Introduction
Methods
Databases and search strategy
Selection criteria
Study selection, data extraction, and quality assessment
Data analysis
Results
Extracted data
Study | Study population | Study design | Indication(s) for eculizumab | N of patientsf with/without eculizumab | N of patients who died | N of patients with medium- to long-term kidney damage | N of patients with medium- to long-term neurological damage | Other relevant outcomes |
---|---|---|---|---|---|---|---|---|
Pape et al. 2015 [27] | Pediatric patients with STEC-HUS with neurological symptoms treated with eculizumab | R | Evident neurological symptoms in the presence of active HUS | 11 | 1/11 | Long-term dialysis in 0/10 survivors | Severe neurological dysfunction in 1/10 survivors (NFS); only subjective deficits in 1/10 survivors (reduced performance regarding concentration and speed of mental processing), no permanent damage in 8/10 survivors | None |
None | ||||||||
Muff-Luett et al. 2021 [28] | Patients ≤ 25 years old with STEC-HUS or non-STEC infection-related TMA treated with eculizumaba | R | Neurologic impairment in 43.4%, risk of death in 13%, other less common indications are not mentioned | 23 | 2/23 | Dialysis in 3/21 survivors (all with STEC-HUS), eGFR median increase of 73.3 (86.4) at follow-up compared to initiation of eculizumab in STEC-HUS (non-STEC infectious HUS) patients | No information | None |
None | ||||||||
Percheron et al. 2018 [29] | Pediatric patients with severeb STEC-HUS or D + HUS treated with eculizumab | R | Neurologic involvement in 20/33, cardiac and neurologic involvement in 8/33, cardiac involvement in 2/33, digestive involvement in 3/33 | 33 | 4/33 | Dialysis in 0/29 survivors, eGFR below 60 in 12/29, significant proteinuria or microalbuminuria in 9/29 | Neurologic sequelae in 5/29 survivors (behavioral disorders, delayed acquisitions, hypotonia, extrapyramidal syndrome, spasticity, and dystonia) | Pancreatic involvement in 4/33 |
None | ||||||||
Costigan et al. 2022 [30] | Pediatric patients (≤ 16 years old) with STEC-HUS with neurological involvementc | R | ‘Severe disease’ (not defined) combined with plasma exchange not being practical, not effective or overwhelming multi-system involvement | 8 | 1/8~ | No informationl | Mild impairment in 1/7~ survivors (difficulty with complex motor tasks) | None |
14 | 0/14~ | No informationl | Mild impairment in 1/14~ (dysarthria, mild weakness) | None | ||||
Travert et al. 2021 [31] | Adult patients (≥ 18 years old) with STEC-HUS | R | Not explicitly mentioned; patients treated with eculizumab had more often dialysis, and more often stroke, coma, or convulsions | 38 | 5/38− | Duration of dialysis > 90 days in 1/22~m | Neurological sequelae in 4/14~m (NFS) | None |
58 | 14/58−j | Duration of dialysis > 90 days in 3/20~m | Neurological sequelae in 4/11~m (NFS) | None | ||||
Monet-Didailler et al. 2020 [32] | Pediatric patients (< 15 years old) with STEC-HUS treated with eculizumab, plus a historical untreated control group | R | Severe acute neurological involvement in 10/18 (with cardiac involvement in 4 of them), increasing hemolysis requiring transfusions and the need for kidney replacement therapy in 5/18, severe acute pancreatitis in 2/18, treatment in the context of an outbreak without severe symptoms in 1/18 | 18 | 0/18~ | Decreased eGFR in 5/18−, proteinuria in 3/18−, prevalence of high blood pressure requiring treatment 17%− | Neurological sequelae in 5/18* (psychomotor delay with language and walking acquisition delay, strabismus, moderate motor impairment) | Other sequelae in 0/18 |
36 g | 0/36~ | Decreased eGFR in 14/36−, proteinuria in 10/36−, prevalence of high blood pressure requiring treatment 11%− | Neurological sequelae in 1/36* (psychomotor delay and attention deficit disorder) | Other sequelae in 1/36 (pancreatic pseudocysts) | ||||
Ağbaş et al. 2018 [33] | Pediatric patients with STEC-HUS from a single outbreak requiring kidney replacement therapyc | R | Multi-organ failure in 2/9e, severe hematologic involvement in 5/9e, prolonged anuria in 2/9e, neurological involvement in 1/9e, gastro-intestinal bleeding/involvement in 3/9e, AKI-anuria in 1/9e, suspicion of complement factor H mutation in 1/9e | 8 | 1/8~ | Proteinuria 4/5−m, eGFR 109−m, hypertension 1/5−m | Neurological sequelae in 0/5~m | None |
11 | 0/11~ | Proteinuria 3/9−m, eGFR 81−m, hypertension 1/9−m | Neurological sequelae in 0/9~m | None | ||||
Kielstein et al. 2012 [34] | Adult patients with STEC-HUS from a single outbreak treated with therapeutic plasma exchangec | R | No information | 193 | 5/193− | Dialysis requirement in 9/193−, median creatinine 1.4 mg/dL* | Severe neurological disorders in 5/193− (seizures) (-) | None |
241 | 9/241−j | Dialysis requirement in 9/241−, median creatinine 1.2 mg/dL* (p = 0.013) | Severe neurological disorders in 1/241− (seizures) | None | ||||
Giordano et al. 2019 [35] | Pediatric patients with STEC-HUS with central nervous system involvementc | R | Severe CNS involvement | 5 | 0/5 k~ | Chronic kidney failure requiring a dialysis-transplant program in 1/5~ | Neurologic sequelae in 1/5~ (NFS) | None |
7 | 0/7~ | Chronic kidney failure requiring a dialysis-transplant program in 0/7~ | Neurologic sequelae in 0/7~ (NFS) | None | ||||
Gitiaux et al. 2013 [36] | Pediatric patients with STEC-HUS with neurological impairmentd treated early (< 10 days) with eculizumab | P | Severity of the condition in 5/7 patients, ineffectiveness of initial plasma exchange in 2/7 | 7 | 2/7 | Proteinuria in 3/5 survivors, mild kidney failure in 1/5 | Neurological sequelae in 0/5 survivors | Persistent diabetes mellitus due to HUS-related pancreas injury in 1/7 |
None | ||||||||
Loos et al. 2017 [37] | Pediatric patients with STEC-HUS from a single outbreak | R | HUS, neurological symptoms and prolonged dialysis with slow recovery of kidney function | 13 (of which 1 LTFUh) | 1/13 h~ | Kidney transplantation/dialysis in 2/11~m, median serum creatinine 0.70−mn, proteinuria in 3/10−m, hypertension in 4/11−m. In analyses not shown, eculizumab treatment was not associated with CKD stage ≥ 2 | No informationl | None |
77 (of which 16 LTFU) | 0/77~ | Kidney transplantation/dialysis in 0/61~m, median serum creatinine 0.66−m, proteinuria in 16/59−m, hypertension in 10/61−m. In analyses not shown, eculizumab treatment was not associated with CKD stage ≥ 2 | No informationl | None | ||||
Ullrich et al. 2013 [38] | Patients with diarrhea, positive stool testing for EHEC, and/or signs of HUS during a single outbreak treated with eculizumaba | P | Severe neurological complications refractory to standard plasma-separation | 7 | No informationl | No informationl | No informationl | Benefit from eculizumab treatment regimen (not explicitly defined) in 0/7 |
Nonei | ||||||||
Netti et al. 2020 [22] | Pediatric patients (< 18 years old) with STEC-HUS with neurological involvement and tested C3 levels at admissionc | R | Severe CNS involvement | 10 | 1/10 k~ | No information | No information | None |
9 | 0/9~ | |||||||
Sellier-Leclerc et al. 2012 [39] | Pediatric patients with STEC-HUS | P | Not explicitly mentioned; patients treated with eculizumab were substantially more often in need of kidney replacement therapy | 12 | 0/12~ | Kidney failure in 0/12~ | No information | None |
68 | 0/68~ | Kidney failure in 0/68~ |
Quality assessment of studies
Study | Travert et al. 2021 [31] | Monet-Didailler et al. 2020 [32] | Kielstein et al. 2012 [34] |
---|---|---|---|
Matching type | Propensity score matching | No information, most likely exact matching | Propensity score matching |
Variables used for matching | Age, age-weighted Charlson comorbidity index, immune-deficiency, dialysis, stroke, coma or convulsions, TPE | Age, sex, presence of anuric acute kidney injury | Body weight, grade of neurologic symptoms, dialysis |
Potential confounders not used for matching | Lab values, requirement of some other treatments than dialysis or TPE (i.e., ICU treatment, RBC transfusions etc.) | Lab values other than those indicating acute kidney injury, non-kidney complications, comorbidity, requirement of certain treatments (i.e., ICU treatment, RBC transfusions etc.) | Age, comorbidity, lab values, requirement of other treatments than dialysis or TPE (i.e., ICU treatment, RBC transfusions, etc.) |
Formulation of propensity score model | Logistic model | Not applicable | Logistic model |
Matching parameters | Nearest-neighbor method, caliper index equal to 0.3, 1:1 matching | 1:2 matching, no additional information provided | 1:1 matching with size of caliper adapted to achieve non-significant difference of covariates between the treatment and control groups |
Propensity score overlap presented? | Yes | Not applicable | No |
How much of the data was discarded due to non-matching? | 8/38 patients from the treatment group with relatively high propensity scores were removed from the matching analysis | No discarded data | 34/193 patients from the treatment group were removed from the matching analysis (no information provided about the reason) |
Were treatment and control groups balanced according to the methods used in the respective study? | Matching variables: yes (no statistically significant differences between the matched groups) Variables not used for matching: no analysis performed | Matching variables: yes (no statistically significant differences between the matched groups) Variables not used for matching: no (patients in treatment group had significantly more neurological manifestations (55% (10/18) vs. 25% (9/36), p = 0.02) | Matching variables: yes (no statistically significant differences between the matched groups) Variables not used for matching: no analysis performed |
Outcome variable(s) | Survival | Kidney outcomes: prevalence of decreased eGFR, proteinuria and high blood pressure requiring treatment at last follow-up Non-kidney outcomes: prevalence of non-kidney sequelae at > 1 year of follow-up | Survival |
Conclusion after matching | Survival: no statistically significant difference between matched treatment and control groups (13.3% (4/30) vs. 23.3% (7/30) died, p = 0.51) | Kidney outcomes: no statistically significant difference between matched treatment and control groups (see Table 1 for the data) Non-kidney outcomes: statistically significantly higher prevalence of non-kidney sequelae in matched treatment group compared to control group (28% (5/18) vs. 6% (2/36), p = 0.02), reflecting the unbalance in the neurological presentation in the matched sample | Survival: no statistically significant difference between matched treatment and control groups (no further data provided) |