Hemolytic Uremic Syndrome

Dr. Seema Hashmi

Prof. Pediatric Nephrology
Sindh Institute of Urology & Transplanatation
PAKISTAN
 Outline
• Background/Epidemiology and other
things to know on “classical” diarrhea-
associated HUS
• The “funky” types of HUS
– Atypical, non-diarrhea associated, recurrent,
familial
• What you should know about atypical HUS
and what to do with that information
 Some Statistical Data
• Most common cause of acute kidney injury in
childhood
Incidence: 3-5/100,000 population in children age 1-18
• Gradual decline from early childhood to adolescence

• Significant morbidity and mortality in acute

phase
• Mortality: 3-5%, usually associated with severe extra-renal
disease

• Primary diagnosis for up to 4.5% of children on

chronic renal replacement therapy
Hemolytic Uremic Syndrome (HUS)
• Triad
– Microangiopathic hemolytic anemia

– Thrombocytopenia

– Acute kidney injury

• Thrombotic Microangiopathy (TMA)

• Hemolytic Uremic Syndrome
• Thrombotic Thrombocytopenic Purpura
 Hemolytic Anemia
Microangiopathic hemolytic anemia with erythrocyte
fragmentation
Coombs negative
Plasma LDH elevated
Haptoglobin decreased
Most sensitive marker to track resolution of intravascular hemolysis
 Severity does not correlate with clinical outcome
 Red cell production increased
 Thrombocytopenia
• Variable and transient
– May be missed
• Consumption of platelets
• Majority of platelets removed in
reticuloendothelial system
• Significant bleeding rare!
– Slightly pro-thrombotic state
– First to recover!
 Acute Kidney Injury
• Abrupt
• Oligoanuria
• Proteinuria
• Hypertension
– Severe and difficult to control in atypical forms
– Absent or mild in infection-associated form –
delayed to recovery period
Thrombotic Microangiopathy (TMA)
• Histopathological term
• Characterized by presence of
• Platelet-fibrin thrombi within the vascular lumen
• Injury to endothelial cells with separation from
underlying basement membrane
• Brain, lung, heart, GI, pancreas all may be involved
D+
Most Common Etiology Worldwide
• Enterohemorrhagic E. coli (EHEC)
O157:H7
• D+ HUS (typical)
• Produces Shiga toxin (Stx) 1 and/or 2
– Encoded on a phage

• Other E. coli strains also produce Stx

– Called Stx-producing E. coli (STEC)
– Over 400 seropathotypes
• Incidence 6/100,000 children under 5 years.
• 90% are secondary to infection with E.coli
O157:H7, O111:H8, O103:H2, O123, O26

All produce Shiga like toxin (Stx)

 Shiga like toxin
EC injury

Monocyte or mesangial cells

NOS IL 8
(or other cytokines)
IL 8, IL 6
(or other cytokines)
NO PMN
activation

O2 Fe2 H2O2 Proteas enzymes

ONOO HO HOCL

Amplification of endothelial injury

Microthrombi
Comprehensive textbook of Pediatr Nephrology
 The kidney is a particular target during EHEC infection in part
because the toxin receptors are expressed at higher density on
glomerular endothelial cells and toxin activities induce endothelial
expression of adhesion molecules that support interactions with
activated platelets and leukocytes which contribute significantly to
clot formation
 Acute mortality

Range from mildly affected(no anuria)-

severely affected(anuric)

Mild (zero mortality rate)

Severe (80%-30%-1-4%)

Pediatr Nephrol (2013) 28:2097-2105

 Prognostic factors for long-term sequelae

• Duration of anuria at the time of presentation

• Need for dialysis
• Severe injury on kidney biopsy
• Decrease effective renal plasma flow

Pediatr Nephrol 2013, 28:2097-2105

 Prognostic factors for long-term sequelae

• Duration of anuria at the time of presentation

• Need for dialysis
• Severe injury on kidney biopsy
• Decrease effective renal plasma flow

Criteria in acute phase that are not consistently associated

with poor outcome are HPT, CNS symptoms, GI symptoms,
severe anemia or thrombocytopenia.
Pediatr Nephrol 2013, 28:2097-2105
 Long –term sequelae
20-40%
• Proteinuria
• Micro albuminuria (20-40%)
• Hypertension (5-15%)
• CKD (19.4%)
• ESRD (3%)

Extra renal outcomes include colonic strictures, gall

bladder disease, DM, & CNS cognitive sequelae
 Therapy
• Nothing proven
• Intensive, supportive medical care
• Dialysis if:
• Anuria x 24 h
• Oliguria (urine output <0.5ml/kg/h) x 48-72 h
• pRBC Transfusion if:
• Hemoglobin <6 g/dl
• Ineffective treatments are:
– Antiplatelet drugs, fibrinolytic agents, IVIG, high-dose
steroids, plasmapheresis, and oral Stx-binding agents
 Careful Monitoring
• Electrolyte abnormalities
– Hyponatremia
– Hypocalcemia
• LDH, serum creatinine, Hgb, platelets
• Watch out for :
Seizures
Pancreatitis
Myocardial dysfunction
Adult respiratory distress syndrome
Sudden neurologic deterioration
 Prevention of HUS –
The Useful Approach
• Changes in feed provided to cattle
• Tighter regulation of meat processing plants
• Irradiation of food and beverages
• No antibiotics in children with bloody diarrhea
• Prompt hospitalization and administration of
isotonic parenteral fluids

• Prevent vascular injury in glomerular microcirculation

• Isolate sick individual from other family members
 HUS- Strep. Pneumonia
• Rare but unique form.
• Preceding infection is severe & invasive,
septicemia, meningitis and/or pneumonia
with empyema.
• Comparatively younger children had more
severe renal and hematological disease and
were more likely to require dialysis.

Comprehensive text book of Ped. Nephrol

 All blood products should be washed and
plasma infusion should be avoided to prevent
administration of additional anti T-antigen
antibodies.
 TTP
Deficiency of von Willebrand Protease (ADAMTS13)
= a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13

• Thrombocytopenia
• Microangiopathic hemolytic anemia
• Neurological symptoms
• Renal dysfunction
• Fever
ADAMTS13
 ADAMTS13 Deficiency
• Cause:
• Rare: loss-of-function mutation (Congenital TTP)
• Acquired inhibitor: IgG auto-antibody
– Associated with use of Clopidogrel and Ticlopidine

• Effect:
• Ultra-large vWF multimers
 ADAMTS13 Deficiency

• Enzyme activity of <5% is primary cause of

microvascular thrombosis
• Enzyme activity <30% in several disease and
physiological states

• Thrombi found at arteriolar-capillary junction – area of

high shear stress
• Affected organs:
• Brain, heart, spleen, kidney, pancreas, adrenals, lungs, and eyes
 Outcome of TTP
• Mortality:
• Historically: 95%
• Today: 20%
 Outcome of TTP
• Mortality:
• Historically: 95%
• Today: 20%

• What made the difference?

• Plasma therapy
 The Weird Ones
• HUS can be also caused by:
– Cobalamin deficiency
– Defect in methylmalonic aciduria and homocystinuria
gene (MMACHC)
– Quinine/Quinidine
– Found in tonic water and tablets that prevent muscle
cramps
– Autoantibodies to ?
– Really rare ones:
– Use of anti-VEGF monoclonal antibodies
– Disseminated adenocarcinoma
Atypical HUS
Classification of Atypical hemolytic uremic syndrome
Overview of Complement pathway

Three parts of Immune system

1. Classical
2. Lectin
3. Alternative
Overview of Complement pathway

Three parts of Immune system

1. Classical
2. Lectin
3.Alternative
 Genetic and immunologic
predisposition
• Complement regulator protein deficiencies.
• Point mutations of regulator proteins.
• Autoantibodies to regulator proteins.
- Factor H antibody
• Gain-of-function of genes in alternative
pathway
• 20% Familial, 80% Sporadic
So what goes wrong?
ATYPICAL HEMOLYTIC-UREMIC SYNDROME
COMPLEMENT DYSREGULATION
• factor H, factor I, or MCP deficiency accounts for 50% of atypical HUS

FACTOR H
• 150kD plasma glycoprotein synthesized in liver
• 20 homologous units of 61 residues (short consensus repeats – SCRs)

• N-terminal domains SCR1 – SCR4 bind C3b

• complement decay accelerating activity located here
• H = three heparin binding sites
• tertiary structure through to be bent backwards
• exposes C-terminal SCR20

• functions as co-factor for factor I-mediated degradation of C3b,Bb

http://www.biochem.ucl.ac.uk/~becky/FH/proteinInfo.php?protein=FH
ATYPICAL HEMOLYTIC-UREMIC SYNDROME
FACTOR H DEFICIENCY
• thought to account for 10-22% of atypical HUS cases
• reported in both familial and sporadic forms
• usually presents in infancy or early childhood, but may present in adulthood

• one study of 16 FH-deficient patients

• 6 with homozygous deficiency
• 4 had membranoproliferative glomerulonephritis
• 2 had atypical HUS
• 10 had heterozygous deficiency
• all developed atypical HUS
• homozygotes had low levels of FH, C3, FB and CH50
• heterozygotes had low to normal values

• act as a co factor for factor I-mediated inactivation of C3b, competes with

factor B for C3b binding, and accelerate C3 convertase decay.

Dragon-Durey, M-A, et al, 2004, J Am Soc Nephrol 15:787-795.

ATYPICAL HEMOLYTIC-UREMIC SYNDROME
FACTOR H DEFICIENCY

• 70 different FH mutations identified to date

• hypertension, rapid progression to ESRD and a very high chance of

recurrence after renal transplant.

http://www.biochem.ucl.ac.uk/~becky/FH//stats.php
ATYPICAL HEMOLYTIC-UREMIC SYNDROME
FACTOR H DEFICIENCY

• type I = absent or reduced protein level

• type II = normal protein level, abnormal function

http://www.biochem.ucl.ac.uk/~becky/FH//stats.php
Dominant negative effect
 Dominant negative effect

In heterozygous state normal and mutant form

of CFH are secreted and although this mutant
form is small in amount, it interacts with mutant
CFH and form oligomers.
ATYPICAL HEMOLYTIC-UREMIC SYNDROME

FACTOR I
• 88kD plasma serine protease synthesized in liver

• N-terminal heavy chain

• LDL-receptor domains x2
• CD5 domain
• FIMAC domain (factor I membrane attack complex)
• C-terminal catalytic domain

• functions to directly cleave C4b or C3b in presence of factor H and MCP

• HUS in early childhood, and progression to ESRD in 50% of cases.
• Recurrence in 45-80% of patients resulting in graft loss.

http://www.biochem.ucl.ac.uk/~becky/FH//proteinInfo.php?protein=FI
ATYPICAL HEMOLYTIC-UREMIC SYNDROME

FACTOR I DEFICIENCY
• reported only in sporadic forms of atypical HUS
• in one study, 2 out of 76 patients with atypical HUS had FI deficiency

• most reported cases involve hyterozygous mutations

• no increased susceptibility to infection

• homozygous FI deficiency associated with increased infection susceptibility

• encapsulated organisms (meningococcus, pneumococcus, hemophilus)
• acquired C3 deficiency due to uncontrolled consumption

• variable penetrance and expressivity

• C3 can be low to normal

Dragon-Durey, M-A, et al, 2005, Springer Semin Immun 27:359-374.

Kavanagh, D, et al, 2005, J Am Soc Nephrol 16:2150-2155.
ATYPICAL HEMOLYTIC-UREMIC SYNDROME

FACTOR I DEFICIENCY

• 15 different FI mutations identified to date

http://www.biochem.ucl.ac.uk/~becky/FH//stats.php
ATYPICAL HEMOLYTIC-UREMIC SYNDROME

MEMBRANE COFACTOR PROTEIN (MCP = CD46)

• ~65 kD transmembrane glycoprotein
• on leukocytes, platelets, endothelial & epithelial cells, fibroblasts, kidney

• extracellular domain
• four SCR domains
• alternative splice sites for O-glycosylation
• multiple isoforms exist
• transmembrane domain
• cytoplasmic C-terminal anchor

• functions as cofactor for FI for degradation of C3b and C4b.

• pathogen receptor for measles, adenovirus, HHV-6, Neisseria.

http://www.biochem.ucl.ac.uk/~becky/FH//proteinInfo.php?protein=MCP
ATYPICAL HEMOLYTIC-UREMIC SYNDROME

MCP DEFICIENCY

• 25 different MCP mutations identified to date

http://www.biochem.ucl.ac.uk/~becky/FH//stats.php
ATYPICAL HEMOLYTIC-UREMIC SYNDROME
COMPLEMENT DYSREGULATION
• pathogenesis of atypical HUS

• infection/inflammation increases rate of C3b formation

• activates complement cascade and C3a/C5a
• C3a/C5a attract leukocytes, producing TNF and IL-8
• cytokines cause endothelial damage and exposure of extracellular matrix
• ECM exposure amplifies deposition of C3b and complement activation
• lack of normal factor H, factor I, or MCP results in unchecked activation
• progressive tissue damage occurs
http://www.biochem.ucl.ac.uk/~becky/FH/hus.php
 Incomplete genetic penetrance
• Mutations in complement genes confers a
predisposition rather than cause of ahus.
• Penetrance among carriers of CFH, MCP and
CFI appears to be 40-50%.
• Risk polymorphisms carries additional risk.
• Environmental effect.
ATYPICAL HEMOLYTIC-UREMIC SYNDROME
COMPLEMENT DYSREGULATION
• FH, FI, and MCP deficiency have incomplete penetrance
• disease modifiers or other factors may have role

• environmental triggers
• infections
• preceded 70% of those with FH mutation
• 60% of those with FI mutation
• 100% of cases of HUS in MCP-mutants
• pregnancy
• trigger in 4% of FH-HUS
• 40% of FI-HUS

• multiple-hits
• one pedigree in which atypical HUS occurred only with inheritance of ALL:
• MCP P131S mutation
• MCP promoter polymorphism
• dinucleotide insertion into FI gene
• resulted in 50% expression level of each protein
Richards, A, 2007, Mol Immunol 44:111-122.
ATYPICAL HEMOLYTIC-UREMIC SYNDROME

COMPLEMENT DYSREGULATION

• outcomes of atypical HUS

• overall 50% of patients develop ESRD
• 25% mortality during acute illness

• end-stage renal disease

• 70% with FH-deficiency HUS develop ESRD or die
• >60% with FI-deficiency HUS develop ESRD
• 86% with MCP-deficiency HUS remain dialysis-free
• 70% had recurrence of HUS

Richards, A, 2007, Mol Immunol 44:111-122.

 From complement abnormality to
thrombotic microangiopathy
• Normally complement regulation remain
intact even when the regulators are partially
reduced.
• Infection, pregnancy or any inflammation
trigger and may lead to problem.
• Gain-of-function mutations in C3 or CFB lead
to C3-convertase hyperactivity.
 Clinical course and outcome

• 67% are affected during childhood.

• Anti-CFH antibody almost always presents
before the age of 16 years.
• Short term and long term outcomes vary
according to underlying mutation.
Recap
 Therapies
• Plasma Therapy
Infusion/Exchange

• Transplant
Kidney
Kidney-Liver

• Eculizumab
 Rational for Plasma Therapy

• Replace deficient factors

• Eliminate antibodies
• It worked for TTP
Plasma Volume Exchange

Plasma Volume Percent Removed

Exchange
0 100%
0.5 39.3%
1.0 63.2%
1.5 77.7%
2.0 86.5%
2.5 91.8%
3.0 95.0%
 Small vs. Large Volume Exchange

• 1.0 plasma volume exchange: minimizes

time required for each procedure but may
need more frequent procedures.
• 2.0 – 3.0 plasma volume exchange:
greater initial diminution of pathologic
substance but requiring considerably more
time to perform the procedure.
Rationale of Plasma Exchange

• The existence of a known pathogenic

substance in the plasma.
– IgG, IgM, phytanic acid, cytokines (?)
• The possibility of removing this substance
more rapidly than it can be renewed in
the body.
 Empiric Plasma
Diagnosis of HUS Exchange
Atypical presentation
Clinical
Exceptions
Plasma Exchange within 24 hrs
1.5 Volumes (60-75 ml/kg) per session
FFP or Octaplas®

Repeat Plasma Exhange Daily x 5

Then 5 sessions/week for 2 weeks
Then 3 sessions/week for 2 weeks

Withdrawal
Alternate Diagnosis
Assess Outcome at Day 33 Plasma Exchange Complication
Early remission
Ariceta et al. Ped Neph 2009
 Plasma Therapy
• Plasma exchange and infusion was standard of
care.
1. Hinged on expert opinion with retrospective studies.
2. Suggest decrease in mortality by 25-50%.
3. Studies riddled with flaws; aHUS often included with Typical
HUS and TTP.
 Plasma Therapy
• Plasma exchange and infusion was standard of care.
1. Hinged on expert opinion with retrospective studies.
2. Suggest decrease in mortality by 25-50%.
3. Studies riddled with flaws; ahus often included with typical HUS and TTP.

• Noris et al; retrospective study from international registry

Plasma treatment induced complete or partial remission of 63,
25, 57, 88 and 75% of episodes in patients of CFH, CFI, C3, THBD
mutations or anti CFH autoantibodies respectively.

40-70% of these patients developed ESRD or died

within first 3 Years
Clin J Am Soc Nephrol S.1844-1859, 2010
 273 patients
• Evaluate the prevalence of known genetic
complement abnormalities in both sporadic and
familial aHUS.
• Compare the prevalence and distribution of
mutation in sporadic and familial cases.
• Examine genotype-phenotype correlation, with
regard to response to plasma therapy, short and long
term outcomes .
• Outcome of kidney transplant.
 273 patients
• Evaluate the prevalence of known genetic
complement abnormalities in both sporadic and
familial aHUS.
• Compare the prevalence and distribution of
mutation in sporadic and familial cases.
• Examine genotype-phenotype correlation, with
regard to response to plasma therapy, short and long
term outcomes .
• Outcome of kidney transplant.
• Common side effects of eculizumab intravenous:
• Anemia Severe.
• Head Pain Severe.
• High Blood Pressure Severe.
• Acute Infection of the Nose, Throat or Sinus Less
Severe.
• Backache Less Severe.
• Cough Less Severe.
• Diarrhea Less Severe.
• Feel Like Throwing Up Less Severe.
 Eculizumab in aHUS
• Legendre et al, 2013, NEJM
• Two prospective phase 2 trials with patients with HUS.
1. Trial 1. Patients with progressive TMA had renal disease and
thrombocytopenia.
2. Trial 2. Patients with progressive TMA in 8 weeks pre treatment
observation period, had renal disease but no evidence of
thrombocytopenia.

• Received eculizumab for 26 weeks and during long term

extension.
• Received Meningococcal vaccine+/- prophylactic
antibiotics.
• Eculizumab was administered IV at a dose of
900mg per week for 4 weeks,
• Dose of 1200mg 1 week later,
• Maintenance dose of 1200mg every 2 weeks.

All patients received meningococcal vaccine at

least 14 days before the initiation of eculizumab.
Trial 1.

• 53% normal platelet count

by day 7.
86% by week 26.
• All people who finished 26
weeks had normalization
of platelet count.
Trial 1

• Dialysis was discontinued

In 4 out of 5 patients.

• Earlier intervention with

ecuilizumab was asso-
ciated with better GFR.
Trial 2

• 80% of the patients

have TMA event free
status by week 26.
Plasma exchange /infusion discontinued
In 88% in Trial 1 and 100% in trial 2.

No infection related serious adverse event

were observed.
 Eculizumab- points to consider

• Cost > $400, 000 per year.

• Frequency of dosing, currently every other
week.
• When to stop therapy, if ever.
aHUS and Transplant
 Eculizumab post- transplant

Highly effective in treating and preventing aHUS-

related relapsing kidney failure
Recurrence and Denovo
 Take home points.
• Atypical HUS is thrombotic microangiopathy caused by
dysregulation of alternate complement pathway.

• Usually there is underlying genetic predisposition that is

unmasked with stress responses leading to clinical symptoms.

• Atypical HUS must be considered in thrombotic

microangiopathy because appropriate treatment is most
effective when started early.

• Eculizumab, a C5 inhibitor is extremely effective in treatment

and prevention of recurrence of aHUS, however cost of
medication creates barrier to treatment.
Thank you
Thank you