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Use of eculizumab in a systemic lupus erythemathosus patient presenting thrombotic microangiopathy and heterozygous deletion in CFHR1-CFHR3. A case report and systematic review

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Abstract

The association of thrombotic microangiopathy (TMA) with systemic lupus erythematosus (SLE) has been described in 0.5 to 10% of cases, and patients present worse outcome. TMA is described as the association of microangiopathic hemolytic anemia, thrombocytopenia, and an organ injury, frequently the kidney. This study describes a successful case of use of eculizumab in a patient with SLE and TMA refractory to standard therapy, and provides a literature review. Case description and search in PubMed and MEDLINE using systemic lupus erythemathous and/or antiphospholipid syndrome (APS) and eculizumab retrieved 15 case reports. Eighteen-year-old female presented acute renal failure and TMA and was diagnosed with SLE. Steroids and IV cyclophosphamide were started together with plasma exchange. After 55 days, she still persisted with microangiopathic anemia, thrombocytopenia, and anuria, and eculizumab was introduced. She had rapid improvement in hematological parameters, and dialysis was discontinued 25 days after the first dose. Genetic analysis showed large heterozygous deletion encompassing the entire CFHR1 and CFHR3, a finding previously associated with patients presenting atypical hemolytic-uremic syndrome (aHUS). Twenty patients who received eculizumab with SLE and/or APS have been published to date: 11 were female and mean age at presentation was 31 years. Seven out of the 20 patients presented only SLE, 5 patients only APS and 8 patients both SLE and APS. Eighteen patients underwent plasma exchange, with a mean of 20 (4–120) sessions per patient. Thirteen patients received rituximab. Hematological response was evident in 100% and kidney recovery in 85% of patients. The terminal complement blockade with eculizumab is an optional treatment for patients with SLE and/or APS presenting TMA and refractory to current immunosuppression therapies. Genetic testing may help recognize patients with aHUS and SLE/APS and therefore help to determine length of treatment with eculizumab.

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Acknowledgments

We sincerely thank Craig B Langman, MD, from the Northwestern University, for his assistance in our report review and his important critiques. We are also grateful to Renato Eick and John Wilkinson for reviewing the English.

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Authors and Affiliations

  1. Department of Nephrology and Kidney Transplant, Hospital Federal de Bonsucesso, Av. Londres 616, Prédio 1, segundo andar, Departamento de Nefrologia e Transplante Renal, Rio de Janeiro, Brazil

    Maria Izabel de Holanda, Teresa Wagner & Luis Fernando Christiani

  2. Histocompatibility and Cryopreservation Laboratory, Rio de Janeiro State University, Rio de Janeiro, Brazil

    Luis Cristóvão Pôrto

  3. Department of Pediatric Nephrology, Unicamp, State University of Campinas, Campinas, Brazil

    Lilian M. P. Palma

Authors
  1. Maria Izabel de Holanda
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  2. Luis Cristóvão Pôrto
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  3. Teresa Wagner
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  4. Luis Fernando Christiani
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  5. Lilian M. P. Palma
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Contributions

MIH—designed the study, followed up patient, collected the data, analyzed results, and wrote manuscript; TW and LFC—followed up patient and analyzed results; LCP—analyzed results and revised manuscript; LMP—designed the study, analyzed results, and revised manuscript.

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Correspondence to Maria Izabel de Holanda.

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Conflict of interest

The authors MIH and LMPP declare that they receive fees as speakers and consultants from Alexion Pharmaceuticals, Brazil.

TW, LFC, and LCP declare no conflicts of interest.

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de Holanda, M.I., Pôrto, L.C., Wagner, T. et al. Use of eculizumab in a systemic lupus erythemathosus patient presenting thrombotic microangiopathy and heterozygous deletion in CFHR1-CFHR3. A case report and systematic review. Clin Rheumatol 36, 2859–2867 (2017). https://doi.org/10.1007/s10067-017-3823-2

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  • DOI: https://doi.org/10.1007/s10067-017-3823-2

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