European Congress of Pathology: Helsinki, 31st August 2011

Complement activation and its relation to the

kidney

Matthew Pickering
Centre for Complement and Inflammation Research
Overview
 Complement biology: lessons from nature
 complement deficiency states

 Complement regulation and the kidney

 C3 glomerulopathies
 Dense deposit disease
 CFHR5 nephropathy
 Atypical haemolytic uraemic syndrome

 Complement therapeutics
 eculizumab
Complement activation
Bacterial
immune complexes ‘always on’
Carbohydrate, ficolins

classical pathway lectin pathway alternative pathway

C3
C5a
C4b2a C3bBb

C5 activation
C3b Factor B
Factor D

MAC C3b C3b C3b C3b

FOREIGN SURFACE ‘Alternative pathway C3
amplification loop’
Complement function
‘safe’ disposal of immune
complexes and apoptotic cells

classical pathway lectin pathway alternative pathway

C3
C5a
C4b2a C3bBb
anaphylatoxin
C5 activation
C3b Factor B
Factor D
opsonization
MAC C3b C3b C3b C3b leucocyte activation
FOREIGN SURFACE
Membrane damage augment antibody
Cell lysis response
Complement regulation
C1 inhibitor

C4bp C1 inhibitor Factor H

classical pathway lectin pathway alternative pathway

C3

C4b2a C3bBb

C3b Factor H
Factor I

iC3b C3b Factor I

MAC
DAF
CD59 CD46 CR1 (CD55)
iC3b
DAF – decay-accelerating factor
The factor H family
1q 1p

Regulators of complement
activation gene cluster
(RCA)
200Kb

1q32

CFH CFHR3 CFHR1 CFHR4 CFHR2 CFHR5

The factor H family

Deletion homozygotes: African American 16%

Hageman et al, Ann. Medicine 2006 European Americans 4.7%
Disorders of complement

‘too little’ complement

Activation protein Tell us what might

deficiency happen if we
therapeutically inhibit
complement

‘too much’
complement’

Regulatory protein
deficiency Provide diseases in
which complement
inhibiting therapies
ought to be effective
Complement activation protein deficiency
Classical pathway C3 Terminal pathway

Infection

Recurrent infection with encapsulated bacteria Recurrent Neisseria

e.g. pneumococci, Haemophilus influenzae infections

SLE-like illness Vasculitis,

glomerulonephritis
Complement dysregulation and disease:
 Physiological control of complement activation

REGULATORS ACTIVATORS

Loss of function Gain of function

The balance is influenced by mutations (extreme) and

and/or polymorphisms (‘fine tuning’)
 Complement dysregulation and disease:

C1 inhibitor deficiency Terminal pathway Alternative pathway

dysregulation dysregulation
[classical pathway dysregulation]

renal thrombotic microangiopathy

Atypical haemolytic
uraemic syndrome

Hereditary angioedema Paroxysmal nocturnal

haemoglobinuria

Dense deposit disease,

C1 inhibitor deficiency - treatment
C1 inhibitor concentrates
C1 inhibitor deficiency

Viro Pharma

Berinert™
CSL Behring

Recombinant C1 inhibitor

Rhucin™
Hereditary angioedema Pharming
Paroxysmal nocturnal haemoglobinuria
Humanised anti-C5 antibody
Terminal pathway
dysregulation

Paroxysmal nocturnal
haemoglobinuria Eculizumab - Soliris™
Alexion Pharmaceuticals
Paroxysmal nocturnal haemoglobinuria
 Pathogenesis of haemolysis:
 CD59 deficiency results in uncontrolled terminal pathway activation
and formation of membrane attack complex  cell lysis

CD59

DAF Charles Parker, Lancet, 2009, vol. 373, pp759-67.

DAF – decay-accelerating factor

Paroxysmal nocturnal haemoglobinuria
Humanised monoclonal antibody against complement C5

‘always on’

eculizumab

alternative pathway
C3
C5a
C3bBb

C5 activation
C3b Factor B
Factor D

MAC C3b C3b C3b C3b ‘Alternative pathway C3

PNH-RED CELL SURFACE amplification loop’
Paroxysmal nocturnal haemoglobinuria
 Eculizumab
 Clinical trials shown to reduce transfusion requirements
 Drug is safe and well-tolerated Hillmen et al, Blood, 2007, vol. 110, pp4123-28.
 Side-effects:
 Increased risk of Neisserial infections
 patients must be immunised before starting treatment
 May reveal additional mechanisms of anaemia
 Allows accumulation of C3 on PNH-red cell
 In some patients this results in extra-vascular haemolysis and may result in eculizumab
resistance Risitano et al, Blood, 2009, vol. 113, pp4094-4100.

 Not ideal – indiscriminate C5 blockade rather than targeting to surface

of PNH-red cell
 Expensive!
 One year treatment - £252,000 per patient……
Alternative pathway dysregulation and disease
 It is associated with renal disease:

‘protective’ and ‘at risk’

polymorphisms

common

mutations

rare

Atypical haemolytic Dense deposit disease

uraemic syndrome
Dense deposit disease
 Electron-dense transformation of the glomerular basement
membrane

Glomerular C3 staining in DDD

DDD retinopathy
Dense deposit disease
 Heterogeneous light microscopic appearances
 Patrick Walker et al., Modern Pathology, 20; 605-16, 2007

25% 18%

Membranoproliferative Crescentic

45% 12%
Mesangial proliferation Acute proliferative & exudative
C3 glomerulopathy
 Glomerular pathology associated with deposition of complement C3
in the absence of immunoglobulins

Dense deposit disease

CFHR5 nephropathy
Dense deposit disease
 Impaired plasma regulation

ACTIVATION 

REGULATION 

Loss of function Gain of function

FACTOR H C3

plasma regulation

surface recognition
Dense deposit disease
 Impaired plasma regulation plasma regulation

surface recognition

C3 nephritic factor

C3

C3bBb Factor H

C3b B, D

Anti-factor H
Models of ‘dense deposit disease’
 Animal models:
 Spontaneous porcine factor H deficiency and gene-targeted factor H-deficient
mice

 Profound plasma C3 depletion – 5% of normal C3 levels

 Spontaneous renal disease – ‘murine/porcine DDD’

600

Plasma C3 - mg/l
Factor H
deficiency 400

200

Wild-type

C3 staining wild-type Cfh-/-

Alternative pathway dysregulation and
disease
 It is associated with renal disease:

‘protective’ and ‘at risk’

polymorphisms

common

mutations

rare

Atypical haemolytic Dense deposit disease

uraemic syndrome
Atypical Haemolytic uraemic syndrome
 Impaired surface regulation

ACTIVATION 

REGULATION 

Loss of function Gain of function

FACTOR H C3
FACTOR I FACTOR B
CD46

plasma regulation

surface recognition
Atypical Haemolytic uraemic syndrome

‘always on’

alternative pathway
C3
C5a
C3bBb

C5 activation
C3b Factor B
Factor D

MAC C3b C3b C3b C3b ‘Alternative pathway C3

RENAL ENDOTHELIUM amplification loop’
Murine model of factor H-associated atypical
haemolytic uraemic syndrome
 Gene-targeted factor H-deficient mice transgenically expressing a mutant
mouse factor H protein (FH16-20)

wild-type mouse CFH Mutated mouse FH16-20

100
Plasma C3 - mg/l

75

50

25

Renal histology in Cfh-/-.FH16-20

0

Cfh-/- Cfh-/-FH16-20
Atypical haemolytic uraemic syndrome - therapy
 C5 inhibition successful in case reports – examples:
 Eculizumab for aHUS – N. Engl. J. Med. 2009 360:5 pp542-543
 Eculizumab for congenital aHUS – N. Engl. J. Med. 2009 360:5 pp544-6

 Open Label Controlled Trial of Eculizumab in Adult Patients With Plasma

Therapy-sensitive / -resistant Atypical Hemolytic Uremic Syndrome (aHUS)
 Successful outcomes announced in ASN 2010 meeting
 http://clinicaltrials.gov/ct2/results?term=eculizumab
Alternative pathway dysregulation and
disease
 It is associated with renal disease:

‘protective’ and ‘at risk’

polymorphisms

common

mutations

rare

Atypical haemolytic Dense deposit disease

uraemic syndrome
Factor H and Age-related macular
degeneration
Factor H and susceptibility to meningococcal
infection

Meningococcal sepsis
Alternative pathway dysregulation and
disease
 It is associated with renal and non-renal disease:

‘protective’ and ‘at risk’

polymorphisms

common
Age-related macular
degeneration Meningococcal sepsis

mutations

rare

Atypical haemolytic Dense deposit disease

uraemic syndrome
The factor H family
Why are the factor H-related proteins
important?
 They are associated with renal disease:

‘protective’ and ‘at risk’

polymorphisms

common

mutations

rare
C3 glomerulonephritis
CFHR5 nephropathy
 Familial C3 glomerulonephritis and mutation in CFH-related
protein 5

CLINICAL FEATURES
• Autosomal dominant
• Persistent microscopic
haematuria
• Episodes of synpharyngitic
macroscopic haematuria
• Progression to end stage renal
disease mainly in males

Aberrantly increased size protein detected in sera

CFHR5 and renal complement
 Does CFHR5 regulate renal complement deposition?

Membranous Class IV lupus

IgA Post-infectious
Am J Kidney Dis, vol 39, N 1, 2002: pp24-27
Why are the factor H-related proteins
important?
 They are associated with renal disease:

PLOS GENETICS May 2011

‘protective’ and ‘at risk’
polymorphisms

common

mutations

rare
Why are the factor H-related proteins
important?
 They are associated with renal disease:

‘protective’ and ‘at risk’

CFHR1-3 deletion
polymorphisms
allele polymorphism
associated with
common protection against
AMD
Age-related macular
degeneration

mutations

rare
Complement and tissue injury
Pathologies in which
complement is activated
Antibody-mediated injury to allografts
 Complement-fixing donor-specific antibodies
 Associated with peritubular C4d staining
 Can complement inhibition prevent / ameliorate antibody-
mediated rejection?

Humanised anti-C5 antibody

C1 inhibitor concentrates

Viro Pharma

Berinert™
CSL Behring
Eculizumab
Alexion Pharmaceuticals
Complement therapeutics
Examples of the many complement inhibitors in development

Eric Wagner and Michael Frank Nature Reviews 2010, vol. 9, 43-56.
Summary
 Abnormal regulation of complement is associated with disease
 The kidney appears to be particularly susceptible
 Renal pathologies resulting directly from complement dysregulation include:
 Atypical haemolytic uraemic syndrome
 C3 glomerulopathies
 Dense deposit disease
 CFHR5 nephropathy

 Our understanding of these rare pathologies may be very relevant

to more common renal pathologies

 Eculizumab is the first complement inhibitor and is highly effective

in:
 Preventing red cell lysis in paroxysmal nocturnal haemoglobinuria
 Atypical haemolytic uraemic syndrome

 Eculizumab may be indicated in more common renal pathologies...

Thanks
 Elena Goicoechea de Jorge
 Katherine Vernon
 Mitali Patel
 Kirsten Rose
 Talat Malik
 Sharmal Narayan
 Marieta Ruseva
 Tamara Montes
 Lola Sanchez-Nino
 Danielle Paixao-Cavalcante
 Fadi Fakhouri
 Terence Cook
 Marina Botto
 Santiago Rodriguez de Cordoba
 Veronique Fremeaux -Bacchi
 Patrick Maxwell
 Danny Gale