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Gouin A, Ribes D, Colombat M, Chauveau D, Prevot G, Lairez O, Pugnet G, Fremeaux-Bacchi V, Huart A, Belliere J, Faguer S. Role of C5 inhibition in Idiopathic Inflammatory Myopathies and Scleroderma Renal Crisis-Induced Thrombotic Microangiopathies. Kidney Int Rep 2021; 6:1015-1021. [PMID: 33912751 PMCID: PMC8071645 DOI: 10.1016/j.ekir.2021.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/19/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Connective tissue diseases, including systemic sclerosis and idiopathic inflammatory myopathies (IIMs), are a very rare cause of thrombotic microangiopathies (TMAs). Whether dysregulation of the complement pathways underlies these secondary forms of TMA and may be targeted by complement blocking agents remains elusive. Methods Kidney pathology and outcomes of 18 critically ill patients with TMA related to inflammatory myopathy flare-up (IIM, n=7) or scleroderma renal crisis (SRC, n=11; biopsy n=9) are assessed. Results IIM-TMA is characterized by acute thrombotic lesions only, whereas SRC-TMA patients also harbored chronic vascular lesions and more interstitial fibrosis. C5b9 deposits, a marker of complement component 5 (C5) cleavage, were observed in the 2 subgroups at the junction of media and intima of arterioles, colocalizing with subendothelial edema. Thus, kidney biopsy distinguished between acute and chronic renal phenotypes that may help to individualize treatment. Treatment of IIM-TMA patients with combined full-code organ support, corticosteroids, B-cell depletion, and complement C5 blocking led to 1-year survival of 72%, compared with 19% in historical cohorts. Treatment of SRC-TMA was more heterogenous and relied on conversion enzyme inhibitor only or with eculizumab (n=6) and immunosuppressor (n=5). One-year survival of SRC-TMA patients was 52%, a result similar to historical cohorts. Eculizumab was followed by a rapid dramatic improvement of TMA in all the treated patients. Conclusion C5 blocking may reverse hematologic abnormalities in IIM- and SRC-TMA, and adding an early and aggressive immunosuppressive regimen may improve the survival of IIM-TMA. Underlying chronic vascular and interstitial lesions mitigate renal response in SRC-TMA.
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Affiliation(s)
- Anna Gouin
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - David Ribes
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Magali Colombat
- Service d'anatomopathologie, Institut Universitaire du Cancer de Toulouse - Oncopole, Centre Hospitalier Universitaire, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Gregoire Prevot
- Service de Pneumologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Olivier Lairez
- Fédération de Cardiologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Gregory Pugnet
- Service de Médecine Interne, Centre Hospitalier Universitaire, Toulouse, France
| | | | - Antoine Huart
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Julie Belliere
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
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