Hemolytic uremic syndrome

Doyeun Oh
Department of Internal Medicine
CHA University School of Medicine
 Disclosures for
Doyeun Oh

Research Support/P.I. No relevant conflicts of interest to declare

Employee No relevant conflicts of interest to declare

Consultant No relevant conflicts of interest to declare

Major Stockholder No relevant conflicts of interest to declare

Speakers Bureau No relevant conflicts of interest to declare

Honoraria No relevant conflicts of interest to declare

Scientific Advisory Board No relevant conflicts of interest to declare

Contents

 Pathogenesis of STEC-HUS and aHUS

 Differential diagnosis of TMA

 Guidelines to manage STEC-HUS and aHUS

01
Initial recognition of HUS 

 Microangiopathic hemolytic anemia (MAHA)

Hb <10 g/dL

shistocytes, increased reticulocyte counts, negative Coombs test

elevated LDH

low haptoglobin

 Thrombocytopenia
(< 150K/mm3)

 Acute kidney injury

(Cr ≥ 1.5 x normal)

02
A B

C D
Needs for correct diagnosis and treatment of HUS

 Clinical features are similar or overlapped among

thrombotic microangiopathies.

 Pathogenesis and clinical outcome with plasma

therapy is different.

 Complement inhibitor can dramatically change the

outcome of aHUS.

04
Definition and terminology
 Thrombotic microangiopathy (TMA): A pathology that results in
thrombosis in capillaries and arterioles, due to an endothelial
injury characterized by hemolytic anemia and thrombocytopenia
 Hemolytic uremic syndrome (HUS) : a disease characterized by
hemolytic anemia, acute kidney failure, and a low platelet count,
without severe ADAMTS13 deficiency
 Shiga toxin producing E coli- associated hemolytic uremic
syndrome (STEC-HUS): HUS caused by infectious agents which
produce Shiga toxin
 Atypical HUS (aHUS): A heterogeneous group of diseases that
have a TMA associated with some degree of acute kidney injury
(AKI), not associated with other forms of TMA
 Complement –mediated TMA Noris M and Remuzzi G. N Engl J Med 2009;361:1676-87
George JN and Nester CM. N Engl J Med 2014; 371:654-666
05
Loirat C, et al. Pediatr Nephrol 2016;31:15-39
Classification of HUS

 STEC-HUS
 S. pneumoniae-HUS, Influenza A / H1N1-HUS
 Alternative complement pathway dysregulation (Genetic,
Acquired)-HUS
 Cobalamin C defect-HUS
 DGKE mutation-HUS
 Unexplained (idiopathic) HUS
 HUS with coexisting disease/condition (secondary HUS)

Loirat C, et al. Pediatr Nephrol 2016;31:15-39

 aHUS
TMA USS

STEC‐HUS TTP

Secondary TMA
Transplantation
Infection
Pregnancy, Eclampsia, preeclampsia, HELLP
Drugs 
Autoimmune disease (SLE, scleroderma)
Malignancy and chemotherapy
Malignant hypertension
Glomerulopathy

TTP : thrombotic thrombocytopenic purpura 06

USS : Upshaw-Schulman syndrome
Pathogenesis of HUS

STEC- Complement
infection dysregulation

Hemolysis Endothelial damage Platelet

activation
Coagulation activation

Microcirculatory platelet-rich
thrombus formation

Acute kidney injury

07
Pathogenesis of STEC‐HUS
 90% of HUS
 3-7% of E. coli or enterotoxin producing organism (S. dysenteriae) infection
 Shiga toxin or Shiga-like toxin (Stx); two types, Stx-1 and Stx-2
 O157:H7, O26:H11/H-, O104:H4, O157:H-, O145:28/H-, O103:H2/H-,
O111:H8/H, O121, O113. (O, lipopolysaccharide Ag; H, flagellar Ag)
 Shiga-toxin binds to the globotriaosylceramide (Gb3) receptor in the cell
membrane, internalizes and induces cell death by inhibiting protein
synthesis. Gb3 receptors are highly expressed in kidney, brain and gut
than other tissues. Children has more Gb3 than adults.
 Shiga-toxin upregulates the expression of E-selectin, ICAM-1, VCAM-1
facilitates leukocyte activation and endothelial injury.
 Shiga-toxin upregulates the expression of P-selectin and induce the
formation of ULVWF and platelet activation and thrombosis.

Salvadori M, et al. World J Nephrol 2013;2:56-76

Jokiranta TS. Blood 2017;129:2847-56
08
Stx-Gb3
binding
Gb3

Endocytosis
Inhibition of
tRNA-ribosome
Golgi
binding

Cytosol

Retrograde traffic

ER

Valerio E, et al. Toxins 2010;2:2359-410

Shiga toxin producing E. Coli infection
Stx
Stx

Stx Stx

Gb3

Stx- induced renal damage

Endothelial damage
Infectious enterocolitis TF-induced fibrin formation
Complement activation

bloody diarrhea renal failure

Stx : Shiga toxin

Gb3 : globotriaosylceramide
09
Pathogenesis of atypical HUS

 5-10% of HUS

 50-60% has genetic abnormalities.

 Genetic mutations (autosomal dominant or recessive) or

autoantibodies against regulatory proteins in the complement
system

 Dysregulation of alternative complement pathway causing

uncontrolled excessive activation of complement system is
the major cause of aHUS. It results in endothelial injury,
leukocyte activation, platelet activation followed by thrombosis,
thrombocytopenia, hemolysis, and renal failure.
Noris M and Remuzzi G. N Engl J Med 2009;361:1676-87
Jokiranta TS. Blood 2017;129:2847-56
11
Classical and lectin Alternative pathway
pathways (C3 tick-over)

C3 convertase C3 convertase
(C4b2a) (C3bBb)

C3

Factor H
C3b Factor I
(C5-convertase)

C5
(activation)

MAC: Membrane attack complex

MCP: Membrane cofactor protein
THBD: thormbomodulin
MAC C5-9
(formation)
MCP
THBD

12
Complement gene  abnormalities in patients with aHUS

Noris M, et al. Clin J Am Soc Nephrol 2010;5: 1844–1859

13
Factor H autoantibody
N-terminal
C-terminal
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
6 17 18 19 20

 3-10% of cases in children

 Functional deficiency of factor H
 Related with homozygous deletion of CFHR
Noris M and Remuzzi G. N Engl J Med  2009;361:1676‐87
Jozsi M, et al. Blood. 2008;111:1512‐1514 14
Sinha A, et al. Kidney Int. 2014;85:1151‐60
Genetic abnormalities in patients with aHUS
Gene Frequency in aHUS, %
CFH 24-28
CFHR1/3 homozygous deletion 3-10
MCP 5-9
CFI 4-8
CFB 0-4
C3 2-8
THBD 0-5
Combined  mutations 3‐5
DGKE 0‐3
Plasminogen NA
Factor XII NA
Noris M and Remuzzi G. Semin Nephrol. 2017 Sep;37(5):447-463
Jokiranta TS. Blood 2017;129:2847-56
15
Summary

 The pathogenesis of STEC-HUS is infection.

 The major pathogenesis of aHUS is dysregulation of
complement system caused by genetic abnormalities or
autoantibody development.

16
Diagnosis of TTP, STEC‐HUS and aHUS

TMA
ADAMTS13<10%
TTP

TMA
STEC (+)
STEC-HUS

TMA
Secondary TMA
Secondary TMA

aHUS
17
Initial recognition of aHUS 

MAHA
Thrombocytopenia
Acute kidney injury
Hypertension
Neurologic disturbances
Respiratory disturbances
GI disturbances
Existence of triggers
Poor response to PEX

18
Multiple hits are necessary for aHUS to manifest

Multiple hits are necessary for aHUS to manifest, including a trigger, mutations, and
at-risk haplotypes in complement genes. Incomplete penetrance of mutations is a
feature in the pathogenesis of aHUS. Mutations are predisposing rather than directly
causal in the development of aHUS.

Kavanagh D. and Goodship THJ, Hematology Am Soc

Hematol Educ Program. 2011;2011:15-20
19
Triggers of aHUS 

 Infection
 Drugs
 Vaccination
 Autoimmune disease
 Pregnancy
 Malignancy or cancer chemotherapy
 Transplantation

Noris M and Remuzzi G. N Engl J Med 2009;361:1676-87

Kavanach D, et al. Seminars Nephrol 2013;33:508-30
20
aHUS patients’ characteristics  at onset

Fremeaux-Bacchi, et al. Clin J Am Soc Nephrol 2013;8: 554–562

21
Diagnosis of aHUS 

The diagnosis of aHUS is made by

excluding other types of TMA by

(1) ADAMTS13 activity >10%

(2) no evidence of STEC-HUS

(3) no secondary TMA (coexisting disease)

22
Secondary TMA (coexisting diseases)

 Transplantation
 Infection
 Pregnancy, Eclampsia, preeclampsia, HELLP
 Drugs
 Autoimmune disease (SLE, scleroderma)
 Malignancy and chemotherapy
 Malignant hypertension
 Glomerulopathy
 These patients may have also aHUS-risk genetic variants.
Kabanach D, et al. Semin Nephrol 2013;33:508-30
Campistol JM, et al. Nefrologia 2013;33:27-45
Cataland SR, et al. Blood 2014;123:2478-84
Scully M, Goodship T. Br J Haematol 2014;164:759-66 23
Detection of complement dysregulation:
Serologic diagnosis 

ELISA, Radial immunodiffusion or Western blot assay

(C3, C4, CFH, antibody against CFH, CFI, CFB),
Flow cytometry (MCP)
Anti-CHF antibody test is the only assay urgently required
during the acute phase because a positive result raises
additional treatment option.
Normal activity cannot exclude aHUS.
Overlapping results in both TTP, STEC-HUS and aHUS

Gavriilaki E, et al. Blood 2015;125:3637-46

Kavanach D, et al. Clin Am Soc Nephrol 2007; 2:591-6
Mannucci Cataland Johnson S, et al. Pediatr Nephrol 2014;29:1967-78
Loirat C, et al. Pediatr Nephrol 2016;31:15-39 24
Detection of complement dysregulation:
Genetic diagnosis

RFLP and sequencing, next generation sequencing,

copy number variation and multiplex ligation-dependent
probe amplification.
It is helpful for the correct diagnosis and predict the
outcome of aHUS, especially for the assessment of the
optimal duration of treatment and the risk of post-renal
transplantation recurrence.
DNA testing is not recommended as an upfront
diagnostic test not only because it is time consuming
but also because several patients have no identifiable
mutation.
Gavriilaki E, et al. Blood 2015;125:3637-46
Kavanach D, et al. Clin Am Soc Nephrol 2007; 2:591-6
Mannucci Cataland Johnson S, et al. Pediatr Nephrol 2014;29:1967-78
25
Investigational assay of atypical hemolytic uremic syndrome

 Modified HAM test

 Quantitative hemolytic assay coupled with RFLP

 In vitro activity assay

 Skin biopsy

Gavriilaki E, et al. Blood 2015;125:3637-46

Yoshida Y, et al. PLoS One 2015;10:e124655
Heinen S, et al. Mol Immunol 2013;54:84-8 26
Magro CM, et al. Am J Dermatopathol 2015;37:349-56
Summary

 Clinical suspicion is the first step to diagnosis aHUS.

 TTP can be excluded by ADAMTS13 activity >10%.
 STEC-HUS can be excluded by the demonstration of Shiga toxin in
stool.
 The diagnosis of aHUS is made by excluding TTP, STEC-HUS and
secondary TMA (coexisting disease).
 Screening for complementary abnormalities by serology is useful
for the diagnosis of aHUS but their concentrations are not
consistently abnormal.
 Genetic screening for complementary abnormalities is most
informative but not mandatory for the diagnosis of aHUS.
27
Needs for guidelines on aHUS

 aHUS is often misdiagnosed as TTP or STEC-HUS, all of which show

common clinical features. However, the pathogenesis and response rate to
plasma exchange differ between syndromes . Eculizumab is a life saving
drug in many cases of aHUS. Delayed treatment of aHUS can cause death
or end-stage renal disease. Therefore, the early differential diagnosis of
aHUS from other forms of TMA is very important for its appropriate
management.

 Guidelines facilitate the standardized management of aHUS and

accelerate the detection and clinical trials of patients with aHUS.

 European pediatric guidelines , British guidelines, Japanese guidelines

28
 Management of HUS and aHUS

TMA Medical Emergency, Multidisciplinary approach

TTP
PEX steroid
ADAMTS13<10%

STEC-HUS
STEC (+)
Supportive care PEX

Secondary TMA
Treatment for secondary TMA

aHUS Eculizumab
PEX KT/LT
PEX : plasma exchange
KT : kidney transplantation 29
LT : liver transplantation
Management of STEC‐HUS

 Supportive care is the mainstay of therapy.

Fluid and electrolyte control, blood pressure control, red blood cell transfusion, hemodialysis..

 Antibiotics: controversial effects

Quinolone and trimehoprim induced Stx production, but azithromycin was effective..

 Plasma exchange (PEX): controversial effects

Because Stx is detectable in the circulation only very early in illness and because Stx- induced

endothelial injury are preceded the development of HUS, the pathogenetic rationale of PEX in

STEC-HUS is lacking.

 Eculizumab: controversial effects

Page AV, Liles WC. Med Clin N Am 2013;97:681-95 30

Prognosis

 Excellent outcome

 Full recovery in > 80%

 End-stage renal disease: less than 5%

 Death: less than 5%

 Complication and mortality is higher in old age adults.

Page AV, Liles WC. Med Clin N Am 2013;97:681-95 31

Recommendations for the treatment of STEC‐ HUS

Supportive care is the mainstay of therapy.

Fluid and electrolyte control, blood pressure control, red blood cell
transfusion, and hemodialysis are necessary..

Antibiotics should be avoided in children with STEC-HUS..

The benefit of therapeutic plasma exchange is controversial and it should be

avoided when STEC-HUS is confirmed.

Eculizumab is not recommended in STEC-HUS.

No clinical benefit has been found with therapeutic anticoagulation,

administration of fresh frozen plasma or glucocorticosteroids. and their use in
STEC-HUS is not recommended.

Page AV, Liles WC. Med Clin N Am 2013;97:681-95

Igarashi T, et al. Clin Exp Nephrol 2014;18:525-57 32
Management of aHUS

 A half of patients with aHUS treated with supportive care

and plasma therapy had died or reached ESRD in 3 years.

 Eculizumab is the treatment of choice as first line

treatment.

Scully M, Goodship T. Br J Haematol 2014;164:759-66

Fremeaux-Bacchi V, et al. Clin J Am Soc Nephrol 2013;8:54-62 33
Plasma therapy on aHUS

 Plasma exchange (PEX) : 1.5 plasma volume

 Plasma infusion: 10-20ml/Kg
 Replacement of complement and elimination of inhibitors.
 Evidence from retrospective case studies
 Not effective in patients with MCP mutation because MCP is not
circulating but a anchored protein in cell membrane.
 Complete hematologic and renal recovery rates are lower than 50%.
Mortality and progression to ESRD are high.
 Complications: anaphylaxis, hypotension, hypervolemia, central
venous access obstruction
 Empirically recommended only in the case with good response or
when eculizumab is not available.

Campistol JM, et al. Nefrologia 2013;33:27-45

Loirat C, et al. Semin Thromb Hemost 2010;36:673-81
Noris M, et al. Clin J Am Soc Nephrol. 2010;5(10):1844-1859
Caprioli J, et al. Blood. 2006;108(4):1267-1272 34
Kidney transplantation in aHUS

 High rate of recurrence (up to 50%)

 Living donor kidney transplantation is contraindicated due
to high rate of recurrence.
 Eculizumab is effective to treat and prevent the recurrence
of aHUS in kidney transplantation.

Franchini M. Clin Chem Lab Med 2015;53:1679-88 35

Liver transplantation in aHUS

 Complement factor H, B, C3 and I are synthesized in the

liver.
 Results of surgery are improving.
 Isolated or combined kidney and liver transplantation may
be an option for the treatment of patients having aHUS
without access to eculizumab treatment.

Nester CM, et al. Mol Immunol 2015;67:31-42

Franchini M. Clin Chem Lab Med 2015;53:1679-88
36
Eculizumab (Soliris®)

 A humanized monoclonal antibody directed against the

complement protein C5 that inhibits terminal complement
activation.

 Successfully used to treat patients with aHUS.

 Controversial effects on typical HUS

Nurnberger J, et al. N Engl J Med 2009 29;360:542-4.

Zuber J, et al. Am J Transplant 2012;12:3337-542.
Lapeyraque AL, et al. N Engl J Med 2011;364:2561-3
Menne J, et al. BMJ 2012;345:e4565
Legengdre CM et al. N Engl J Med 2013;368:2169-81 37
Lectin Pathway Classical Pathway Alternative Pathway

C3
Natural Inhibitors:
Factor H, I, MCP,
Eculizumab CD55

C5

Tissue injury, TMA (?)

38
ESRD and Death Patient (%)

More than 50%

Less than 20%

PEX/PI Eculizumab
Caprioli J, et al. Blood. 2006;108(4):1267-1272
Noris M, et al. Clin J Am Soc Nephrol. 2010;5(10):1844-1859
Legengdre CM et al. N Engl J Med 2013;368:2169-81
Fakhouri F, et al. Am J Kidney Dis. 2016 Jul;68(1):84-93
Greenbaum LA, et al. Kidney International (2016) 89, 701–711 39
Eculizumab is effective in aHUS

Trial 1 Trial 2
(n=17) (n= 20)
Complete TMA response 11 (65%) 5(25%)
TMA event free 15 (88%) 16 (80%)
Platelet normalization 14 (82%) NA
LDH normalization 13(82%) 19 (95%)
Hb improvement by ≥ 2g/dL 11 (65%) 9 (45%)
eGFR improvement by ≥ 15ml/min/1.73m2 8 (47%) 1 (5%)

Legengdre CM et al. N Engl J Med 2013;368:2169-81 40

 Eculizumab is a safe and effective treatment in patients 
with aHUS: outcomes by 26 weeks of treatment 

Pediatric  Adult aHUS 
aHUS (n= 41)
(n=22)
Complete TMA response 14 (64%)  30 (73%) 
TMA event free 21 (95%)  37 (90%)
Platelet normalization 21 (95%)  40 (98%)
LDH normalization 18 (82%) 37 (90%)
Hb improvement by ≥ 2g/dL 15 (68%) 25 (61%)
eGFR improvement by ≥ 15ml/min/1.73m2 19 (86%) 22 (54%)

Fakhouri F, et al. Am J Kidney Dis. 2016 Jul;68(1):84-93

Greenbaum LA, et al. Kidney International (2016) 89, 701–711;
41
 Prophylaxis of infections before eculizumab

 Complement system is responsible for immunity against

infections. Immunity against N. meningitis depends on the
lytic terminal complement complex.
 Eculizumab use is susceptible to meningitis and hemophilus
infection.
 Vaccination 2 weeks prior to ecculizumab is required.
 Antibiotic treatment with vaccination can be started in the
case that treatment with eculizumab cannot be delayed.
 Neither vaccines nor antibiotic prophylaxis guarantee full
protection against infections. Patient/family/caregiver
education on signs of infection is necessary.

Loirat C, et al. Pediatr Nephrol 2016;31:15-39 42

Management of aHUS with anti‐CFH antibody: 
immunosuppressive treatment

 Indicated in anti-CFH autoantibody

 Combined with PEX
 Steroid, cyclophosphamide, RTX, MMF, azathioprine

Franchini M. Clin Chem Lab Med 2015;53:1679-88

Sinha A, et al. Kidney Int. 2014;85:1151-60 43
Recommendations for the treatment of  aHUS 

Eculizumab should be considered as a first-line treatment for patients with

symptomatic aHUS

All patients who are clinically suspected of having aHUS should be offered a
trial of PEX and/or plasma infusions if eculizumab is not available

Live-related renal transplantation alone should be avoided in cases of aHUS

All patients receiving eculizumab should receive a meningococcal vaccination

or antibioprophylaxis prior to receiving the first dose of eculizumab

Loirat C, et al. Pediatr Nephrol 2016;31:15-39

Kato H, et al. Clin Exp Nephrol 2016;20:536-43
Cheong HI, et al. J Kor Med Sci 2016;31:1516-28
Taylor CM, et al. Br J Haematol. 2010;148:37-47
Campistol JM, et al. Nefrologia. 2015;35:421-47 44
Summary

 HUS is highly recommended to care in the hospital by

multidisciplinary approach.

 Supportive care including plasma exchange is the main treatment of

HUS and should be initiated until the differential diagnosis is
clarified.

 The benefit of therapeutic plasma exchange is controversial and it

should be avoided when STEC-HUS is confirmed.

 Eculizumab is recommended as a first-line treatment for patients

with symptomatic aHUS.

45
Conclusions
 HUS is a heterogeneous syndrome characterized by microangiopathic
hemolytic anemia, thrombocytopenia and acute kidney injury.
 The pathogenesis of STEC-HUS is infection and the major pathogenesis of
aHUS is dysregulation of complement system.
 Diagnosis of STEC-HUS can be made by the demonstration of Shiga toxin
in the stool.
 Diagnosis of aHUS can be made by excluding TTP, STEC-HUS and
secondary TMA.
 HUS is highly recommended to care in the hospital by multidisciplinary
approach.
 Supportive care including plasma exchange and hemodialysis is the main
treatment of HUS and should be initiated until the differential diagnosis is
clarified.
 The benefit of therapeutic plasma exchange is controversial and it should
be avoided when STEC-HUS is confirmed.
 Eculizumab is recommended as a first-line treatment for patients with
symptomatic aHUS.
46
ขอบคุณสําหรั บการฟั ง

2020 APSTH 
Gwangju, KOREA  
September 3 ‐5, 2020