w ahus pathology is linked to dysregulation of the alternative complement pathway.

Transcription

1 ahus - Pathogenesis, Etiology, and Clinical Advances Craig B. Langman MD The Isaac A Abt MD Professor of Kidney Diseases Feinberg School of Medicine, Northwestern University Head, Kidney Diseases The Ann and Robert H Lurie Children s Hospital of Chicago Chicago, IL c-langman@northwestern.edu Introduction w ahus pathology is linked to dysregulation of the alternative complement pathway. w Despite remarkable progress made over the last decade, ahus pathology remains poorly recognized clinically. w ahus carries a significant risk of ESKD (50%) and death (25%) at the first presentation. w Only 50-60% of ahus can be found to have identifiable mutations or autoantibodies involving the regulatory proteins of the alternative complement pathway, so a diagnosis of ahus does not require them. Overview of Complement System: 3(+1) Activation Pathways Amplification Initiation Terminal pathway Classical pathway (antigen-antibody induced) Mannose-lectin pathway (mannose-lectin induced) C3 C3b Inflammation Opsonization and phagocytosis Membrane attack complex (MAC) and cell lysis Alternative pathway (continuously active) 3 1

2 Overview of Complement System: 3(+1) Activation Pathways Overview of Complement System: 3(+1) Activation Pathways The Alternative Complement Pathway: Activation Amplification Initiation Terminal pathway Classical pathway (antigen-antibody induced) Mannose-lectin pathway (mannose-lectin induced) C3 C3b Inflammation Opsonization and phagocytosis Membrane attack complex (MAC) and cell lysis Alternative pathway (continuously active) Amplification Initiation Terminal pathway Classical pathway (antigen-antibody induced) C5a Potent Anaphylatoxin Chemotaxis Proinflammatory Leukocyte/Monocyte Activation Endothelial Activation Prothrombotic C3a C3bBb C3b Mannose-lectin pathway (mannose-lectin induced) C5a C3 C3b C5 C5b Inflammation (C3a/C5a: anaphylatoxins) Opsonization and phagocytosis (C3b/C4b) MAC and cell lysis (C5b-C9) Alternative pathway (continuously active) Thrombin (+1) (Huber-Lang et al. Nat Med. 2006) P C3 FD Terminal pathway of the complement cascade C3 C3b FB Stepwise activation of C5 to C9 C3a Amplification (10 0 >>10 10 within minutes) C3b Ba Bb C5b-9 (MAC/TCC) Opsonization C3-Convertase Lysis C3b C3b C3b C3b Surface FB P TCC = terminal complement complex. FD C3b 7 2

3 31/08/14 Terminal pathway Amplification Initiation Overview of Complement System: 3(+1) Activation Pathways Classical pathway (antigen-antibody induced) Mannose-lectin pathway (mannose-lectin induced) Soluble and Membrane Bound Complement Regulators Alternative pathway The Alternative Pathway C3 Convertase Regulation C3 (continuously active) C3 Array of alternative pathway regulators, both soluble and membrane bound C3a CFI Major (soluble) complement regulator: CFI CFI Factor HC3b (CFH) CFH Bb CFH Thrombin CFH TM TM Inflammation Opsonization and phagocytosis Membrane attack complex (MAC) and cell lysis Keir L, Coward RJ. Pediatr Nephrol. 2011;26(4): Journal of Immunological Methods. 2011;365:

4 Complement Balance Loss of Complement Regulation Leads to Chronic Uncontrolled Complement Activation in ahus Autoantibodies to Factor H in ahus: DEAP-HUS Health C3 C5 Complement regulation Ligand recognition M- CFI C3a C3a Activation Inhibition M-CFH M- TM FD Bb Bb Bb HUS-associated factor H autoantibodies (described mainly in children) mimic the effect of C-terminal factor H mutations, as they inhibit the regulatory function of factor H at cell surfaces by blocking its C-terminal recognition region Associated with CFHR1,3 mutations. Anti-factor H IgG antibodies Epigenetic Factors, including common infections and stressors further accelerate complement over-activity and lead to overt clinical disease. Keir L, Coward RJ. Pediatr Nephrol. 2011;26(4): Dragon-Durey et al., JASN, 2005; Jozsi et al., Blood, Hofer, Clin J Am Soc Nephrol 8: ,

5 Clinical Course of DEAP- ahus Kidney Survival with Plasma and Immunosuppression in DEAP-HUS Complement Imbalance Leads to ahus Health Loss of Inhibition Increase in Activation CASCADE PROGRESSION 5

6 Thrombotic Microangiopathy Pathogenesis of Thrombotic Microangiopathy (TMA) ADAMTS13 Deficiency VWF-platelet Aggregates DIC Fibrin-platelet Thrombi Shiga toxins Complement Dysregulation Lupus Erythematosus Scleroderma Renal Crisis Diacyl Gylcerol Kinase-ε Deficiency Anti-VEGF Antibody Microangiopathy Metastasizing Cancer Tumor Cells TMA Based Diseases and Conditions that Unmask TMA w Common TMA diseases are ahus, TTP, STEC-HUS Defined by the clinical characteristics of TMA (Thrombocytopenia, Hemolysis, and organ dysfunction) There are other rare TMA diseases Degos Syndrome (Malignant Atrophic Papulosis) CAPS Cobalamin-C deficiency (hyperhomocysteinemia, MMA) Thrombosis and/or Luminal Stenosis Thrombocytopenia Abnormal Shear Stress Ischemic Organ injury Brain Kidney Heart Pancreas, liver, lung Erythrocyte Fragmentation w Other diseases are initiated by different etiology and may unmask TMA Malignant Hypertension shear stress leads to endothelial damage SLE antibody directed complement activation Pregnancy-related (Preeclampsia / HELLP syndrome) Increase in complement activity and shear stress Drug Induced TMA direct toxicity to endothelium Viral Induced TMA [HIV, H1N1] Scleroderma Renal Crisis 17 DOI: adapted by Langman,

7 Complement Mutations of ahus Are Seen Frequently in Other TMA-Based Diseases Idiopathic = ahus (mutations in only 50-60%) Idiopathic, 3%-6% Pregnancy-associated, 15% HELLP syndrome, 20% Organ transplantation, 16% C3 Idiopathic, 4%-6% CFI Idiopathic, 15%-20% Pregnancy-associated, 20% HELLP syndrome, 10% Drugs, rare Organ transplantation, 15% MCP HELLP 10%; Idiopathic 6%-10% CFH Anti-CFH antibodies THBD Idiopathic, 2% CFB * Idiopathic, 6%-10% DGKε * 2 reported cases. HELLP = hemolytic anemia, elevated liver enzymes, and low platelet count. Noris M et al. N Engl J Med. 2009;361: Int J Nephrol. 2012; 2012: , adapted by Langman,

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9 Patients with DGKE have alternative complement pathway protein mutations Children post Bone Marrow Transplantation with TMA have alternative complement pathway abnormalities 9

10 The Clinical Facets of TMA Revealed AKI and Pregnancy: ahus is a postpartum process for the most part Post-Partum ahus and ahus are Similar in Genetics: Pregnancy is an accelerating factor for complement dysregulation, causing ahus Infection Induced Shigatoxin HUS Strep Pneumoniae HUS Disorders of Complement Regulation Genetic mutations Acquired defects, eg. antibodies Defective Cobalamin Metabolism DGK-ξ Deficiency Drugs Quinine induced Tacrolimus, cyclosporine Bleomycin, mitomycin, cisplatin Bevacizumab Rifampicin Clopidopogrel/Ticlopidine Malignancy Post BMT Langman (2012) as adapted from Pediatr Nephrol. 2011;26(4): TMA Connective Tissue Disorders SLE Antiphospholipid-Ab syndrome ADAMTS 13 Abnormalities Genetic abnormality Autoantibodies HIV Pregnancy ahus 10

11 Outcome of pp-ahus is dismal,sans Rx ahus Beliefs versus Evidence Atypical Hemolytic Uremic Syndrome (ahus) Understanding the Disease and the Differential Diagnosis Diagnosis does not require identification of a genetic mutation w Genetic mutations can be identified in only 50-70% of ahus patients 1 w While genetic testing may reveal a patient s specific complement mutation, ahus is not ruled out because a mutation could not be identified 1. Noris M et al. CJASN. 2010;10(5):

12 Genetic and Acquired Complement Abnormalities ahus 200 Families in which one member (sporadic form) or more than one member (familial form) met the criteria for ahus Genetic / acquired abnormality - CFH - MCP - CFI - C3 - CFB All Patients (n=214) (9.3) 18 (8.4) 18 (8.4) 4 (1.9) Familial Form* (n=28) 10 (35.7) 4 (14.3) 0 3 (10.7) 1 (3.6) Sporadic Form (n=172) 45 (26.1) 15 (8.7) 18 (10.4) 13 (7.6) 2 (1.2) P-Value for Familial vs Sporadic Forms Familial and Sporadic Forms (n=200) 54 (27.0) 20 (10.0) 18 (9.0) 16 (8.0) 3 (1.5) Anti-CFH antibodies 14 (6.5) 0 14 (8.1) 14 (7.0) Combined 9 (42.) 2 (7.1) 6 (3.5) (4.0) THBD Complement-mediated disease 142 (66.3) 20 (71.4) 113 (65.7) (66.0) Undetermined / incomplete 72 (33.6) 8 (4/4) (28.6) 59 (34.3) (34.0) Should we Screen Relatives? In ahus, There is No Difference in Severity of Disease for Patients With an Identified Mutation Compared to Those With No Identified Mutation 1,2 Consequences No Identifiable Mutation Identifiable Mutation % of patients that died or progressed to ESRD within 28-37% 40-44% the first clinical manifestation 1,2 % of patients that died, required dialysis, or had permanent renal damage within the first year after diagnosis 2 65% 63% % of patients that died or required dialysis long term 2 51% 57% CFH = complement factor H. MCP = membrane cofactor protein. CFI = complement factor I. CFB = complement factor B. THBD = thrombomodulin. Fremeaux-Bacchi et al. CJASN epress. Published on January 10, 2013 as doi: /CJN ESRD = end stage renal disease. 1. Noris M et al. NEJM. 2009;361: Caprioli et al. Blood. 2006;108:

13 31/08/14 Chronic Complement-Mediated TMA Results in Damage to Vital Organs Systemic TMA in ahus CHRONIC UNCONTROLLED Cardiovascular2,3,4,6 COMPLEMENT ACTIVATION Myocardial infarction Thromboembolism Cardiomyopathy Diffuse vasculopathy Renal7,8,9,11,12 Elevated creatinine Edema Malignant hypertension Renal failure Dialysis Transplant Pulmonary1,6,14 CNS1,2,3,4,5 Confusion Seizures Stroke Encephalopathy Diffuse cerebral dysfunction w Cardiovascular complications reported in up to 43% of ahus patients1 Myocardial infarction,2 cardiomyopathy,1 cardiac insufficiency3 Disseminated stenotic vascular lesions4 Gastrointestinal2,3,5,10,11,12 Liver necrosis Pancreatitis Diabetes Mellitus Colitis Diarrhea Nausea/vomiting Abdominal pain w Pulmonary Pulmonary hemorrhage,1 pulmonary Blood11 w ahus can cause progressive and sudden damage across multiple organs through TMA manifestations Evidence of TMA or progressive systemic involvement should prompt high suspicion of ahus System Signs/Symptoms Number (%) of Patients with Complication Renal Kidney impairment 30 (100) Cardiovascular Thrombi (various locations), cardiac arrest, cardiomyopathy 14 (47) Gastrointestinal Diarrhea, vomiting, pancreatitis, splenic vein occlusion 11 (37) Neurologic Seizure, acute disseminated encephalomyelitis, stroke, transient ischemic attacks, facial paralysis, headache 6 (20) edema,2 dyspnea3 w Ocular hemorrhage4 Impaired Quality of Life13 Fatigue Pain/anxiety Hemolysis Ocular occlusion Reduced mobility Decreased platelets Fatigue Transfusions Dyspnea Pulmonary hemorrhage Pulmonary edema Incidence of ahus Complications by System¹ w Adrenal gland Visual15 dysfunction5 w Necrosis of peripheral 1.Ohanian M et al. Clinical Pharmacology: Advances and Applications. 2011;3: Hosler et al. Arch Pathol Lab Med. 2003;127: Noris et al. CJASN. 2010;10: Neuhaus et al. Arch Dis Chilid. 1997;76: Vesely et al Blood. 2003;102: Sallee et al. Nephrol Dial Trans. 2010;25: Kose et al. Semin Thromb Hemost. 2010;36: Davin et al. Am J Kid Dis. 2010;55: Caprioli et al. Blood. 2006;108: Dragon-Durey et al. J Am Soc Nephrol. 2010;21: Loirat et al. Pediatr Nephrol. 2008;23: Stahl et al. Blood. 2008;111: Chatelet V et al. Am J Transplant Nov;9(11): Sellier-Leclerc et al. J Am Soc Nephrol. 2007;18: Larakeb A et al. Pediatr Nephrol. 2007;22: extremities6 ahus complications in >1 system 19 (63) 11 (37%) of the 30 ahus patients experienced thrombi beyond the kidney 1. Sellier-Leclerc et al. J Am Soc Nephrol. 2007;18: Al Akash et al. Pediatr Nephrol. 2011;26: George et al. Blood. 2010;116: Larakeb et al. Pediatr Nephro. 2007;22: Hosler et al. Arch Pathol Lab Med. 2003;127: Malina et al. Pediatr Nephrol. 2011; 26: Loirat et al. Pediatr Nephrol. 2008;23: Langman C et al. Systemic Multi-Organ Complications in Atypical Hemolytic Uremic Syndrome (ahus): Retrospective Study in a Medical Practice Setting. Poster presented at EHA Abstract

14 Diagnosis Differential Diagnosis for TMAs: ahus, TTP and STEC-HUS Microangiopathic Hemolysis 2,3 Thrombocytopenia 1,2 Schistocytes 2,3 and/or Platelet count <150,000 Or AND Elevated LDH 2 and/or >25% Decrease from baseline 1 Decreased haptoglobin 2 and/or Decreased hemoglobin 2 Plus One or More of the Following: Neurological Symptoms 4-7 Renal Impairment 2,9,10 Gastrointestinal Symptoms 2,6,12 Confusion 4,5 and/or Elevated creatinine 10 and/or Diarrhea +/ blood 12 and/or Seizures 6,8 and/or Decreased egfr 2,10 and/or Nausea/vomiting 6 and/or Other cerebral abnormalities 5 Elevated blood pressure 11 and/or Abdominal pain 6 and/or Abnormal urinalysis 9 Gastroenteritis 2,12 Published Clinical Evidence Shows a Platelet Count>30,000/mm 3 or Serum Creatinine > µmol/l (> mg/dl) can Support a Clinical Diagnosis of ahus 1 Patient Characteristics* ADAMTS13 Deficiency group n=160 (standard deviation) ADAMTS13 Detectable group n=54 (standard deviation) P-Value Platelet count, 10 9 /L 17.4 (14.2) 66.6 (49.3) < Creatinine level, µmol/l mg/dl 114 (68.4) 1.29 (0.77) 454 (326) 5.13 (3.68) < Evaluate ADAMTS13 activity and Shiga-toxin/EHEC* test 8,13-15 * This Shiga-toxin/EHEC pathway is intended test as educational is warranted information with history/presence for healthcare providers. of GI symptoms. It does not replace a healthcare professional s judgment or clinical diagnosis. 1. Data on file. Alexion Pharmaceuticals, Inc.; 2. Caprioli et al. Blood 2006;108:1267-7; 3. Noris M et al. NEJM 2009;361: ; 4. Neuhaus et al. Arch Dis Chilid 1997;76: ; 5. Noris M et al. JASN 2005;16: ; 6. Dragon-Durey et al. J Am Soc Nephrol 2010;21: ; 7. Davin et al. Am J Kid Dis 2010;55: ; 8. Bianchi et al. Blood 2002;110: ; 9. Al-Akash et al. Pediatr Nephrol 2011;26: ; 10. Sellier-Leclerc AL. JASN 2007;18: ; 11. Benz et al. Curr Opin Nephrol Hypertens 2010;19: ; 12. Noris M et al. Clin J Am Soc Nephrol 2010;5: ; 13. Tsai H-M. Int J Hematol 2010;91:1 19; 14. Barbot et al. Br J Haematol 2001;113:649; 15. Bitzan M. Semin Thromb Hemost 2010;36: ; 16. Zuber J et al. Nat Rev Nephrol 2012 Nov;8: Patient Characteristics* *Adult patients Adjusted Odds Ratio Table Adapted from Coppo P et al. PLoS ONE 5(4): e doi: /journal.pone Zuber J et al. Nat Rev Nephrol 2012 Nov;8: % CI P-Value Platelet count /L <0.001 Creatinine level 200 µmol/l (2.26 mg/dl) <

15 Pediatric Criteria match for bedside diagnosis of ahus vs TTP Differential Diagnosis for TMAs: ahus, TTP and STEC-HUS Microangiopathic Hemolysis 2,3 Thrombocytopenia 1,2 Schistocytes 2,3 and/or Platelet count <150,000 Or AND Elevated LDH 2 and/or >25% Decrease from baseline 1 Decreased haptoglobin 2 and/or Decreased hemoglobin 2 Plus One or More of the Following: Neurological Symptoms 4-7 Confusion 4,5 and/or Seizures 6,8 and/or Other cerebral abnormalities 5 Renal Impairment 2,9,10 Elevated creatinine 10 and/or Decreased egfr 2,10 and/or Elevated blood pressure 11 and/or Abnormal urinalysis 9 Gastrointestinal Symptoms 2,6,12 Diarrhea +/ blood 12 and/or Nausea/vomiting 6 and/or Abdominal pain 6 and/or Gastroenteritis 2,12 Historical Management Evaluate ADAMTS13 activity and Shiga-toxin/EHEC* test 8,13-15 While waiting for ADAMTS13 results, a platelet count >30,000 mm 3 or serum creatinine > 1.5mg/dL almost eliminates a diagnosis of severe ADAMTS13 deficiency (TTP) 16,17 5% ADAMTS13 Activity 8,13,14 >5% ADAMTS13 Activity 12 Shiga-toxin/EHEC Positive 14 Personal Communication, 2014; Yoko Yashida, Nara University TTP ahus STEC-HUS * This Shiga-toxin/EHEC pathway is intended test as educational is warranted information with history/presence for healthcare providers. of GI symptoms. It does not replace a healthcare professional s judgment or clinical diagnosis. 1. Data on file. Alexion Pharmaceuticals, Inc.; 2. Caprioli et al. Blood 2006;108:1267-7; 3. Noris M et al. NEJM 2009;361: ; 4. Neuhaus et al. Arch Dis Chilid 1997;76: ; 5. Noris M et al. JASN 2005;16: ; 6. Dragon-Durey et al. J Am Soc Nephrol 2010;21: ; 7. Davin et al. Am J Kid Dis 2010;55: ; 8. Bianchi et al. Blood 2002;110: ; 9. Al-Akash et al. Pediatr Nephrol 2011;26: ; 10. Sellier-Leclerc AL. JASN 2007;18: ; 11. Benz et al. Curr Opin Nephrol Hypertens 2010;19: ; 12. Noris M et al. Clin J Am Soc Nephrol 2010;5: ; 13. Tsai H-M. Int J Hematol 2010;91:1 19; 14. Barbot et al. Br J Haematol 2001;113:649; 15. Bitzan M. Semin Thromb Hemost 2010;36: ; 16. Zuber J et al. Nat Rev Nephrol 2012 Nov;8: Yoshida, unpublished (2014) 46 15

16 Supportive Care for Patients With ahus w Transfusion w Dialysis w Antihypertensive therapy Ariceta G et al. Pediatr Nephrol. 2009;24: ; Noris M et al. N Engl J Med. 2009;361: ; Taylor CM et al. Br J Haematol. 2010;148:37-47; Waters AM et al. Pediatr Nephrol. 2011;26: Plasma Therapy for ahus w Considered historically as first-line treatment w Theory of Plasma infusion (PI) Offers replacement of defective complement components and regulators with functional proteins May be dose limited because of impaired renal function and hypertension w Theory of Plasma exchange Allows removal of mutant complement factors H, I, B; C3; and complement factor H autoantibodies while restoring functional complement regulators Does not benefit MCP/CD46 mutations Can provide larger amounts of plasma than possible with PI Ariceta G, et al. Pediatr Nephrol. 2009;24: ; Nathanson S, et al. Pediatr Nephrol. 2006;21: ; Noris M, et al. N Engl J Med. 2009;361: ; Taylor CM, et al. Br J Haematol. 2010;148:37-47; Waters AM, et al. Pediatr Nephrol. 2011;26: ahus Management Rapidly Evolving Management of Children with ahus 2009 Plasma Exchange 2012 PE regime could not be followed; -- PE adverse events Eculizumab first line for ahus 16

17 Audit Analysis of Plasma Protcol in ahus N=71 N=59 Audit Analysis of Plasma Rx in ahus in Children Normal Fx HBP Proteinuria Abnormal Fx Dialysis All (71) Dialysis (42) No Dialysis (29) (45%) (48%) 31% with a major catheter complication in first 33 days Pressure instability in the circuit Central venous obstruction Clots in the circuit Catheter infections Thrombosis 12 (29%) 0 Initial Response to Plasma Rx in ahus Short-Term Hematological Affected Response to Plasma Long-Term Recurrence After Protein Therapy Outcome Kidney Transplantation Rate of death or ESRD: Factor H 60% Rate: 80%-90% 70%-80% CFHR1, R3 70%-80% Rate of ESRD: 30%-40% Rate: 20% d MCP No definitive indication Rate of death or ESRD: <20% Rate: 15%-20% for therapy Factor I 30%-40% Rate of death or ESRD: Rate: 70%-80% 60%-70% Factor B 30% Rate of death or ESRD: 70% Recurrence in 1 case C3 40%-50% Rate of death or ESRD: 60% Rate: 40%-50% THBD 60% Rate of death or ESRD: 60% Recurrence in 1 case 1. Noris M et al. N Engl J Med. 2009;361:

18 Affected Protein Long-Term Outcome with Plasma Rx in ahus Short-Term Hematological Response to Plasma Therapy 1. Noris M et al. N Engl J Med. 2009;361: Long-Term Outcome Recurrence After Kidney Transplantation 1.00 Rate of death or ESRD: Factor H 60% Rate: 80%-90% Up to 70% of patients 70%-80% with ahus who have the most common mutation 0.75 die, require dialysis, or CFHR1, R3 70%-80% Rate of ESRD: 30%-40% Rate: 20% have chronic d renal insufficiency MCP No definitive indication for therapy Factor I 30%-40% 0.50 Rate of death or ESRD: <20% Rate: 15%-20% Rate of death or ESRD: 60%-70% Rate: 70%-80% CFH mutation = most common population Factor B 30% Rate of death or ESRD: 70% Recurrence in 1 case Follow-up (months) C3 40%-50% Rate of death or ESRD: 60% Rate: 40%-50% Modified from Caprioli et al. Blood. 2006;108(4): THBD 60% Rate of death or ESRD: 60% Recurrence in 1 case Cumulative Fraction of Patients Free of Events 0.25 No. at Risk ahus Outcomes After Isolated Kidney Transplantation Short-Term Hematological Affected Response to Plasma Long-Term Recurrence After Protein Therapy Outcome Kidney Transplantation Rate of death or ESRD: Factor H 60% Rate: 80%-90% 70%-80% CFHR1, R3 70%-80% Rate of ESRD: 30%-40% Rate: 20% d MCP No definitive indication Rate of death or ESRD: <20% Rate: 15%-20% for therapy Factor I 30%-40% Rate of death or ESRD: Rate: 70%-80% 60%-70% Factor B 30% Rate of death or ESRD: 70% Recurrence in 1 case C3 40%-50% Rate of death or ESRD: 60% Rate: 40%-50% THBD 60% Rate of death or ESRD: 60% Recurrence in 1 case 60% of ahus patients continued to experience complement-mediated TMA within one year following kidney transplant 2 1. Noris M et al. N Engl J Med. 2009;361: Bresin E, Daina E, Noris M et al. International Registry of Recurrent and Familial HUS/TTP. Clin J Am Soc Nephrol. 2006;1: Eculizumab Blocks Terminal Complement 1,2 Proximal Terminal Complement Cascade 2,3 C3 C3b C5 C5b C3a C5a C5b-9 Please see full prescribing information for Soliris (eculizumab). Soliris Eculizumab binds with high affinity to C5 1,2 Terminal complement C5a and C5b-9 formation blocked 1,2 Proximal functions of complement remain intact 1,2 Weak anaphylatoxin 2,4 Immune complex clearance 2 Microbial opsonization 2 1. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 2012; 2. Rother RP et al. Nature Biotech 2007;25: ; 3. Walport MJ. N Engl J Med 2001;344: ; 4. Figueroa JE, Densen P. Clin Microbiol Rev 1991;4:

19 Eculizumab Treatment Expectations In ahus Clinical Trials, Many Benefits Occurred Rapidly, While Others Occurred Over Time 1,2 1 to 2 Weeks* Increase or normalization in platelet count 1,2 Reduction or elimination of PE/PI and no new dialysis 1,2 Significant improvement in QoL 1,2 1 Month* Maintenance or improvement in renal function Increase in egfr 1,2 Reduction creatinine Decrease or normalization in microangiopathic hemolysis (as measured by LDH) 2 Ongoing Eculizumab treatment inhibits complement-mediated TMA 1,2 86% of patients in prospective studies continued in long-term extension studies 3,4 Eculizumab treatment is recommended for a patient s lifetime 1 6 Months* Maintenance or greater improvement in renal function 1,2 Hematologic normalization 1,2 >2 Years* Sustained maintenance or improvement in renal function (as measured by egfr) 3,4 Sustained hematologic normalization 3,4 Sustained reduction or elimination of PE/PI and no new dialysis 3,4 *Benefits at these time intervals were experienced by many patients but do not indicate that every patient will achieve the same results; most AEs were mild or moderate in severity. 1. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 2012; 2. European Medicines Agency. Committee for Medicinal Products for Human Use (CHMP). Assessment report: Soliris (eculizumab) procedure no.: EMEA/H/C/000791/II/0027. Published September 22, Accessed February 23, 2012; 3. Licht C et al. Presented at the 54th Annual Meeting of the American Society of Hematology, December 8, 2012, Atlanta, Georgia, USA. Abstract 985; 4. Greenbaum L et al. Presented at the 54th Annual Meeting of the American Society of Hematology, December 9, 2012, Atlanta, Georgia, USA. Abstract WARNING: SERIOUS MENINGOCOCCAL INFECTIONS Soliris (eculizumab) increases the patient s susceptibility to meningococcal infection due to its mechanism of action w To reduce the risk of infection, a tetravalent vaccine against serotypes A, C, Y and W135 (preferably conjugate), is strongly recommended to vaccinate patients at least 14 days prior to receiving the first dose of Soliris Patients less than 2 years of age or not vaccinated at least 14 days before starting treatment with Soliris must receive treatment with appropriate prophylactic antibiotics until 14 days after vaccination. Revaccinate according to current medical guidelines for vaccine use w Vaccination may not be sufficient to prevent meningococcal infection and the use of antibacterial agents may need to be considered w Monitor patients for early signs of meningococcal infection; evaluate immediately if infection is suspected and treat with antibiotics if necessary Please see full prescribing information for Soliris (eculizumab). Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; Eculizumab Multinational Clinical Program Includes Broad ahus Patient Populations in over 130 Patients 1-6 Age Duration from ahus diagnosis to study Identified genetic Complement mutations Platelet count in patients with TMA Degree of organ damage *Based on study definition. Dialysis PE/PI Renal transplant 2 Months 1 1 Day 6 None identified 2 Normal platelet count 1 CKD Stage 1 2 None 3 None 3 Adults (80 years old) Months 1 Multiple per patient 2 Reduced platelet count 1 CKD Stage 5 2 Chronic 3 No intervention 1 * 230 Interventions 1 3 Prior kidney grafts lost 3 Please see full prescribing information for Soliris (eculizumab). 1. Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; 2012; 2. Soliris (eculizumab) European Public Assessment Report. Available at [accessed December 15, 2011]; 3. Data on file. Alexion Pharmaceuticals, Inc. 4. Soliris (eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc.; Fakhouri F et al. Presented at American Society of Hematology 2013 Annual Meeting; December 8-11, 2013; New Orleans, LA. 6. Greenbaum L et al. Presented at American Society of Hematology 2013 Annual Meeting; December 8 11, 2013; New Orleans, LA. 19

20 Eculizumab Clinical Trial Data w Results from the largest prospective clinical trial of Eculizumab in adult patients with ahus and the 1 st prospective clinical trial of Eculizumab in pediatric patients with ahus 1,2 w Eculizumab demonstrated rapid and sustained improvements in hematological parameters, and continued, on-going improvement in renal function in adult patients with ahus 1,2 In both the adult and pediatric trials over 80% of patients on dialysis at baseline discontinued dialysis by week 26 1,2 w Eculizumab demonstrated effectiveness in broad patient populations 1,2 w Earlier intervention with Eculizumab therapy in adult and pediatric patients resulted in better clinical outcomes supporting recent guidelines recommending immediate treatment with Eculizumab in adults with ahus once an unequivocal diagnosis has been made 1,2,3 w 2+ year data from two pivotal Phase 2 extension studies highlights long-term benefits of Eculizumab therapy in patients with ahus 4 w Eculizumab demonstrated improvement in patients with long duration of disease (up to 286 months and up to 47 months on long term PE/PI) 5 1. Greenbaum L et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Poster SA-PO Fakhouri F et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Abstract FROR Zuber J et al. Nat Rev Nephrol Nov;8(11): Legendre CM et al. [Abstract] J Am Soc Nephrol. 2012;23 (suppl.): 89A. 5. Licht C et al. [Abstract] J Am Soc Nephrol. 2012;23 (suppl.):89a; Advances in Eculizumab Clinical Program in ahus (N=63): First Prospective Trial in Pediatrics and the Largest Prospective Trial in Adults with ahus Clinical Diagnosis of ahus With: TMA (measured by platelet count, hemolysis) Organ damage (serum creatinine ULN) ADAMTS13 >5%; no positive STEC test No requirement for identified genetic mutation No specification for PE/PI prior to enrollment* Largest Prospective Trial of Adult Patients with ahus (N=41) 18 years old Ongoing Long-Term Extension Study *In prospective pediatric trial, no more than 5 weeks of prior PE/PI. Prospective First Prospective Trial of Pediatric Patients with ahus (N=22) <18 years old Ongoing Long-Term Extension Study ADAMTS13 = A disintegrin and metalloproteinase with thrombospondin Type 1 motif, 13; CKD = chronic kidney disease; STEC = Shiga toxin-producing E. coli; ULN = upper limit of normal. 1. Soliris (eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc.; Patients who became dialysis-free 83% of Adult Patients Eliminated Dialysis with Ongoing Eculizumab Treatment 100% 80% 60% 40% 20% 0% 83% (20) 20/24 % Discontinued Dialysis *2 patients not on dialysis at BL initiated and remained on dialysis through 26 weeks. Patients on Dialysis at Baseline C w Of the 17 patients not on dialysis at baseline, 15 patients (88%) remained dialysis-free through the study evaluation period Fakhouri F et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Abstract FROR

21 C Open-label, Multi-center Clinical Trial of Eculizumab in Pediatric Patients With Atypical Hemolytic-Uremic Syndrome First Prospective Trial of Pediatric Patients with ahus ENTRY CRITERIA Clinical Diagnosis of ahus With: TMA (measured by platelet count, hemolysis) Organ damage (serum creatinine ULN) ADAMTS13 >5%; no positive STEC test No requirement for identified genetic mutation No specification for PE/PI prior to enrollment Enrolled Patients Represent Heterogeneous Pediatric Population w First-ever prospective trial of eculizumab in pediatric patients with ahus w Majority of patients received eculizumab without any prior use of PE/PI Median of 6 days from diagnosis to first dose of eculizumab 55% (12/22) of patients received no PE/PI prior to treatment with eculizumab w 73% of patients presented for screening during their first ahus manifestation w 50% (11/22) of patients on dialysis at baseline w 9% (2/22) of patients had prior kidney transplant w 55% (12/22) of patients had no identified genetic mutation Greenbaum L et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Poster SA-PO849. C Rapid and Sustained Improvement in Platelet Count with Ongoing Eculizumab Treatment 95% of Patients Achieved Platelet Count Normalization 164 x 10 9 /L: Mean Change from Baseline in Platelets at Week 27 Platelet Change from Baseline (x10 9 /L) * * * * * *P< Study Week Mean (SD) platelet count ( 10 9 /L) at baseline: 87.5 (42.34); Mean (SD) platelet count at Week 27: (66.24). Greenbaum L et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Poster SA-PO849. * * * * * C

22 Significant and Continued Improvement in egfr with Ongoing Eculizumab Treatment Gain of 64 ml/min/1.73m 2 : Mean Change from Baseline in egfr at Week 27 egfr Change from Baseline (ml/min/1.73m 2 ) # * * Mean (SD) egfr at baseline: 32.7 (30.37); Mean (SD) egfr at Week 27: 97.2 (51.78). * * * *P<0.001 # P<0.05 Study Week Greenbaum L et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Poster SA-PO849. * * * C * 82% of Children with ahus Eliminated Dialysis with Ongoing Eculizumab Treatment Patients on Dialysis at Baseline Patients who became dialysis-free 100% 80% 60% 40% 20% 0% 82% (9) 9/11 % Discontinued Dialysis *One patient discontinued dialysis during baseline window and before first dose of eculizumab. C Patients Not on Dialysis at Baseline Of the 11 patients not on dialysis at baseline, all patients (100%) remained dialysis-free through the end of the study evaluation period Greenbaum L et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Poster SA-PO849. Adverse Event Findings Were Consistent with Other Eculizumab Studies C (N=22) AEs occurring in 20% n (%) Pyrexia 11 (50) Cough 8 (36) Abdominal pain 7 (32) Diarrhea 7 (32) Upper respiratory tract infection 7 (32) Vomiting 6 (27) Nasopharyngitis 6 (27) w Most AEs were mild or moderate w No meningococcal infections w One patient was noted to have low positive values for neutralizing antibodies to eculizumab Overall, there had been no observed correlation of antibody development to clinical response or adverse events w No new reports of hepatotoxicity during eculizumab treatment w No new safety concerns Greenbaum L et al. Presented at the American Society of Nephrology Kidney Week 2013 Annual Meeting; November 5-10, 2013; Atlanta, Georgia. Poster SA-PO849 w No deaths C

23 Demonstrated Efficacy for Patients Treated with Soliris through 2 years Terminal Complement Inhibitor Eculizumab in Atypical Hemolytic Uremic Syndrome C.M. Legendre, C. Licht, P. Muus, L.A. Greenbaum, S. Babu, C. Bedrosian, C. Bingham, D.J. Cohen, Y. Delmas, K. Douglas, F. Eitner, T. Feldkamp, D. Fouque, R.R. Furman, O. Gaber, M. Herthelius, M. Hourmant, D. Karpman, Y. Lebranchu, C. Mariat, J. Menne, B. Moulin, J. Nürnberger, M. Ogawa, G. Remuzzi, T. Richard, R. Sberro-Soussan, B. Severino, N.S. Sheerin, A. Trivelli, L.B. Zimmerhackl, T. Goodship, and C. Loirat N Engl J Med 2013; 368: June 6, 2013DOI: /NEJMoa Do Identified Genetic Mutations Impact Response to Soliris? Patients Achieved Hematological Normalization Regardless of the Identification of a Genetic Complement Mutation Patients Achieved and Maintained Hematological Normalization* Through 2 Years with Ongoing Soliris TMA Event Free Status %(Patients) % (12/13) 75% (3/4) ahus Patients with Progressing TMA (Trial 1) 93% (13/14) 83% (5/6) Patients with Long Duration of ahus and CKD (Trial 2) Mutation No Mutation * Hematological Normalization defined as Normalization of platelet count and LDH over two consecutive measurements obtained at least 4 weeks (28 days) apart Please see Soliris (eculizumab) Summary of Product Characteristics. Alexion Europe SAS; Al-Akash SI et al. Presented at the 54th Annual Meeting of the American Society of Hematology, December 9, 2012, Atlanta, Georgia, USA. Abstract

24 Real World Experience Stopping Ecu: Is it Safe? ahus - Fate of Patients Who Discontinued Eculizumab Outcomes for 18 ahus Patients Discontinued from Eculizumab Trials 18 Patients Discontinued from Eculizumab* (5) Prospective Trials (13) Retrospective Trial (4) Patients (1) TMA Complication (4) TMA Complication (9) Remaining Patients (1) 1 Dose Protocol (1) Discontinued at 26 wks Violation Factor H & C3 mutations No identified mutation (3) Continued (1) 1 Dose then Stopped (1) 4 Doses then Eculizumab No identified mutation Discontinued Factor H mutation (1) Lost to (2) Continued on Eculizumab (1) 1 dose, stop; then 3 Follow-up One pt: Factor H mutation doses in < 1 wk Factor I mutation One pt: no identified mutation No identified mutation (1) Discontinued After 26 Weeks MCP mutation 5 Patients had 7 TMA Complications 4/5 with TMA Resumed Eculizumab N = 67 patients (37 prospective trials; 30 retrospective trials). Data on file. 3/5 remain on Long-term Eculizumab Treatment Other Treatments w Liver-Kidney Transplantation to Cure Atypical Hemolytic Uremic Syndrome Jeffrey M. Saland, Piero Ruggenenti, Giuseppe Remuzzi, and the Consensus Study Group. J Am Soc Nephrol. 2009;20: Results of a consensus conference in 2007 in Bergamo Complicated structure based on anecdotal experiences No subsequent analysis of algorithms proposed w Factor H concentrate May provide sufficient factor H to replace or reduce need for plasma exchange w Rituximab Has been used, with plasma exchange and corticosteroids, to treat ahus in a patient with anti factor H autoantibodies Lionet A et al. NDT Plus. 2009;2: ; Waters AM et al. Pediatr Nephrol. 2011;26:

25 Conclusions w ahus is the prototypical TMA-based disease and is characterized by the classic triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. ahus results from abnormalities in the alternative complement pathway. ahus is a systemic, chronic disease which affects many additional organs outside of an acute presentation. w The proposed diagnostic pathway allows clear delineation of a clinical syndrome. Demonstration of the genetic defect is not needed for diagnosis or initial treatment. w Historical treatments (plasma therapy and liver transplantation) directed at restoring the deficient or defective complement regulatory proteins are generally associated with temporal failure and complications. In ahus, there is no evidence that plasma alters the ultimate course of disease w Eculizumab appears efficacious and safe in over 100 patients with ahus who have been studied in a controlled fashion. ahus Registry Registry w Observational, non-interventional, multinational w Patients with a diagnosis of ahus, regardless of treatment, will be eligible for enrollment after providing written, informed consent Inclusion Criteria w Male or female patients of any age, including minors, who have been diagnosed with ahus w Diagnosis of ahus includes: Clinical diagnosis of ahus Patients with or without an identified complement regulatory factor genetic abnormality or anti-complement factor antibody ADAMTS13 >5% (if performed) Exclusion Criteria w Patients with hemolytic uremic syndrome (HUS) only due to Shiga toxin are excluded 25