medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2021-13-128-137medsovet-6408Research ArticleПРЕГРАВИДАРНАЯ ПОДГОТОВКА И БЕРЕМЕННОСТЬPREGRAVID PREPARATION AND PREGNANCYОсобенности нефропатии при различных вариантах тромботических микроангиопатий в акушерской практикеFeatures of nephropathy in various types of thrombotic microagniopathies in obstetric practicehttps://orcid.org/0000-0002-6125-590XКирсановаТ. В.KirsanovaT. V.

Кирсанова Татьяна Валерьевна, к.м.н., старший научный сотрудник отделения репродуктивной гематологии и клинической гемостазиологии

117997, Россия, Москва, ул. Академика Опарина, д. 4

Tatyana V. Kirsanova, Cand. Sci. (Med.), Senior Researcher Department of Reproductive Hematology and Clinical Hemostasiology

4, Academician Oparin St., Moscow, 117997, Russia

A_Tatya@mail.ruhttps://orcid.org/0000-0003-0362-580XБалакиреваА. И.BalakirevaA. I.

Балакирева Алина Игоревна, аспирант кафедры внутренних болезней факультета фундаментальной медицины

119192, Россия, Москва, Ломоносовский проспект, д. 27, корп. 11

Alina I. Balakireva, Postgraduate Student of the Department of Internal Medicine of the Faculty of Fundamental Medicine

27, Bldg. 1, Lomonosovsky Ave, Moscow, 119991, Russia

koluvanova@gmail.comhttps://orcid.org/0000-0001-6883-4456ФедороваТ. А.FedorovaT. A.

Федорова Татьяна Анатольевна, д.м.н., профессор, руководитель отдела трансфузиологии и экстракорпоральной гемокоррекции

117997, Россия, Москва, ул. Академика Опарина, д. 4

Tatiana A. Fedorova, Dr. Sci. (Med.), Professor, Head of the Department of Transfusiology and Extracorporeal Hemocorrection

27, Bldg. 1, Lomonosovsky Ave, Moscow, 119991, Russia

tfedorova1@mail.ruНациональный медицинский исследовательский центр акушерства, гинекологии и перинатологии имени академика В.И. КулаковаРоссияKulakov National Medical Research Center of Obstetrics, Gynecology and PerinatologyRussian FederationМосковский государственный университет имени М.В. ЛомоносоваРоссияLomonosov Moscow State UniversityRussian FederationНациональный медицинский исследовательский центр акушерства, гинекологии и перинатологии имени академика В.И. КулаковаРоссияLomonosov Moscow State UniversityRussian Federation202116102021013128137Copyright © Кирсанова Т.В., Балакирева А.И., Федорова Т.А., 20212021Кирсанова Т.В., Балакирева А.И., Федорова Т.А.Kirsanova T.V., Balakireva A.I., Fedorova T.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/6408Введение

Введение. С учетом того что основной причиной острого повреждения почек (ОПП), возникающего во время беременности или в раннем послеродовом периоде, являются различные варианты тромботических микроангиопатий (ТМА), а само ОПП представляет серьезное акушерское осложнение с риском тяжелых осложнений и смертности у матери и плода, мы оценили особенности поражения почек у пациенток с различными вариантами ТМА при беременности.

Цель исследования

Цель исследования. Изучить особенности нефропатии при различных вариантах ТМА, ассоциированных с беременностью.

Материалы и методы

Материалы и методы. В исследование вошло 313 беременных, рожениц и родильниц, из которых 71 женщина имела аГУС, 124 – HELLP-синдром, 70 – ПЭ различной степени выраженности, также была выделена группа пациенток с более редкими причинами ТМА: ТТП, КАФС и сепсисом (13 пациенток) и 45 пациенток для группы контроля. Были оценены и сопоставлены основные клинические, лабораторные и инструментальные данные, оценивался исход родов. Также пяти пациенткам с аГУС было выполнено гистологическое исследование почек.

Результаты и обсуждение

Результаты и обсуждение. По результатам проведенного исследования было выявлено, что наиболее тяжелые проявления ТМА в виде поражения органов-мишеней и нефропатии характерны для пациенток с аГУС, где все женщины развивали ОПП, в некоторых случаях с формированием хронической болезни почек. В группе с HELLP-синдромом ОПП было зафиксировано в 39%, однако функция почек быстро восстанавливалась. Обнаружено, что сам факт наличия ОПП свидетельствует о более тяжелом прогнозе не только для самих пациенток, но и для ребенка, являясь основным фактором риска перинатальной смерти. Анализ мочевого осадка и морфологическая картина свидетельствуют о том, что возникающая ишемия почечной ткани в случаях аГУС, HELLP-синдрома и других вариантов ТМА может привести к некрозу канальцев по сравнению с ПЭ. Наши результаты позволяют предположить, что именно ОПП при HELLP-синдроме является основным фактором риска перинатальной смерти. Увы, такую связь сложно проследить у пациентов с аГУС в связи с тем, что все они имели ОПП.

Выводы

Выводы. Своевременное распознавание феномена ОПП во всех случаях акушерской ТМА позволяет снизить риски для матери и плода. От ОПП зависит прогноз как для матери, так и для ребенка, а своевременная терапия способна привести к регрессу явлений ОПП и полному восстановлению функции почек

Introduction

Introduction. We assessed the features of kidney injury in patients with different types of TMA during pregnancy, taking into consideration the fact that the acute kidney injury (AKI) that occurs during pregnancy or in the early postpartum period is main- ly caused by various types of thrombotic microangiopathies (TMA), and AKI itself is a serious obstetric complication with the risk of serious complications and mortality for both mother and fetus.

Objective of the study

Objective of the study. To study the features of nephropathy in different types of pregnancy-associated TMA.

Materials and methods

Materials and methods. The study included 313 pregnant women, women in childbirth and puerperas, of which 71 women had atypical hemolytic uremic syndrome (aHUS), 124 – HELLP syndrome, 70 – varying degrees of severity of PE, a group of patients with more rare causes of TMA was also identified: TTP, CAPS and sepsis (13 patients) and 45 patients for the control group. We assessed and compared the main clinical, laboratory and instrumental data, and assessed the outcome of labour. Also, histological examination of the kidneys was performed in five patients with aHUS.

Results and discussion

Results and discussion. The results of the study have shown that the most severe manifestations of TMA in the form of target organ injury and nephropathy are usually occur in patients with aHUS, where all women developed AKI, in some cases with the formation of chronic kidney disease. In the HELLP syndrome group, AKI was recorded in 39%, but renal function quickly restored. It was found that the very fact of the presence of AKI points to a more unfavourable prognosis not only for the patients themselves, but also for the child, being the main risk factor for perinatal death. The findings of urinary sediment tests and morphological evaluation indicate that the resulting ischemia of the renal tissue in cases of aHUS, HELLP syndrome and other types of TMA can lead to tubular necrosis as compared with PE. Our results suggest that it is AKI in HELLP syndrome that is the main risk factor for perinatal death. Alas, this relationship is difficult to trace in patients with aHUS, as all of them had AKI.

Conclusions

Conclusions. Timely recognition of the AKI phenomenon in all cases of obstetric TMA can reduce the risks for both mother and fetus. Both the prognosis for mother and the prognosis for child depend on AKI, and timely therapy can lead to a regression of AKI phenomena and the complete restoration of renal function.

HELLP-синдромгемолитико-уремический синдромострое повреждение почектромботические микроангиопатиибеременностьHELLP syndromehemolytic uremic syndromeacute kidney injurythrombotic microangiopathiespregnancyReferencesRao S., Jim B. Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century. Kidney Int Rep. 2018;3(2):247–257. https://doi.org/10.1016/j.ekir.2018.01.011.Rao S., Jim B. Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century. Kidney Int Rep. 2018;3(2):247–257. https://doi.org/10.1016/j.ekir.2018.01.011.Naqvi R. Hemolytic Uremic syndrome associated with pregnancy: Outcome from acute Kidney Injury. Pak J Med Sci. 2020;36(6):1153–1157. https://doi.org/10.12669/pjms.36.6.2931.Naqvi R. Hemolytic Uremic syndrome associated with pregnancy: Outcome from acute Kidney Injury. Pak J Med Sci. 2020;36(6):1153–1157. https://doi.org/10.12669/pjms.36.6.2931.Haroon F., Murtaza F., Dhrolia Qureshi R., Imtiaz S., Ahmed A. Frequency of Pregnancy-Related Complications Causing Acute Kidney Injury in Pregnant Patients at a Tertiary Care Hospital. Saudi J Kidney Dis Transpl. 2019;30(1): 194–201. Available at: https://www.sjkdt.org/text.asp?2019/30/1/194/252910.Haroon F., Murtaza F., Dhrolia Qureshi R., Imtiaz S., Ahmed A. Frequency of Pregnancy-Related Complications Causing Acute Kidney Injury in Pregnant Patients at a Tertiary Care Hospital. Saudi J Kidney Dis Transpl.2019;30(1):194–201. Available at: https://www.sjkdt.org/text.asp?2019/30/1/194/252910.Bruel A., Kavanagh D., Norris M., Delmas Y., Wong E.K., Bresin E. et al. Hemolytic Uremic Syndrome in Pregnancy and Postpartum. Clin J Am Soc Nephrol. 2017;12(8):1237–1247. Available at: https://doi.org/10.2215/CJN.00280117.Bruel A., Kavanagh D., Norris M., Delmas Y., Wong E.K., Bresin E. et al. Hemolytic Uremic Syndrome in Pregnancy and Postpartum. Clin J Am Soc Nephrol. 2017;12(8):1237–1247. Available at: https://doi.org/10.2215/CJN.00280117.Zafrani L., Mariotte E., Darmon M., Canet E., Merceron S., Boutboul D. et al. Acute renal failure is prevalent in patients with thrombotic thrombocytopenic purpura associated with low plasma ADAMTS13 activity. J Thromb Haemost. 2015;13(3):380–389. https://doi.org/10.1111/jth.12826.Zafrani L., Mariotte E., Darmon M., Canet E., Merceron S., Boutboul D. et al. Acute renal failure is prevalent in patients with thrombotic thrombocyto penic purpura associated with low plasma ADAMTS13 activity. J Thromb Haemost. 2015;13(3):380–389. https://doi.org/10.1111/jth.12826.Erdemoğlu M., Kuyumcuoğlu U., Kale A., Akdeniz N. Factors affecting maternal and perinatal outcomes in HELLP syndrome: evaluation of 126 cases. Clin Exp Obstet Gynecol. 2019;37(3):213–216. Available at: https://ceog.imrpress.com/EN/Y2010/V37/I3/213.Erdemoğlu M., Kuyumcuoğlu U., Kale A., Akdeniz N. Factors affecting maternal and perinatal outcomes in HELLP syndrome: evaluation of 126 cases. Clin Exp Obstet Gynecol. 2019;37(3):213–216. Available at: https://ceog.imrpress.com/EN/Y2010/V37/I3/213.Gedik E., Yücel N., Sahin T., Koca E., Colak Y.Z., Togal T. Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital. Hypertens Pregnancy. 2017;36(1):21–29. https://doi.org/10.1080/10641955.2016.1218505.Gedik E., Yücel N., Sahin T., Koca E., Colak Y.Z., Togal T. Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital. Hypertens Pregnancy. 2017;36(1):21–29. https://doi.org/10.1080/10641955.2016.1218505.Sibai B.M., Ramadan M.K., Usta I., Salama M., Mercer B.M., Friedman S.A. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol. 1993;169(4):1000–1006. https://doi.org/10.1016/0002-9378(93)90043-i.Sibai B.M., Ramadan M.K., Usta I., Salama M., Mercer B.M., Friedman S.A. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol. 1993;169(4):1000–1006. https://doi.org/10.1016/0002-9378(93)90043-i.Gul A., Aslan H., Cebeci A., Polat I., Ulusoy S., Ceylan Y. Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure. Renal Fail. 2004;26(5):557–562. https://doi.org/10.1081/jdi-200031750.Gul A., Aslan H., Cebeci A., Polat I., Ulusoy S., Ceylan Y. Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure. Renal Fail. 2004;26(5):557–562. https://doi.org/10.1081/jdi-200031750.Martínez de Ita A.L., García Cáceres E., Helguera Martínez A.M., Cejudo Carranza E. Acute renal insufficiency in HELLP syndrome. Ginecol Obstet Mex. 1998;66:462–468. Available at: https://pubmed.ncbi.nlm.nih.gov/9823704/.Martínez de Ita A.L., García Cáceres E., Helguera Martínez A.M., Cejudo Carranza E. Acute renal insufficiency in HELLP syndrome. Ginecol Obstet Mex. 1998;66:462–468. Available at: https://pubmed.ncbi.nlm.nih.gov/9823704/.Abraham K.A., Connolly G., Farrell J., Walshe J.J. The HELLP syndrome, a prospective study. Renal Fail. 2001;23(5):705–713. https://doi.org/10.1081/jdi-100107367.Abraham K.A., Connolly G., Farrell J., Walshe J.J. The HELLP syndrome, a prospective study. Renal Fail. 2001;23(5):705–713. https://doi.org/10.1081/jdi-100107367.Huang C., Chen S. Acute kidney injury during pregnancy and puerperium: a retrospective study in a single center. BMC Nephrol. 2017;18(1):146. https://doi.org/10.1186/s12882-017-0551-4.Huang C., Chen S. Acute kidney injury during pregnancy and puerperium: a retrospective study in a single center. BMC Nephrol. 2017;18(1):146. https://doi.org/10.1186/s12882-017-0551-4.Selçuk N.Y., Odabas A.R., Cetinkaya R., Tonbul H.Z., San A. Outcome of pregnancies with HELLP syndrome complicated by acute renal failure (1989– 1999). Renal Fail. 2000;22(3):319–327. https://doi.org/10.1081/jdi-100100875.Selçuk N.Y., Odabas A.R., Cetinkaya R., Tonbul H.Z., San A. Outcome of pregnancies with HELLP syndrome complicated by acute renal failure (1989– 1999). Renal Fail. 2000;22(3):319–327. https://doi.org/10.1081/jdi-100100875.Drakeley A.J., Le Roux P.A., Anthony J., Penny J. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol. 2002;186(2):253–256. https://doi.org/10.1067/mob.2002.120279.Drakeley A.J., Le Roux P.A., Anthony J., Penny J. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol. 2002;186(2):253–256. https://doi.org/10.1067/mob.2002.120279.American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6):864–874. Available at: https://pubmed.ncbi.nlm.nih.gov/1597042.American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6):864–874. Available at: https://pubmed.ncbi.nlm.nih.gov/1597042.Prakash J., Pant P., Prakash S., Sivasankar M., Vohra R., Doley P.K. Changing picture of acute kidney injury in pregnancy: Study of 259 cases over a period of 33 years. Indian J Nephrol. 2016;26(4):262–267. https://doi.org/10.4103/0971-4065.161018.Prakash J., Pant P., Prakash S., Sivasankar M., Vohra R., Doley P.K. Changing picture of acute kidney injury in pregnancy: Study of 259 cases over a period of 33 years. Indian J Nephrol. 2016;26(4):262–267. https://doi.org/10.4103/0971-4065.161018.Prakash J., Ganiger V.C. Acute Kidney Injury in Pregnancy-specific Disorders. Indian J Nephrol. 2017;27(4):258–270. https://doi.org/10.4103/0971-4065.202406.Prakash J., Ganiger V.C. Acute Kidney Injury in Pregnancy-specific Disorders. Indian J Nephrol. 2017;27(4):258–270. https://doi.org/10.4103/0971-4065.202406.Птушкин В.В., Кулагин А.Д., Лукина Е.А., Давыдкин И.Л., Константинова Т.С., Шамрай В.С. и др. Результаты открытого многоцентрового клинического исследования Ib фазы по оценке безопасности, фармакокинетики и фармакодинамики первого биоаналога экулизумаба у нелеченых пациентов с пароксизмальной ночной гемоглобинурией в фазе индукции терапии. Терапевтический архив. 2020;92(7):77–84. https://doi.org/10.26442/00403660.2020.07.000818.Ptushkin V.V., Kulagin A.D., Lukina E.A., Davydkin I.L., Konstantinova T.S., Shamrai V.S. et al. Results of phase Ib open multicenter clinical trial of the safety, pharmacokinetics and pharmacodynamics of first biosimilar of eculizumab in untreated patients with paroxysmal nocturnal hemoglobinuria during induction of therapy. Terapevticheskii arkhiv = Therapeutic Archive. 2020;92(7):77–84. (In Russ.) https://doi.org/10.26442/00403660.2020.07.000818.Kulagin A., Ptushkin V., Lukina E., Gapchenko E., Markova O., Zuev E., Kudlay D. Phase III clinical trial of Elizaria® and Soliris® in adult patients with paroxysmal nocturnal hemoglobinuria: results of comparative analysis of efficacy, safety, and pharmacological data. Blood. 2019;134(1 Suppl.):3748. https://doi.org/10.1182/blood-2019-125693.Kulagin A., Ptushkin V., Lukina E., Gapchenko E., Markova O., Zuev E., Kudlay D. Phase III clinical trial of Elizaria® and Soliris® in adult patients with paroxysmal nocturnal hemoglobinuria: results of comparative analysis of efficacy, safety, and pharmacological data. Blood. 2019;134(1 Suppl.):3748. https://doi.org/10.1182/blood-2019-125693.Kulagin A., Ptushkin V., Lukina E., Davydkin I., Korobkin A., Shamrai V. et al. Randomized multicenter noninferiority phase III clinical trial of the first biosimilar of eculizumab. Ann Hematol. 2021. https://doi.org/10.1007/s00277-021-04624-7.Kulagin A., Ptushkin V., Lukina E., Davydkin I., Korobkin A., Shamrai V. et al. Randomized multicenter noninferiority phase III clinical trial of the first biosimilar of eculizumab. Ann Hematol. 2021. https://doi.org/10.1007/s00277-021-04624-7.Кирсанова Т.В., Виноградова М.А., Колыванова А.И., Шмаков Р.Г. HELLPсиндром: клинико-лабораторные особенности и дисбаланс плацентарных факторов ангиогенеза. Акушерство и гинекология. 2018;(7):46–55. https://doi.org/10.18565/aig.2018.7.46-55.Kirsanova T.V., Vinogradova M.A., Kolyvanova A.I., Shmakov R.G. HELLPsyndrome: its clinical and laboratory features and imbalance of placental angiogenic factors. Akusherstvo i ginekologiya = Obstetrics and Gynecology. 2018;(7):46–55. (In Russ.) https://doi.org/10.18565/aig.2018.7.46-55.Коротчаева Ю.В., Козловская Н.Л., Шифман Е.М., Демьянова К.А. Поздние осложнения беременности как триггеры акушерского атипичного гемолитико уремического синдрома. Нефрология и диализ. 2020;22(2):198–209. https://doi.org/10.28996/2618-9801-2020-2-198-209.Korotchaeva Y.V., Kozlovskaya N.L., Shifman E.M., Demyanova K.A. Late pregnancy complications as a triggers of obstetric atypical hemolytic uremic syndrome. Nefrologiya i dializ = Nephrology and Dialysis. 2020;22(2):198–209. (In Russ.) https://doi.org/10.28996/2618-9801-2020-2-198-209.Sabau L., Terriou L., Provot F., Fourrier F., Roumier C., Caron C. et al. Are there any additional mechanisms for haemolysis in HELLP syndrome? Thrombosis Res. 2016;142:40–43. https://doi.org/10.1016/j.thromres.2016.03.014.Sabau L., Terriou L., Provot F., Fourrier F., Roumier C., Caron C. et al. Are there any additional mechanisms for haemolysis in HELLP syndrome? Thrombosis Res. 2016;142:40–43. https://doi.org/10.1016/j.thromres.2016.03.014.Sibai B.M., Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol. 2007;196(6):514.e1–514.e9. https://doi.org/10.1016/j.ajog.2007.02.021.Sibai B.M., Barton J.R. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol. 2007;196(6):514.e1–514.e9. https://doi.org/10.1016/j.ajog.2007.02.021.Randeree I.G., Czarnocki A., Moodley J., Seedat Y.K., Naiker I.P. Acute renal failure in pregnancy in South Africa. Renal Fail. 1995;17(2):147–153. https://doi.org/10.3109/08860229509026251.Randeree I.G., Czarnocki A., Moodley J., Seedat Y.K., Naiker I.P. Acute renal failure in pregnancy in South Africa. Renal Fail. 1995;17(2):147–153. https://doi.org/10.3109/08860229509026251.Sibai B.M., Ramadan M.K. Acute renal failure in pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets. Am J Obstet Gynecol. 1993;168(6):1682–1690. https://doi.org/10.1016/0002-9378(93)90678-c.Sibai B.M., Ramadan M.K. Acute renal failure in pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets. Am J Obstet Gynecol. 1993;168(6):1682–1690. https://doi.org/10.1016/0002-9378(93)90678-c.Vesely S.K., George J.N., Lämmle B., Studt J.D., Alberio L., El-Harake M.A., Raskob G.E. ADAMTS13 activity in thrombotic thrombocytopenic purpurahemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood. 2003;102(1):60–68. https://doi.org/10.1182/blood-2003-01-0193.Vesely S.K., George J.N., Lämmle B., Studt J.D., Alberio L., El-Harake M.A., Raskob G.E. ADAMTS13 activity in thrombotic thrombocytopenic purpurahemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood. 2003;102(1):60–68. https://doi.org/10.1182/blood-2003-01-0193.Raife T., Atkinson B., Montgomery R., Vesely S., Friedman K. Severe deficiency of VWF-cleaving protease (ADAMTS13) activity defines a distinct population of thrombotic microangiopathy patients. Transfusion. 2004;44(2):146–150. https://doi.org/10.1111/j.1537-2995.2004.00626.x.Raife T., Atkinson B., Montgomery R., Vesely S., Friedman K. Severe deficiency of VWF-cleaving protease (ADAMTS13) activity defines a distinct population of thrombotic microangiopathy patients. Transfusion. 2004;44(2):146–150. https://doi.org/10.1111/j.1537-2995.2004.00626.x.Zheng X.L., Kaufman R.M., Goodnough L.T., Sadler J.E. Effect of plasma exchange on plasma ADAMTS13 metalloprotease activity, inhibitor level, and clinical outcome in patients with idiopathic and nonidiopathic thrombotic thrombocytopenic purpura. Blood. 2004;103(11):4043–4049. https://doi.org/10.1182/blood-2003-11-4035.Zheng X.L., Kaufman R.M., Goodnough L.T., Sadler J.E. Effect of plasma exchange on plasma ADAMTS13 metalloprotease activity, inhibitor level, and clinical outcome in patients with idiopathic and nonidiopathic thrombotic thrombocytopenic purpura. Blood. 2004;103(11):4043–4049. https://doi.org/10.1182/blood-2003-11-4035.Coppo P., Bengoufa D., Veyradier A., Wolf M., Bussel A., Millot G.A. et al. Severe ADAMTS13 deficiency in adult idiopathic thrombotic microangiopathies defines a subset of patients characterized by various autoimmune manifestations, lower platelet count, and mild renal involvement. Medicine (Baltimore). 2004;83(4):233–244. https://doi.org/10.1097/01.md.0000133622.03370.07.Coppo P., Bengoufa D., Veyradier A., Wolf M., Bussel A., Millot G.A. et al. Severe ADAMTS13 deficiency in adult idiopathic thrombotic microangiopathies defines a subset of patients characterized by various autoimmune manifestations, lower platelet count, and mild renal involvement. Medicine (Baltimore). 2004;83(4):233–244. https://doi.org/10.1097/01.md.0000133622.03370.07.Nair R.K., Khaira A., Sharma A., Mahajan S., Dinda A.K. Spectrum of renal involvement in paroxysmal nocturnal hemoglobinuria: report of three cases and a brief review of the literature. Int Urol Nephrol. 2008;40(2):471–475. https://doi.org/10.1007/s11255-008-9356-5.Nair R.K., Khaira A., Sharma A., Mahajan S., Dinda A.K. Spectrum of renal involvement in paroxysmal nocturnal hemoglobinuria: report of three cases and a brief review of the literature. Int Urol Nephrol. 2008;40(2):471–475. https://doi.org/10.1007/s11255-008-9356-5.Hothi D.K., Bass P., Morgan M., Acharya J., Humphries S.E., Gilbert R.D. Acute renal failure in a patient with paroxysmal cold hemoglobinuria. Pediatr Nephrol. 2007;22(4):593–596. https://doi.org/10.1007/s00467-006-0352-7.Hothi D.K., Bass P., Morgan M., Acharya J., Humphries S.E., Gilbert R.D. Acute renal failure in a patient with paroxysmal cold hemoglobinuria. Pediatr Nephrol. 2007;22(4):593–596. https://doi.org/10.1007/s00467-006-0352-7.Pollard T.D., Weiss I.W. Acute tubular necrosis in a patient with march hemoglobinuria. N Engl J Med. 1970;283(15):803–804. https://doi.org/10.1056/NEJM197010082831509.Pollard T.D., Weiss I.W. Acute tubular necrosis in a patient with march hemoglobinuria. N Engl J Med. 1970;283(15):803–804. https://doi.org/10.1056/NEJM197010082831509.Qian Q., Nath K.A., Wu Y., Daoud T.M., Sethi S. Hemolysis and acute kidney failure. Am J Kidney Dis. 2010;56(4):780–784. https://doi.org/10.1053/j.ajkd.2010.03.025.Qian Q., Nath K.A., Wu Y., Daoud T.M., Sethi S. Hemolysis and acute kidney failure. Am J Kidney Dis. 2010;56(4):780–784. https://doi.org/10.1053/j.ajkd.2010.03.025.Ye W., Shu H., Yu Y., Li H., Chen L., Liu J., Li X.M. Acute kidney injury in patients with HELLP syndrome. Int Urol Nephrol. 2019;51(7):1199–1206. https://doi.org/10.1007/s11255-019-02111-7.Ye W., Shu H., Yu Y., Li H., Chen L., Liu J., Li X.M. Acute kidney injury in patients with HELLP syndrome. Int Urol Nephrol. 2019;51(7):1199–1206. https://doi.org/10.1007/s11255-019-02111-7.

The authors declare that there are no conflicts of interest present.