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Pediatric Nephrology

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Open Access 06-12-2023 | Hemolytic Uremic Syndrome | Systematic Review/Meta-analysis

Eculizumab in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome: a systematic review

Authors: Paul L. de Zwart, Thomas F. Mueller, Giuseppina Spartà, Valerie A. Luyckx

Published in: Pediatric Nephrology | Issue 5/2024

Abstract

Background

Infection-associated hemolytic uremic syndrome (IA-HUS), most often due to infection with Shiga toxin-producing bacteria, mainly affects young children. It can be acutely life-threatening, as well as cause long-term kidney and neurological morbidity. Specific treatment with proven efficacy is lacking. Since activation of the alternative complement pathway occurs in HUS, the monoclonal C5 antibody eculizumab is often used off-label once complications, e.g., seizures, occur. Eculizumab is prohibitively expensive and carries risk of infection. Its utility in IA-HUS has not been systematically studied. This systematic review aims to present, summarize, and evaluate all currently available data regarding the effect of eculizumab administration on medium- to long-term outcomes (i.e., outcomes after the acute phase, with a permanent character) in IA-HUS.

Methods

PubMed, Embase, and Web of Science were systematically searched for studies reporting the impact of eculizumab on medium- to long-term outcomes in IA-HUS. The final search occurred on March 2, 2022. Studies providing original data regarding medium- to long-term outcomes in at least 5 patients with IA-HUS, treated with at least one dose of eculizumab during the acute illness, were included. No other restrictions were imposed regarding patient population. Studies were excluded if data overlapped substantially with other studies, or if outcomes of IA-HUS patients were not reported separately. Study quality was assessed using the ROBINS-I tool for risk of bias in non-randomized studies of interventions. Data were analyzed descriptively.

Results

A total of 2944 studies were identified. Of these, 14 studies including 386 eculizumab-treated patients met inclusion criteria. All studies were observational. Shiga toxin-producing E. coli (STEC) was identified as the infectious agent in 381 of 386 patients (98.7%), effectively limiting the interpretation of the data to STEC-HUS patients. Pooling of data across studies was not possible. No study reported a statistically significant positive effect of eculizumab on any medium- to long-term outcome. Most studies were, however, subject to critical risk of bias due to confounding, as more severely ill patients received eculizumab. Three studies attempted to control for confounding through patient matching, although residual bias persisted due to matching limitations.

Discussion

Current observational evidence does not permit any conclusion regarding the impact of eculizumab in IA-HUS given critical risk of bias. Results of randomized clinical trials are eagerly awaited, as new therapeutic strategies are urgently needed to prevent long-term morbidity in these severely ill patients.

Systematic review registration number

OSF Registries, MSZY4, Registration DOI https://doi.org/10.17605/OSF.IO/MSZY4.

Available only for authorised users

Various definitions of HUS and its subcategories are in use in the scientific literature, which can be confusing. Some scholars define ‘typical HUS’ as STEC-HUS, and ‘aHUS’ as all other types of HUS, including non-STEC infectious HUS. Others define ‘aHUS’ as complement-mediated HUS. We use the term ‘HUS’ to describe types of TMA that primarily involve acute kidney injury. We prefer using causative terminology for subcategories, differentiating infection-associated HUS (IA-HUS), which includes STEC-HUS as well as HUS associated with other infections, from complement-mediated HUS (CM-HUS) and other types of HUS. Other types of TMA that are not primarily associated with kidney injury, such as thrombotic thrombocytopenic purpura (TTP), are not classified as HUS and not further considered in this article.

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Title: Eculizumab in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome: a systematic review
Authors: Paul L. de Zwart
Thomas F. Mueller
Giuseppina Spartà
Valerie A. Luyckx
Publication date: 06-12-2023
Publisher: Springer Berlin Heidelberg
Keyword: Hemolytic Uremic Syndrome
Published in: Pediatric Nephrology / Issue 5/2024
Print ISSN: 0931-041X
Electronic ISSN: 1432-198X
DOI: https://doi.org/10.1007/s00467-023-06216-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Eculizumab in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome: a systematic review

Abstract

Background

Methods

Results

Discussion

Systematic review registration number

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Discussion

Systematic review registration number

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