Abstract
Shiga toxin-associated haemolytic uraemic syndrome (Stx HUS) is the leading cause of paediatric acute kidney injury. This toxin-mediated disease carries a significant morbidity and mortality but has no direct treatments. Rare familial atypical HUS (aHUS) is now understood to result from over-activation of the alternative complement pathway causing glomerular endothelial damage. By understanding the pathogenic mechanisms of this disease, the monoclonal antibody eculizumab, which blocks the final common pathway of complement, is now being used to treat aHUS. For this reason, clinicians and scientists are studying the role of the alternative complement pathway in Stx HUS with the aim of targeting treatment in a similar way. There is some evidence suggesting that complement plays a role in the pathogenesis of Stx HUS, but other mechanisms may also be important. Clinically, modulating the complement system using plasma exchange provides no proven benefit in Stx HUS, and the use of eculizumab has provided conflicting results. Understanding the local effect of Stx on the glomerulus, in particular regulation of the complement and coagulation systems, may lead to advances in defining the precise pathogenesis of this disease. Then, targeted treatment strategies could be devised and clinical trials undertaken.
Similar content being viewed by others
References
Scheiring J, Andreoli SP, Zimmerhackl LB (2008) Treatment and outcome of Shiga-toxin-associated hemolytic uremic syndrome (HUS). Pediatr Nephrol 23:1749–1760
Ake JA, Jelacic S, Ciol MA, Watkins SL, Murray KF, Christie DL, Klein EJ, Tarr PI (2005) Relative nephroprotection during Escherichia coli O157:H7 infections: association with intravenous volume expansion. Pediatrics 115:e673–680
Barbour T, Johnson S, Cohney S, Hughes P (2012) Thrombotic microangiopathy and associated renal disorders. Nephrol Dial Transplant 27:2673–2685
Garg AX, Suri RS, Barrowman N, Rehman F, Matsell D, Rosas-Arellano MP, Salvadori M, Haynes RB, Clark WF (2003) Long-term renal prognosis of diarrhea-associated hemolytic uremic syndrome: a systematic review, meta-analysis, and meta-regression. JAMA 290:1360–1370
Spinale JM, Ruebner RL, Copelovitch L, Kaplan BS (2013) Long-term outcomes of Shiga toxin hemolytic uremic syndrome. Pediatr Nephrol. doi:10.1007/s00467-012-2383-6
Rosales A, Hofer J, Zimmerhackl LB, Jungraithmayr TC, Riedl M, Giner T, Strasak A, Orth-Höller D, Würzner R, Karch H, German-Austrian HUS Study Group (2012) Need for long-term follow-up in enterohemorrhagic Escherichia coli-associated hemolytic uremic syndrome due to late-emerging sequelae. Clin Infect Dis 54:1413–1421
Garg AX, Clark WF, Salvadori M, Macnab J, Suri RS, Haynes RB, Matsell D, Investigators WHS (2005) Microalbuminuria three years after recovery from Escherichia coli O157 hemolytic uremic syndrome due to municipal water contamination. Kidney Int 67:1476–1482
Garg AX, Salvadori M, Okell JM, Thiessen-Philbrook HR, Suri RS, Filler G, Moist L, Matsell D, Clark WF (2008) Albuminuria and estimated GFR 5 years after Escherichia coli O157 hemolytic uremic syndrome: an update. Am J Kidney Dis 51:435–444
Gianviti A, Tozzi AE, De Petris L, Caprioli A, Ravà L, Edefonti A, Ardissino G, Montini G, Zacchello G, Ferretti A, Pecoraro C, De Palo T, Caringella A, Gaido M, Coppo R, Perfumo F, Miglietti N, Ratsche I, Penza R, Capasso G, Maringhini S, Li Volti S, Setzu C, Pennesi M, Bettinelli A, Peratoner L, Pela I, Salvaggio E, Lama G, Maffei S, Rizzoni G (2003) Risk factors for poor renal prognosis in children with hemolytic uremic syndrome. Pediatr Nephrol 18:1229–1235
Trachtman H, Austin C, Lewinski M, Stahl RA (2012) Renal and neurological involvement in typical Shiga toxin-associated HUS. Nat Rev Nephrol 8:658–669
Nathanson S, Kwon T, Elmaleh M, Charbit M, Launay EA, Harambat J, Brun M, Ranchin B, Bandin F, Cloarec S, Bourdat-Michel G, Piètrement C, Champion G, Ulinski T, Deschênes G (2010) Acute neurological involvement in diarrhea-associated hemolytic uremic syndrome. Clin J Am Soc Nephrol 5:1218–1228
Bitzan M, Schaefer F, Reymond D (2010) Treatment of typical (enteropathic) hemolytic uremic syndrome. Semin Thromb Hemost 36:594–610
Goldwater PN, Bettelheim KA (2012) Treatment of enterohemorrhagic Escherichia coli (EHEC) infection and hemolytic uremic syndrome (HUS). BMC Med 10:12
Scheiring J, Rosales A, Zimmerhackl LB (2010) Clinical practice. Today’s understanding of the haemolytic uraemic syndrome. Eur J Pediatr 169:7–13
Keir LS, Marks SD, Kim JJ (2012) Shigatoxin-associated hemolytic uremic syndrome: current molecular mechanisms and future therapies. Drug Des Devel Ther 6:195–208
Zheng XL, Sadler JE (2008) Pathogenesis of thrombotic microangiopathies. Annu Rev Pathol 3:249–277
Ruggenenti P, Noris M, Remuzzi G (2001) Thrombotic microangiopathy, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura. Kidney Int 60:831–846
Keir L, Coward RJ (2011) Advances in our understanding of the pathogenesis of glomerular thrombotic microangiopathy. Pediatr Nephrol 26:523–533
Noris M, Remuzzi G (2009) Atypical hemolytic uremic syndrome. N Engl J Med 361:1676–1687
Nürnberger J, Philipp T, Witzke O, Opazo Saez A, Vester U, Baba HA, Kribben A, Zimmerhackl LB, Janecke AR, Nagel M, Kirschfink M (2009) Eculizumab for atypical hemolytic-uremic syndrome. N Engl J Med 360:542–544
Gruppo RA, Rother RP (2009) Eculizumab for congenital atypical hemolytic-uremic syndrome. N Engl J Med 360:544–546
Ceribelli A, Andreoli L, Cavazzana I, Franceschini F, Radice A, Rimoldi L, Sinico RA, Carlsson M, Wieslander J, Tincani A (2009) Complement cascade in systemic lupus erythematosus: analyses of the three activation pathways. Ann N Y Acad Sci 1173:427–434
Johnson S, Waters A (2012) Is complement a culprit in infection-induced forms of haemolytic uraemic syndrome? Immunobiology 217:235–243
Mayilyan KR (2012) Complement genetics, deficiencies, and disease associations. Protein Cell 3:487–496
Caprioli J, Noris M, Brioschi S, Pianetti G, Castelletti F, Bettinaglio P, Mele C, Bresin E, Cassis L, Gamba S, Porrati F, Bucchioni S, Monteferrante G, Fang CJ, Liszewski MK, Kavanagh D, Atkinson JP, Remuzzi G, HUS/TTP IRoRaF (2006) Genetics of HUS: the impact of MCP, CFH, and IF mutations on clinical presentation, response to treatment, and outcome. Blood 108:1267–1279
Amara U, Rittirsch D, Flierl M, Bruckner U, Klos A, Gebhard F, Lambris JD, Huber-Lang M (2008) Interaction between the coagulation and complement system. Adv Exp Med Biol 632:71–79
Amara U, Flierl MA, Rittirsch D, Klos A, Chen H, Acker B, Brückner UB, Nilsson B, Gebhard F, Lambris JD, Huber-Lang M (2010) Molecular intercommunication between the complement and coagulation systems. J Immunol 185:5628–5636
Krisinger MJ, Goebeler V, Lu Z, Meixner SC, Myles T, Pryzdial EL, Conway EM (2012) Thrombin generates previously unidentified C5 products that support the terminal complement activation pathway. Blood 120:1717–1725
Delvaeye M, Noris M, De Vriese A, Esmon CT, Esmon NL, Ferrell G, Del-Favero J, Plaisance S, Claes B, Lambrechts D, Zoja C, Remuzzi G, Conway EM (2009) Thrombomodulin mutations in atypical hemolytic-uremic syndrome. N Engl J Med 361:345–357
Peerschke EI, Yin W, Ghebrehiwet B (2010) Complement activation on platelets: implications for vascular inflammation and thrombosis. Mol Immunol 47:2170–2175
Licht C, Pluthero FG, Li L, Christensen H, Habbig S, Hoppe B, Geary DF, Zipfel PF, Kahr WH (2009) Platelet-associated complement factor H in healthy persons and patients with atypical HUS. Blood 114:4538–4545
Monnens L, Molenaar J, Lambert PH, Proesmans W, van Munster P (1980) The complement system in hemolytic-uremic syndrome in childhood. Clin Nephrol 13:168–171
Kim Y, Miller K, Michael AF (1977) Breakdown products of C3 and factor B in hemolytic-uremic syndrome. J Lab Clin Med 89:845–850
Robson WL, Leung AK, Fick GH, McKenna AI (1992) Hypocomplementemia and leukocytosis in diarrhea-associated hemolytic uremic syndrome. Nephron 62:296–299
Thurman JM, Marians R, Emlen W, Wood S, Smith C, Akana H, Holers VM, Lesser M, Kline M, Hoffman C, Christen E, Trachtman H (2009) Alternative pathway of complement in children with diarrhea-associated hemolytic uremic syndrome. Clin J Am Soc Nephrol 4:1920–1924
Ståhl AL, Sartz L, Karpman D (2011) Complement activation on platelet-leukocyte complexes and microparticles in enterohemorrhagic Escherichia coli-induced hemolytic uremic syndrome. Blood 117:5503–5513
Ståhl AL, Sartz L, Nelsson A, Békássy ZD, Karpman D (2009) Shiga toxin and lipopolysaccharide induce platelet-leukocyte aggregates and tissue factor release, a thrombotic mechanism in hemolytic uremic syndrome. PLoS One 4:e6990
Fang CJ, Fremeaux-Bacchi V, Liszewski MK, Pianetti G, Noris M, Goodship TH, Atkinson JP (2008) Membrane cofactor protein mutations in atypical hemolytic uremic syndrome (aHUS), fatal Stx-HUS, C3 glomerulonephritis, and the HELLP syndrome. Blood 111:624–632
Orth D, Khan AB, Naim A, Grif K, Brockmeyer J, Karch H, Joannidis M, Clark SJ, Day AJ, Fidanzi S, Stoiber H, Dierich MP, Zimmerhackl LB, Würzner R (2009) Shiga toxin activates complement and binds factor H: evidence for an active role of complement in hemolytic uremic syndrome. J Immunol 182:6394–6400
Ehrlenbach S, Rosales A, Posch W, Wilflingseder D, Hermannb M, Brockmeyerc J, Karch H, Satchell S, Wurzner R, Orth-Höller D (2013) Shiga toxin 2 reduces complement inhibitor CD59 expression on human renal tubular epithelial and glomerular endothelial cells. Infect Immun. doi:10.1128/IAI.01079-12
Fernández GC, Te Loo MW, van der Velden TJ, van der Heuvel LP, Palermo MS, Monnens LL (2003) Decrease of thrombomodulin contributes to the procoagulant state of endothelium in hemolytic uremic syndrome. Pediatr Nephrol 18:1066–1068
Morigi M, Galbusera M, Gastoldi S, Locatelli M, Buelli S, Pezzotta A, Pagani C, Noris M, Gobbi M, Stravalaci M, Rottoli D, Tedesco F, Remuzzi G, Zoja C (2011) Alternative pathway activation of complement by Shiga toxin promotes exuberant C3a formation that triggers microvascular thrombosis. J Immunol 187:172–180
Nevard CH, Blann AD, Jurd KM, Haycock GB, Hunt BJ (1999) Markers of endothelial cell activation and injury in childhood haemolytic uraemic syndrome. Pediatr Nephrol 13:487–492
Zoja C, Locatelli M, Pagani C, Corna D, Zanchi C, Isermann B, Remuzzi G, Conway EM, Noris M (2012) Lack of the lectin-like domain of thrombomodulin worsens Shiga toxin-associated hemolytic uremic syndrome in mice. J Immunol 189:3661–3668
Rutjes NW, Binnington BA, Smith CR, Maloney MD, Lingwood CA (2002) Differential tissue targeting and pathogenesis of verotoxins 1 and 2 in the mouse animal model. Kidney Int 62:832–845
Keepers TR, Psotka MA, Gross LK, Obrig TG (2006) A murine model of HUS: Shiga toxin with lipopolysaccharide mimics the renal damage and physiologic response of human disease. J Am Soc Nephrol 17:3404–3414
Kim JJ, Goodship TH, Tizard J, Inward C (2011) Plasma therapy for atypical haemolytic uraemic syndrome associated with heterozygous factor H mutations. Pediatr Nephrol 26:2073–2076
Clark WF (2012) Thrombotic microangiopathy: current knowledge and outcomes with plasma exchange. Semin Dial 25:214–219
Waters AM, Licht C (2011) aHUS caused by complement dysregulation: new therapies on the horizon. Pediatr Nephrol 26:41–57
Loirat C, Sonsino E, Hinglais N, Jais JP, Landais P, Fermanian J (1988) Treatment of the childhood haemolytic uraemic syndrome with plasma. A multicentre randomized controlled trial. The French Society of Paediatric Nephrology. Pediatr Nephrol 2:279–285
Rizzoni G, Claris-Appiani A, Edefonti A, Facchin P, Franchini F, Gusmano R, Imbasciati E, Pavanello L, Perfumo F, Remuzzi G (1988) Plasma infusion for hemolytic-uremic syndrome in children: results of a multicenter controlled trial. J Pediatr 112:284–290
Michael M, Elliott EJ, Craig JC, Ridley G, Hodson EM (2009) Interventions for hemolytic uremic syndrome and thrombotic thrombocytopenic purpura: a systematic review of randomized controlled trials. Am J Kidney Dis 53:259–272
Kemper MJ (2012) Outbreak of hemolytic uremic syndrome caused by E. coli O104:H4 in Germany: a pediatric perspective. Pediatr Nephrol 27:161–164
Menne J, Nitschke M, Stingele R, Abu-Tair M, Beneke J, Bramstedt J, Bremer JP, Brunkhorst R, Busch V, Dengler R, Deuschl G, Fellermann K, Fickenscher H, Gerigk C, Goettsche A, Greeve J, Hafer C, Hagenmüller F, Haller H, Herget-Rosenthal S, Hertenstein B, Hofmann C, Lang M, Kielstein JT, Klostermeier UC, Knobloch J, Kuehbacher M, Kunzendorf U, Lehnert H, Manns MP, Menne TF, Meyer TN, Michael C, Münte T, Neumann-Grutzeck C, Nuernberger J, Pavenstaedt H, Ramazan L, Renders L, Repenthin J, Ries W, Rohr A, Rump LC, Samuelsson O, Sayk F, Schmidt BM, Schnatter S, Schöcklmann H, Schreiber S, von Seydewitz CU, Steinhoff J, Stracke S, Suerbaum S, van de Loo A, Vischedyk M, Weissenborn K, Wellhöner P, Wiesner M, Zeissig S, Büning J, Schiffer M, Kuehbacher T, Consortium E-H (2012) Validation of treatment strategies for enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome: case–control study. BMJ 345:e4565
Loos S, Ahlenstiel T, Kranz B, Staude H, Pape L, Härtel C, Vester U, Buchtala L, Benz K, Hoppe B, Beringer O, Krause M, Müller D, Pohl M, Lemke J, Hillebrand G, Kreuzer M, König J, Wigger M, Konrad M, Haffner D, Oh J, Kemper MJ (2012) An outbreak of Shiga toxin-producing Escherichia coli O104:H4 hemolytic uremic syndrome in Germany: presentation and short-term outcome in children. Clin Infect Dis 55:753–759
Lapeyraque AL, Malina M, Fremeaux-Bacchi V, Boppel T, Kirschfink M, Oualha M, Proulx F, Clermont MJ, Le Deist F, Niaudet P, Schaefer F (2011) Eculizumab in severe Shiga-toxin-associated HUS. N Engl J Med 364:2561–2563
Greinacher A, Friesecke S, Abel P, Dressel A, Stracke S, Fiene M, Ernst F, Selleng K, Weissenborn K, Schmidt BM, Schiffer M, Felix SB, Lerch MM, Kielstein JT, Mayerle J (2011) Treatment of severe neurological deficits with IgG depletion through immunoadsorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial. Lancet 378:1166–1173
Kielstein JT, Beutel G, Fleig S, Steinhoff J, Meyer TN, Hafer C, Kuhlmann U, Bramstedt J, Panzer U, Vischedyk M, Busch V, Ries W, Mitzner S, Mees S, Stracke S, Nürnberger J, Gerke P, Wiesner M, Sucke B, Abu-Tair M, Kribben A, Klause N, Schindler R, Merkel F, Schnatter S, Dorresteijn EM, Samuelsson O, Brunkhorst R, Registry obotcot DS-H (2012) Best supportive care and therapeutic plasma exchange with or without eculizumab in Shiga-toxin-producing E. coli O104:H4 induced haemolytic-uraemic syndrome: an analysis of the German STEC-HUS registry. Nephrol Dial Transplant 27:3807–3815
Menne J, Kielstein JT, Wenzel U, Stahl RA (2012) Treatment of typical hemolytic-uremic syndrome : Knowledge gained from analyses of the 2011 E. coli outbreak. Internist (Berl) 53:1420–1430
Nitschke M, Sayk F, Härtel C, Roseland RT, Hauswaldt S, Steinhoff J, Fellermann K, Derad I, Wellhöner P, Büning J, Tiemer B, Katalinic A, Rupp J, Lehnert H, Solbach W, Knobloch JK (2012) Association between azithromycin therapy and duration of bacterial shedding among patients with Shiga toxin-producing enteroaggregative Escherichia coli O104:H4. JAMA 307:1046–1052
Ge S, Hertel B, Emden SH, Beneke J, Menne J, Haller H, von Vietinghoff S (2012) Microparticle generation and leucocyte death in Shiga toxin-mediated HUS. Nephrol Dial Transplant 27:2768–2775
Ghosh SA, Polanowska-Grabowska RK, Fujii J, Obrig T, Gear AR (2004) Shiga toxin binds to activated platelets. J Thromb Haemost 2:499–506
Karpman D, Manea M, Vaziri-Sani F, Ståhl AL, Kristoffersson AC (2006) Platelet activation in hemolytic uremic syndrome. Semin Thromb Hemost 32:128–145
Hughes AK, Stricklett PK, Schmid D, Kohan DE (2000) Cytotoxic effect of Shiga toxin-1 on human glomerular epithelial cells. Kidney Int 57:2350–2359
Psotka MA, Obata F, Kolling GL, Gross LK, Saleem MA, Satchell SC, Mathieson PW, Obrig TG (2009) Shiga toxin 2 targets the murine renal collecting duct epithelium. Infect Immun 77:959–969
Eremina V, Jefferson JA, Kowalewska J, Hochster H, Haas M, Weisstuch J, Richardson C, Kopp JB, Kabir MG, Backx PH, Gerber HP, Ferrara N, Barisoni L, Alpers CE, Quaggin SE (2008) VEGF inhibition and renal thrombotic microangiopathy. N Engl J Med 358:1129–1136
Mason JC, Steinberg R, Lidington EA, Kinderlerer AR, Ohba M, Haskard DO (2004) Decay-accelerating factor induction on vascular endothelium by vascular endothelial growth factor (VEGF) is mediated via a VEGF receptor-2 (VEGF-R2)- and protein kinase C-alpha/epsilon (PKCalpha/epsilon)-dependent cytoprotective signaling pathway and is inhibited by cyclosporin A. J Biol Chem 279:41611–41618
Okuda T, Tokuda N, Numata S, Ito M, Ohta M, Kawamura K, Wiels J, Urano T, Tajima O, Furukawa K (2006) Targeted disruption of Gb3/CD77 synthase gene resulted in the complete deletion of globo-series glycosphingolipids and loss of sensitivity to verotoxins. J Biol Chem 281:10230–10235
Acknowledgements
Dr. Lindsay Keir is supported by a British Medical Research Council Clinical Research Training Fellowship (Grant No. G0901987).
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Keir, L.S., Saleem, M.A. Current evidence for the role of complement in the pathogenesis of Shiga toxin haemolytic uraemic syndrome. Pediatr Nephrol 29, 1895–1902 (2014). https://doi.org/10.1007/s00467-013-2561-1
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00467-013-2561-1