Insights from the use in clinical practice of eculizumab in adult patients with atypical hemolytic uremic syndrome affecting the native kidneys: an analysis of 19 cases.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a devastating form of renal thrombotic microangiopathy. Despite plasma exchange, the standard treatment of aHUS for decades, the renal prognosis for patients with aHUS has remained poor. We assessed the off-trial use of eculizumab in adult patients with aHUS affecting the native kidneys. STUDY DESIGN: A retrospective study was conducted. aHUS was defined as the presence of 3 or more of the following: acute kidney injury (serum creatinine >1.4 mg/dL [120 µmol/L]), mechanical hemolytic anemia, thrombocytopenia, and the presence of thrombotic microangiopathy features in a kidney biopsy specimen. Patients who had received 4 or more weekly 900-mg infusions of eculizumab were included. SETTING & PARTICIPANTS: 19 patients were identified through a query sent to all French nephrology centers. OUTCOMES & MEASUREMENTS: Evolution of kidney function, hemolysis, and thrombocytopenia after the initiation of eculizumab therapy. RESULTS: All patients had acute kidney injury (serum creatinine range, 2.2-17.0 mg/dL) and 12 required hemodialysis. Thirteen patients carried a mutation in 1 complement gene and 1 had anti-factor H antibodies. For first-line therapy, 16 patients underwent plasma exchange and 3 patients received eculizumab. Median time between aHUS onset and eculizumab therapy initiation was 6 (range, 1-60) days and median time to platelet count normalization after eculizumab therapy initiation was 6 (range, 2-42) days. At the 3-month follow-up, 4 patients still required dialysis, 8 had non-dialysis-dependent chronic kidney disease, and 7 had normalized kidney function. At last follow-up (range, 4-22 months), 3 patients remained dialysis dependent, 7 had non-dialysis-dependent chronic kidney disease (estimated glomerular filtration rate, 17-55 mL/min/1.73 m(2)), and 9 had normal kidney function. Risks of reaching end-stage renal disease within 3 months and 1 year of aHUS onset were reduced by half in eculizumab-treated patients compared with recent historical controls. LIMITATIONS: Retrospective study and use of historical controls. CONCLUSIONS: Our data indicate that eculizumab improves kidney disease outcome in patients with aHUS.

[Antineutrophil cytoplasmic antibody associated vasculitis in a patient treated with adalimumab for a rheumatoid arthritis]. / Vascularite à anticorps anticytoplasme des polynucléaires neutrophiles chez une patiente traitée par adalimumab pour une polyarthrite rhumatoïde.

Tumor necrosis factor alpha (TNFalpha) plays a central role in the pathogenesis of inflammatory diseases, especially in rheumatoid arthritis, accounting for the increased use of antitumor necrosis factor alpha (anti-TNFalpha) in these disorders. However, these drugs are not devoid of side effects and an increasing number of auto-immune diseases are currently reported. We report an extracapillary and necrotizing glomerulonephritis associated with positive antineutrophil cytoplasmic antimyeloperoxydase antibodies in a 58-year-old woman with a long-standing rheumatoid arthritis treated with adalimumab since four years. Despite the instauration of corticotherapy, cyclophosphamide, plasma exchanges and dialysis, she did not recover her impaired renal function. The link between the vasculitis and adalimumab is not proven, but is highly probable. Vasculitis are more and more reported with anti-TNFalpha therapy but severe renal disease remains exceptional. Pathogenesis probably involves modified immune response with production of autoantibodies. Though anti-TNFalpha treatment is unquestionably indicated in rheumatoid arthritis, we should be aware about the possible link between this treatment and induced vasculitis. Moreover, the use of anti-TNFalpha treatment to manage vasculitis needs to be assessed.