to-diagnose rare disease that carries severe morbidity and mortality. Anti-C5 monoclonal antibodies (aC5-mab) are standard treatments, but large studies and long-term data are scarce. Here, we report our single institution experience to augment the knowledge of CM-TMA treated with aC5-mab therapy. METHODS We aimed to assess the short and long-term effects of aC5-mab in patients diagnosed with CM-TMA treated outside of a clinical trial. This was a retrospective study. We included all patients diagnosed with CM-TMA and treated with aC5-mab at our institution. There were no exclusion criteria. Endpoints included complete TMA response (CR) defined as normalization of hematological parameters and ≥25% improvement in serum creatinine (Cr) from baseline in patients with renal disease, relapse defined as losing the previously achieved CR, morbidity, adverse events, and survival. RESULTS We found 28 patients with CM-TMA treated with aC5-mab. The median age was 50 years. Baseline laboratories: platelet counts 93 × 109 /L, hemoglobin 8.6 g/dL, lactate dehydrogenase 1326 U/L, serum Cr 4.7 mg/dL, and estimated glomerular filtration rate 19 mL/min. One individual was on renal replacement therapy (RRT) and 10 initiated RRT within 5 days of the first dose of aC5-mab. Genetic variants associated with CM-TMA included mutations in C3, CFB, CFH, CFHR1/3, CFI, and MCP. The mean duration of hospitalization was 24 days. The median time to initiation of aC5-mab was 10 days. Sixteen subjects received RRT. At the time of hospital discharge, 27 were alive, 14 remained on RRT, and 4 had a CR. At 6 months, 23 patients were alive, 18 continued aC5-mab, 8 remained on RRT, and 9 had a CR. At the last follow-up visit past 6 months, 20 were alive, 14 continued aC5-mab, 5 remained on RRT, 12 had a CR, and 1 was lost to follow-up. CONCLUSIONS Our study provides real-world experience and insight into the long-term outcomes of CM-TMA treated with aC5-mab. Our findings validate that CM-TMA is an aggressive disease with significant morbidity and mortality, and confirm that aC5-mab is a relatively effective therapy for CM-TMA. Our study adds practical, real-world experience to the literature, but future research remains imperative.
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Affiliation(s)
- Damian A Laber
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Parth C Patel
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Constantine N Logothetis
- Divisions of Hematology and Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ankita K Patel
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Michael Jaglal
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Mintallah Haider
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Nathan Visweshwar
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Geetha Rajasekaran-Rathnakumar
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Jennifer Eatrides
- Department of Satellite and Community Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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14
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Zadeh S, Price H, Drews R, Bouffard MA, Young LH, Narayanaswami P. Novel uses of complement inhibitors in myasthenia gravis-Two case reports. Muscle Nerve 2024; 69:368-372. [PMID: 38205840 DOI: 10.1002/mus.28037] [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] [Received: 10/25/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION/AIMS Myasthenia gravis (MG) is a rare, life-threatening immune-related adverse effect (irAE) of immune checkpoint inhibitor (ICI) treatment. C5-complement inhibitors are effective treatments for acetylcholine receptor antibody (AChR ab) positive generalized MG. We describe the use of eculizumab/ravulizumab in two patients with MG receiving concomitant pembrolizumab. METHODS This was a retrospective review of two medical records. RESULTS Patient 1: An 80-year-old male with recurrent, non-muscle invasive transitional cell carcinoma of the bladder developed ICI-induced AChR ab positive MG (ICI-MG), myositis, and myocarditis 2 weeks after the first dose of pembrolizumab. Myositis responded to corticosteroids. MG responded to eculizumab, followed by ravulizumab. He died of metastatic cancer 8 months later. Patient 2: A 58-year-old male had refractory thymoma-associated AChR ab-positive MG, which responded to eculizumab. He developed metastatic Merkel cell cancer necessitating pembrolizumab. MG remained stable on eculizumab. He had no irAEs for 22 months, with positron emission tomographic resolution of cancer. He then developed mild, indolent retinal vasculitis, which responded to prednisone. Discontinuation of pembrolizumab for 5 months resulted in cancer recurrence; pembrolizumab was resumed with peri-infusion pulse prednisone. MG remained stable and he continues eculizumab. DISCUSSION In the first patient, eculizumab, followed by ravulizumab, improved ICI-MG. In the second patient, eculizumab treatment may have had a prophylactic effect on the development of ICI-induced irAEs. The effect of complement inhibition on cancer outcomes of ICI therapy is unknown. A possible biologic basis for complement inhibitors in reducing irAEs of ICI, especially in the presence of underlying autoimmune disease, merits evaluation.
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Affiliation(s)
- Sean Zadeh
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Hayley Price
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Reed Drews
- Department of Hematology/Oncology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Marc A Bouffard
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy H Young
- Retina Services, Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, Massachusetts, USA
| | - Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
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15
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Kuroda Y, Watanabe G, Satou K, Ono H, Tsukita K, Suzuki Y. [ Eculizumab led to beneficial clinical course in a patient with generalized myasthenia gravis who developed COVID 19-associated pneumonia]. Rinsho Shinkeigaku 2024; 64:109-112. [PMID: 38281749 DOI: 10.5692/clinicalneurol.cn-001922] [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: 01/30/2024]
Abstract
A 74-year-old woman developed myasthenia gravis (MG) at the age of 32. She had a thymoma removed the following year, but her MG symptoms did not stabilize, and she required frequent hospitalization for fast-acting treatment (FT). She started eculizumab in March of two years ago and was followed up on an outpatient basis as her MG symptoms became milder. In February of this year, she was admitted to our hospital due to mild COVID-19-associated pneumonia with general malaise and fever. Her COVID-19-associated pneumonia was treated with intravenous sotrovimab, dexamethasone, and unfractionated heparin, and oral therapy for MG stayed the same. Eculizumab was not administered during hospitalization due to the combination of stable MG symptoms and the fact that the drug is not paid for by the Japanese insurance system. The patient's MG and COVID-19-associated pneumonia were not severe during hospitalization. However, the risk of myasthenic crisis and death is high when patients with MG develop COVID-19-associated pneumonia. Several reports suggest that the condition of patients with eculizumab-treated MG who develop COVID-19-associated pneumonia is not severe, and that that inhibition of the complement pathway with eculizumab is effective for COVID-19-associated pneumonia. Complement deposition in organ microvessels has been observed in patients with COVID-19, which suggests that complement overload may be a risk factor for COVID-19-associated pneumonia. Excessive complement activation may be involved in the pathogenesis; thus, eculizumab may function by inhibiting this pathway. In this case, eculizumab was discontinued while the patient had COVID-19-associated pneumonia, however, CH50, which is an indicator of complement, was suppressed during hospitalization due to the COVID-19-associated pneumonia. Therefore, eculizumab may have interfered with this course of events. This case demonstrates that eculizumab may be safe for and tolerated by patients with MG and COVID-19-associated pneumonia, but more cases need to be accumulated to support this conclusion.
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Affiliation(s)
- Yusuke Kuroda
- Department of neurology, NHO Sendai Medical Center
- Department of neurology, Tohoku University Hospital
| | | | - Kazuki Satou
- Department of neurology, Tohoku University Hospital
| | - Hirohiko Ono
- Department of neurology, Tohoku University Hospital
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16
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Rodriguez-Pintó I, Espinosa G, Cervera R. What we know and what we don't know about catastrophic antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI46-SI53. [PMID: 38320593 DOI: 10.1093/rheumatology/kead556] [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] [Received: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 02/08/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a severe condition with high mortality. Since its description in 1992, an important effort has been made to improve and disseminate knowledge on CAPS. Most of our current knowledge comes from the studies performed using the CAPS Registry, a database created in 2000 to gather as many cases as possible in order to better define this disease. It has demonstrated that this condition has multiple faces and is often triggered by a precipitating factor that leads to a thrombotic microangiopathy and cytokine storm involving almost any organ of the body. Analysis of the CAPS Registry has also shown that patients receiving anticoagulation, glucocorticoids and plasma exchange and/or IVIG have a better prognosis. However, there are still many unresolved questions. In this review we summarize what is known and what is still a matter of research in this condition.
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Affiliation(s)
- Ignasi Rodriguez-Pintó
- Autoimmune Diseases Unit, Hospital Universitari Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
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17
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Marignier R, Laplaud D, Zéphir H, Papeix C, Leray E, Amri E, Piotaix M, de Sèze J. Real-life study to assess effectiveness and safety of eculizumab in patients with neuromyelitis optica spectrum disorders in France: protocol for ECUP4, an observational study. Front Neurol 2024; 14:1303874. [PMID: 38318238 PMCID: PMC10839895 DOI: 10.3389/fneur.2023.1303874] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/20/2023] [Indexed: 02/07/2024] Open
Abstract
Background Eculizumab, a humanized monoclonal antibody targeting the C5 complement protein, has been approved for the treatment of neuromyelitis optica spectrum disorders (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive (Ab+). The aim of this study is to evaluate the long-term effectiveness and safety of eculizumab in French adults with NMOSD and to describe patients' characteristics, disability, and quality of life using data collected in a real-world setting. Methods This is the protocol for ECUP4, an ongoing prospective, observational, non-comparative, multicenter study conducted in 32 reference centers in France. Eligible patients must also be enrolled in NOMADMUS, a nested cohort of the French national multiple sclerosis registry (OFSEP). The primary endpoint is the annualized relapse rate. Secondary endpoints include the long-term safety of eculizumab, as well as patients' characteristics, treatment outcomes, disability, pain, visual acuity, and quality of life. Visits and treatments follow routine clinical practice. The case report forms (CRF) comprise data recorded in the context of the NOMADMUS cohort, collected during routine visits. The inclusion period is planned for 3 years, with no limitation on the number of patients enrolled. The maximum follow-up duration will be 5.5 years. Conclusion The efficacy and safety of eculizumab in patients with AQP4+ NMOSD have been demonstrated in randomized clinical trials that showed a significant reduction in the risk of relapse, with a safety profile consistent with other indications. This study will provide clinical and patient-reported evidence of the benefits of eculizumab, using data from a real-world setting in France. Trial registration number This study is registered at the French public repertory Health data Hub, N° F20211228123801. All information can be accessed at: https://www.health-data-hub.fr/.
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Affiliation(s)
- Romain Marignier
- Service de Neurologie, SEP Neuroinflammation et Pathologies de la Myéline, Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle (MIRCEM) - Hôpital Pierre Wertheimer, Bron, France
| | - David Laplaud
- Service de Neurologie du CHU de Nantes, CR2TI-Inserm U1064, CRC-SEP Pays de la Loire, Nantes Université, Nantes, France
| | - Hélène Zéphir
- Service de Neurologie du CHU Hôpital Roger Salengro, Lille, France
| | - Caroline Papeix
- Service de Neurologie, Hôpital Fondation A. de Rothshchild, Paris, France
| | - Emmanuelle Leray
- Univ Rennes, EHESP, CNRS, Inserm, ARENES UMR 6051, RSMS U 1309, Rennes, France
| | - Ekbel Amri
- Alexion, AstraZeneca Rare Disease, Levallois Perret, France
| | | | - Jérôme de Sèze
- Service de Neurologie du Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
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18
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Cordero L, Cavero T, Gutiérrez E, Trujillo H, Sandino J, Auñón P, Rivero M, Morales E. Rational use of eculizumab in secondary atypical hemolytic uremic syndrome. Front Immunol 2024; 14:1310469. [PMID: 38274833 PMCID: PMC10808527 DOI: 10.3389/fimmu.2023.1310469] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Background Secondary atypical hemolytic uremic syndrome (secondary aHUS) is a heterogeneous group of thrombotic microangiopathies (TMA) associated with various underlying conditions. Unlike primary aHUS, there is still no hard evidence on the efficacy of complement blockade in secondary aHUS, since the two main series that investigated this subject showed discrepant results. Our work aims to reassess the efficacy of eculizumab in treating secondary aHUS. Methods Observational, retrospective, single-center study, in which we analyzed the hematological and renal evolution of 23 patients diagnosed with secondary aHUS who received treatment with eculizumab and compared them with a control cohort of 14 patients. Complete renal response was defined as the recovery of renal function before the event, partial renal response as a recovery of 50% of lost glomerular filtration rate, and hematological response as normalization of hemoglobin and platelets. Results We found no statistically significant differences in baseline characteristics or disease severity between both groups. After a median of 5 doses of eculizumab, the group of patients who received complement blockade presented a significant difference in renal response (complete in 52.3% of patients and partial in 23.8%) compared to the control cohort (complete response 14.3% and partial of 14.3%). Rates of hematological remission were similar in both groups (90.9% in the eculizumab cohort and 85.7% in the control cohort). Conclusion Early and short-term use of eculizumab in patients with secondary aHUS could be an effective and safe therapeutic option, assuring better renal recovery compared to patients who do not receive complement blockade.
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Affiliation(s)
- Lucía Cordero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Cavero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Eduardo Gutiérrez
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Hernando Trujillo
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Justo Sandino
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pilar Auñón
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Rivero
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Enrique Morales
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
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19
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Acharya R, Clapp WL, Upadhyay K. Efficacy and Safety of Eculizumab in Enteroaggregative E. coli Associated Hemolytic Uremic Syndrome. Pediatr Rep 2024; 16:26-34. [PMID: 38251312 PMCID: PMC10801546 DOI: 10.3390/pediatric16010003] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) may present atypically without the full triad of classical HUS. Eculizumab has been shown to be efficacious in complement-mediated atypical HUS and some cases of Shiga-toxin (ST) associated HUS. We report the utility of eculizumab in enteroaggregative E. coli (EAEC) associated HUS. CASE SUMMARY A female toddler presented with hemolytic anemia, oliguric acute kidney injury (AKI) without thrombocytopenia, and peripheral schistocytes. The stool examination for ST was negative but positive for EAEC. She required several hemodialysis sessions and received one dosage of eculizumab with rapid reversal of AKI and hemolytic markers. A kidney biopsy revealed acute tubular injury and segmental glomerular basement membrane splitting. Genetic testing was negative for complement mutations or deficiencies. A follow-up six months later showed persistently normal renal function and hematological markers. CONCLUSION The clinical and histological manifestations of non-ST-associated diarrheal HUS and the role of eculizumab in this condition warrant future larger studies.
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Affiliation(s)
- Ratna Acharya
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Nemours Children’s Hospital, Orlando, FL 32827, USA;
| | - William L. Clapp
- Division of Anatomic Pathology, Department of Pathology, University of Florida, Gainesville, FL 32610, USA;
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
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20
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Domínguez-Vargas A, Ariño F, Silva D, González-Tórres HJ, Aroca-Martinez G, Egea E, Musso CG. Pregnancy-Associated Atypical Hemolytic Uremic Syndrome: A Case Report with MCP Gene Mutation and Successful Eculizumab Treatment. AJP Rep 2024; 14:e96-e100. [PMID: 38384402 PMCID: PMC10881257 DOI: 10.1055/a-2164-8438] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 02/23/2024] Open
Abstract
Pregnancy-associated atypical hemolytic uremic syndrome (P-aHUS) is a rare condition characterized by microangiopathic hemolytic anemia and kidney injury from thrombotic microangiopathy. P-aHUS occurs in approximately 1 in 25,000 pregnancies and is strongly related to complement dysregulation and pregnancy-related disorders, such as preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelet (HELLP) syndrome, resulting in adverse perinatal and fetal outcomes. Complement dysregulation in P-aHUS is commonly attributed to genetic mutations or autoantibodies affecting complement factors, including CFH , CFI , and MCP. We present a case of a 25-year-old primigravida who experienced severe preeclampsia and HELLP syndrome followed by the development of complicated P-aHUS during the early postpartum period. The patient exhibited severe clinical manifestations, including hypertensive emergency, central nervous system involvement, renal impairment, and microangiopathic hemolytic anemia. Timely initiation of eculizumab therapy resulted in successful disease remission. Further genetic analysis revealed a likely rare pathogenic MCP gene variant.
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Affiliation(s)
- Alex Domínguez-Vargas
- División Ciencias de la Salud, Universidad del Norte, Barranquilla, Colombia
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Fanny Ariño
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Diana Silva
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
| | | | - Gustavo Aroca-Martinez
- División Ciencias de la Salud, Universidad del Norte, Barranquilla, Colombia
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
- Departamento de Nefrología, Clínica de la Costa, Barranquilla, Colombia
| | - Eduardo Egea
- División Ciencias de la Salud, Universidad del Norte, Barranquilla, Colombia
| | - Carlos G. Musso
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
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21
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Ng JY, Lenton D, Kerridge I, Wong C. A Case Report of Quinine-Induced Thrombotic Microangiopathy Successfully Treated With Eculizumab. J Investig Med High Impact Case Rep 2024; 12:23247096241235617. [PMID: 38477293 PMCID: PMC10938615 DOI: 10.1177/23247096241235617] [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] [Received: 12/17/2023] [Revised: 01/31/2024] [Accepted: 02/11/2024] [Indexed: 03/14/2024] Open
Abstract
Drug-induced thrombotic microangiopathy (DITMA) is a life-threatening condition which may be immune or nonimmune mediated. Quinine is the most implicated drug in immune-mediated DITMA. However, the optimal treatment is unclear. Complement inhibition by eculizumab has demonstrated success in many DITMA (e.g., carfilzomib, gemcitabine, and tacrolimus), but there are limited data in DITMA, including quinine-associated cases. A 55-year-old female was diagnosed with quinine-associated thrombotic microangiopathy (TMA), as confirmed by a positive quinine-dependent platelet-associated antibody. This was successfully treated with eculizumab with complete resolution of thrombocytopenia and anemia by 1 and 6 weeks. She required hemodialysis for a month and gained full recovery of renal function. We discuss various challenges with the diagnosis and management of DITMA. We also review published data on the use of eculizumab in various DITMA. Our case demonstrates successful treatment of quinine-induced TMA with eculizumab. We recommend further studies to assess the efficacy of complement inhibition in quinine and other DITMA.
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Affiliation(s)
| | | | - Ian Kerridge
- Royal North Shore Hospital, Sydney, NSW, Australia
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Avdonin PP, Blinova MS, Generalova GA, Emirova KM, Avdonin PV. The Role of the Complement System in the Pathogenesis of Infectious Forms of Hemolytic Uremic Syndrome. Biomolecules 2023; 14:39. [PMID: 38254639 PMCID: PMC10813406 DOI: 10.3390/biom14010039] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/24/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Hemolytic uremic syndrome (HUS) is an acute disease and the most common cause of childhood acute renal failure. HUS is characterized by a triad of symptoms: microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. In most of the cases, HUS occurs as a result of infection caused by Shiga toxin-producing microbes: hemorrhagic Escherichia coli and Shigella dysenteriae type 1. They account for up to 90% of all cases of HUS. The remaining 10% of cases grouped under the general term atypical HUS represent a heterogeneous group of diseases with similar clinical signs. Emerging evidence suggests that in addition to E. coli and S. dysenteriae type 1, a variety of bacterial and viral infections can cause the development of HUS. In particular, infectious diseases act as the main cause of aHUS recurrence. The pathogenesis of most cases of atypical HUS is based on congenital or acquired defects of complement system. This review presents summarized data from recent studies, suggesting that complement dysregulation is a key pathogenetic factor in various types of infection-induced HUS. Separate links in the complement system are considered, the damage of which during bacterial and viral infections can lead to complement hyperactivation following by microvascular endothelial injury and development of acute renal failure.
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Affiliation(s)
- Piotr P. Avdonin
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
| | - Maria S. Blinova
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
| | - Galina A. Generalova
- Saint Vladimir Moscow City Children’s Clinical Hospital, 107014 Moscow, Russia; (G.A.G.); (K.M.E.)
- Department of Pediatrics, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Khadizha M. Emirova
- Saint Vladimir Moscow City Children’s Clinical Hospital, 107014 Moscow, Russia; (G.A.G.); (K.M.E.)
- Department of Pediatrics, A.I. Evdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Pavel V. Avdonin
- Koltzov Institute of Developmental Biology RAS, ul. Vavilova, 26, 119334 Moscow, Russia; (M.S.B.); (P.V.A.)
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24
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Lee J, Lee H, Kim S, Suh HS. Efficacy of complement inhibitors for patients with paroxysmal nocturnal hemoglobinuria: a systematic review and meta-analysis. Ther Adv Hematol 2023; 14:20406207231216080. [PMID: 38105771 PMCID: PMC10725119 DOI: 10.1177/20406207231216080] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/19/2023] [Indexed: 12/19/2023] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematological disease. The development of complement inhibitors such as eculizumab, ravulizumab, and pegcetacoplan has revolutionized the management of PNH, leading to improvements in overall survival and quality of life for patients. Objectives This systematic review aims to provide comprehensive evidence of the efficacy of complement inhibitors in relation to treatment duration. Design This is a systematic review and meta-analysis. Data sources and methods A thorough literature search was conducted in MEDLINE, EMBASE, and the Cochrane Library up to 3 May 2022. We included all prospective interventional studies including single-arm trials. The primary outcomes of interest were lactate dehydrogenase (LDH) levels, hemoglobin (Hb) concentrations, transfusion avoidance, and Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scores. Results Our study included a total of 27 studies, comprising 5 randomized controlled trials and 11 single-arm trials, with a total of 912 patients with PNH. We stratified the studies according to treatment duration, based on the most frequently reported period of 26 weeks. Our analysis showed that treatment-naïve patients who received complement inhibitors had a pooled estimate of a decrease in LDH levels from baseline by -1462.0 U/L (95% CI: -1735.6 to -1188.5) for treatment ⩽26 weeks and -1696.5 U/L (95% CI: -2122.7 to -1270.2) for treatment >26 weeks. The mean Hb levels were increased by 1.4 g/dL (95% CI: 0.5-2.3) and 1.9 g/dL (95% CI: 0.7-3.1) in each group. Treatment with any complement inhibitor prevented the need for transfusion in at least 50% of patients with PNH in all treatment periods. Clinically meaningful improvements in FACIT-F were observed both before and after 26 weeks, with a pooled estimate of 6.8 (95% CI: 6.0-7.6) and 9.5 (95% CI: 7.0-12.0), respectively. Conclusion Our findings suggest that complement inhibitors can result in positive treatment outcomes and sustained benefits for patients with PNH.
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Affiliation(s)
- Jiyeon Lee
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation Through Science, Kyung Hee University, Seoul, Republic of Korea
| | - Haeseon Lee
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation Through Science, Kyung Hee University, Seoul, Republic of Korea
| | - Siin Kim
- College of Pharmacy, Woosuk University, Wanju-gun, Republic of Korea
| | - Hae Sun Suh
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- Institute of Regulatory Innovation Through Science, Kyung Hee University, Seoul, Republic of Korea
- College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea
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25
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Wooden B, Tarragon B, Navarro-Torres M, Bomback AS. Complement inhibitors for kidney disease. Nephrol Dial Transplant 2023; 38:ii29-ii39. [PMID: 37218685 DOI: 10.1093/ndt/gfad079] [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] [Received: 03/15/2023] [Indexed: 05/24/2023] Open
Abstract
A refined understanding of the role of complement in the pathogenesis of glomerular and other kidney diseases has, over the past two decades, been matched by the development of novel, complement-targeting therapies. As we increasingly recognize the important role that complement activation across all three pathways-classical, lectin and alternative-plays in glomerular lesions both rare (e.g. C3 glomerulopathy) and common (e.g. immunoglobulin A nephropathy), we can identify avenues for precise, targeted approaches to modifying the natural history of these kidney diseases. In this review, we survey the evidence on using complement inhibition from the earliest, small-scale studies focusing on C5-targeting agents to more recent, large, multicenter, randomized trials utilizing complement blockade higher up in the complement pathway at the level of C3. We conclude by examining where the field of complement targeting therapy may be headed in light of these studies.
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Affiliation(s)
- Benjamin Wooden
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Blanca Tarragon
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariela Navarro-Torres
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
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Chelghoum S, Haddoum F, Djenouhat K, Hamlaoui MT, Adjlane N, Boukheloua M. Atypical hemolytic and uremic syndrome in Algeria: diagnostic difficulties and therapeutic constraints. Nephrol Ther 2023; 19:483-490. [PMID: 37915194 DOI: 10.1684/ndt.2023.37] [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: 08/10/2023]
Abstract
Atypical Hemolytic Uremic Syndrome (aHUS) is a systemic disease due to dysregulation of the alternate complement pathway, mortality is estimated at 10% and more than 50% of patients progress to end-stage renal disease. The aim of this study was to summarize the clinical data and biological results as well as the evolution and management of patients with aHUS seen over a period of four years in one specialized department in Algeria. Our study was observational and longitudinal. The inclusion criteria were: the clinical-biological triad of aHUS and age ≤ 16 years. The type of treatment, the presence of complement mutation or anti-complement factor autoantibodies were not eligibility conditions. On inclusion and every six months, demographic data, clinical and biological history and results after treatment were collected prospectively. Our workforce consisted of 21 children with aHUS. Thirteen patients benefited from a complement study; among them, 7 had complement abnormalities. Eleven children had familial HUS; among them 8 died and 6 were less than one year old. Plasma exchanges were performed in two children. Six patients received eculizumab, with an average age of 3.6 years. After the acute phase, 9 children recovered their kidney function, one child had developed a chronic kidney disease (CKD), and 11 died, among them 8 belong to aHUS families. Fifty percent of deaths occurred in the first 3 months. At 2 years of evolution, out of 7 children having reached this stage, five had renal sequelae and four of them had CKD. The severe prognosis of this disease makes early diagnosis and treatment essential.
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Affiliation(s)
- Souad Chelghoum
- CHU Mustapha Pacha, service de néphrologie, dialyse et transplantation, 1945, place du 1er mai, Sidi M’Hamed 16000, Alger, Algérie
| | - Farid Haddoum
- CHU Mustapha Pacha, service de néphrologie, dialyse et transplantation, 1945, place du 1er mai, Sidi M’Hamed 16000, Alger, Algérie
| | - Kamel Djenouhat
- Laboratoire de biologie médicale, Établissement public hospitalier, Rouïba 16012, Alger, Algérie
| | - Mohamed-Taher Hamlaoui
- Hôpital Nefissa Hamoud, CHU Hussein-dey, service de néphrologie pédiatrique, Unité de soins intensifs, Hussein-Dey 16005, Alger, Algérie
| | - Nawel Adjlane
- Hôpital Nefissa Hamoud, CHU Hussein-dey, service de chirurgie infantile, Hussein-Dey 16005, Alger, Algérie
| | - Mourad Boukheloua
- Hôpital Nefissa Hamoud, CHU Hussein-dey, service de cardiologie, Unité de cardiologie interventionnelle, Hussein-Dey 16005, Alger, Algérie
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27
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Qureshi ZA, Altaf F, Khanzada M, Thet A, Espinosa L. Ceftriaxone-Induced Thrombotic Thrombocytopenic Purpura Treated Successfully With Plasmapheresis and Eculizumab: A Rare Case Report. Cureus 2023; 15:e48898. [PMID: 38024015 PMCID: PMC10653270 DOI: 10.7759/cureus.48898] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Thrombotic Thrombocytopenic Purpura (TTP) is a subtype of thrombotic microangiopathy (TMA) resulting in thrombocytopenia, anemia, fever, renal and neurological deficits. Although many drugs have been associated with drug-induced TTP, ceftriaxone has never been reported. Our case reports a patient who was started on ceftriaxone and developed TTP. Peripheral smear showed schistocytes and thrombocytopenia. Surprisingly, antibody formation against the metalloproteinase (ADAMTS13) levels were low-normal. The patient was treated with plasmapheresis and eczulimab, leading to platelet recovery and symptom resolution. TTP is a rare disorder and can be acquired or idiopathic. TTP can be diagnosed with normal ADAMTS13 as well. Further research is required to assess the mechanism by which ceftriaxone causes TTP. Physicians should consider the possibility of TTP in patients with similar presentations following ceftriaxone therapy and use it for timely diagnosis and treatment. Early diagnosis and treatment of ceftriaxone-induced TTP can prevent devastating consequences.
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Affiliation(s)
- Zaheer A Qureshi
- Internal Medicine, The Frank H. Netter M.D. School of Medicine at Quinnipiac University, Bridgeport, USA
- Internal Medicine, BronxCare Health System, Bronx, USA
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | - Faryal Altaf
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | - Aung Thet
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Luis Espinosa
- Internal Medicine, BronxCare Health System, Bronx, USA
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28
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Stevens KH, Baas LM, van der Velden TJAM, Bouwmeester RN, van Dillen N, Dorresteijn EM, van Zuilen AD, Wetzels JFM, Michels MAHM, van de Kar NCAJ, van den Heuvel LP. Modeling complement activation on human glomerular microvascular endothelial cells. Front Immunol 2023; 14:1206409. [PMID: 37954621 PMCID: PMC10634509 DOI: 10.3389/fimmu.2023.1206409] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 10/03/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Atypical hemolytic uremic syndrome (aHUS) is a rare kidney disease caused by dysregulation of the complement alternative pathway. The complement dysregulation specifically leads to damage to the glomerular endothelium. To further understand aHUS pathophysiology, we validated an ex vivo model for measuring complement deposition on both control and patient human glomerular microvascular endothelial cells (GMVECs). Methods Endothelial cells were incubated with human test sera and stained with an anti-C5b-9 antibody to visualize and quantify complement depositions on the cells with immunofluorescence microscopy. Results First, we showed that zymosan-activated sera resulted in increased endothelial C5b-9 depositions compared to normal human serum (NHS). The levels of C5b-9 depositions were similar between conditionally immortalized (ci)GMVECs and primary control GMVECs. The protocol with ciGMVECs was further validated and we additionally generated ciGMVECs from an aHUS patient. The increased C5b-9 deposition on control ciGMVECs by zymosan-activated serum could be dose-dependently inhibited by adding the C5 inhibitor eculizumab. Next, sera from five aHUS patients were tested on control ciGMVECs. Sera from acute disease phases of all patients showed increased endothelial C5b-9 deposition levels compared to NHS. The remission samples showed normalized C5b-9 depositions, whether remission was reached with or without complement blockage by eculizumab. We also monitored the glomerular endothelial complement deposition of an aHUS patient with a hybrid complement factor H (CFH)/CFH-related 1 gene during follow-up. This patient had already chronic kidney failure and an ongoing deterioration of kidney function despite absence of markers indicating an aHUS flare. Increased C5b-9 depositions on ciGMVECs were observed in all samples obtained throughout different diseases phases, except for the samples with eculizumab levels above target. We then tested the samples on the patient's own ciGMVECs. The C5b-9 deposition pattern was comparable and these aHUS patient ciGMVECs also responded similar to NHS as control ciGMVECs. Discussion In conclusion, we demonstrate a robust and reliable model to adequately measure C5b-9-based complement deposition on human control and patient ciGMVECs. This model can be used to study the pathophysiological mechanisms of aHUS or other diseases associated with endothelial complement activation ex vivo.
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Affiliation(s)
- Kes H. Stevens
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Laura M. Baas
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thea J. A. M. van der Velden
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Romy N. Bouwmeester
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Niels van Dillen
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Eiske M. Dorresteijn
- Department of Pediatric Nephrology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, Netherlands
| | - Arjan D. van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jack F. M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marloes A. H. M. Michels
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lambertus P. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Pediatrics/Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
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29
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Oda T, Sawai T. Editorial: Role of complement activation in kidney diseases. Front Med (Lausanne) 2023; 10:1297938. [PMID: 37928465 PMCID: PMC10621785 DOI: 10.3389/fmed.2023.1297938] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Affiliation(s)
- Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
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30
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Antozzi C, Mantegazza R. Impact of Ravulizumab on Patient Outcomes and Quality of Life in Generalized Myasthenia Gravis. Patient Relat Outcome Meas 2023; 14:305-312. [PMID: 37876920 PMCID: PMC10590807 DOI: 10.2147/prom.s408175] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune ion channel disorder in which antibodies to different end-plate antigens impair neuromuscular transmission, ultimately leading to muscle weakness and fatigability. In about 85% of patients with MG, autoantibodies against the acetylcholine receptor (AChR) activate the complement cascade, causing damage to the neuromuscular junction. MG is a chronic disorder for which standard therapies with corticosteroids, immunosuppressive drugs, and immunomodulation with plasma exchange or intravenous immunoglobulins modify the course of the disease, but the residual burden of physical, psychological, and social disability highlights several unmet needs, among these the need for specific, targeted, and well tolerated therapies able to improve the patients' quality of life. Complement inhibition paved the way to precision medicine in MG since, for the first time, a specific therapy targeting a crucial pathogenetic step has been designed, tested, and proven to be effective in a controlled fashion. Ravulizumab represents the first long-acting complement inhibitor approved for treatment of patients with generalized MG, able to provide rapid, complete, and sustained complement inhibition. Ravulizumab improved the MG Activity of Daily Living scale and other clinical parameters up to 26 weeks as shown by the CHAMPION MG trial, and by its open label extension, with the added value of being administered every 8 weeks. The schedule of administration is likely to improve patients' adherence and hence their quality of life. The introduction of complement inhibition will considerably change the traditional therapeutic strategy for MG.
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Affiliation(s)
- Carlo Antozzi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Immunotherapy and Apheresis Departmental Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Fishman J, Anderson S, Talbird SE, Dingli D. Analysis of Costs per Responder in US Adults with Paroxysmal Nocturnal Hemoglobinuria with a Suboptimal Response to Prior Eculizumab Treatment. Hematol Rep 2023; 15:578-591. [PMID: 37873795 PMCID: PMC10594490 DOI: 10.3390/hematolrep15040060] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/06/2023] [Indexed: 10/25/2023] Open
Abstract
European Society for Blood and Marrow Transplantation (EBMT) hematologic response categories comprehensively assess complement inhibitor responses in patients with paroxysmal nocturnal hemoglobinuria (PNH). Using data from the 16-week randomized controlled period of the phase 3 PEGASUS trial (N = 80), we estimated the treatment cost per responder by the EBMT response category for pegcetacoplan and eculizumab in adults with PNH and a suboptimal response to eculizumab. Average drug costs per responder, number needed to treat, and incremental drug costs per responder were estimated using dosages administered during the trial (base case). A US payer perspective (2020 US dollars) was used. Scenario analyses were conducted for various costs, dosages, treatment durations, patient populations, and settings. In total, 30 of 41 (73%) who switched to pegcetacoplan and 2 of 39 (5%) patients who continued eculizumab had a good, major, or complete response (good-to-complete responders) at Week 16. Average weekly drug costs per good-to-complete responder were USD 15,923 with pegcetacoplan and USD 216,100 with eculizumab; average weekly drug costs per patient were USD 11,651 and USD 11,082, respectively. Average drug costs per good-to-complete responder with pegcetacoplan were similar across complement inhibitor-naïve populations and were consistently lower than with eculizumab. Switching from eculizumab to pegcetacoplan allowed more patients with a suboptimal response to attain a good-to-complete response at lower costs. These results apply to patients with a suboptimal response to prior eculizumab treatment only.
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Affiliation(s)
- Jesse Fishman
- Apellis Pharmaceuticals, Inc., Waltham, MA 02451, USA;
| | - Seri Anderson
- RTI Health Solutions, Research Triangle Park, NC 27709, USA;
| | | | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;
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San PP, Jacob S. Role of complement in myasthenia gravis. Front Neurol 2023; 14:1277596. [PMID: 37869140 PMCID: PMC10585143 DOI: 10.3389/fneur.2023.1277596] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Myasthenia gravis is a prototypic neuroimmune disorder with autoantibodies targeting the acetylcholine receptor complex at the neuromuscular junction. Patients present with mainly ocular muscle weakness and tend to have a generalized muscle weakness later in the clinical course. The weakness can be severe and fatal when bulbar muscles are heavily involved. Acetylcholine receptor antibodies are present in the majority of patients and are of IgG1 and IgG3 subtypes which can activate the complement system. The complement involvement plays a major role in the neuromuscular junction damage and the supporting evidence in the literature is described in this article. Complement therapies were initially studied and approved for paroxysmal nocturnal hemoglobinuria and in the past decade, those have also been studied in myasthenia gravis. The currently available randomized control trial and real-world data on the efficacy and safety of the approved and investigational complement therapies are summarized in this review.
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Affiliation(s)
- Pyae Phyo San
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Galli N, Pettine L, Panigada M, Daprai L, Suriano G, Grancini A, Barcellini W, Fattizzo B. Non-capsulated Neisseria meningitidis sepsis in a paroxysmal nocturnal hemoglobinuria patient treated with ravulizumab: case report and review of the literature. Front Immunol 2023; 14:1269325. [PMID: 37854608 PMCID: PMC10580757 DOI: 10.3389/fimmu.2023.1269325] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/30/2023] [Indexed: 10/20/2023] Open
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is a rare acquired haematopoietic stem cell disease characterized by complement-mediated intravascular hemolysis, thrombosis, and bone marrow failure. Eculizumab and ravulizumab are anti-C5 monoclonal antibodies that reduce hemolysis, anaemia and thrombotic risk, but are associated with increased risk of infection with encapsulated bacteria, including Neisseria meningitidis. We report a case of life-threatening infection by non-groupable Neisseria meningitidis in a young PNH patient treated with ravulizumab. Despite prompt admission to the intensive care unit, microbe isolation was delayed due to the negativity of capsular antigens, and the patient required intubation, dialysis, and transfusion support for pancytopenia. Notably, PNH disease activity remained controlled and no additional anti-C5 doses were administered. Increasing awareness regarding septic risk in PNH patients on complement inhibitors despite vaccinations is pivotal. A warning about serotypes generally not pathogenetic and not covered by vaccination, such as non-capsulated forms, is emerging.
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Affiliation(s)
- Nicole Galli
- Ematologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Loredana Pettine
- Ematologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Panigada
- Anestesia e Terapia Intensiva Adulti, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Daprai
- Laboratorio di Microbiologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Laboratorio Analisi, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Grazia Suriano
- Anestesia e Terapia Intensiva Adulti, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Grancini
- Laboratorio di Microbiologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Laboratorio Analisi, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Ematologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Ematologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Karabag Yilmaz E, Cebi MN, Karahan I, Saygılı S, Gulmez R, Demirgan EB, Durak C, Aygun F, Ozaltin F, Caliskan S, Canpolat N. COVID-19 associated thrombotic microangiopathy. Nephrology (Carlton) 2023; 28:557-560. [PMID: 37485596 DOI: 10.1111/nep.14225] [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] [Received: 11/26/2022] [Revised: 04/26/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
A limited number of cases of thrombotic microangiopathy (TMA) have previously been reported in association with COVID-19. Our report describes two cases of TMA associated with COVID-19, one of which was successfully treated with eculizumab. The first case was a 23-month-old girl, and the second case was a 9-month-old boy. PCR tests for SARS-CoV-2 were positive in both cases, and laboratory results showed microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. No known aetiology for TMA was found in either case. Stool tests for Shigatoxin-producing Escherichia coli were negative. Coagulation tests, ADAMTS13 activity, serum complement levels, and homocysteine levels were all within the normal range. No known genetic mutation was found, including mutations of complement, diacylglycerol kinase epsilon, and cobalamin C. In the first case, eculizumab was administered due to persistent haemolysis and prolonged anuria. In conclusion, TMA may be associated with COVID-19 infection. Treatment with eculizumab may be beneficial in selected patients because of the potential activation of the complement system.
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Affiliation(s)
- Esra Karabag Yilmaz
- Department of Paediatric Nephrology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Memnune Nur Cebi
- Department of Paediatrics, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Iremnaz Karahan
- Department of Paediatrics, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Seha Saygılı
- Department of Paediatric Nephrology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Ruveyda Gulmez
- Department of Paediatric Nephrology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Ebru Burcu Demirgan
- Department of Paediatric Nephrology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Cansu Durak
- Department of Paediatric Intensive Care Unit, Sancaktepe Sehit Prof. Dr. İlhan Varank Training and Research Hospıtal, Istanbul, Turkey
| | - Fatih Aygun
- Department of Paediatric Intensive Care Unit, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Fatih Ozaltin
- Nephrogenetics Laboratory, Department of Pediatrics, Hacettepe University School of Medicine, Ankara, Turkey
- Department of Paediatric Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Salim Caliskan
- Department of Paediatric Nephrology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Nur Canpolat
- Department of Paediatric Nephrology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Kamgang Semeu P, Taghavi M, Geers C, Mouthon L, Barreto Gutierrez L, Stordeur P. Scleroderma renal crisis triggered by ibuprofen: Insights on complement-directed therapy. J Scleroderma Relat Disord 2023; 8:NP6-NP8. [PMID: 37744046 PMCID: PMC10515997 DOI: 10.1177/23971983231163663] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/25/2023] [Indexed: 09/26/2023]
Abstract
Scleroderma renal crisis is a severe complication of systemic sclerosis with a poor prognosis. Therefore, identifying precipitating factors is essential. Among known risk factors, only few are reversible. On the contrary, anti-C5 therapy appears effective, at least in some cases. We describe a 59-year-old man with diffuse cutaneous systemic sclerosis who developed life-threatening scleroderma renal crisis following ibuprofen administration. Despite aggressive management, he did not improve. Renal biopsy have displayed features of thrombotic microangiopathy but no complement deposition. We then discuss the pathomechanism of scleroderma renal crisis that could drive eculizumab treatment since some renal biopsies exhibit complement deposits and others do not.
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Affiliation(s)
- Prochore Kamgang Semeu
- Division of Nephrology, Department of Internal Medicine, ULB-VUB Center for Hereditary Metabolic Diseases, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Taghavi
- Division of Nephrology, Department of Internal Medicine, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Geers
- Department of Pathology, Brugmann University Hospital and UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Luc Mouthon
- Department of Internal Medicine and Reference Center for Vasculitis and Systemic Sclerosis, Cochin Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Faculty of Medicine, Paris-Descartes University, Paris, France
| | - Leonel Barreto Gutierrez
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrick Stordeur
- National Reference Center for the Complement System, Laboratory of Immunology, LHUB-ULB, Université Libre de Bruxelles, Brussels, Belgium
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Kelen K, Horváth O, Kis É, Mikes B, Sallay P, Prohászka Z, Szabó AJ, Reusz GS. Immunosuppressive Therapy of Antibody-Mediated aHUS and TTP. Int J Mol Sci 2023; 24:14389. [PMID: 37762692 PMCID: PMC10531618 DOI: 10.3390/ijms241814389] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The recent classification of pediatric thrombotic microangiopathies (TMA) takes into consideration mechanisms of disease for guidance to targeted therapies. We present our experience with seven patients with antibody mediated atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP). Five children had aHUS with antibodies against complement factor H (CFH-ab) and two with TTP with antibodies against metalloproteinase ADAMTS13. In the aHUS cases diagnosed and treated before the eculizumab era, CFH-ab was detected using the ELISA assay. Mutational analysis of selected complement genes was performed. TTP was diagnosed if, in addition to microangiopathic hemolytic anemia and thrombocytopenia, ischemic organ involvement and severe deficiency in ADAMTS13 activity were present. Treatment protocol consisted of plasma exchanges (PE) and steroid pulses, followed by the combination of cyclophosphamide and rituximab to achieve long-term immunosuppression. Four patients with CFH-ab and the TTP patients with ADAMTS13 antibodies came into sustained remission. After a median follow-up of 11.7 (range 7.7-12.9) years without maintenance therapy, no disease recurrence was observed; nevertheless, six patients, two had hypertension and two had proteinuria as a late consequence. One patient, with late diagnosis of CFH-ab and additional genetic risk factors who was treated only with PE and plasma substitution, reached end-stage renal disease and was later successfully transplanted using eculizumab prophylaxis. In the cases of antibody-mediated TMAs, PE and early immunosuppressive treatment may result in sustained remission with preserved kidney function. Further data are needed to establish optimal treatment of anti-FH antibody-associated HUS.
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Affiliation(s)
- Kata Kelen
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Orsolya Horváth
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Éva Kis
- Department of Pediatric Cardiology, Gottsegen György Hungarian Institute of Cardiology, 1096 Budapest, Hungary;
| | - Bálint Mikes
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Péter Sallay
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
| | - Zoltán Prohászka
- Research Laboratory, Department of Medicine and Hematology, Semmelweis University, 1083 Budapest, Hungary;
| | - Attila József Szabó
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
- Pediatric Center, MTA Center of Excellence, Semmelweis University, 1083 Budapest, Hungary
- ELKH-SE Pediatrics and Nephrology Research Group, 1052 Budapest, Hungary
| | - György S. Reusz
- Bókay Street Unit, Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary; (K.K.); (O.H.); (B.M.); (P.S.); (A.J.S.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Shahid K, Qayyum S. Eculizumab Versus Ravulizumab for the Treatment of Atypical Hemolytic Uremic Syndrome: A Systematic Review. Cureus 2023; 15:e46185. [PMID: 37905269 PMCID: PMC10613336 DOI: 10.7759/cureus.46185] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/02/2023] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a type of thrombotic microangiopathy and is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. The complement cascade plays an integral role in aHUS. Mutations in the complement cascade, especially in the alternative pathway (AP) lead to an unregulated and continuous activation of the cascade. Eculizumab and ravulizumab are humanized monoclonal antibodies that inhibit the complement cascade. This systematic analysis reviews the evidence for both antibodies to compare them in terms of safety and efficacy. This review will also assess the evidence for biomarker associations with interventions, the role of genetic mutations in the prognosis of disease, and the financial burden of both treatment options. An in-depth search was conducted across PubMed, Science Direct, and Cochrane Library following the PRISMA 2020 guidelines. Both eculizumab and ravulizumab were comparable in safety and efficacy but ravulizumab was preferred by patients and their caregivers as it posed a lower financial burden and had less frequent dosing. Soluble complement 5b-9 (sC5b), especially in urine, has the potential to be used as a biomarker to assess response to treatment. Genetic mutations, especially mutations in complement factor I (CFI), membrane cofactor protein (MCP), and complement factor H (CFH), were associated with a higher risk of recurrence, and therefore care should be taken when attempting to discontinue treatment in this subset of patients. Treatment with a monoclonal antibody should be initiated as soon as a genetic mutation is identified. Blinded, double-arm, clinical trials preferably with larger sample sizes are needed to effectively compare both the monoclonal antibodies.
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Affiliation(s)
- Kamran Shahid
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shahid Qayyum
- Nephrology, Diaverum Dialysis Center, Wadi Al Dawasir, SAU
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Mauch TJ, Chladek MR, Cataland S, Chaturvedi S, Dixon BP, Garlo K, Gasteyger C, Java A, Leguizamo J, Lloyd-Price L, Pham TP, Symonds T, Tomazos I, Wang Y. Treatment preference and quality of life impact: ravulizumab vs eculizumab for atypical hemolytic uremic syndrome. J Comp Eff Res 2023; 12:e230036. [PMID: 37515502 PMCID: PMC10690411 DOI: 10.57264/cer-2023-0036] [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] [Received: 03/17/2023] [Accepted: 07/14/2023] [Indexed: 07/31/2023] Open
Abstract
Aim: Ravulizumab and eculizumab are complement C5 inhibitors approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Ravulizumab requires less frequent infusions than eculizumab, which may reduce treatment burden. This study investigated patients' treatment preferences and the impact of both treatments on patient and caregiver quality of life. Materials & methods: Two surveys were conducted (one for adult patients with aHUS and one for caregivers of pediatric patients with aHUS) to quantitatively assess treatment preference and the patient- and caregiver-reported impact of ravulizumab and eculizumab on quality of life. Patients were required to have a diagnosis of aHUS, to be currently receiving treatment with ravulizumab and to have received prior treatment with eculizumab. Participants were recruited via various sources: the Alexion OneSource™ patient support program, the Rare Patient Voice recruitment agency, the aHUS Foundation and directly via a clinician involved in the study. Results: In total, 50 adult patients (mean age: 46.5 years) and 16 caregivers of pediatric patients (mean age: 10.1 years) completed the surveys. Most adult patients (94.0%) and all caregivers reported an overall preference for ravulizumab over eculizumab; infusion frequency was one of the main factors for patients when selecting their preferred treatment. Fewer patients reported disruption to daily life and the ability to go to work/school due to ravulizumab infusion frequency (4.0% and 5.7%, respectively) than eculizumab infusion frequency (72.0% and 60.0%), with similar results for caregivers. Conclusion: Adult patients and caregivers of pediatric patients indicated an overall preference for ravulizumab than eculizumab for the treatment of aHUS, driven primarily by infusion frequency. This study contributes to the emerging real-world evidence on the treatment impact and preference in patients with aHUS.
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Affiliation(s)
- Teri J Mauch
- Division of Pediatric Nephrology, University of Nebraska Medical Center & Omaha Children's Hospital, Omaha, NE 68114, USA
| | - Michael R Chladek
- Clinical Outcomes Assessments & Quantitative Sciences, Clinical Outcomes Solutions, LLC, Chicago, IL 60604, USA
| | - Spero Cataland
- Division of Hematology, Wexner Medical Center, Ohio State University, Columbus, OH 43203, USA
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | | | | | - Anuja Java
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jorge Leguizamo
- Georgia Cancer Specialists, Northside Hospital Cancer Institute, Atlanta, GA 30341, USA
| | - Lucy Lloyd-Price
- Clinical Outcomes Assessments, Clinical Outcomes Solutions Ltd, Kent, CT19 4RH, UK
| | - Tan P Pham
- Clinical Outcomes Assessments & Quantitative Sciences, Clinical Outcomes Solutions, LLC, Chicago, IL 60604, USA
| | - Tara Symonds
- Clinical Outcomes Assessments, Clinical Outcomes Solutions Ltd, Kent, CT19 4RH, UK
| | | | - Yan Wang
- Alexion, AstraZeneca Rare Disease, Boston, MA 02210, USA
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Savaşan S, Özdemir Ö, Gadgeel M. Identification of Paroxysmal Nocturnal Hemoglobinuria-Type Bone Marrow Mast Cells. Cureus 2023; 15:e44919. [PMID: 37814756 PMCID: PMC10560574 DOI: 10.7759/cureus.44919] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/11/2023] Open
Abstract
Hematopoietic stem cells (HSCs) give rise to mast cells (MCs), and a relative increase in bone marrow (BM) MC is common in various BM failure (BMF) conditions. Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal HSC disorder, frequently associated with BMF, characterized by decreased expression of glycosylphosphatidylinositol membrane anchor for complement regulatory proteins. Eculizumab, a monoclonal antibody that blocks complement factor 5, successfully controls PNH symptoms. In this study, we, for the first time, demonstrated PNH-type culture-grown BM MC (c-BMMC) using flow cytometry in two BMF patients and monitored population size during eculizumab therapy. Further research may unravel the properties of PNH-type c-BMMC.
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Affiliation(s)
- Süreyya Savaşan
- Pediatric Hematology/Oncology/Bone Marrow Transplantation, Children's Hospital of Michigan, Detroit, USA
- Pediatrics, Central Michigan University, Mt. Pleasant, USA
- Oncology/Bone Marrow Transplantation, Barbara Ann Karmanos Cancer Center, Detroit, USA
- Hematology/Oncology Flow Cytometry Laboratory, Children's Hospital of Michigan, Detroit, USA
| | - Öner Özdemir
- Pediatric Allergy and Immunology, Research and Training Hospital, Sakarya University Medical Faculty, Sakarya, TUR
| | - Manisha Gadgeel
- Hematology/Oncology Flow Cytometry Laboratory, Children's Hospital of Michigan, Detroit, USA
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Ptushkin V, Arshanskaya E, Vinogradova O, Kudlay D, Nikitin E. The Features of COVID-19's Course and the Efficacy of the Gam-COVID-Vac Vaccine in Patients with Paroxysmal Nocturnal Hemoglobinuria. Hematol Rep 2023; 15:503-512. [PMID: 37754667 PMCID: PMC10531158 DOI: 10.3390/hematolrep15030052] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 09/28/2023] Open
Abstract
COVID-19 and other infectious diseases can exacerbate the course of paroxysmal nocturnal hemoglobinuria (PNH). The efficacy and safety of the Gam-COVID-Vac vaccine in patients with PNH has not been adequately studied. A retrospective, observational, cohort, non-comparative study was performed to assess the course of COVID-19 as well as the safety and efficacy of the Gam-COVID-Vac (Sputnik V) vaccine in patients with paroxysmal nocturnal hemoglobinuria (PNH). The study included data from 52 patients with PNH aged 18 to 75 years, 38 of whom received background therapy with eculizumab (Elizaria®) between March 2020 and January 2022. COVID-19 was diagnosed according to the results of PCR testing. The patients were divided into two groups for comparison of the incidence of COVID-19. Group 1 included non-vaccinated patients with PNH, and Group 2 included patients vaccinated prior to the onset of COVID-19. According to vaccination, patients were subdivided into non-vaccinated and vaccinated groups without signs of previous COVID-19 at the beginning of the analyzed period, and patients vaccinated half a year or more after recovery from COVID-19. Testing for anti-SARS-CoV-2 IgG levels was carried out in patients with PNH in the year after their COVID-19. Tests for anti-SARS-CoV-2 RBD IgG levels were performed on vaccinated patients. In total, 28 (53.8%) of the enrolled patients had COVID-19, including asymptomatic forms in 7 (25%) and mild forms in 16 (57%) patients. A total of 22 (42.3%) patients were fully vaccinated with Gam-COVID-Vac, of which 13 (25%) patients were vaccinated without the signs of previous SARS-CoV-2infection, and 9 (17.3%) patients were vaccinated after COVID-19. The number of patients who had COVID-19 was about two times higher in Group 1 (non-vaccinated; 24) (61.5%), whereas in Group 2 (vaccinated), the number of patients with COVID-19 was only 4 (30.8%). The proportion and number of patients who did not have COVID-19 was higher in the group of vaccinated patients (9; 69.2%) than in the group of non-vaccinated patients (15; 38.5%) (p = 0.054). In patients who had been infected with COVID-19, maximum concentrations of anti-SARS-CoV-2 IgG were observed 2-3 months after the acute infection phase, followed by a gradual decline by month 9-10. The mean RBD IgG concentration was higher in the group of patients who had been infected by COVID-19 than in the group of patients without COVID-19 (p = 0.047). Therapy type, including eculizumab, did not have a significant impact on RBD IgG titers (p > 0.05). Hospitalization was required in five (18%) patients, all of whom had breakthrough hemolysis and severe lung damage on CT scans. After the first dose, adverse events (AEs) were reported in 41% of the patients (body temperature increased in 18%; headache in 13.6%; and pain in joints in 4.5%; colitis exacerbation was observed in 4.5%). After the second dose, no AEs were reported. The performed study suggests the possible efficacy and demonstrates the safety of Gam-COVID-Vac (Sputnik V) for the prophylaxis of COVID-19 in patients with PNH who experience immunosuppression due to target therapy.
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Affiliation(s)
- Vadim Ptushkin
- Moscow City Hematology Center, S.P. Botkin City Clinical Hospital, Moscow 125284, Russia
- Department of Oncology, Hematology and Radiation Therapy, Pirogov Russian National Research Medical University, Moscow 117997, Russia
| | - Evgeniya Arshanskaya
- Moscow City Hematology Center, S.P. Botkin City Clinical Hospital, Moscow 125284, Russia
| | - Olga Vinogradova
- Moscow City Hematology Center, S.P. Botkin City Clinical Hospital, Moscow 125284, Russia
- Department of Oncology, Hematology and Radiation Therapy, Pirogov Russian National Research Medical University, Moscow 117997, Russia
| | - Dmitry Kudlay
- Department of Pharmacology, Pharmacy Institute, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow 119991, Russia
| | - Eugene Nikitin
- Moscow City Hematology Center, S.P. Botkin City Clinical Hospital, Moscow 125284, Russia
- Hematology and Transfusiology Department, Russian Medical Academy of Continuous Professional Education, Moscow 125993, Russia
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Padilha WSC, Cesar BN, Pacheco ST, De Sousa AA, Ledesma FL, Malheiros DMAC, Teixeira MCA. Bevacizumab-Associated Thrombotic Microangiopathy Treated with Eculizumab: A Case Report. Am J Case Rep 2023; 24:e940906. [PMID: 37644709 PMCID: PMC10474846 DOI: 10.12659/ajcr.940906] [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] [Received: 04/24/2023] [Revised: 07/18/2023] [Accepted: 07/15/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Bevacizumab is an approved targeted therapy for metastatic cancer treatment. It can have adverse effects on multiple organs. Despite its low incidence, thrombotic microangiopathy (TMA) is the most severe complication. TMA has been associated with complement dysregulation, and treatment with eculizumab can be effective, despite the paucity of literature on eculizumab therapy for bevacizumab-associated TMA. To date, 10 cases have been reported, with less than half of them including a kidney biopsy. We present a new case of bevacizumab-associated TMA successfully treated with eculizumab, along with kidney biopsy records and an overview of mechanisms underlying TMA development in bevacizumab-treated patients. CASE REPORT A female patient diagnosed with metastatic breast cancer who was treated with bevacizumab in conjunction with chemotherapy was admitted to the hospital for acute kidney injury requiring hemodialysis, microangiopathic hemolytic anemia, and thrombocytopenia. TMA was diagnosed and was later confirmed by a kidney biopsy. Primary causes for TMA, such as ADAMTS13 deficiency and shiga toxin associated hemolytic-uremic syndrome, were ruled out, and the patient's condition was ultimately found to be triggered by exposure to bevacizumab. After discontinuing bevacizumab and receiving 4 weekly doses of eculizumab, kidney function and hematological parameters improved. CONCLUSIONS Bevacizumab-associated TMA can be reversed or attenuated in some patients with the use of eculizumab (inhibiting complement system overactivation), possibly reducing time to recovery, with fewer long-term sequelae. This additional case encourages future clinical trials to evaluate the safety and efficacy of eculizumab in cases of TMA associated with bevacizumab.
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Affiliation(s)
| | - Bruno Nogueira Cesar
- Department of Nephrology, Hospital DFStar Rede D’Or São Luiz, Brasília, DF, Brazil
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43
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Kirsanova TV, Balakireva AI, Fedorova TA, Pyregov AV, Rogachevskiy OV. [Various phenotypes of postpartum atypical hemolytic uremic syndrome: the role of genetic testing in determining prognosis. Case report]. TERAPEVT ARKH 2023; 95:511-515. [PMID: 38158972 DOI: 10.26442/00403660.2023.06.202233] [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] [Received: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
We report a case of atypical hemolytic uremic syndrome (aHUS) that occurred after childbirth in a patient with a history of numerous recurrent episodes of TMA with nephrotic proteinuria and impaired renal function. At 33 weeks of the first spontaneous pregnancy, proteinuria up to 0.8 g/l was first registered, at 38 weeks she was hospitalized with proteinuria, reaching a maximum of 13 g/l, she was delivered promptly, after which progressive thrombocytopenia was noted over the next few days (up to 44×109/l) and anemia and severe arterial hypertension, which could not be corrected by several groups of antihypertensive drugs. Initiated plasma therapy had no effect. After exclusion of all other causes of TMA, therapy with eculizumab was initiated, which made it possible to quickly and completely stop the phenomena of TMA. The presented observation demonstrates the successful treatment of recurrent course of aHUS with eculizumab with the achievement of complete recovery of kidney function in a patient with a homozygous mutation in the MCP gene. It is worth noting the importance of genetic research even in those situations where clinically aHUS is beyond doubt.
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Affiliation(s)
- T V Kirsanova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | | | - T A Fedorova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - A V Pyregov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
| | - O V Rogachevskiy
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology
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44
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Yerigeri K, Kadatane S, Mongan K, Boyer O, Burke LLG, Sethi SK, Licht C, Raina R. Atypical Hemolytic-Uremic Syndrome: Genetic Basis, Clinical Manifestations, and a Multidisciplinary Approach to Management. J Multidiscip Healthc 2023; 16:2233-2249. [PMID: 37560408 PMCID: PMC10408684 DOI: 10.2147/jmdh.s245620] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy (TMA) defined by the triad of hemolytic anemia, thrombocytopenia, and acute kidney injury. Microthrombi develop in the glomerular capillaries secondary to endothelial damage and exert shear stress on red blood cells, consume platelets, and contribute to renal dysfunction and failure. Per current understanding of pathophysiology, HUS is classified into infectious, secondary, and atypical disease. The most common etiology is infectious sequelae of Shiga toxin-producing Escherichia coli (STEC); other causative organisms include shigella and salmonella. Secondary HUS arises from cancer, chemotherapy, solid organ and hematopoietic stem cell transplant, pregnancy, or autoimmune disorders. Primary atypical hemolytic-uremic syndrome (aHUS) is associated with genetic mutations in complement and complement regulatory proteins. Under physiologic conditions, complement regulators keep the alternative complement system continuously active at low levels. In times of inflammation, mutations in complement-related proteins lead to uncontrolled complement activity. The hyperactive inflammatory state leads to glomerular endothelial damage, activation of the coagulation cascade, and TMA findings. Atypical hemolytic-uremic syndrome is a rare disorder with a prevalence of 2.21 to 9.4 per million people aged 20 years or younger; children between the ages of 0 and 4 are most affected. Multidisciplinary health care is necessary for timely management of its extra-renal manifestations. These include vascular disease of the heart, brain, and skin, pulmonary hypertension and hemorrhage, and pregnancy complications. Adequate screening is required to monitor for sequelae. First-line treatment is the monoclonal antibody eculizumab, but several organ systems may require specialized interventions and coordination of care with sub-specialists.
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Affiliation(s)
- Keval Yerigeri
- Department of Internal Medicine-Pediatrics, Case Western Reserve University/The MetroHealth System, Cleveland, OH, USA
| | - Saurav Kadatane
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kai Mongan
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Olivia Boyer
- Department of Pediatric Nephrology, Dialysis and Transplantation, Necker-Enfants Malades Hospital, MARHEA reference Center, Imagine Institute, Paris Cité University, Paris, France
| | - Linda L G Burke
- aHUS Global Advocate with aHUS Alliance, Cape Elizabeth, ME, USA
| | - Sidharth Kumar Sethi
- Department of Pediatric Nephrology and Pediatric Renal Transplant Medicine, Kidney and Urology Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Christoph Licht
- Department of Paediatrics, Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Rupesh Raina
- Division of Pediatric Nephrology, Akron Children’s Hospital, Akron, OH, USA
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Roldão M, Ferrer F, Lopes K. Eculizumab discontinuation in a patient with atypical hemolytic uremic syndrome after ChAdOx1 nCoV-19 vaccination. Clin Nephrol Case Stud 2023; 11:114-116. [PMID: 37485074 PMCID: PMC10357373 DOI: 10.5414/cncs111070] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/31/2023] [Indexed: 07/25/2023] Open
Abstract
Eculizumab has proven to be effective in patients with atypical hemolytic uremic syndrome (aHUS) in clinical trials and in the real world, but the optimal duration of therapy remains unknown. Standard maintenance treatment is often life-long, but the possibility of discontinuation has not yet been systematically tested. We describe a case of aHUS after ChAdOx1 nCoV-19 vaccination in a patient with homozygous CFHR3/CFHR1 gene deletion who discontinued eculizumab maintenance therapy 24 weeks after achieving disease remission. We report the safety of discontinuing eculizumab treatment with the aim of minimizing the risk of adverse reactions, reducing the risk of meningitis, improving quality of life, and reducing the considerable treatment costs.
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Affiliation(s)
- Marisa Roldão
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
| | - Francisco Ferrer
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
| | - Karina Lopes
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
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46
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Nakashima I, Nakahara J, Yokote H, Manabe Y, Okamura K, Hasegawa K, Fujihara K. Long-term safety and effectiveness of eculizumab in patients with aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder: a 2-year interim analysis of post-marketing surveillance in Japan. Ther Adv Neurol Disord 2023; 16:17562864231181177. [PMID: 37441104 PMCID: PMC10333632 DOI: 10.1177/17562864231181177] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/23/2023] [Indexed: 07/15/2023] Open
Abstract
Background The terminal complement C5 inhibitor eculizumab is approved in Japan for relapse prevention in aquaporin-4 antibody-positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD) and is undergoing mandatory post-marketing surveillance (PMS) of clinical use. Objectives The objective of the study is to assess the real-world, long-term safety and effectiveness of eculizumab in Japanese patients with AQP4+ NMOSD. Design Regulatory-mandated PMS analysis implemented as an all-case surveillance of all patients with AQP4+ NMOSD who have been treated with eculizumab in Japan since its approval in November 2019. Methods This PMS interim analysis assessed the safety and effectiveness of eculizumab in Japanese patients with AQP4+ NMOSD from November 2019 to April 2022. Results Of 147 patients treated with eculizumab who consented to publication, 71 had at least one case report form collected and locked at the interim analysis data cut-off, constituting the safety analysis set; three patients from PREVENT (NCT01892345) were excluded from the effectiveness analysis set. Twelve and 10 patients in the safety and effectiveness analysis sets discontinued, respectively. In the safety analysis set, 67/71 patients (94.4%) were female, mean illness duration was 6.8 [standard deviation (SD): 6.2] years, mean age at eculizumab initiation was 50.7 (SD: 13.3) years, and mean eculizumab treatment duration was 44.6 (SD: 23.7) weeks. At diagnosis of NMOSD, 34/71 patients (47.9%) and 35/71 patients (49.3%) in the safety analysis set had symptoms of optic neuritis and transverse myelitis, respectively. In the safety analysis set, 19/71 patients (26.8%) reported adverse events, 10/71 (14.1%) reported adverse drug reactions (ADRs), and 7/71 (9.9%) reported serious ADRs; no meningococcal infections were observed. In the effectiveness analysis set, 64/68 patients (94.1%) were female, mean disease duration was 6.9 (SD: 6.3) years, mean age at eculizumab initiation was 50.6 (SD: 13.2) years, and 27/68 (39.7%) were tested for C5 genetic polymorphism (all negative). In the 2 years before eculizumab, 51/68 patients (75.0%) experienced relapse. Relapse rate was 0.02/patient-year after eculizumab initiation versus 0.74/patient-year in the 2 years before eculizumab. Overall, 37/68 patients (54.4%) were prescribed immunosuppressants in the 6 months before and 19/40 (47.5%) in the 6-12 months after starting eculizumab treatment. The proportion of patients taking >10 mg/day of prednisolone decreased from 45.6% at 24-20 weeks before to 23.1% and 0% at 48-52 and 100-104 weeks after eculizumab, respectively. Conclusion This article reports interim PMS data for Japanese patients and provides updated real-world evidence for the safety of eculizumab and its effectiveness at preventing relapses in patients with AQP4+ NMOSD. Safety and effectiveness results are consistent with those from PREVENT.
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Affiliation(s)
- Ichiro Nakashima
- Division of Neurology, Tohoku Medical and
Pharmaceutical University, 1-12-1 Fukumuro, Miyagino-ku, Sendai, Miyagi
983-8512, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School
of Medicine, Tokyo, Japan
| | - Hiroaki Yokote
- Department of Neurology, Nitobe Memorial Nakano
General Hospital, Tokyo, Japan
| | - Yasuhiro Manabe
- Department of Neurology, National Hospital
Organization Okayama Medical Center, Okayama, Japan
| | | | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics,
Fukushima Medical University School of Medicine, Fukushima, Japan
- Multiple Sclerosis and Neuromyelitis Optica
Center, Southern TOHOKU Research Institute for Neuroscience, Koriyama,
Japan
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47
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Syed S, Khan R, Khurram F, Khan FH, Safi D, Safi SUD. Treatment of eculizumab refractory paroxysmal nocturnal hemoglobinuria: A systematic review about current treatment options and future direction. SAGE Open Med 2023; 11:20503121231181267. [PMID: 37388903 PMCID: PMC10302528 DOI: 10.1177/20503121231181267] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/25/2023] [Indexed: 07/01/2023] Open
Abstract
Objectives C5 inhibitors such as eculizumab and ravulizumab are the first-line treatment in the management of paroxysmal nocturnal hemoglobinuria (PNH). However, some patients develop novel symptoms as part of their treatment with eculizumab, and the disease is termed as eculizumab refractory PNH. The aim of this study was to conduct a systematic review on the available treatment modalities for the management of eculizumab refractory PNH. Methods Two authors independently searched two databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 70 studies were obtained: 4 out 70 studies were found to meet the inclusion criteria. Results Four studies were found to meet the inclusion criteria of our study. Two studies were published in 2021 and two studies were published in 2020. All four studies were multicenter clinical trials. Two studies were phase III clinical trials, one study was a phase II clinical trial, and one study was a phase I clinical trial. Two studies were about pegcetacoplan, one was about danicopan, and one was about iptacopan. Conclusion Based upon the findings of our systematic review, we recommend an individualized treatment plan based on the mechanism of eculizumab refractoriness and the mechanism of PNH breakthrough. This recommendation is subject to the available resources and clinical expertise available at different hospitals. More studies using study designs such as randomized controlled trials comparing multiple drugs should be performed to accurately assess the different medications and aid in designing guidelines of the management of eculizumab refractory PNH. Level of evidence Level I.
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Affiliation(s)
- Saad Syed
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Reda Khan
- Crescent Cardiology Associates, Frisco, TX, USA
| | | | | | - Danish Safi
- West Virginia University Cancer Institute, Morgantown, WV, USA
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48
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Desai JV, Kumar D, Freiwald T, Chauss D, Johnson MD, Abers MS, Steinbrink JM, Perfect JR, Alexander B, Matzaraki V, Snarr BD, Zarakas MA, Oikonomou V, Silva LM, Shivarathri R, Beltran E, Demontel LN, Wang L, Lim JK, Launder D, Conti HR, Swamydas M, McClain MT, Moutsopoulos NM, Kazemian M, Netea MG, Kumar V, Köhl J, Kemper C, Afzali B, Lionakis MS. C5a-licensed phagocytes drive sterilizing immunity during systemic fungal infection. Cell 2023; 186:2802-2822.e22. [PMID: 37220746 PMCID: PMC10330337 DOI: 10.1016/j.cell.2023.04.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 03/10/2023] [Accepted: 04/21/2023] [Indexed: 05/25/2023]
Abstract
Systemic candidiasis is a common, high-mortality, nosocomial fungal infection. Unexpectedly, it has emerged as a complication of anti-complement C5-targeted monoclonal antibody treatment, indicating a critical niche for C5 in antifungal immunity. We identified transcription of complement system genes as the top biological pathway induced in candidemic patients and as predictive of candidemia. Mechanistically, C5a-C5aR1 promoted fungal clearance and host survival in a mouse model of systemic candidiasis by stimulating phagocyte effector function and ERK- and AKT-dependent survival in infected tissues. C5ar1 ablation rewired macrophage metabolism downstream of mTOR, promoting their apoptosis and enhancing mortality through kidney injury. Besides hepatocyte-derived C5, local C5 produced intrinsically by phagocytes provided a key substrate for antifungal protection. Lower serum C5a concentrations or a C5 polymorphism that decreases leukocyte C5 expression correlated independently with poor patient outcomes. Thus, local, phagocyte-derived C5 production licenses phagocyte antimicrobial function and confers innate protection during systemic fungal infection.
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Affiliation(s)
- Jigar V Desai
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA
| | - Dhaneshwar Kumar
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA; Departments of Biochemistry and Computer Science, Purdue University, West Lafayette, IN, USA
| | - Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Daniel Chauss
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | | | - Michael S Abers
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA
| | - Julie M Steinbrink
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - John R Perfect
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Barbara Alexander
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Vasiliki Matzaraki
- Department of Genetics, University of Groningen, Groningen, the Netherlands
| | - Brendan D Snarr
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA
| | - Marissa A Zarakas
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA
| | - Vasileios Oikonomou
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA
| | - Lakmali M Silva
- Oral Immunity and Infection Section, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - Raju Shivarathri
- Center for Discovery & Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Emily Beltran
- Complement and Inflammation Research Section, National Heart Lung and Blood Institute, NIH, Bethesda, MD, USA
| | - Luciana Negro Demontel
- Complement and Inflammation Research Section, National Heart Lung and Blood Institute, NIH, Bethesda, MD, USA
| | - Luopin Wang
- Departments of Biochemistry and Computer Science, Purdue University, West Lafayette, IN, USA
| | - Jean K Lim
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dylan Launder
- Department of Biological Sciences, University of Toledo, Toledo, OH, USA
| | - Heather R Conti
- Department of Biological Sciences, University of Toledo, Toledo, OH, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA
| | - Micah T McClain
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, NC, USA
| | - Niki M Moutsopoulos
- Oral Immunity and Infection Section, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA
| | - Majid Kazemian
- Departments of Biochemistry and Computer Science, Purdue University, West Lafayette, IN, USA
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University, Nijmegen, the Netherlands
| | - Vinod Kumar
- Department of Genetics, University of Groningen, Groningen, the Netherlands; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University, Nijmegen, the Netherlands
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Claudia Kemper
- Complement and Inflammation Research Section, National Heart Lung and Blood Institute, NIH, Bethesda, MD, USA
| | - Behdad Afzali
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases, NIH, Bethesda, MD, USA.
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Tajima T, Hata K, Kusakabe J, Miyauchi H, Badshah JS, Kageyama S, Zhao X, Kim SK, Tsuruyama T, Kirchner VA, Watanabe T, Uemoto S, Hatano E. Anti-complement 5 antibody ameliorates antibody-mediated rejection after liver transplantation in rats. Front Immunol 2023; 14:1186653. [PMID: 37398677 PMCID: PMC10313232 DOI: 10.3389/fimmu.2023.1186653] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023] Open
Abstract
Antibody-mediated rejection (AMR) remains a refractory rejection after donor-specific antibody (DSA)-positive or blood-type incompatible liver transplantation (LT), even in the era of pre-transplant rituximab desensitization. This is due to the lack of not only effective post-transplant treatments but also robust animal models to develop/validate new interventions. Orthotopic LT from male Dark Agouti (DA) to male Lewis (LEW) rats was used to develop a rat LT-AMR model. LEW were pre-sensitized by a preceding skin transplantation from DA 4-6 weeks before LT (Group-PS), while sham procedure was performed in non-sensitized controls (Group-NS). Tacrolimus was daily administered until post-transplant day (PTD)-7 or sacrifice to suppress cellular rejections. Using this model, we validated the efficacy of anti-C5 antibody (Anti-C5) for LT-AMR. Group-PS+Anti-C5 received Anti-C5 intravenously on PTD-0 and -3. Group-PS showed increased anti-donor (DA) antibody-titers (P <0.001) and more C4d deposition in transplanted livers than in Group-NS (P <0.001). Alanine aminotransferase (ALT), alkaline phosphatase (ALP), total bile acid (TBA), and total bilirubin (T-Bil) were all significantly higher in Group-PS than in Group-NS (all P <0.01). Thrombocytopenia (P <0.01), coagulopathies (PT-INR, P =0.04), and histopathological deterioration (C4d+h-score, P <0.001) were also confirmed in Group-PS. Anti-C5 administration significantly lowered anti-DA IgG (P <0.05), resulting in decreased ALP, TBA, and T-Bil on PTD-7 than in Group-PS (all P <0.01). Histopathological improvement was also confirmed on PTD-1, -3, and -7 (all P <0.001). Of the 9,543 genes analyzed by RNA sequencing, 575 genes were upregulated in LT-AMR (Group-PS vs. Group-NS). Of these, 6 were directly associated with the complement cascades. In particular, Ptx3, Tfpi2, and C1qtnf6 were specific to the classical pathway. Volcano plot analysis identified 22 genes that were downregulated by Anti-C5 treatment (Group-PS+Anti-C5 vs. Group-PS). Of these, Anti-C5 significantly down-regulated Nfkb2, Ripk2, Birc3, and Map3k1, the key genes that were amplified in LT-AMR. Notably, just two doses of Anti-C5 only on PTD-0 and -3 significantly improved biliary injury and liver fibrosis up to PTD-100, leading to better long-term animal survival (P =0.02). We newly developed a rat model of LT-AMR that meets all the Banff diagnostic criteria and demonstrated the efficacy of Anti-C5 antibody for LT-AMR.
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Affiliation(s)
- Tetsuya Tajima
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jiro Kusakabe
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hidetaka Miyauchi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Joshua Sam Badshah
- Department of Surgery , Division of Abdominal Transplantation, Stanford University School of Medicine, Stanford, CA, United States
| | - Shoichi Kageyama
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Xiangdong Zhao
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sung-Kwon Kim
- Alexion Pharmaceuticals Inc., New Haven, CT, United States
| | - Tatsuaki Tsuruyama
- Department of Drug Discovery Medicine, Pathology Division, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Varvara A. Kirchner
- Department of Surgery , Division of Abdominal Transplantation, Stanford University School of Medicine, Stanford, CA, United States
| | - Takeshi Watanabe
- Division of Immunology, Institute for Frontier Life and Medical Sciences, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Shiga University of Medical Science, Otsu, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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50
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Röth A, Ichikawa S, Ito Y, Kim JS, Nagy Z, Obara N, Panse J, Schrezenmeier H, Sica S, Soret J, Usuki K, Yoon SS, Balachandran N, Buri M, Lundberg P, Patel H, Shinomiya K, Sostelly A, Nishimura JI. Crovalimab treatment in patients with paroxysmal nocturnal haemoglobinuria: Long-term results from the phase I/II COMPOSER trial. Eur J Haematol 2023. [PMID: 37321625 DOI: 10.1111/ejh.14011] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES This study reports long-term outcomes from the open-label extension (OLE) period of the Phase I/II COMPOSER trial (NCT03157635) that evaluated crovalimab in patients with paroxysmal nocturnal haemoglobinuria, who were treatment-naive or switched from eculizumab at enrolment. METHODS COMPOSER consists of four sequential parts followed by the OLE. The primary OLE objective was to assess long-term crovalimab safety, with a secondary objective to assess crovalimab pharmacokinetics and pharmacodynamics. Exploratory efficacy endpoints included change in lactate dehydrogenase (LDH), transfusion avoidance, haemoglobin stabilisation and breakthrough haemolysis (BTH). RESULTS A total 43 of 44 patients entered the OLE after completing the primary treatment period. Overall, 14 of 44 (32%) experienced treatment-related adverse events. Steady state exposure levels of crovalimab and terminal complement inhibition were maintained over the OLE. During the OLE, mean normalised LDH was generally maintained at ≤1.5× upper limit of normal, transfusion avoidance was achieved in 83%-92% of patients and haemoglobin stabilisation was reached in 79%-88% of patients across each 24-week interval. Five BTH events occurred with none leading to withdrawal. CONCLUSIONS Over a 3-year median treatment duration, crovalimab was well tolerated and sustained C5 inhibition was achieved. Intravascular haemolysis control, haemoglobin stabilisation and transfusion avoidance were maintained, signifying long-term crovalimab efficacy.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Satoshi Ichikawa
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Yoshikazu Ito
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Zsolt Nagy
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Naoshi Obara
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Juliette Soret
- Centre d'Investigations Cliniques, Hôpital Saint-Louis, Paris, France
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | | | - Muriel Buri
- Biostatistics Oncology Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pontus Lundberg
- Oncology Biomarker Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Himika Patel
- Product Development Hematology, Genentech, Inc., South San Francisco, California, USA
| | - Kenji Shinomiya
- Primary Clinical Science and Strategy, Chugai Pharmaceutical Co., Tokyo, Japan
| | | | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
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