Hemolytic-uremic syndrome (HUS) is characterized by hemolytic anemia, thrombocytopenia, and renal failure caused by platelet thrombi in the microcirculation of the kidney and other organs. Typical (acquired) HUS is triggered by infectious agents such as strains of E. coli (Stx-E. coli) that produce powerful Shiga-like exotoxins, whereas atypical HUS (aHUS) can be genetic, acquired, or idiopathic (of unknown cause). Onset of atypical HUS ranges from prenatal to adulthood. Individuals with genetic atypical HUS frequently experience relapse even after complete recovery following the presenting episode. Sixty percent of genetic aHUS progresses to end-stage renal disease (ESRD).
Atypical HUS is considered genetic when two or more members of the same family are affected by the disease at least six months apart and exposure to a common triggering infectious agent has been excluded, or when a disease-causing mutation(s) is identified in one of the nine genes in which mutations are known to be associated with aHUS, irrespective of familial history. The nine genes are: CFH (encoding complement factor H), accounting for an estimated 30% of aHUS; CD46 (MCP) (encoding membrane cofactor protein) accounting for approximately 12% of aHUS; CFI (encoding complement factor I), accounting for an estimated 5%-10% of aHUS; C3 (encoding the third component of complement C3) accounting for 5% of aHUS; rarely, CFB (encoding complement factor B); and THBD (encoding thrombomodulin) accounting for about 5% of aHUS. Deletions involving CFHR1 and CFHR3 or CFHR1 and CFHR4 account for 5%-15% of aHUS.
Predisposition to atypical HUS (aHUS) is inherited in an autosomal recessive or autosomal dominant manner with incomplete penetrance. Rarely digenic inheritance and uniparental isodisomy are observed. Autosomal recessive inheritance: Heterozygotes (carriers) are usually asymptomatic; however, rarely carriers have developed aHUS in adulthood. At conception, each sib of an individual with autosomal recessive aHUS has a 25% chance of inheriting two disease-causing mutations, a 50% chance of inheriting one mutation and being a carrier, and a 25% chance of inheriting neither mutation. Autosomal dominant inheritance: Some individuals diagnosed with autosomal dominant aHUS have an affected parent or an affected close relative, but in the majority the family history is negative because of reduced penetrance of the disease-causing mutation in an asymptomatic parent, early death of a parent, late onset in a parent (or close relative), or a de novo mutation in the proband. Each child of an individual with autosomal dominant aHUS has a 50% chance of inheriting the mutation. In both genetic types, clinical severity and disease phenotype often differ among individuals with the same mutations; thus, age of onset and/or disease progression and outcome cannot be predicted. Prenatal diagnosis for pregnancies at increased risk is possible if the disease-associated mutation(s) has (have) been identified in the family.