Волчаночный нефрит (ВН) является одним из наиболее частых среди органных проявлений системной красной волчанки (СКВ). Его различные клинические признаки развиваются не менее чем у 50% больных СКВ. Помимо ВН в спектр ассоциированных с СКВ вариантов поражения почек входит и сосудистая патология. Одним из вариантов поражения микроциркуляторного русла почек является тромботическая микроангиопатия (ТМА), механизмы развития которой разнообразны. Обзор посвящен основным формам ТМА, включая антифосфолипидный синдром и нефропатию, ассоциированную с антифосфолипидным синдромом, ТМА, обусловленную нарушениями регуляции системы комплемента и дефицитом ADAMTS13. В большинстве случаев эти формы ТМА сочетаются с ВН, однако могут существовать и как единственные варианты поражения почек. Обсуждаются вопросы патогенеза, влияние ТМА на почечный прогноз и подходы к лечению.
Lupus nephritis (LN) is one of the most common organ-specific manifestations of systemic lupus erythematosus (SLE). Various clinical signs of LN develop in at least 50% of patients with SLE. In addition to LN, the spectrum of renal lesions associated with SLE also includes vascular pathology. One of the variants of renal microvascular injury is thrombotic microangiopathy (TMA), the mechanisms of which are diverse. The review focuses on the main forms of TMA, including antiphospholipid syndrome and nephropathy associated with antiphospholipid syndrome, TMA caused by complement system regulation disorders and deficiency of ADAMTS13. In most cases, these forms of TMA are combined with LN. However, they may also exist as a single form of kidney damage. This article discusses the TMA pathogenesis, the impact on kidney prognosis, and treatment options.
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24. Krone KA, Allen KL, McCrae KR. Impaired fibrinolysis in the antiphospholipid syndrome. Curr Rheumatol Rep. 2010;12(1):53-7. DOI:10.1007/s11926-009-0075-4
25. Antovic A, Bruzelius M. Impaired Fibrinolysis in the Antiphospholipid Syndrome. Semin Thromb Hemost. 2021;47(5):506-11. DOI:10.1055/s-0041-1725098
26. Canaud G, Bienaimé F, Tabarin F, et al. Inhibition of the mTORC pathway in the antiphospholipid syndrome. N Engl J Med. 2014;371(4):303-12. DOI:10.1056/NEJMoa1312890
27. Timmermans SAMEG, Damoiseaux JGMC, Reutelingsperger CP, van Paassen P. More about complement in the antiphospholipid syndrome. Blood. 2020;136(12):1456-9. DOI:10.1182/blood.2020005171
28. Козловская Н.Л., Шилов Е.М., Метелева Н.А., и др. Клинические и морфологические особенности волчаночного нефрита при системной красной волчанке с антифосфолипидным синдромом. Терапевтический архив. 2006;78(5):21-31 [Kozlovskaia NL, Shilov EM, Meteleva NA, et al. Clinical and morphological characteristics of lupus nephritis in systemic lupus erythematosus with antiphospholipid syndrome. Terapevticheskii Arkhiv (Ter. Arkh.). 2006;78(5):21-31 (in Russian)].
29. Gerhardsson J, Sundelin B, Zickert A, et al. Histological antiphospholipid-associated nephropathy versus lupus nephritis in patients with systemic lupus erythematosus: an observational cross-sectional study with longitudinal follow-up. Arthritis Res Ther. 2015;17(1):109. DOI:10.1186/s13075-015-0614-5
30. Praga M, Rodríguez de Córdoba S. Secondary atypical hemolytic uremic syndromes in the era of complement blockade. Kidney Int. 2019;95(6):1298-300. DOI:10.1016/j.kint.2019.01.043
31. Palma LMP, Sridharan M, Sethi S. Complement in Secondary Thrombotic Microangiopathy. Kidney Int Rep. 2021;6(1):11-23. DOI:10.1016/j.ekir.2020.10.009
32. Park MH, Caselman N, Ulmer S, Weitz IC. Complement-mediated thrombotic microangiopathy associated with lupus nephritis. Blood Adv. 2018;2(16):2090-4. DOI:10.1182/bloodadvances.2018019596
33. Figueiredo CR, Escoli R, Santos P, et al. Thrombotic microangiopathy in a patient with systemic lupus erythematosus and anti-factor H autoantibodies. CEN Case Rep.
2022;11(1):26-30. DOI:10.1007/s13730-021-00627-5
34. Łukawska E, Polcyn-Adamczak M, Niemir ZI. The role of the alternative pathway of complement activation in glomerular diseases. Clin Exp Med. 2018;18(3):297-318. DOI:10.1007/s10238-018-0491-8
35. Cavero T, Rabasco C, López A, et al. Eculizumab in secondary atypical haemolytic uraemic syndrome. Nephrol Dial Transplant. 2017;32(3):466-74. DOI:10.1093/ndt/gfw453
36. Kidney Disease: Improving Global Outcomes (KDIGO) Lupus Nephritis Work Group. “KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int. 2024;105(1S):S1-69. DOI:10.1016/j.kint.2023.09.002
37. Mancini I, Ferrari B, Valsecchi C, et al. ADAMTS13-specific circulating immune complexes as potential predictors of relapse in patients with acquired thrombotic thrombocytopenic purpura. Eur J Intern Med. 2017;39:79-83. DOI:10.1016/j.ejim.2016.11.003
38. Turner N, Sartain S, Moake J. Ultralarge von Willebrand factor-induced platelet clumping and activation of the alternative complement pathway in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndromes. Hematol Oncol Clin N Am. 2015;29. DOI:10.1016/j.hoc.2015.01.008
39. Yue C, Su J, Gao R, et al. Characteristics and Outcomes of Patients with Systemic Lupus Erythematosus-associated Thrombotic Microangiopathy, and Their Acquired ADAMTS13 Inhibitor Profiles. J Rheumatol. 2018;45(11):1549-56. DOI:10.3899/jrheum.170811
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________________________________________________
1. Klinicheskie rekomendatsii. Diagnostika i lechenie volchanochnogo nefrita. Moscow, 2021. Available at: https://rusnephrology.org/wpcontent/uploads/2021/02/lupus.pdf. Accessed: 16.02.2024 (in Russian).
2. Hanly JG, O’Keeffe AG, Su L, et al. The frequency and outcome of lupus nephritis: results from an international inception cohort study. Rheumatology (Oxford). 2016;55(2):252-62. DOI:10.1093/rheumatology/kev311
3. Bobkova IN, Moiseev SV, Lysenko LV, Kamyshova ES. Lupus nephritis in the XXI century. Terapevticheskii Arkhiv (Ter. Arkh.). 2022;94(6):713-7 (in Russian). DOI:10.26442/00403660.2022.06.201559
4. Tektonidou MG, Dasgupta A, Ward MM. Risk of End-Stage Renal Disease in Patients with Lupus Nephritis, 1971-2015: A Systematic Review and Bayesian Meta-Analysis. Arthritis Rheumatol. 2016;68(6):1432-41. DOI:10.1002/art.39594
5. Wu LH, Yu F, Tan Y, et al. Inclusion of renal vascular lesions in the 2003 ISN/RPS system for classifying lupus nephritis improves renal outcome predictions. Kidney Int.
2013;83(4):715-23. DOI:10.1038/ki.2012.409
6. Mejía-Vilet JM, Córdova-Sánchez BM, Uribe-Uribe NO, et al. Prognostic significance of renal vascular pathology in lupus nephritis. Lupus. 2017;26(10):1042-50. DOI:10.1177/0961203317692419
7. Moake JL. Thrombotic microangiopathies. N Engl J Med. 2002;347(8):589-600. DOI:10.1056/NEJMra020528
8. Kozlovskaya NL, Dobronravov VA, Bobrova LA, et al. Clinical guidelines for the management of adult patients with atypical hemolytic-uremic syndrome. Nephrology and Dialysis. 2023;25(4): 465-92 (in Russian). DOI:10.28996/2618-9801-2023-4-465-492
9. Solovyev SK, Kozlovskaya NL, Aseeva EA, et al. Lupus nephritis – modern aspects of diagnosis and therapy. Part I. Rheumatology Science and Practice. 2024;62(1):55-64 (in Russian). DOI:10.47360/1995-4484-2024-55-64
10. Kotzen ES, Roy S, Jain K. Antiphospholipid Syndrome Nephropathy and Other Thrombotic Microangiopathies Among Patients With Systemic Lupus Erythematosus. Adv Chronic Kidney Dis. 2019;26(5):376-86. DOI:10.1053 /j.ackd. 2019.08.012
11. Song D, Wu LH, Wang FM, et al. The spectrum of renal thrombotic microangiopathy in lupus nephritis. Arthritis Res Ther. 2013;15(1):R12. DOI:10.1186/ar4142
12. Barrera-Vargas A, Rosado-Canto R, Merayo-Chalico J, et al. Renal Thrombotic Microangiopathy in Proliferative Lupus Nephritis: Risk Factors and Clinical Outcomes: A Case-Control Study. J Clin Rheumatol. 2016;22(5):235-40. DOI:10.1097/RHU.0000000000000425
13. Strufaldi FL, Menezes Neves PDMM, Dias CB, et al. Renal thrombotic microangiopathy associated to worse renal prognosis in Lupus Nephritis. J Nephrol. 2021;34(4):1147-56. DOI:10.1007/s40620-020-00938-3
14. Ding Y, Tan Y, Qu Z, Yu F. Renal microvascular lesions in lupus nephritis. Renal Failure. 2020;42(1):19-29. DOI:10.1080/0886022X.2019.1702057
15. Chua JS, Baelde HJ, Zandbergen M, et al. Complement Factor C4d Is a Common Denominator in Thrombotic Microangiopathy. JASN. 2015;26(9):2239-47. DOI:10.1681/ASN.2014050429
16. Babar F, Cohen SD. Thrombotic Microangiopathies with Rheumatologic Involvement. Rheum Dis Clin North Am. 2018;44(4):635-49. DOI:10.1016/j.rdc.2018.06.010
17. Scully M, Cataland S, Coppo P, et al. Consensus on the standardization of terminology in thrombotic thrombocytopenic purpura and related thrombotic microangiopathies. J Thromb Haemost. 2017;15(2):312-22. DOI:10.1111/jth.13571
18. Reshetnyak TM. Antiphospholipid syndrome: diagnosis and clinical manifestations (a lecture). Rheumatology Science and Practice. 2014;52(1):56-71 (in Russian). DOI:10.14412/1995-4484-2014-56-71
19. Tektonidou MG, Sotsiou F, Nakopoulou L, et al. Antiphospholipid syndrome nephropathy in patients with systemic lupus erythematosus and antiphospholipid antibodies: prevalence, clinical associations, and long-term outcome. Arthritis Rheum. 2004;50(8):2569-79. DOI:10.1002/art.20433
20. Rodríguez-Pintó I, Moitinho M, Santacreu I, et al. Catastrophic antiphospholipid syndrome (CAPS): Descriptive analysis of 500 patients from the International CAPS Registry. Autoimmun Rev. 2016; 15(12):1120-4. DOI:10.1016/j.autrev.2016.09.010
21. Demyanova KA, Kozlovskaya NL, Bobrova LA, Kuchieva AM. Multiple organ failure in acute thrombotic microangiopathies. Nephrology and dialysis. 2013;15(4):368. Available at: https://journal.nephro.ru/index.php?r=journal/articleView&articleId=520. Accessed: 22.03.2024 (in Russian).
22. Barbhaiya M, Zuily S, Naden R, et al. 2023 ACR/EULAR antiphospholipid syndrome classification criteria. Ann Rheum Dis. 2023;82(10):1258-70. DOI:10.1136/ard-2023-224609
23. Domingues V, Chock EY, Dufrost V, et al. Increased risk of acute and chronic microvascular renal lesions associated with antiphospholipid antibodies in patients with systemic lupus erythematosus: A systematic review and meta-analysis. Autoimmun Rev. 2022;21(10):103158. DOI:10.1016/j.autrev.2022.103158
24. Krone KA, Allen KL, McCrae KR. Impaired fibrinolysis in the antiphospholipid syndrome. Curr Rheumatol Rep. 2010;12(1):53-7. DOI:10.1007/s11926-009-0075-4
25. Antovic A, Bruzelius M. Impaired Fibrinolysis in the Antiphospholipid Syndrome. Semin Thromb Hemost. 2021;47(5):506-11. DOI:10.1055/s-0041-1725098
26. Canaud G, Bienaimé F, Tabarin F, et al. Inhibition of the mTORC pathway in the antiphospholipid syndrome. N Engl J Med. 2014;371(4):303-12. DOI:10.1056/NEJMoa1312890
27. Timmermans SAMEG, Damoiseaux JGMC, Reutelingsperger CP, van Paassen P. More about complement in the antiphospholipid syndrome. Blood. 2020;136(12):1456-9. DOI:10.1182/blood.2020005171
28. Kozlovskaia NL, Shilov EM, Meteleva NA, et al. Clinical and morphological characteristics of lupus nephritis in systemic lupus erythematosus with antiphospholipid syndrome. Terapevticheskii Arkhiv (Ter. Arkh.). 2006;78(5):21-31 (in Russian).
29. Gerhardsson J, Sundelin B, Zickert A, et al. Histological antiphospholipid-associated nephropathy versus lupus nephritis in patients with systemic lupus erythematosus: an observational cross-sectional study with longitudinal follow-up. Arthritis Res Ther. 2015;17(1):109. DOI:10.1186/s13075-015-0614-5
30. Praga M, Rodríguez de Córdoba S. Secondary atypical hemolytic uremic syndromes in the era of complement blockade. Kidney Int. 2019;95(6):1298-300. DOI:10.1016/j.kint.2019.01.043
31. Palma LMP, Sridharan M, Sethi S. Complement in Secondary Thrombotic Microangiopathy. Kidney Int Rep. 2021;6(1):11-23. DOI:10.1016/j.ekir.2020.10.009
32. Park MH, Caselman N, Ulmer S, Weitz IC. Complement-mediated thrombotic microangiopathy associated with lupus nephritis. Blood Adv. 2018;2(16):2090-4. DOI:10.1182/bloodadvances.2018019596
33. Figueiredo CR, Escoli R, Santos P, et al. Thrombotic microangiopathy in a patient with systemic lupus erythematosus and anti-factor H autoantibodies. CEN Case Rep.
2022;11(1):26-30. DOI:10.1007/s13730-021-00627-5
34. Łukawska E, Polcyn-Adamczak M, Niemir ZI. The role of the alternative pathway of complement activation in glomerular diseases. Clin Exp Med. 2018;18(3):297-318. DOI:10.1007/s10238-018-0491-8
35. Cavero T, Rabasco C, López A, et al. Eculizumab in secondary atypical haemolytic uraemic syndrome. Nephrol Dial Transplant. 2017;32(3):466-74. DOI:10.1093/ndt/gfw453
36. Kidney Disease: Improving Global Outcomes (KDIGO) Lupus Nephritis Work Group. “KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int. 2024;105(1S):S1-69. DOI:10.1016/j.kint.2023.09.002
37. Mancini I, Ferrari B, Valsecchi C, et al. ADAMTS13-specific circulating immune complexes as potential predictors of relapse in patients with acquired thrombotic thrombocytopenic purpura. Eur J Intern Med. 2017;39:79-83. DOI:10.1016/j.ejim.2016.11.003
38. Turner N, Sartain S, Moake J. Ultralarge von Willebrand factor-induced platelet clumping and activation of the alternative complement pathway in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndromes. Hematol Oncol Clin N Am. 2015;29. DOI:10.1016/j.hoc.2015.01.008
39. Yue C, Su J, Gao R, et al. Characteristics and Outcomes of Patients with Systemic Lupus Erythematosus-associated Thrombotic Microangiopathy, and Their Acquired ADAMTS13 Inhibitor Profiles. J Rheumatol. 2018;45(11):1549-56. DOI:10.3899/jrheum.170811
40. George JN, Nester CM. Syndromes of thrombotic microangiopathy. N Engl J Med. 2014;371:654-66. DOI:10.1056/NEJMra1312353
41. Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. Treatment of thrombotic thrombocytopenic purpura. Terapevticheskii Arkhiv (Ter. Arkh.). 2021;93(6):736-45 (in Russian). DOI:10.26442/00403660.2021.06.200894
42. Saha M, McDaniel JK, Zheng XL. Thrombotic thrombocytopenic purpura: pathogenesis, diagnosis and potential novel therapeutics. J Thromb Haemost. 2017;15(10):1889-900. DOI:10.1111/jth.13764
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Авторы
Л.А. Боброва*1, Н.Л. Козловская2,3
1ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия; 2ФГАОУ ВО «Российский университет дружбы народов им. Патриса Лумумбы», Москва, Россия; 3ГБУЗ г. Москвы «Городская клиническая больница им. А.К. Ерамишанцева» Департамента здравоохранения г. Москвы, Москва, Россия
*bobrova_l_a@staff.sechenov.ru
________________________________________________
Larisa A. Bobrova*1, Natalia L. Kozlovskaya2,3
1Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; 2Patrice Lumumba People’s Friendship University of Russia, Moscow, Russia; 3Yeramishantsev City Clinical Hospital, Moscow, Russia
*bobrova_l_a@staff.sechenov.ru