aHUS: Advances in Pathogenesis, Diagnosis and Treatment

Kenneth V. Lieberman, MDKenneth V. Lieberman, MD

Chief, Pediatric NephrologyChief, Pediatric Nephrology The Joseph M. The Joseph M. SanzariSanzari ChildrenChildren’’s Hospitals Hospital

Hackensack University Medical CenterHackensack University Medical Center Professor of PediatricsProfessor of Pediatrics

UMDNJ UMDNJ –– New Jersey Medical SchoolNew Jersey Medical School

2

Consultant/Advisory Board: Consultant/Advisory Board: Alexion Pharmaceuticals; Alexion Pharmaceuticals; Athena DiagnosticsAthena Diagnostics

Speaker:Speaker: Alexion PharmaceuticalsAlexion Pharmaceuticals

DisclosuresDisclosures

3

ObjectivesObjectives

Discuss the role of unregulated complement in complement mediated diseases

Provide an overview in the advances of pathophysiology and disease severity in aHUS

Discuss the challenges in the differential diagnosis of aHUS, STEC-HUS, and TTP

Discuss the state of the art treatment in aHUS and benefits of early intervention

4

Thrombotic Thrombotic MicroangiopathyMicroangiopathy (TMA)(TMA)

Endothelial cell injury with the subsequent Endothelial cell injury with the subsequent release of plateletrelease of platelet--aggregating substances aggregating substances resulting in the formation of thrombotic lesions resulting in the formation of thrombotic lesions in terminal arterioles and capillariesin terminal arterioles and capillaries

MicroangiopathicMicroangiopathic hemolytic anemia with hemolytic anemia with thrombocytopenia (thrombocytopenia (nonimmunenonimmune))

Systemic organ involvement Systemic organ involvement (kidney, central nervous system)(kidney, central nervous system)

5

TMA: Platelet, Endothelial, and TMA: Platelet, Endothelial, and Leukocyte Activation Leading to Leukocyte Activation Leading to

Inflammation, Thrombosis, and Systemic Inflammation, Thrombosis, and Systemic Small Vessel OcclusionSmall Vessel Occlusion

1. Desch

K, et al. J Am Soc Nephrol. 2007;18(9):2457-2460. 2. Licht

C, et al. Blood. 2009;114(20):4538-4545. 3. Noris

M, et al. N Engl J Med. 2009;361(17):1676-1687. 4. Ståhl

AL, et al. Blood 2008;111(11):5307-5315.

5. Camous

L, et al. Blood. 2011;117(4):1340-1349.

Endothelium activation

Endothelial swelling and disruption

Plateletaggregation

Platelet

Platelet

activation

Chronic uncontrolled

complement

activation

Leukocyteactivation

Platelet consumption

Mechanical

hemolysis

(Schistocytes)

Blood clots

Inflammation

Occlusion

Ischemia

Hypoxia

6

Manifestations of TMAManifestations of TMA

1.Ohanian M et al. Clinical Pharmacology: Advances and Applications. 2011;3:5-12. 2. Hosler

et al. Arch Pathol Lab Med. 2003;127:834-839. 3. Noris

et al. CJASN. 2010;10:1844-1859.

4. Neuhaus

et al.

Arch Dis Chilid. 1997;76:518-521. 5. Vesely

et al Blood. 2003;102:60-68. 6. Sallee

et al. Nephrol Dial Trans. 2010;25:2028-32. 7. Kose

et al. Semin Thromb Hemost. 2010;36:669-672. 8. Davin

et al. Am J Kid Dis. 2010;55:708-777. 9. Caprioli

et al. Blood. 2006;108:1267-7. 10. Dragon-Durey

et al. J Am Soc Nephrol. 2010;21:2180-2187. 11. Loirat

et al. Pediatr Nephrol. 2008;23:1957-1972. 12. Stahl et al. Blood. 2008;111:5307-5315. 13. Chatelet

V et al. Am J Transplant. 2009 Nov;9(11):2644-2645. 14. Sellier-Leclerc

et al. J Am Soc Nephrol. 2007;18:2392-2400.

RenalRenal7,8,9,11,127,8,9,11,12

Elevated Elevated creatininecreatinineEdemaEdemaMalignantMalignant

hypertensionhypertensionRenal failureRenal failureDialysisDialysisTransplantTransplant

GastrointestinalGastrointestinal2,3,5,10,11,122,3,5,10,11,12

Liver necrosisLiver necrosisPancreatitisPancreatitisDiabetes MellitusDiabetes MellitusColitisColitisDiarrheaDiarrheaNausea/vomitingNausea/vomitingAbdominal painAbdominal pain

BloodBlood1111

HemolysisHemolysisDecreased plateletsDecreased platelets

FatigueFatigueTransfusionsTransfusions

Impaired Quality of LifeImpaired Quality of Life1313

FatigueFatiguePain/anxietyPain/anxietyReduced mobilityReduced mobility

PulmonaryPulmonary1,6,141,6,14

DyspneaDyspneaPulmonary hemorrhagePulmonary hemorrhagePulmonary edemaPulmonary edema

CardiovascularCardiovascular2,3,4,62,3,4,6

Myocardial infarctionMyocardial infarctionThromboembolismThromboembolismCardiomyopathyCardiomyopathyDiffuse Diffuse vasculopathyvasculopathy

CNSCNS1,2,3,4,51,2,3,4,5

ConfusionConfusionSeizuresSeizuresStrokeStrokeEncephalopathyEncephalopathyDiffuse cerebral dysfunction

Thrombotic Thrombotic MicroangiopathyMicroangiopathy

Systemic Organ DamageSystemic Organ Damage CNSCNS KidneyKidney GI SystemGI System HeartHeart OthersOthers

7

TTP TTP --

Dr. Eli Dr. Eli MoschcowitzMoschcowitz

Attending Physician, The Mount Attending Physician, The Mount Sinai HospitalSinai Hospital

An Acute Febrile An Acute Febrile PleiochromicPleiochromicAnemia with Hyaline Anemia with Hyaline Thrombosis of the Terminal Thrombosis of the Terminal Arterioles and Capillaries: An Arterioles and Capillaries: An UndescribedUndescribed DiseaseDisease

ArchivArchiv Intern Med 1925; Intern Med 1925; 36(1):8936(1):89--9393

Read before the NY Read before the NY Pathological Society, Feb. 7, Pathological Society, Feb. 7, 19241924

Reprinted: Mt Sinai J Med Reprinted: Mt Sinai J Med 2003; 70(5):3532003; 70(5):353--355355

8

HUS HUS ––

Dr. Conrad von GasserDr. Conrad von Gasser

Swiss hematologist, in September 1955, described five Swiss hematologist, in September 1955, described five children in whom he had noted: diarrhea, hemolytic children in whom he had noted: diarrhea, hemolytic uremia, thrombocytopenia, and acute renal failureuremia, thrombocytopenia, and acute renal failure

Biopsy/Autopsy noted: hemorrhagic colitis, thrombosis of Biopsy/Autopsy noted: hemorrhagic colitis, thrombosis of capillaries and capillaries and precapillaryprecapillary arterioles in the lungs, brain, arterioles in the lungs, brain, heart, and kidneys as well as renal cortical necrosisheart, and kidneys as well as renal cortical necrosis

Gasser C et al. (1955) HemolyticGasser C et al. (1955) Hemolytic--uremic uremic syndrome(ssyndrome(s): ): bilateral necrosis of the renal cortex in acute acquired bilateral necrosis of the renal cortex in acute acquired hemolytic anemia. hemolytic anemia. SchweizSchweiz Med Med WochenschrWochenschr 8585::905905--909909

9

Atypical HUS (~10%)Atypical HUS (~10%)

Fitzpatrick, et al: Atypical (nonFitzpatrick, et al: Atypical (non--diarrheadiarrhea--associated) associated) hemolytichemolytic--uremic syndrome in childhood. J uremic syndrome in childhood. J PediatrPediatr, 1993, 1993

Kaplan, et al: Hemolytic uremic syndrome with recurrent Kaplan, et al: Hemolytic uremic syndrome with recurrent episodes: an important subset. episodes: an important subset. ClinClin NephrolNephrol, 1977, 1977

Kaplan, et al: Hemolytic uremic syndrome in families. N Kaplan, et al: Hemolytic uremic syndrome in families. N EnglEngl J Med, 1975J Med, 1975

10

Thrombotic Thrombotic MicroangiopathiesMicroangiopathiesPrimary Primary TMAsTMAs

Hemolytic Uremic Hemolytic Uremic Syndrome (HUS)Syndrome (HUS)

––

Typical and AtypicalTypical and Atypical

Thrombotic Thrombotic Thrombocytopenic Thrombocytopenic PurpuraPurpura(TTP)(TTP)

––

Acquired and InheritedAcquired and Inherited

Secondary Secondary TMAsTMAsSystemic sclerosis (CREST)Systemic sclerosis (CREST)Systemic Lupus Systemic Lupus ErythematosusErythematosus

(SLE)(SLE)Malignant hypertensionMalignant hypertensionSepsis (DIC)Sepsis (DIC)Bone marrow transplantationBone marrow transplantationHELLP (HELLP (HemolysisHemolysis, Elevated Liver , Elevated Liver

enzymes, Low Platelets): enzymes, Low Platelets): pregnancypregnancy--associatedassociatedDrugs (quinine induced; Drugs (quinine induced;

tacrolimustacrolimus, cyclosporine; , cyclosporine; bleomycinbleomycin, , mitomycinmitomycin, , cisplatincisplatin; ; bevacizumabbevacizumab; ; rifampicinrifampicin; ; clopidopogrel/ticlopidineclopidopogrel/ticlopidine))

11

Classification of HUSClassification of HUS

AtypicalAtypical––

Formerly DFormerly D--

––

May have diarrheaMay have diarrhea––

FamilialFamilial

––

RecurrentRecurrent––

Can be sporadicCan be sporadic

––

Often insidious Often insidious presentationpresentation

––

Inexorable Inexorable progressionprogression

TypicalTypical––

Formerly D+Formerly D+

––

Diarrhea Diarrhea prodromeprodrome (usually bloody)(usually bloody)

––

E. coli & E. coli & ShigellaShigella––

Generally explosive Generally explosive presentationpresentation

––

Can be epidemic, Can be epidemic, endemic or sporadicendemic or sporadic

12

aHUS: A LifeaHUS: A Life--Threatening DiseaseThreatening DiseaseRare, genetic disease that affects both children and Rare, genetic disease that affects both children and adultsadults

Permanent, uncontrolled complement activation causes Permanent, uncontrolled complement activation causes platelet and endothelial cell activation and systemic platelet and endothelial cell activation and systemic TMATMA

Systemic TMA causes progressive renal failure, as well Systemic TMA causes progressive renal failure, as well as multipleas multiple--organ damageorgan damage

Despite plasma exchange/infusion, more than half of Despite plasma exchange/infusion, more than half of aHUS patients die or suffer from endaHUS patients die or suffer from end--stage renal stage renal disease (ESRD) within 1 year of diagnosisdisease (ESRD) within 1 year of diagnosis

1. Noris

M, et al. N Engl J Med. 2009;361(17):1676-1687. 2. Noris

M, et al. Clin J Am Soc Nephrol. 2010;5(10):

1844-1859. 3. Sellier-Leclerc

AL, et al. J Am Soc Nephrol. 2007;18(8):2392-2400. 4. Caprioli

J, et al. Blood. 2006;108(4):1267-1279.

13

Early History of ComplementEarly History of Complement

Began with studies on bacterial killing Began with studies on bacterial killing ““Pfeiffer phenomenonPfeiffer phenomenon””11

Identification of Identification of thermolabilethermolabile factor in normal serum that enhanced factor in normal serum that enhanced antibody activity (Nuttall,1888, Bordet 1894, Ehrlich 1899)antibody activity (Nuttall,1888, Bordet 1894, Ehrlich 1899)3,4,53,4,5

Optimal reactions of immune destruction depend on 2 principlesOptimal reactions of immune destruction depend on 2 principles1,2,31,2,3::––

1 present in immune serum (fresh or heated)1 present in immune serum (fresh or heated)••

Called Called ““amboceptoramboceptor””

or or ““antibodyantibody””––

1 present in fresh (unheated) 1 present in fresh (unheated) nonimmunenonimmune

serumserum••

Called Called ““alexinalexin””

or or ““complementcomplement””

DonathDonath and Landsteiner in human disease (paroxysmal cold and Landsteiner in human disease (paroxysmal cold hemoglobinuria)hemoglobinuria)55

1. Ross GD. Introduction and history of complement research. Immunobiology of the Complement System. Orlando, FL: Academic Press, Inc; 1986:1-20.2. Figueroa JE, Densen P. Clin Microbiol Rev. 1991;4:359-395; 3. Ross GD, ed. Immunobiology of the Complement System. Orlando, FL: Academic Press, Inc;

1986:1-20. 4. Ehrlich P, Morgenroth J. Zur theorie der lysinwirkung. Berliner Klinische Wochenschrift. 1899;36:6-9. 5. Donath

J, Landsteiner K. Uber

paroxysmale

haemoglobinurie. Muchen Medicine Wochenschr. 1904;51:1590-1593.

14

C5a C5bC6C7C8C9

Balance Between Regulation and Amplification Balance Between Regulation and Amplification

Immune Complex Clearance Microbial Opsonization

C5C5

Prox

imal

Prox

imal

Term

inal

Term

inal

Natural Inhibitors: Factor H, I, MCP, CD55

-

C3 + HC3 + H22

O O --

ALWAYS ACTIVEALWAYS ACTIVE

(chronic)(chronic)

AmplificationAmplification

C3C3

Lectin Pathway Classical Pathway Alternative Pathway

1. Figueroa JE, Densen P.1. Figueroa JE, Densen P.

ClinClin MicrobiolMicrobiol RevRev. 1991;4:359. 1991;4:359--395. 2. 395. 2. WalportWalport

MJ.MJ.

N N EnglEngl J MedJ Med. 2001;344:1058. 2001;344:1058--1066. 3. 1066. 3. RotherRother

RP et al.RP et al.

Nature BiotechNature Biotech. . 2007;25:12562007;25:1256--1264. 4. Meyers G et al.1264. 4. Meyers G et al.

BloodBlood. 2007;110: Abstract 3683. 5. Hill A et al.. 2007;110: Abstract 3683. 5. Hill A et al.

Br J Br J HaematolHaematol.. 2010;149:4142010;149:414--425. 6.425. 6.

HillmenHillmen

P et al.P et al.

Am J Am J HematolHematol. . 2010;85:5532010;85:553--559. 7.559. 7.

International PNH Interest Group.International PNH Interest Group.

Blood.Blood. 2005;106:36992005;106:3699--3709. 8. 3709. 8. HillmenHillmen

P et al. P et al. N N EnglEngl J MedJ Med. 1995;333:1253. 9.. 1995;333:1253. 9.

Nishimura J et al.Nishimura J et al.Medicine. Medicine. 2004;83:1932004;83:193--207. 10.207. 10.

CaprioliCaprioli

J et al.J et al.

BloodBlood. 2006;108:1267. 2006;108:1267--1279. 11. 1279. 11. NorisNoris

M et al.M et al.

ClinClin J Am Soc J Am Soc NephrolNephrol. . 2010;5:18442010;5:1844--1859. 12. George JN et al. 1859. 12. George JN et al. Blood.Blood. 2010;116:40602010;116:4060--4069. 13. 4069. 13. LoiratLoirat

C et al.C et al.

PediatrPediatr NephrolNephrol.. 2008;23:19572008;23:1957--1972. 14. Stahl A, et al1972. 14. Stahl A, et al

BloodBlood. 2008;111:5307. 2008;111:5307--5315. 15.5315. 15.

HoslerHosler

GA et al.GA et al.

Arch Arch PatholPathol Lab MedLab Med. 2003;127;834. 2003;127;834--839. 16. 839. 16. AricetaAriceta

G et al. G et al. PediatrPediatr NephrolNephrol.. 2009;24:6872009;24:687--696.696.

Natural Inhibitor: CD59

-C5a

Potent AnaphylatoxinChemotaxisProinflammatoryLeukocyte ActivationEndothelial ActivationProthrombotic

C5b-9

Membrane Attack Complex

Cell LysisProinflammatoryPlatelet ActivationLeukocyte ActivationEndothelial ActivationProthrombotic

Natural Inhibitor: CD59

-

15

Research on Complement InhibitorsResearch on Complement InhibitorsA variety of genetic mutations in complement inhibitor genes havA variety of genetic mutations in complement inhibitor genes have been e been described starting in the early 1970described starting in the early 1970’’s for both PNH and aHUSs for both PNH and aHUS

1.

Timeline adapted from: Le Quintrec

M et al. Semin Thromb Hemost. 2010;36:641-665. 2. Noris

M et al. Clin J Am Soc Nephrol. 2010;5:1844-1859. 3. Loirat

C et al. Pediatr Nephrol. 2008;23:1957-1972. 4. Kavanagh

D, Goodship

T. Curr Opin Hematol. 2010;17:432-438; Zipfel

PF et al. PLOS Genetics 2009.

5. Kavanagh

D et al. Br Med Bull. 2006;77-78:5-22; 6. Noris

M et al. N Engl J Med. 2009;361:1676-1687.

Link With Low C3

Homozygous CFH Deficiency

CFI Mutations

C3 MutationsLink With RCA – CFH Mutations

(SCR20) Thrombomodulin Mutations

Hybrid (CFH-CFHRI)

Heterozygous CFH Deficiency

Association With Low CFH MCP Mutations

Anti-FH Auto-Antibodies

Homozygous MCP Deficiency

CFB Mutations

1973 1981 1994 1998 2003 2004 2005 2006 2007 2009

ΔCFHR1/ΔCFHR3 Deletion

1985

PIG-A Gene

16

Chronic Uncontrolled Complement ActivationChronic Uncontrolled Complement Activation Leads to Devastating ConsequencesLeads to Devastating Consequences

Lectin Pathway Classical Pathway

Immune Complex Clearance Microbial Opsonization C3C3

C5C5

Prox

imal

Prox

imal

Term

inal

Term

inal

Natural Inhibitors: Factor H, I, MCP, CD55

-

C3 + HC3 + H22

O O --

ALWAYS ACTIVEALWAYS ACTIVE

(chronic)(chronic)

AmplificationAmplification

C5a

Potent AnaphylatoxinChemotaxisProinflammatoryLeukocyte ActivationEndothelial ActivationProthrombotic

C5b-9

Membrane Attack Complex

Cell LysisProinflammatoryPlatelet ActivationLeukocyte ActivationEndothelial ActivationProthrombotic

AnaphylaxisInflammationThrombosis

AnaphylaxisInflammationThrombosis

ConsequencesConsequencesCell Destruction

InflammationThrombosis

Cell DestructionInflammationThrombosis

ConsequencesConsequences

Alternative Pathway

Natural Inhibitor: CD59

-

aHUS: Chronic uncontrolled complement activation (loss of Factor H, I, MCP or TM mutations)

PNH: Loss of MIRL proteins CD59, CD 55

APLS-C5a

1. Figueroa JE, Densen P.1. Figueroa JE, Densen P.

ClinClin MicrobiolMicrobiol RevRev. 1991;4:359. 1991;4:359--395. 2. 395. 2. WalportWalport

MJ.MJ.

N N EnglEngl J MedJ Med. 2001;344:1058. 2001;344:1058--1066. 3. 1066. 3. RotherRother

RP et al.RP et al.

Nature BiotechNature Biotech. . 2007;25:12562007;25:1256--1264. 4. Meyers G et al.1264. 4. Meyers G et al.

BloodBlood. 2007;110: Abstract 3683. 5. Hill A et al.. 2007;110: Abstract 3683. 5. Hill A et al.

Br J Br J HaematolHaematol.. 2010;149:4142010;149:414--425. 6.425. 6.

HillmenHillmen

P et al.P et al.

Am J Am J HematolHematol. . 2010;85:5532010;85:553--559. 7.559. 7.

International PNH Interest Group.International PNH Interest Group.

Blood.Blood. 2005;106:36992005;106:3699--3709. 8. 3709. 8. HillmenHillmen

P et al. P et al. N N EnglEngl J MedJ Med. 1995;333:1253. 9.. 1995;333:1253. 9.

Nishimura J et al.Nishimura J et al.Medicine. Medicine. 2004;83:1932004;83:193--207. 10.207. 10.

CaprioliCaprioli

J et al.J et al.

BloodBlood. 2006;108:1267. 2006;108:1267--1279. 11. 1279. 11. NorisNoris

M et al.M et al.

ClinClin J Am Soc J Am Soc NephrolNephrol. . 2010;5:18442010;5:1844--1859. 12. George JN et al. 1859. 12. George JN et al. Blood.Blood. 2010;116:40602010;116:4060--4069. 13. 4069. 13. LoiratLoirat

C et al.C et al.

PediatrPediatr NephrolNephrol.. 2008;23:19572008;23:1957--1972. 14. Stahl A, et al1972. 14. Stahl A, et al

BloodBlood. 2008;111:5307. 2008;111:5307--5315. 15.5315. 15.

HoslerHosler

GA et al.GA et al.

Arch Arch PatholPathol Lab MedLab Med. 2003;127;834. 2003;127;834--839. 16. 839. 16. AricetaAriceta

G et al. G et al. PediatrPediatr NephrolNephrol.. 2009;24:6872009;24:687--696.696.

17

Complement Involved in Many DiseasesComplement Involved in Many Diseases

Paroxysmal nocturnal Paroxysmal nocturnal hemoglobinuriahemoglobinuria (PNH)(PNH)

Atypical Hemolytic Uremic Syndrome (aHUS)Atypical Hemolytic Uremic Syndrome (aHUS)

Cold agglutinin disease (CAD)Cold agglutinin disease (CAD)

AntiAnti--phospholipidphospholipid syndrome (APS) and syndrome (APS) and Catastrophic APSCatastrophic APS

MPGN Type II (Dense Deposit Disease; DDD)MPGN Type II (Dense Deposit Disease; DDD)

Antibody / Immune complex diseasesAntibody / Immune complex diseases

AgeAge--related macular degenerationrelated macular degeneration

Recurrent fetal lossRecurrent fetal loss

AsthmaAsthma

Rheumatoid arthritisRheumatoid arthritis

LupusLupus

Ischemia and reperfusion injury (intestinal, hepatic)Ischemia and reperfusion injury (intestinal, hepatic)

18

Most aHUS patients (including patients with identifiable Most aHUS patients (including patients with identifiable mutations) have normal C3 and C4 levels, and complement mutations) have normal C3 and C4 levels, and complement regulatory protein levels are almost always normalregulatory protein levels are almost always normal

As a result, measurement of complement protein or As a result, measurement of complement protein or complement regulatory protein levels are extremely complement regulatory protein levels are extremely insensitive and cannot rule out the presence of aHUSinsensitive and cannot rule out the presence of aHUS––

Serum C3 Serum C3 ––

normal in up to 80%normal in up to 80%1,2,3 1,2,3

––

Serum C4 Serum C4 ––

normal in up to 93%normal in up to 93%22

––

Factor H levels Factor H levels ––

normal in up to 87% of aHUS patients normal in up to 87% of aHUS patients with identified CFH mutationwith identified CFH mutation44

Complement Activity TestingComplement Activity Testing

1. Pickering M et al. J Exp Med. 2007;204(6):1249-1256.

2. Ariceta

G et al. Pediatr Nephrol. 2009;24:687-696. 3. Taylor et al. BJH. 2009;148:37-47.

4. Noris

M et al. CJASN. 2010;10(5):1844-1859.

19

Signs and symptoms of complementSigns and symptoms of complement--mediated TMAmediated TMA1,21,2

Decreased platelet countDecreased platelet count11

Evidence of Evidence of microangiopathicmicroangiopathic hemolysishemolysis11

Evidence of organ impairment/damage (Evidence of organ impairment/damage (egeg. serum . serum creatininecreatinine >ULN)>ULN)2,32,3

Differentiate from other TMA diseasesDifferentiate from other TMA diseases1,21,2

ADAMTS13 Activity >5% ADAMTS13 Activity >5% →→ excludes severe ADAMTS13 deficiency excludes severe ADAMTS13 deficiency (congenital or acquired TTP)(congenital or acquired TTP)4,5,6,74,5,6,7

Absence of positive STEC test Absence of positive STEC test →→ excludes STEC as sole cause excludes STEC as sole cause of TMAof TMA88

No requirement for identified complement gene mutationNo requirement for identified complement gene mutationGenetic mutation cannot be identified in 30%Genetic mutation cannot be identified in 30%--50% of patients with 50% of patients with aHUSaHUS55

Definition of aHUS Definition of aHUS

1. Davin

et al. Am J Kid Dis. 2010;55(4):708-777. 2. Noris

et al. JASN. 2005;16(5):1177-1183. 3. Dragon-Durey

et al. J Am Soc Nephrol. 2010;21(12):2180-2187. 4. Sellier-Leclerc

AL. JASN. 2007;18:2392-2400. 5. Noris

M et al. Clin J Am Soc Nephrol. 2010;5:1844-1859. 6. Tsai H-M. Int J Hematol. 2010;91:1-19. 7. Lamelle

et al. Haematologica. 2008; 93(2) :172-177. 8. Barbot

et al. Brit J Haem. 2001;113(3):649.

20

Atypical Hemolytic Uremic Syndrome (aHUS):Atypical Hemolytic Uremic Syndrome (aHUS): A Genetic, Devastating and LifeA Genetic, Devastating and Life--Threatening DiseaseThreatening Disease

Sudden death and vital organ Sudden death and vital organ damagedamage11

3333--40% of patients die or 40% of patients die or progress to End Stage Renal progress to End Stage Renal Disease (ESRD) with the first Disease (ESRD) with the first clinical manifestationclinical manifestation2,32,3

Chronic progressive course Chronic progressive course with premature mortalitywith premature mortality2,3,42,3,4

65% of all patients have died, 65% of all patients have died, require dialysis, or have require dialysis, or have permanent renal damage permanent renal damage within the first year after within the first year after diagnosis despite plasma diagnosis despite plasma exchange or plasma infusion exchange or plasma infusion (PE/PI)(PE/PI) 22

1. Sallee

M et al. Nephrol Dial Transplant. 2010;25:2028-2032. 2. Caprioli

et al Blood. 2006;108:1267-1272. 3. Noris

M et al. CJASN. 2010;10:1844-1859. 4. Noris M et al. N Engl J Med. 2009;361:1676-1687.

1.001.00

0.750.75

0.500.50

0.250.25

0.000.0000 33 66 252512.512.5

Cum

ulat

ive

Frac

tion

of P

atie

nts

Cum

ulat

ive

Frac

tion

of P

atie

nts

Free

of E

vent

sFr

ee o

f Eve

nts

FollowFollow--up (months)up (months)

Modified from Caprioli

et al. Blood. 2006. CFH Mutation Depicted.

21

aHUS can cause progressive and sudden damage across multiple orgaHUS can cause progressive and sudden damage across multiple organs ans throughthrough TMA manifestationsTMA manifestations––

Evidence of TMA or progressiveEvidence of TMA or progressive

systemic involvement should prompt high systemic involvement should prompt high suspicion of aHUSsuspicion of aHUS

Incidence of aHUS Complications by SystemIncidence of aHUS Complications by System¹¹

1. Langman

C et al. Systemic Multi-Organ Complications in Atypical Hemolytic Uremic Syndrome (aHUS): Retrospective Study in a Medical Practice Setting. Poster presented at EHA. 2012. Abstract 0490.

System Signs/Symptoms Number (%) of Patients with Complication

Renal Kidney impairment 30 (100)

Cardiovascular Thrombi (various locations), cardiac arrest, cardiomyopathy

14 (47)

Gastrointestinal Diarrhea, vomiting, pancreatitis, splenic

vein occlusion

11 (37)

Neurologic Seizure, acute disseminated encephalomyelitis, stroke, transient ischemic attacks, facial paralysis, headache

6 (20)

aHUS complications in >1 system 19 (63)

11 (37%) of the 30 aHUS patients experienced thrombi beyond the kidney

22

Plasma Therapy for aHUS

Remuzzi G, et al. Treatment of the hemolytic uremic syndrome with plasma. Clin Nephrol 1979, 12:279-84.

Loirat C, et al. Treatment of the childhood haemolytic uremic syndrome with plasma. A multicentre randomized controlled trial. Pediatr Nephrol1988, 2:279-85.

Nathanson S, et al. Successful plasma therapy in hemolytic uremic syndrome with factor H deficiency. Pediatr Nephrol 2001, 16:554-6.

Ariceta G, et al. Guideline for the investigation and initial therapy of diarrhea-negative hemolytic uremic syndrome. Pediatr Nephrol 2009, 24:687-96.

Ruebner RL, Kaplan BS, Copelovitch L. A time for reappraisal of “atypical” hemolytic uremic syndrome: should all patients be treated the same? Eur J Pediatr 2012, 171:1519-25.

23

Affected ProteinResponse to Short-term

Plasma Therapy

(remission rate, %)

Long-term Outcome

(rate of death or ESRD, %)

Recurrence After Kidney Transplantation

(rate)

Factor H 60% 70%-80% 80%-90%

CFHR1, R3 70%-80% 30%-40% 20%

MCP No definitive indication for therapy <20% 15%-20%

Factor I 30%-40% 60%-70% 70%-80%

Factor B 30% 70% Recurrence in 1 case

C3 40%-50% 60% 40%-50%

THBD 60% 60% Recurrence in 1 case

Noris

M et al. N Engl J Med. 2009;361:1676-1687.

aHUS Response to Plasma Therapy and Outcome aHUS Response to Plasma Therapy and Outcome After Kidney TransplantationAfter Kidney Transplantation

23

24

Atypical Hemolytic Uremic Syndrome in Children: Complement Mutations and Clinical Characteristics

Geerdink

LM, et al. Pediatr

Nephrol

2012; 27:1283-91.

Treatment of First Episode

Long-term Outcome –

10 years (mean 7.5)

Time to first relapse, from 1 month to 8.5 years

25

aHUS is Frequently Diagnosed in Patients With aHUS is Frequently Diagnosed in Patients With ComorbidComorbid

Diseases Diseases

25% (47/191) of patients with aHUS and no known affected family 25% (47/191) of patients with aHUS and no known affected family member member have coexisting diseases have coexisting diseases Complement mutations identifiable in only 27% of aHUS patientsComplement mutations identifiable in only 27% of aHUS patients

––

Similar to rate in all aHUS patients with no known affected famiSimilar to rate in all aHUS patients with no known affected family member (41%) ly member (41%)

Comorbid

DiseasesaHUS Patients With

Comorbid

Disease, n (%)

aHUS Patient With No Identified Mutation

and Comorbid

Disease, n

aHUS Patient With Identified Mutation

and Comorbid

Disease, n

Malignancy and Chemotherapy 1 (2%) 1 0

Malignant Hypertension 14 (30%) 12 2

Post Transplant HUS* and Calcineurin

Inhibitors 11 (23%) 8 3

Pregnancy-related HUS 10 (21%) 7 3

Systemic disease-Scleroderma-SLE

3 (6%) 2 1

Glomerulopathy† 8 (17%) 4 4

Total 47 (100%) 34 13

*Primary cause nephropathy unknown -

6 /11 pts (3 w/mutations), 2 IgA

nephrop., 1 DM nephrop., 1 MPGN, 1 reflux nephropathy.†Glomerulopathy: MPGN, nephrotic

syndrome, mesangioproliferative

glomerulonephritis, membranous glomerulonephritis.*Noris

M et al. Clin J Am Soc Nephrol. 2010;5:1844-1859.

26

aHUS Patients Generally are Not Effectively and Safely Treated WaHUS Patients Generally are Not Effectively and Safely Treated With Plasma ith Plasma Exchange/InfusionExchange/Infusion

3333--40% of patients die or progress to ESRD with the first clinical 40% of patients die or progress to ESRD with the first clinical manifestationmanifestation1,21,2

65% of all patients have died, require dialysis, or have permane65% of all patients have died, require dialysis, or have permanent renal damage nt renal damage within the first year after diagnosis despite PE/PIwithin the first year after diagnosis despite PE/PI 11

No wellNo well--controlled clinical trials showing plasma exchange/infusion to bcontrolled clinical trials showing plasma exchange/infusion to be either safe e either safe or effective as aHUS therapyor effective as aHUS therapy3,43,4

Frequent and severe complications in adults and in childrenFrequent and severe complications in adults and in children5,65,6

Plasma exchange/infusion does not target the cause of aHUS: uncoPlasma exchange/infusion does not target the cause of aHUS: uncontrolled, ntrolled, excessive complement activationexcessive complement activation22

–

Uncontrolled complement activation and resulting platelet activation demonstrated to persist during PE/PI7,87,8

aHUS: Medical Evidence aHUS: Medical Evidence Challenges Common PerceptionsChallenges Common Perceptions

1. Caprioli

et al. Blood. 2006;108:1267-1272. 2. Noris M et al. N Engl J Med. 2009;361:1676-1687. 3. Loirat

C et al. Semin Thromb Hemost. 2010;36:673-681. 4. Pazdur

R. 2011 http://connection.asco.org/forums. 5. George et al. Blood. 2010;116:4060-4069. 6. Michon

B et al. Transfusion. 2007;47:1837-1842. 7. Stahl A et al Blood. 2008;111:5307-5315. 8. Licht

C et al. Blood. 2009;114:4538-4545.

27

Clinical presentation can be similar to other systemic TMAsClinical presentation can be similar to other systemic TMAs11--33

Historical treatment did not require differential diagnosis betwHistorical treatment did not require differential diagnosis between een aHUS, TTP and STECaHUS, TTP and STEC--HUS HUS –– historically grouped as historically grouped as TTP/HUSTTP/HUS4,54,5

aHUS is a rare disease leading to lack of clinical suspicionaHUS is a rare disease leading to lack of clinical suspicion

Rarity of aHUS may impact accurate and rapid diagnosisRarity of aHUS may impact accurate and rapid diagnosis––

Perception that genetic mutation needs to be identifiedPerception that genetic mutation needs to be identified66

––

Perception that aHUS is only a pediatric diseasePerception that aHUS is only a pediatric disease66

––

Perception that aHUS is only a renal diseasePerception that aHUS is only a renal disease66

Challenges in Diagnosing aHUSChallenges in Diagnosing aHUS

1. George et al. Blood. 2010;116(20):4060-4069. 2. Noris M et al. N Engl J Med. 2009;361:1676-1687. 3. Zipfel

PF et al. Curr Opin Nephrol Hypertens. 2010;19(4):372-378.

4. Bianchi

et al. Blood. 2002;100(2):710-713. 5. Loirat

C et al. Semin Thromb Hemost. 2010;36:673-681. 6. Noris

M et al. CJASN. 2010;10(5):1844-1859.

28

Genetic mutation cannot be identified in 30%Genetic mutation cannot be identified in 30%--50% 50% of patients with aHUSof patients with aHUS11

Absence of identifiable genetic mutations does Absence of identifiable genetic mutations does not rule out aHUSnot rule out aHUS11

Results generally takes weeks to months Results generally takes weeks to months –– therefore does therefore does not impact initial clinical managementnot impact initial clinical management22

aHUS: Diagnosis Does Not Require aHUS: Diagnosis Does Not Require Identification of a Genetic MutationIdentification of a Genetic Mutation

1. Noris

M et al. Clin J Am Soc Nephrol. 2010;5:1844-1859. 2. Noris, M et al. Seminars in Nephrology. 2010;30:395-408.

29

aHUS

>5% ADAMTS13 Activ>5% ADAMTS13 Activityity1212

TTP

≤≤5% ADAMTS13 5% ADAMTS13 ActivityActivity8,13,148,13,14

STEC-HUS

ShigaShiga--toxin/EHEC toxin/EHEC PositivePositive1414

Evaluate ADAMTS13 Activity and Shiga-toxin/EHEC* Test8,13,14,15

Differential Diagnosis for Differential Diagnosis for TMAsTMAs: aHUS, TTP and STEC: aHUS, TTP and STEC--HUSHUSThrombocytopeThrombocytopeniania1,21,2

Platelet count <150,000 Platelet count <150,000 OrOr >25% Decrease from baseline>25% Decrease from baseline11

Renal ImpairmeRenal Impairmentnt2,9,102,9,10

Elevated Elevated CreatinineCreatinine1010

and/orand/or Decreased eGFRDecreased eGFR2,102,10

and/orand/or Elevated Blood PressureElevated Blood Pressure1111

and/or and/or Abnormal UrinalysisAbnormal Urinalysis99

Neurological SymptoNeurological Symptomsms4,5,6,74,5,6,7

ConfusionConfusion4,54,5

and/orand/or SeizuresSeizures6,86,8

and/or and/or Other Cerebral AbnormalitiesOther Cerebral Abnormalities55

Plus One or More of the Following:Plus One or More of the Following:

Gastrointestinal SymptomsGastrointestinal Symptoms2,6,122,6,12

Diarrhea +/Diarrhea +/--

BloodBlood1212and/or and/or Nausea/VomitingNausea/Vomiting66

and/orand/or Abdominal PainAbdominal Pain66

and/orand/or GastroenteritisGastroenteritis2,122,12

MicroangiopathicMicroangiopathic

HemolysisHemolysis2,32,3

SchistocytesSchistocytes2,3 2,3 and/orand/or Elevated LDHElevated LDH22

and/orand/or Decreased HaptoglobinDecreased Haptoglobin2 2 and/orand/or

Decreased HemoglobinDecreased Hemoglobin2 2

ANDAND

* Shiga-toxin/EHEC test is warranted with history/presence of GI symptoms.1. Data on file. Alexion Pharmaceuticals, Inc. 2. Caprioli

et al. Blood. 2006;108(4):1267-7. 3. Noris

et al. NEJM. 2009;361:1676-1687. 4. Neuhaus

et al. Arch Dis Chilid. 1997;76(6):518-521. 5. Noris

et al. JASN. 2005;16(5):1177-1183. 6. Dragon-Durey

et al. J Am Soc Nephrol. 2010;21(12):2180-2187. 7. Davin

et al. Am J Kid Dis. 2010;55(4):708-777. 8. Bianchi et al. Blood. 2002;110:710-713. 9. Al-Akash

et al. Pediatr Nephrol. 2011 Apr;26(4):613-619. 10. Sellier-Leclerc

AL. JASN. 2007;18:2392-2400. 11. Benz et al. Curr Opin Nephrol Hypertens. 2010;19(3):242-247. 12. Noris

M et al. Clin J Am Soc Nephrol. 2010;5:1844-1859. 13. Tsai H-M. Int J Hematol. 2010;91:1-19. 14. Barbot

et al. Brit J Haem. 2001;113(3):649. 15. Bitzan

M. Semin Thromb Hemost. 2010;36:594-610.

This pathway is intended as educational information for healthcare providers. It does not replace a healthcare professional’s judgment or clinical diagnosis.

Novel Strategies Novel Strategies for the Treatment of aHUSfor the Treatment of aHUS

Eculizumab

(Soliris) First in Class Humanized Anti-C5 Monoclonal Antibody

32

EculizumabEculizumab

Blocks Terminal ComplementBlocks Terminal Complement1,21,2

C5C5

Prox

imal

Term

inal

1. Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc. 2011. 2. Rother

RP et al. Nature Biotech. 2007;25(11):1256-64. 3. Walport

MJ. N Engl J Med. 2001;344(14):1058-66. 4. Figueroa JE, Densen P. Clin Microbiol Rev. 1991;4(3):359-395.

C5aC5a

EculizumabEculizumab

Proximal functions of complement remain intact1,2

•

Weak anaphylatoxin2,4

•

Immune complex clearance2

•

Microbial opsonization2

Terminal complement - C5a and C5b-9 activity blocked1,2

Eculizumab binds with high affinity to C51,2

Complement CascadeComplement Cascade2,32,3

C5bC5b--99C5bC5b

C3C3 C3aC3a

C3bC3b

33

Eculizumab

for Congenital Atypical Hemolytic-Uremic Syndrome

18 m.o. boy; 4th

relapse; normal ADAMTS13; no identifiable mutations

Gruppo

RA, Rother

RP. N Engl J Med 2009, 360:544-5

34

EculizumabEculizumab

Multinational, Multinational, MultiMulti--Center Clinical Program in aHUS (N=67)Center Clinical Program in aHUS (N=67)

Clinical Diagnosis Clinical Diagnosis of aHUSof aHUS11

Clinical Diagnosis of aHUS WithClinical Diagnosis of aHUS With11

TMA (measured by platelet count, TMA (measured by platelet count, hemolysishemolysis))Organ Damage (serum Organ Damage (serum creatininecreatinine ≥≥ULN)ULN)ADAMTS13 >5%; no positive STEC testADAMTS13 >5%; no positive STEC testNo requirement for identified genetic mutationNo requirement for identified genetic mutation

Medical Practice Setting (C09-001)

(N=30)

19 Patients <18 years old

RetrospectiveRetrospective11Prospective (26 weeks)Prospective (26 weeks)11

Long-term Extension Studies2,3

86% (32/37) of patients continued chronic Eculizumab

treatment in extension studies

Patients with long duration of aHUS (C08-003)

(N=20)

Adult/Adolescent

aHUS patients with progressing TMA (C08-002)

(N=17)

Adult/Adolescent

1. Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc. 2011 2. Licht

C, et al. Presented

at

2011 Annual

ASN Congress. Abstract TH-PO366. 3. Greenbaum

L., et al. Presented

at

2011 Annual

ASN Congress. Abstract TH-PO367.

35

EculizumabEculizumab

Multinational Clinical Program Multinational Clinical Program Includes Broad aHUS Patient PopulationIncludes Broad aHUS Patient Population

2 month12 month2 month11AgeAge

Duration fromDuration from

aHUS Diagnosis to StudyaHUS Diagnosis to Study

Identified GeneticIdentified GeneticComplement MutationsComplement Mutations

TMA in Patients WithTMA in Patients With

Degree of Organ DamageDegree of Organ Damage

DialysisDialysis

Renal TransplantRenal Transplant None3NoneNone33

None3NoneNone33

CKD Stage 12CKD Stage 1CKD Stage 122

None identified2None identifiedNone identified22

<1 month1<1 month<1 month11

Normalplatelet count2

NormalNormalplatelet countplatelet count22

Adults1AdultsAdults11

3 prior kidney grafts lost3

3 prior kidney 3 prior kidney grafts lostgrafts lost33

3/week33/week3/week33

CKD Stage 52CKD Stage 5CKD Stage 522

Multiple per patient2Multiple per patientMultiple per patient22

286 months1286 months286 months11

Reducedplatelet count2ReducedReducedplatelet countplatelet count22

No intervention1*

No No interventionintervention11**

230 interventions3

230 230 interventionsinterventions33PE/PIPE/PI

*Based on study definition.1. Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc. 2011. 2. European Public Assessment Report available on http://www.ema.europa.eu

[accessed December 15, 2011]. 3. Alexion Pharmaceuticals, Inc. Data on file.

36

Prospective Studies: Prospective Studies: EculizumabEculizumab

Dosing Schedule* Dosing Schedule*

Pretreatment Induction Phase Maintenance Phase

≥2 weeks before induction

Week

→ 1 2 3 4 5 6 7 89 and every

2 weeks

thereafter

Neisseria

meningitidis

vaccination

Eculizumab

dose, mg

→900 900 900 900 1200 X 1200 X 1200

Administration: Administration: IV infusion over 35 min every 7 d during induction and every 14 IV infusion over 35 min every 7 d during induction and every 14 d during d during maintenancemaintenance

––

Dose adjustmentDose adjustment

to every 12 days may be necessary to every 12 days may be necessary

Meningococcal prophylaxisMeningococcal prophylaxis: patients received meningococcal vaccination prior to receipt o: patients received meningococcal vaccination prior to receipt of f EculizumabEculizumab or received prophylactic treatment with antibiotics until 2 weeor received prophylactic treatment with antibiotics until 2 weeks after vaccinationks after vaccination

Severe TMA complications Severe TMA complications observed in aHUS patients deviating from recommended dosing observed in aHUS patients deviating from recommended dosing scheduleschedule

−−

5/18 patients experienced TMA complications following missed dos5/18 patients experienced TMA complications following missed dosee−−

EculizumabEculizumab

was reinitiated in 4/5 patientswas reinitiated in 4/5 patients*For patients <18 years of age, administration of Eculizumab

is based on body weight.1. Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc. 2011. 2. European Public Assessment Report available on http://www.ema.europa.eu

[accessed December 15, 2011]. 3. Alexion Pharmaceuticals, Inc. Data on file.

37

Patients with long duration of aHUS (C08-003)

(N=20)

aHUS patients with progressing TMA (C08-002)

(N=17)

Reduction in TMA (Change in platelet count) Primary

TMA event-free status PrimaryHematologic normalization Coprimary CoprimaryReduction in PE/PI or new dialysis(TMA intervention rate)

Change in renal function (eGFR, CKD stage)

HRQoL

measures

EculizumabEculizumab

Prospective Trials: Prospective Trials: Key Clinical Trial EndpointsKey Clinical Trial Endpoints

TMA event-free status: For 12 consecutive weeks, no decrease in platelet count >25% from baseline, and no plasma exchange/infusion, and no new dialysis

Hematologic normalization: Normalization of both platelet count and LDH sustained for at least 2 consecutive measurements that span a period of at least 4 weeks

TMA intervention rate: Number of plasma exchange or plasma infusion interventions or dialyses required per patient per day

HRQoL

= health-related

quality

of life. *Primary

endpoint

requested

by the regulatory

authorities.Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals, Inc. 2011.

38

Long Duration of aHUS Clinical Trial Patient Long Duration of aHUS Clinical Trial Patient PopulationPopulation

Long duration of aHUS and substantial renal damage Long duration of aHUS and substantial renal damage despite prior longdespite prior long--term PE/PI term PE/PI

––

Median duration from aHUS diagnosis to screening: Median duration from aHUS diagnosis to screening: 48 months (range 0.6648 months (range 0.66--286)286)

––

50% of patients with 50% of patients with eGFReGFR

<30 mL/min/1.73M<30 mL/min/1.73M22, , including 2 patients on chronic dialysisincluding 2 patients on chronic dialysis

––

PE/PI for a median duration of 10 months PE/PI for a median duration of 10 months (range 2.4(range 2.4--47) prior to 47) prior to eculizumabeculizumab

Licht

C et al. ESPN Annual Meeting 2011 (Poster PS2-FRI-272); Licht

C et al. ASN Annual Meeting 2011 (Poster TH-PO366).

Patients With Long Duration of aHUS (C08-003)

39

No decrease in platelet count No decrease in platelet count >25% from baseline >25% from baseline ANDAND

No plasma exchange/infusion No plasma exchange/infusion ANDAND

No new dialysisNo new dialysis

For at least 12 consecutive weeksFor at least 12 consecutive weeks

In 20/20 patients:In 20/20 patients:––

Elimination of PE/PI Elimination of PE/PI ANDAND––

No new dialysisNo new dialysis

The benefit was sustained through The benefit was sustained through the entire study period (median the entire study period (median eculizumabeculizumab 62 weeks)62 weeks)

EculizumabEculizumab

Led to TMA EventLed to TMA Event--Free Status in 85% Free Status in 85% of Patients At Median of 62 Weeks Treatmentof Patients At Median of 62 Weeks Treatment

Licht

C et al. ASH Annual Meeting 2011 (Poster 3033).

Median of 62 Weeks Treatment

Week 26

80% (16/20)

85% (17/20)

Complement-Mediated TMAPatients With Long Duration of aHUS (C08-003)

40

EculizumabEculizumab

Eliminated PE/PI in 100% of Patients Eliminated PE/PI in 100% of Patients and No Patient Required New Dialysisand No Patient Required New Dialysis

P<0.0001

0(0-0)

Med

ian

(ran

ge)

TMA

Inte

rven

tion

Rat

e (p

er p

atie

nt p

er d

ay)

Baseline Week 26

0.23(0.05-1.09)

(N=20) (N=20)

In every patient:–

Elimination of PE/PI AND–

No new dialysis

Reduction from:–

Approximately median (range) of 1.5 (0.4-7.6) interventions

per patient per week prior to eculizumab

treatment–

0 interventions in all 20 patients during the entire study period

The benefit was sustained The benefit was sustained through the entire study period through the entire study period (median (median eculizumabeculizumab 62 weeks)62 weeks)

TMA intervention rate: Number of plasma exchange or plasma infusion interventions and number of new dialyses required per patient per day.Licht

C et al. ASH Annual Meeting 2011 (Poster 3033).

Burden of DiseasePatients With Long Duration of aHUS (C08-003)

41

Chronic Eculizumab

Improved Renal Function During Median of 62 Weeks

Patients With Long Duration of aHUS (C08-003) Renal Function

42

Earlier Intervention with Eculizumab

Led to Greater Improvement in eGFR

Patients With Long Duration of aHUS (C08-003) Renal Function

43

Progressing TMA Clinical Trial Patient Progressing TMA Clinical Trial Patient PopulationPopulation

aHUS patients with progressing TMAaHUS patients with progressing TMA–– Shorter duration of disease compared with Shorter duration of disease compared with

Study C08Study C08--003003–– 10 months median duration (range 0.2610 months median duration (range 0.26--236) 236)

from aHUS diagnosisfrom aHUS diagnosis

Greenbaum

L et al. ASN Annual Meeting 2011 (Poster TH-PO367).

aHUS Patients With Progressing TMA (C08-002)

44

Chronic Chronic EculizumabEculizumab

Inhibited ComplementInhibited Complement--Mediated TMA Mediated TMA as Measured by a Significant Increase in Platelet Countas Measured by a Significant Increase in Platelet Count

Mean platelet increase Mean platelet increase between baseline and between baseline and 52 weeks: 90 x1052 weeks: 90 x1099/L /L ((PP<0.0001)<0.0001)

Significant increase in Significant increase in platelet count as early platelet count as early as Day 7 (as Day 7 (PP=0.027)=0.027)

Platelet increase Platelet increase sustained through a sustained through a median duration of median duration of 64 weeks64 weeks

*P≤0.01†P<0.05

Number of Patients 17 16 15 14 15 15 14 6 13 13 13 12 11 12

†

† † * * * * * * * * * * * * * * * * *

Greenbaum

L et al. ASH Annual Meeting 2011 (Oral Presentation 193).

Mean (SE) Changes from Baseline to Week 52Mean (SE) Changes from Baseline to Week 52

in Platelet Countin Platelet Count

Complement-Mediated TMAaHUS Patients With Progressing TMA (C08-002)

45

Study C08Study C08--002002

0 50 100 150

Complement Activity, the Cause of Symptoms and Complement Activity, the Cause of Symptoms and Clinical Manifestations of aHUS, Was Reduced in All Clinical Manifestations of aHUS, Was Reduced in All

Patients During Patients During EculizumabEculizumab

TreatmentTreatment

Chronic Uncontrolled Complement Activation

Chronic Uncontrolled Complement Activation

Reduction observed Reduction observed in all patients after in all patients after commencement of commencement of EculizumabEculizumab

Reduction sustained through end of study

*Based on a *Based on a pharmacodynamicpharmacodynamic

assay that quantified the complement activity in patientassay that quantified the complement activity in patient’’s serum by measuring the degree of s serum by measuring the degree of hemolysishemolysis; the measure of ; the measure of hemolysishemolysis

is the amount of hemoglobin release as determined via spectrophis the amount of hemoglobin release as determined via spectrophotometer.otometer.

Change From Baseline to End of Change From Baseline to End of Study PeriodStudy PeriodStudy C08Study C08--003003

aHUS Patients With Progressing TMA (C08-002)

46

No decrease in platelet count No decrease in platelet count >25% from baseline AND>25% from baseline AND

No plasma exchange/infusion No plasma exchange/infusion ANDAND

No new dialysisNo new dialysis

For at least 12 consecutive weeksFor at least 12 consecutive weeks

Benefit sustained through a Benefit sustained through a median duration of 64 weeksmedian duration of 64 weeks

Chronic Eculizumab Inhibited ComplementChronic Eculizumab Inhibited Complement--Mediated Mediated TMA: 88% of Patients Achieved TMA EventTMA: 88% of Patients Achieved TMA Event--Free StatusFree Status

*Two patients discontinued Eculizumab treatment after 1 and 4 do*Two patients discontinued Eculizumab treatment after 1 and 4 doses and did not achieve TMA eventses and did not achieve TMA event--free status.free status.Greenbaum L et al. ASH Annual Meeting 2011 (Oral Presentation 19Greenbaum L et al. ASH Annual Meeting 2011 (Oral Presentation 193).3).

88%(15/17*)

(N=17)

Complement-Mediated TMAaHUS Patients With Progressing TMA (C08-002)

47

Sustained eculizumab treatment showed a statistically significanSustained eculizumab treatment showed a statistically significant, timet, time--dependent increase in eGFRdependent increase in eGFR

––

31 mL/min/1.73m31 mL/min/1.73m22

(95% CI, 17(95% CI, 17--45) through Week 26 (45) through Week 26 (PP=0.0001)=0.0001)

––

31 mL/min/1.73m31 mL/min/1.73m22

(95% CI, 14(95% CI, 14--44) through a median duration of 64 weeks (44) through a median duration of 64 weeks (PP=0.0003)=0.0003)

Chronic EculizumabTreatment Significantly Chronic EculizumabTreatment Significantly Improved eGFRImproved eGFR

Greenbaum L et al. ASH Annual Meeting 2011 (Oral Presentation 19Greenbaum L et al. ASH Annual Meeting 2011 (Oral Presentation 193).3).

Cha

nge

from

Bas

elin

e of

eG

FR 40

30

20

10

0 95% CI

eGFR (simple means)eGFR (estimated 3-piece linear trend)

-42 0 21 56 84 112 154 224 280 336 392Days

Renal FunctionaHUS Patients With Progressing TMA (C08-002)

48

Eculizumab Eliminated Dialysis in 4/5 Patients Eculizumab Eliminated Dialysis in 4/5 Patients (80%) (80%)

Greenbaum L et al. ASH Annual Meeting 2011 (Oral Presentation 19Greenbaum L et al. ASH Annual Meeting 2011 (Oral Presentation 193).3).

(n=5)

Patients remained dialysis-free at a median duration of 64 weeks eculizumab treatment

One patient developed a new dialysis requirement during eculizumab treatment; this patient discontinued eculizumab due to an adverse event unrelated to eculizumab treatment (worsening of pancytopenia)

Patients eliminated dialysis within 14 days following initiation of eculizumab

Renal FunctionaHUS Patients With Progressing TMA (C08-002)

49

Earlier Intervention with Eculizumab Leads to Greater Improvement in Renal Function

Renal FunctionaHUS Patients With Progressing TMA (C08-002)

50

Children (2 months to 11 years, n=15), adolescents Children (2 months to 11 years, n=15), adolescents (12 to 18 years, n=4)(12 to 18 years, n=4)11

Median (range) duration of eculizumab treatment: 28 (1Median (range) duration of eculizumab treatment: 28 (1--70) weeks70) weeks22

47% with no identified genetic mutation47% with no identified genetic mutation11

Medical practice setting:Medical practice setting:22

––

No requirement for PE/PINo requirement for PE/PI––

No requirement for platelet count, ADAMTS13 activity, No requirement for platelet count, ADAMTS13 activity, complement mutation, or LDH/creatinine valuescomplement mutation, or LDH/creatinine values

––

Median duration since aHUS diagnosis was 19 months Median duration since aHUS diagnosis was 19 months (range: <1(range: <1--177 months)177 months)

Medical Practice Patient Population Medical Practice Patient Population (age <18 years)(age <18 years)

1. Soliris1. Soliris®®

(eculizumab). Prescribing information. Alexion Pharmaceuticals,(eculizumab). Prescribing information. Alexion Pharmaceuticals,

Inc. 2011. 2. Alexion Pharmaceuticals, Inc. Data on file.Inc. 2011. 2. Alexion Pharmaceuticals, Inc. Data on file.

Medical Practice Setting (C09-001)

51

Key Outcomes from the Retrospective Trial Key Outcomes from the Retrospective Trial

1. Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals,

Inc. 2011. 2. Alexion Pharmaceuticals, Inc. Data on file.

Eculizumab Inhibited Complement-Mediated TMAs Measured By Normalization in Platelet Count

Eculizumab Inhibited Complement-Mediated TMA:

68% of Patients Achieved TMA Event-Free Status

TMA Intervention Rate: Number of PE/PI and new dialysis events per day per patient.

Eculizumab Reduced Burden of Disease as Measured by Reduction in PE/PI and New Dialysis

Note: For all parameters, improvement in at least 2 consecutive measurements over 4 weeks.

*One patient obtained eGFR improvement after renal transplantation.

Eculizumab Markedly Improved Renal Function

Medical Practice Setting (C09-001)

52

Patient History and Outcomes AcrossPatient History and Outcomes Across Eculizumab Clinical Program in aHUSEculizumab Clinical Program in aHUS

Patients With Long Patients With Long Duration of aHUS Duration of aHUS

(C08(C08--003)003)

Adolescent/Adult Adolescent/Adult Prospective StudyProspective Study11

(N=20)(N=20)

aHUS Patients With aHUS Patients With Progressing TMA Progressing TMA

(C08(C08--002)002)

Adolescent/Adult Adolescent/Adult Prospective StudyProspective Study22

(N=17)(N=17)

Medical Medical Practice Setting Practice Setting

(C09(C09--001)001)Retrospective Retrospective

Pediatric StudyPediatric Study3,43,4

(N=19)(N=19)

Median (range) Duration Median (range) Duration Since aHUS DiagnosisSince aHUS Diagnosis

48 months (0.66-286 mo)

10 months (0.26-236 mo)

19 months (0.39-177 mo)

Uncontrolled Complement Uncontrolled Complement Activation InhibitedActivation Inhibited Yes Yes Yes

ComplementComplement--mediated TMA mediated TMA InhibitedInhibited Yes Yes Yes

Burden of Interventions Burden of Interventions ReducedReduced Yes Yes Yes

Renal Function Renal Function Maintained or Improved Improved Improved

Requirement for DialysisRequirement for Dialysis No New Dialysis Eliminated in 80% Eliminated in 50%, no new dialysis

Safety During Study PeriodSafety During Study Period Well tolerated* Well tolerated* Well tolerated‡‡

Complement mutationComplement mutation Similar outcomes with or without identified mutation

*All patients alive; no meningococcal infections.*All patients alive; no meningococcal infections.‡‡1 patient died (not drug related); 1 meningococcal infection (po1 patient died (not drug related); 1 meningococcal infection (postst--study followstudy follow--up period).up period).1. Licht C et al. ASN Annual Meeting 2011 (Poster TH-PO366). 2. Greenbaum et al. ASN Annual Meeting 2011 (Poster TH-PO367).

3. Soliris®

(eculizumab). Prescribing information. Alexion Pharmaceuticals,

Inc. 2011. 4. Alexion Pharmaceuticals, Inc. Data on file.

53

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Severe TMA Complications Observed After Eculizumab Discontinuation

55

Definition of Severe TMA Complication

56

Eculizumab Discontinuation from aHUS Clinical Trials -

Outcome

57

Eculizimab Discontinuation from aHUS Clinical Trials -

Outcomes

58

Patients Who Discontinue Eculizumab are at Early and Ongoing Risk of Severe TMA Complications

59

Important Safety Information

60

Warning

61

Warnings and Precautions

62

Treatment Emergent Adverse Events Occurring in >10% of Adult and Adolescent Patients Enrolled in aHUS Study 1 and Study 2

63

Treatment-Emergent Adverse Events Occurring in >15% of Patients <18 Years of Age Enrolled in aHUS Study 3

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Patient Safety Information Card

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*Benefits at these time intervals were experienced by many patie*Benefits at these time intervals were experienced by many patients but do not indicate that every patient will nts but do not indicate that every patient will achieve the same results.achieve the same results.1. Soliris1. Soliris®®

[package insert]. Cheshire, CT: Alexion Pharmaceuticals, Inc; 2[package insert]. Cheshire, CT: Alexion Pharmaceuticals, Inc; 2011. 2. Data on file. Alexion Pharmaceuticals, Inc.011. 2. Data on file. Alexion Pharmaceuticals, Inc.

Eculizumab Treatment ExpectationsEculizumab Treatment Expectations In aHUS Clinical Trials, Many Eculizumab Benefits Occurred RapiIn aHUS Clinical Trials, Many Eculizumab Benefits Occurred Rapidly, dly,

While Others Occurred Over TimeWhile Others Occurred Over Time

Ongoing Eculizumab Treatment Inhibits ComplementOngoing Eculizumab Treatment Inhibits Complement--mediated TMAmediated TMA1,21,2

1 to 2 Weeks*1 to 2 Weeks*Increase or Increase or normalization in normalization in platelet count in platelet count in patients with patients with progressing TMAprogressing TMA1,21,2

Reduction or Reduction or elimination of PE/PI elimination of PE/PI and no new dialysisand no new dialysis1,21,2

4 Weeks*4 Weeks*Maintenance or Maintenance or improvement in improvement in renal functionrenal function

••

Increase in eGFRIncrease in eGFR1,21,2

Decrease or Decrease or normalization in normalization in hemolysis (as hemolysis (as measured by measured by LDH)LDH)22

26 Weeks*26 Weeks*Maintenance or Maintenance or greater improvement greater improvement in renal functionin renal function11

Hematologic Hematologic normalizationnormalization11

The majority of patients in prospective studies continued in extension studies1

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Eculizumab treatment results in a rapid and sustained inhibitionEculizumab treatment results in a rapid and sustained inhibition of the TMA of the TMA processprocess

In patients with eculizumab initiation 10 months after aHUS diagIn patients with eculizumab initiation 10 months after aHUS diagnosis, nosis, eculizumab resulted in sustained improvement in renal function aeculizumab resulted in sustained improvement in renal function and 80% of nd 80% of patients eliminated dialysispatients eliminated dialysis

In patients receiving longIn patients receiving long--term PE/PI with a median 48 month since aHUS term PE/PI with a median 48 month since aHUS diagnosis and severe renal impairment, eculizumab eliminated PE/diagnosis and severe renal impairment, eculizumab eliminated PE/PI in all PI in all patients and no new dialysis sessions were requiredpatients and no new dialysis sessions were required

Eculizumab treatment leads to significant and sustained, timeEculizumab treatment leads to significant and sustained, time--dependent dependent improvement in renal function through 26 weeks and median duratiimprovement in renal function through 26 weeks and median duration on >60 weeks>60 weeks

In all three trials, earlier intervention with eculizumab is assIn all three trials, earlier intervention with eculizumab is associated with greater ociated with greater improvement in renal functionimprovement in renal function

Eculizumab Prospective Clinical Trial Eculizumab Prospective Clinical Trial ConclusionsConclusions

Licht C et al. ESPN Annual Meeting 2011 (Poster PS2Licht C et al. ESPN Annual Meeting 2011 (Poster PS2--FRIFRI--272); Licht C et al. ASN Annual Meeting 2011 (Poster TH272); Licht C et al. ASN Annual Meeting 2011 (Poster TH--PO366); Loirat C et al. ESPN PO366); Loirat C et al. ESPN Annual Meeting 2011 (Poster PS2Annual Meeting 2011 (Poster PS2--FRIFRI--273); Greenbaum L et al. ASN Annual Meeting 2011 (Poster TH273); Greenbaum L et al. ASN Annual Meeting 2011 (Poster TH--PO367).PO367).

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Mayo Medical LaboratoriesMayo Medical Laboratories

ADAMTS13: Will be offered in-house the first week of AugustTest run 7 days a week with 24 hour TAT (first week of Aug.)ADAMTS13 activity: price to be finalized on August 6ADAMTS13 inhibitor: price to be finalized on August 6Critical call back for all results <10% activity

ADAMTS13Test

Stool culture: List price $82.80E. Coli Rapid culture (EIA): List price $126.30E. Coli PCR: List price $327.90 – 100% specific/100% accurate24 hour TAT for PCR real-time

Shiga-

Toxin Test

High sensitivity flow cytometry for PNH24 hour TATFlow for PNH: List price $377.40 Interpretation: List price additional $117.40Interpretation will be provided by Mayo on all abnormal results

Flow Cytometry

for PNH

TAT=Turn-around time; EIA=Electrophoresis immunoassay

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MORL (Molecular Otolaryngology & Renal Research MORL (Molecular Otolaryngology & Renal Research Laboratories) at The University of IowaLaboratories) at The University of Iowa––

http://http://www.healthcare.uiowa.edu/labs/morl/index.htmwww.healthcare.uiowa.edu/labs/morl/index.htm

–

Phone: 319-335-6623

The Mario Negri Institute for Pharmacological Research –

http://www.marionegri.it/mn/en/index.html#

–

Phone: +39.02.39014.1

Institute of Genetic Medicine at Newcastle University Institute of Genetic Medicine at Newcastle University ((GoodshipGoodship Lab)Lab)––

http://http://www.ncl.ac.uk/igm/services/ngswww.ncl.ac.uk/igm/services/ngs//

––

Phone ++ (0)191 241 8616Phone ++ (0)191 241 8616

Genetics Testing LabsGenetics Testing Labs

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RegistryRegistryPatients with a diagnosis of aHUS, regardless of treatment, willPatients with a diagnosis of aHUS, regardless of treatment, will be eligible for be eligible for enrollment after signing an informed consent.enrollment after signing an informed consent.

Inclusion CriteriaInclusion CriteriaMale or female patients of any age, including minors, who have bMale or female patients of any age, including minors, who have been diagnosed een diagnosed with aHUSwith aHUSDiagnosis of aHUS includes:Diagnosis of aHUS includes:––

Clinical diagnosis of aHUSClinical diagnosis of aHUS––

Patients with or without an identified complement regulatory facPatients with or without an identified complement regulatory factor genetic tor genetic abnormality or antiabnormality or anti--complement factor antibodycomplement factor antibody

––

ADAMTS13 >5% (if performed)ADAMTS13 >5% (if performed)

Exclusion CriteriaExclusion CriteriaPatients with Hemolytic Uremic Syndrome (HUS) only due to Shiga Patients with Hemolytic Uremic Syndrome (HUS) only due to Shiga Toxin Toxin are excludedare excluded

aHUS Registry aHUS Registry An Observational, NonAn Observational, Non--interventional, Multiinterventional, Multi--center, Multicenter, Multi--national national

Study of Patients With Atypical HemolyticStudy of Patients With Atypical Hemolytic--Uremic SyndromeUremic Syndrome